Rehabilitative mental health care in Karachi – A case study of a single psychiatric set up.


It is 9:00 A.M. The wide green lawn ensconsed in the quadrangle of the double storey building  is bathed in mellow hues. Soon enough, they start emerging from their rooms, wearing fresh clothes after their morning showers. Single file, they are guided downstairs to begin the daily morning excercise session. A variety of expressions meets the eyes. Some look bored, a few seem indifferent, while others are quite enthusiastic – smiles lighting up their features. No, these are not children from a boarding school. They are mentally ill patients and residents of Karwan-e-Hayat PCRC (Psychiatric Care and Rehabilitation Centre) located in Keamari, in Karachi, Pakistan.

People have varied and often gross misperceptions about mental health institutions and their resident patients. A rehabilitation centre is often thought to be at par with an assylum with violent, drooling, dishevelled and possibly jumpy patients sitting in dark, narrow cells restrained by chains and administered electric shocks daily. These impressions belie the image of a rehabilitation centre like Karwan-e-Hayat PCRC. Though the entrance hall is flanked by burly security guards and has strong grills in order to prevent the patients from escaping, the rest of the Centre is bright, airy, clean and built on the model of Western rehabilitation centres. There are separate dining halls, activity rooms that are lined with the patient’s own creations and indoor game rooms for male and female patients. Two buildings adjacent to each other within the same compound house the male and female residential wards, semi private rooms and airconditioned private rooms. Presently it has 65 beds but in future there are plans to increase the number to 100 beds which is the Centre’s actual capacity. In short, it epitomizes the modern residential and Day Care facility for the mentally ill.

Karwan-e-Hayat started out as an NGO in 1983 committed to caring for the underprivileged  mentally ill patients. It got off to a good start with names such as Begum Ra’ana Liaquat Ali Khan, Cardinal Joseph Cordeiro, Ms. Anita Ghulam Ali, Prof. Dr. Zaki Hasan, and Dr Zafar Quraishi, who is currently the President of the NGO, as its founding members. In a city like Karachi where mental illness had a great deal of stigma associated with it they made the correct move – that of  organizing awareness camps. The target? Again, smartly enough – katchi abadi and slum dwellers who stood in utmost danger of being fleeced by miracle workers and fake pirs. In a simultaneous move, seminars were arranged in high profile schools like St. Joseph’s Convent and Karachi Grammar School. Since then, the NGO has come a long way. The Consultant Psychiatrist of Karwan-e-Hayat PCRC, Dr S. Ajmal Kazmi, met with Dr. Zafar Qureshi in 1995, then the Director of Karwan-e-Hayat. This interaction led to the concept of a rehabilitation centre in Karachi. The next few months brought on a search for a suitable location. KPT (Karachi Port Trust) were the owners of this premises in Keamari and after spending around Rs. 80 lacs for renovation, it became fully functional in 2004. As it is primarily a charity organization, 90% of the patients are treated free of cost thanks to various donors like Rotary Club Karachi and Infaq Foundation.

Theoretically, Karwan-e-Hayat combines two concepts – a rehabilitation program and a crisis  house. As such it provides services like medical examination and assistance, rehabilitation counselling and occupational training opportunities found in rehabilitation programs. As a crisis house in a community setting it is based on the model of rehabilitation and accordingly is staffed by mental health care professionals. The relatively little research that exists on such centres has not only found that they are very acceptable to their residents, but also suggests that they may be able to offer an alternative to inpatient care for about a quarter of the patients admitted to hospital, and that they may be more cost-effective in the long run than inpatient care since most patients are eventually assimilated back into society!

Karwan e Hayat follows a  multidimensional approach for treatment of adult patients between the ages of 18 years to 65 years. Drug addicts were earlier not treated here due to the vast differences in treatment methodology and other complexities. However, drug addicts suffering from psychoses are now admitted and treated.

