We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights -- that among these are Life, Liberty and the pursuit of Happiness.

--The United States Declaration of Independence, 1776.

A couple of cases reminded me recently of the nebulous nature of freedom. As a psychiatrist practising in the United States, it was an article of faith that personal freedom was sacred. No one could deprive you of it without due cause and due process of the law. In Pakistan, like many other things, the idea of freedom is quite malleable and subject to multiple interpretations.

A*, a woman in her thirties was recently brought to my clinic by a family friend. At her initial visit, it was quite clear that she was suffering from ‘psychosis’, that specific disorganisation of thoughts and behaviours that, to a layperson, signifies madness. She talked in a disconnected fashion about conspiracies against her, she railed against her family for ‘plotting against me’, she was sure she was being targeted by unnamed intelligence agencies for unspecified reasons and she appeared generally angry and irritated. Like a lot of people in her position, she had been forcibly committed to a psychiatric hospital against her will by her family; a decision that I was in agreement with, seeing her current condition.

This situation, sadly, is quite common. A person in a family will begin to get ill, stop sleeping, start hallucinating, become agitated and/or violent and refuse to seek or accept treatment. The very illness that they are suffering from makes them think there are imaginary conspiracies against them. They start suspecting family members and loved ones of plotting against them, trying to steal from them or kill them. Often the family will come to me, distraught, unsure what they should do. In most cases the patient will refuse to come, believing there is nothing wrong with them.

The illness can be the result of any number of things: drugs or alcohol abuse in both men and women, complications of pregnancy or childbirth in women, dementia or other disorders of the elderly, depression and anxiety in adolescents and disorders related to relationships, academics and the like among young people. In a recent column in these pages (http://tns.thenews.com.pk/mad/), I had described how we deal with uncooperative but obviously ill patients.

But what to do if there is no solution but to admit the person to a hospital for their own safety or that of others?

In the United States where I spent a large part of my early medical career, the usual procedure for such a case was for the family or a mental health facility to go to court and file a mental health ‘petition’. This was basically an application to the court outlining what the person is suffering from and requesting that they be detained against their will in a psychiatric hospital for up to seven days for evaluation. Usually, this would be granted especially if the petitioner was a law enforcement agency who had picked up the patient, say, at a grocery store or a public place where they had made a scene.

Once in the hospital, the patient would be evaluated by a psychiatrist and, if necessary, we would go back to court to get a ‘45-day order’ and then again, if needed, a ‘180 day order’. Thus, at each step of the way, the purported patient would have legal recourse and could appear before the judge and plead their own case to be released.

No such procedure exists in Pakistan. We do have a ‘Mental Health Act’ passed as far back as 2001 which is supposed to deal with cases like this. In fact, the Act has never been properly implemented in letter and spirit. What actually happens in cases of acute illness where a person is refusing treatment is that a family member goes to see a psychiatrist who, based on the family’s description, recommends detention and treatment in a mental health facility. The facility then sends a team of two or three people including a doctor, a nurse and one or two orderlies to the patient’s home to pick them up and bring them to the hospital where they are confined (and treated) against their will.

Besides the fact that such a detention is patently illegal, the potential for abuse in such a situation is obvious. This is analogous to the situation in 16th and 17th century Britain and Europe where angry husbands would bring rebellious wives to asylums and leave them there accusing them of witchcraft and sorcery. Relatives would bribe officials to commit family members to institutions for life to occupy their properties. The person thus detained in Pakistan has no legal recourse and cannot plead their case before a judge.

In the case of my patient A* though, there was a twist to the tale. A* was an intelligent, resourceful woman. Through a friend, she contacted a lawyer and had him file a ‘habeas corpus’ petition challenging her illegal detention (a habeas corpus writ is basically a plea filed to a judge that a detained person be produced in court and be allowed to state their case). The petition was granted and the judge ordered her release from the psychiatric hospital.

This was the first time in the last seven or so years of practising in Pakistan that I came across a patient who managed to secure her own release. Her desperate family contacted the family friend who she still trusted and that’s how she was brought to me.

(To be continued)