By Deborah Oyine Aluh

IN a small room with faded paint and worn-out chairs, a diverse group of people with mental health conditions gathered, their stories etched upon their faces.

They seemed visibly relieved to have a respite from the chaotic and overcrowded environment of the psychiatric wards. This gathering marked the beginning of narratives coming from a place of pain and the thoughts of improving the quality of care for people with mental health conditions in psychiatric hospitals.

In four focus group discussions, 30 patients in two psychiatric hospitals in Nigeria discussed their perceptions and experiences of coercive practices within the hospitals. Strikingly, the expressions of abuse and hopelessness were the same across the hospitals. It seemed to be a parallel universe where people seeking healthcare got harmed by the very hospitals they had turned to for help.

Talking about mental health issues is no longer taboo these days because almost everyone has either experienced or knows someone who has experienced a common mental health problem like anxiety or depression. Society is, however, still uncomfortable talking about serious problems like schizophrenia or other psychotic disorders.

Society is, however, still uncomfortable talking about serious problems like schizophrenia or other psychotic disorders.

Apart from the widespread stigma and discrimination against people with these conditions, they are subject to a wide range of human rights violations.  They could be subject to coercive practices like the use of chains, holding them hostage in cages, sheds, prayer camps, and severe beatings in traditional healing centres and other community settings.

When people read about the cruel treatment faced by individuals with mental health conditions in the media or reports from human rights organisations, they are often filled with shock and horror. It is easy to assume that the mistreatment and human rights violations happen mainly in traditional healing centres and prayer homes.

We think to ourselves; if only these patients could afford proper psychiatric care in hospitals, they would be treated with the respect and dignity they deserve.

Our study findings have shed light on the harsh reality that even when these people pay exorbitant fees for psychiatric care, they are still not spared from the horrors of human rights violations.

Experiences and ordeals narrated by those that are affected

The participants of the focus group discussions perceived coercion in mental health care to be a necessary evil in severe cases. Still, they recognised that it was anti-therapeutic to their recovery.

They knew that coercive measures were an extension of the stigma they experienced due to their mental health condition and, interestingly, also highlighted that it was a vicious cycle of abuse.

Using coercive measures made them frustrated and agitated (as would any other person), and this reaction is met with even stiffer coercive measures evoking more frustration and agitation, thereby perpetuating a cycle of aggression and coercion.

The study participants narrated their experience of involuntary admission, which revolved mainly around deception, maltreatment, and disdain. They were either deceived into going to the psychiatric hospital or tied in chains which often caused injuries. They were flogged for refusing to accept medications, some of which caused intolerable side effects.

They were flogged for refusing to accept medications, some of which caused intolerable side effects.

Mechanical restraint with chains was a common experience for reasons including refusing medications, preventing absconding, and in other cases, punitively. The use of chains was viewed by participants as dehumanising and excruciatingly painful. They could not understand why mental health workers who were supposedly knowledgeable about mental health would cause them additional trauma by using inhumane devices such as chains.

Although the common assumption is that ‘their head is not correct’, meaning that they lack the ability to think reasonably, and these coercive measures were done for their good.

The study participants unanimously reported that they had clear memories of these negative experiences and that it was traumatic for them and aggravated their conditions. In the words of one of the study participants, “Nobody is supposed to be treated as an animal. For you to be forced to have a chemical, to be injected, or to be chained is not normal.”

Nobody is supposed to be treated as an animal. For you to be forced to have a chemical, to be injected, or to be chained is not normal.

What must Nigeria do going forward to protect patients in psychiatric hospitals?

At the time the study was conducted, the existing mental health law was the obsolete colonial Lunacy Act of 1958, which was not only derogatory but did not recognise the rights of people with mental health conditions. This meant that being diagnosed with a mental health condition automatically stripped one of many fundamental human rights.

Thankfully, Nigeria’s National Mental Health Act 2021 has been passed, but this is just the first step among several steps the government and society need to take in protecting the rights of this vulnerable population.

Although frequently criticised, mechanical restraints are a typical feature in many psychiatric facilities around the world, yet they are usually soft, flexible belts rather than chains.

The hospitals had a limited supply of belts and occasionally made do with chains. With less than 300 psychiatrists for its enormous population of over 200 million, Nigeria has very low levels of human resources and infrastructure for mental health care which severely worsens this issue.

The World Health Organization (WHO) recommends that setting up community mental health services can be an effective way to encourage people to seek help early and safeguard their human rights. This is daunting for a resource-limited country like Nigeria. However, integrating mental health care into primary care is an effective and feasible alternative. While this is being done, the existing primary care must be revitalised to be accessible and affordable to all.

Another crucial aspect that cannot be overlooked is the stigma surrounding mental health conditions which is a major barrier to early help-seeking for mental health conditions. Addressing this stigma is not solely the responsibility of governments; each of us has a vital role in ending discrimination toward people with mental health conditions.

Deborah is a PhD student researching the contextual factors influencing the use of coercion in mental health services at the Lisbon Institute of Global Mental Health. She is also a staff of the Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria Nsukka. Nigeria. Sh can be reached via Twitter: @debbilici0uss

This article is republished from Health Policy Research Group (HPRG), University of Nigeria; you can read the original here.