Occupational therapy activities

Generally, firstly an RMO (Resident Medical Officer) medically examines the patient in the OPD and takes his history. Next he is sent to a Psychiatrist for consultation where, if needed, he is prescribed medication or admitted as an inpatient. The Centre offers admission to some patients who need inpatient care because of acute and severe mental health conditions like Schizophrenia, Bipolar Disorder etc. The patient may also be referred to the Clinical Psychologists for psychological testing and psychotherapy to resolve his inner conflicts. Inpatients are divided into three main categories for individual psychotherapy which takes place twice a week: 1. Obsessive Compulsive Disorder and Depression, 2. Schizophrenia, and 3. Personality disorders. Testing material worth Rs. 3.5 lacs has been acquired by the Centre to facilitate psychological diagnosis. Occupational Therapists attend to the patient in the Centre’s Day Care. They give the patient something  purposeful to do in the Activity Rooms with the intention of improving his general sense of self. Sessions for improving the patients’ awareness about their illness are also conducted frequently with a view towards helping them manage their self care. Various organizations such as the Institute of Professional Psychology and the Aga Khan Hospital send their students to the centre for internships and community service.

All these professionals work together to firstly diagnose and then help a chronically ill patient ease into society or at the very least sustain daily functioning ability. There are plans to include a Social Worker in the team this year as in other Western countries, but Dr Kazmi laments that the training provided in Pakistan at Masters level in Sociology or Social Work is far off the mark.

Karwan e Hayat ward

A typical day at the Centre starts with the ward boy waking up those in the Inpatient facility and encouraging them to wash themselves and take a shower. Some of the long term stable patients are encouraged to lead the morning Excercise Session. The patients then return to their wards or rooms for the morning round by the mental health professionals. Any decisions taken during this round are noted and the team then divides in two groups for better management of the not so stable inpatients and the Day Care activities. The Day Care group session includes both male and female patients who are stable enough to take part in discussions on basic topics such as “The importance of cleanliness”, “Ways to control anger” or “Hobbies”. The objective of such discussions is to draw the patients out of their fantasy world towards practical life and develop their interests.

All other activities apart from the group session are carried out in a segregated environment under supervision. During occupational therapy the patients are encouraged to make arts and craft items as per their interest. Many simply colour in drawing books and often the colours they pick or their manner of colouring is quite suggestive of their inner emotional states. Computers in the activity room are a relatively recent acquisition and selected patients are even taught programs like Microsoft Word by others. Evenings bring with them time for indoor games like table tennis, cards, carrom board and sometimes cricket. While it is encouraging to see the careful supervision of various activities, it is surprising that the patients are exposed to several cable channels and can watch movies – blood, gore and dances included, without a bat of an eyelid by the supervisors, in the activity room. Major activities at the Centre culminate with the Day Care closing at around 4:00 P.M. There is a skeleton staff for night duty to prevent possible mishaps.

Overall, it is creditable that Karwan-e-Hayat has not only managed to live up to its mission objectives by establishing centres such as its outpatient clinic on Khayaban e Jami and PCRC at Keamari during the past 24 years, but has fostered healthy links between psychiatrists, psychologists and occupational therapists – bringing them all under one roof at PCRC. Job satisfaction appears to be moderate amongst the staff members which is saying something, since the Centre is located at quite a distance from their homes. Yet many psychologists are sceptical about the level of therapeutic care being provided at the Centre as psychiatrists take centre stage in the proceedings.

There are several other rehabilitation centres – for drug addicts or psychotic patients etc located in the city but an impromptu survey taken from mental health professionals and patients revealed that most are not as spacious or as well organized. Moreover, there were complaints regarding the quality of meals provided elsewhere and the level of hygience maintained in the kitchens. Similar complaints of boredom, lack of good and comfort come from patients at this centre as well but they seem to be fewer in comparison.

The seemingly eternal rivalry between psychiatrists and psychologists has also proved to be a bone of contention in many cases with each faction wanting to show their supremacy over the other in terms of treatment efficacy. Dr. Kazmi’s rejoinder is interesting to note: ” Team work should always be there. If you work alone you can never do as well.  I’m lucky to be working with an honest and hardworking team. If someone is at the forefront, it is because there are several unnamed people at his back.”

Mental Health Professionals and policy makers would do well to take a leaf out of Karwan-e-Hayat’s book. With Schizophrenia at 11% and Depression at 15% world over, the demand for mental health facilities is bound to increase with the rise in population. Already, a figure of 1.5 million mentally ill people is estimated for Karachi. Karwan-e-Hayat’s PCRC is but a drop in the ocean. True, it is one of the few fairly good centres and is providing free treatment to poor patients but it is definitely too far from the city and has a limited capacity. There is dire need for many more centres, not only in Karachi but in the whole country.

N.B. This article was published in 2009 in Expose’ magazine, Karachi.

Photos courtesy: Karwan e Hayat website

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