Summary - Thirty-five year old Abdi spent 20 months in a privately-run residential center in Somaliland’s capital Hargeisa. Abdi’s family believed he was sick, maybe with a mental health condition, and they didn’t know what to do. As a result, his sister who felt she couldn’t care for him at home placed him in the center.
|Patients have been inside for a long time. The centers are not catering for people to return to society, patients are not getting any counselling or psychotherapy. When they are discharged, they are not given any prescription and there are no outpatient services.– Psychiatrist Doctor, Hargeisa, January 27, 2015|
Abdi – like many others in Somaliland who are perceived as having a psychosocial disability, or a mental health condition – then spent 14 months shackled at the ankles in the center, locked inside for almost the entire time. “It was very difficult to be inside all day long,” he said. “I was counting the days until I got out.”
The center’s staff gave Abdi psychotropic medication but sought no consent from him nor offered any explanation about why he needed it or how it might affect him. “On admission I was prescribed olanzapine, and was on olanzapine for the whole time there, but the nurse didn’t explain why.” But he had no choice other than to take it. “Sometimes if you refuse to take the medication or you become aggressive the guards beat you with a stick and slap you,” Abdi said.
Abdi and his relatives were not given any information about his diagnosis. Abdi had no power to leave the center. His sister determined when he would ever be allowed to go home.
When Human Rights Watch met Abdi at his sister’s home in Hargeisa, three days after he was discharged, his relief was palpable: “I was so happy to leave, I felt like a prisoner there, I felt like I was getting my freedom back when I left.”
There is no official data on prevalence of mental health conditions in Somaliland. However, existing research points to alarmingly high levels, including severe conditions, caused by the violence of the civil war, widespread use of the amphetamine-like stimulant khat, entrenched unemployment and lack of health services. And yet people with psychosocial disabilities have been abandoned by the state, left to their own devices or reliant on often ill-informed relatives, who also have no place to turn for help on how to support a relative with psychosocial disabilities.
In addition to four under-resourced and dilapidated public mental health wards dotted across Somaliland, expensive privately-run residential centers with no legal mandate have mushroomed in the capital, Hargeisa. Far from offering residents’ rest, rehabilitation or medical treatment, both public and private institutions are largely serving as places of confinement, and subject many residents to involuntary treatment and unlawful detention without free and informed consent.
Based on research in the towns of Hargeisa, Berbera and Gabiley, this report examines the abuses against people with actual or perceived mental health conditions or psychosocial disabilities in public and private institutions. Between October 2014 and July 2015 Human Rights Watch visited two public mental health wards, six privately-run residential centers and one facility that uses traditional and religious practice to treat and purportedly heal inpatients. Human Rights Watch interviewed 115 people, including 47 people with actual or perceived psychosocial disabilities currently or formerly within institutions, and found that most residents experience abuses. These include arbitrary detention, chaining, verbal and physical abuse, involuntary medication, overcrowding and poor conditions. Basic due process, judicial oversight and channels of redress are non-existent. Although women with psychosocial disabilities also suffer serious abuses in healing centers and in their communities, this reports focuses largely on men, because most of the centers hold men.
Families and relatives are the main support systems available to individuals with psychosocial disabilities, but often struggle to provide effective support, given the lack of community-support systems such as outpatient medical services and counselling based on free and informed consent. Family members are often ill-informed, with limited information about mental health conditions and what constitutes sound treatment and care, and must confront significant social stigma. Some rely on traditional Islamic healers or over the counter medicines from unregulated and unlicensed pharmacies for sporadic help. As a result, individuals with psychosocial disabilities often end up being chained at home.
Human Rights Watch found a number of factors that are making people with actual or perceived psychosocial disabilities increasingly vulnerable to institutionalization and abuse. These include high prevalence of mental health conditions, the dearth of appropriate government-supported community-based services for families who are struggling with challenges that arise because of a relative with a psychosocial disability, and the lack of information about mental health. Given increasing demand for inpatient care, private centers, claiming to offer mental health treatment, are proliferating without appropriate legal framework, regulation or oversight.
Most people with psychosocial disabilities interviewed for this research were placed in the institutions against their will by their relatives. Regardless of how they enter, residents in both public and private institutions have no control over when they leave, yet do not go through any judicial process to authorize such detention. The Hargeisa district court has been endorsing admissions to three of the private centers, despite the lack of legal groundings for these admissions, without the person’s informed consent or the individual ever appearing before the court, in addition to the lack of psychiatric assessment, or timeframe for “treatment”.
