Having volunteered at an addiction rehab center in Karachi, I bore witness to some complex struggles faced by women in urban Pakistan. Being a middleaged Pakistani woman myself, some of their personal experiences deeply resonated with me. Apart from one woman who belonged to a lower socio-economic family, all the women belonged to the middle and upper-middle class strata. They had full access to education and better standards of living, but unfortunately this was no guarantee that they can or are “safe”, that they would not experience violence, trauma, and abuse from family members, often their own parents, uncles, brothers, or husbands. This constant distress and lack of physical and psychological safety resulted in dysfunctional or maladjusted behaviours, including addictions, as well as mood and personality disorders, which (in some cases) had become more pronounced after an abusive marriage or the stress of childbirth.

By default, along with a spectrum of abuse and trauma most women are at a high risk for depression, posttraumatic stress disorder, substance abuse and (in extreme cases) even suicide.

I am mindful that every Pakistani woman’s situation would not be so bleak, but it is true that no matter how much privilege a woman has she will most likely be considered (and treated) inferior to male counterparts and peers in Pakistan. Hence by default, along with a spectrum of abuse and trauma most women are at a high risk for depression, post-traumatic stress disorder, substance abuse and (in extreme cases) even suicide. Women live their lives with less social and individual freedom, with regards to their bodies, how they want to pursue dreams and aspirations, essentially how they want to live. Women have been conditioned to live with shame and guilt, conditioned to be martyrs and to accept sacrifice as a virtue. This is an unnatural and damaging way for a human being to exist, even if it is upheld in culture. These challenges are further exacerbated as therapy remains tabooed and people are less likely to consider therapy as a viable site of help.

A young woman I met last year, suffered severe and progressed mood and personality disorders, as assessed by a psychiatrist. She would actively self-harm as well as abuse herself with easily available medicines. Though she had been abused and traumatized since she was three years old, her parents and adult siblings remained in denial, insisting that it was a result of “bad company”. This lack of understanding and support quickly further exacerbated her condition, leaving her physically and mentally incapable of functioning like a person her age. Her therapy and psychiatric treatment were discontinued by her parents, and soon after her sessions ceased, she actively began using more medication in larger quantities as well as engaged in intense self-harm. This capable young woman with so much potential wasn’t even given a chance to heal.

Another case is a sixty-year old woman with neurosis and obsessive-compulsive disorder since teenage. With old age her dysfunction is more and they benefited from it. However, their family members never knew about it. In their social circles and families, going for therapy means “pagal ho gaye hain” (one has gone ‘mad’). When I asked this group what kind of background check they did before they started sessions with a therapist, not a single person had. Because they were doing this covertly, they did not want to ask around about a therapist. When I asked a few males in the same peer group whether they had tried personal therapy, they had not. How did they feel about their wife, sister, or daughter going for therapy? They were fine with it, provided it was kept quiet, the taboo and shame associated with mental illness bothered them. Unfortunately, due to the taboo and stigma, many end up with frauds claiming to be therapists.

These experiences not only bring forth the terrain of stigma a client navigates in Pakistan to access therapy but also shines light on the paucity of knowledge and mechanisms to access verified mental health professionals.

These experiences not only bring forth the terrain of stigma a client navigates in Pakistan to access therapy but also shines light on the paucity of knowledge and mechanisms to access verified mental health professionals. Few and limited studies have been done on the lack of psychiatrists and psychologists and mental health clinics in Pakistan, and there has been no research on psychotherapy and counselling. Counselling and Psychotherapy – often considered a first step in the mental health well-being and pronounced, she continues to struggle with all types of relationships, is unable to set boundaries or trust others, and as a result has spent the last decade in isolation. Her condition is worsening with time, but she refuses to try therapy, “How can I go and talk about personal things with a complete stranger? That is so shameful.”

As per my limited research for this piece I can see a growing desire in people to go to therapy leading them to navigate the stigma associated with seeking therapy. I spoke to a few women aged late 20s to early 30s who had secretly tried therapy. They understood they needed support and the importance of therapy, “healing” process – remain unrecognized in Pakistan.

Sometimes your mind needs support that is not medicine, it needs mental support and holding with a trained professional, so your mind can heal and become stronger.

Many people (especially in Pakistan) remain confused about the distinction between a Psychiatrist and Psychologist. Psychiatrists are medical doctors who can diagnose illness, manage and provide a range of treatments for complex and serious mental illnesses, they can also prescribe medication. While psychologists are not medical doctors and cannot prescribe medication. They can do some basic assessments and talk therapy. Counsellor and Therapist are also confused: A Therapist works with a client to address mental health and wellbeing issues; in this way their work is similar to a Counsellor. However, a therapist works with clients on a deeper level by supporting them to gain awareness about patterns and coping mechanisms, subsequently facilitating better mental health and wellbeing. Therapists are not doctors nor have doctoral level education (necessarily) but a practitioner will have verified training and work with a trained supervisor. Therapists also use different techniques and may specialize in a particular psychodynamic model.

All this information isn’t readily available to anyone trying to step into their healing journey through mental health services. Mental health and wellbeing as well it the treatment of mental issues remains a huge stigma in Pakistan. This deters people from seeking help, especially women who may already feel stigmatized and be dealing with gender biases. There is little to no education on mental health and low awareness - this is what truly needs to change, to drive empowerment and change. I like to give the example of “physiotherapy” – sometimes your body needs support that is not medicine, it needs physical support with a trained professional, so your body can heal and become stronger. Psychotherapy works the same way - sometimes your mind needs support that is not medicine, it needs mental support and holding with a trained professional, so your mind can heal and become stronger. To support the mental health of women it is necessary that accessing such support is destigmatized and mechanisms to ensure the protection and safety of the client are put in place. Coupled with this it is necessary that mental health professionals are properly verified as per their credentials and experience.

Sarah Dawood is a senior specialist for Strategy & Communications in the corporate sector. In a personal capacity, she actively works and volunteers to drive awareness about the importance of mental health & wellbeing.