While a handful of residents said that there were some benefits to being at the centers, many residents told Human Rights Watch that they wanted to leave the public or private centers, but that their families had refused to bring them home or they had not seen a doctor competent to evaluate and discharge them. Some residents said that they had been held against their will for between one month and five years. None of the residents interviewed by Human Rights Watch had ever had access to a judge to challenge their detention.
The private centers hold residents in a heavily-controlled, often punitive, environment where guards and other staff subject residents to stringent timetables, protracted confinement and chaining.
Health workers and other support staff in the private centers Human Rights Watch visited chain residents as a form of restraint, frequently on admission, or because staff fear residents would be aggressive or try to escape. The widespread use of chaining creates a tense environment for residents, as one nurse at a private center explained: “Patients act aggressively as they feel that their freedom is being taken away from them, they feel the place is like a prison.” Chaining is also used in the public Berbera General Hospital mental health ward. The common and prolonged use of chaining, and to a lesser extent seclusion, as documented in public and private centers in Somaliland, violates basic international standards prohibiting ill-treatment, and may constitute torture.
Some residents were subjected to involuntary medical treatment, through force and sedation. Medical staff regularly prescribes psychotropic medications without informing residents of their diagnosis, the reason they are being prescribed the drug, getting consent or offering them any alternatives. Only one out of 30 residents interviewed for this research knew his diagnosis. Only four, including Abdi, knew what psychotropic medication they had been prescribed.
Guards at the institutions on occasion punish residents who infringe rules or resist orders by beating them with sticks, slapping them or chaining them as punishment. Public facilities, as well as three of the private centers were unhygienic and dilapidated. In at least two private centers, residents’ rooms are dark most of the time. Understaffing and lack of adequately trained staff was a problem in all of the private and public institutions Human Rights Watch visited. There are currently only two qualified psychiatric doctors in Somaliland for an estimated population of 3.5 million. For the everyday care of residents, the private centers in particular rely heavily on attendants and support staff, who are insufficiently trained, if at all.
Management of many of the centers provide very little, and often no, meaningful activities to residents, compounding their sense of imprisonment and hopelessness. Mowlid, who was detained for 15 months in one privately-run residential center, explained: “My family thought that place would help me, but in fact, it was too hard, I was constantly thinking, thinking, thinking. I just felt like I was in a prison.” The services provided in both public and private centers largely fail to prepare the residents to return to their communities. Many people are readmitted by their families, sometimes on multiple occasions.
While people with certain psychosocial disabilities may benefit from care in medical facilities based on free and informed consent, many could clearly receive the necessary support and services – including healthcare and medical care – within their communities. In fact, many of those interviewed for this research said they would prefer to receive treatment on an outpatient basis while living with their families. A psychiatric doctor that has worked at both public and private institutions said that most patients in private centers should be dealt with on an out-patient basis.
The Somaliland authorities have recognized that mental health is a serious health problem but have so far failed to provide adequate support to public inpatient and outpatient services, oversight of the proliferating private sector or establish community-based services. The little money from the government budget going to mental health is going to institutions. International support for the health sector has overlooked mental health.
Addressing Somaliland’s mental health crisis will require significant efforts. In the short term, the authorities should ensure that there is adequate regulation and monitoring of both public mental health wards and private centers, to prevent and respond to the serious abuses described in this report.
In the medium term, the Somaliland authorities, with support from their international partners and the Somaliland diaspora, should halt the increased institutionalization of mental health treatment and develop community-based mental health and support services. The government should work with people with psychosocial disabilities and their families and communities to tackle underlying stigma associated with mental disability, and find appropriate ways for individuals with psychosocial disabilities to live in a safe, independent and dignified manner in their community.
Somaliland needs to recruit and train more mental health professionals and social workers, mainstream mental health into primary care provision, guarantee access to treatment and counseling on the basis of free and informed consent, and ensure a steady, regulated supply of psychotropic medication. At the same time Somaliland, with the support of international partners, should strengthen existing mental health policies and move towards implementation of those plans, including by adopting mental health legislation in line with international human rights standards.
Given the apparent significant number of people institutionalized because of their consumption of khat, the authorities should consider providing similar services for people who use drugs at the community level.
Somaliland has an opportunity to build community support systems for people with psychosocial disabilities early on, regulate and monitor the private institutions who claim to offer mental health care treatment, stop the use of abusive and punitive chaining and thwart the move towards institutionalization.