Making Psychiatry Relevant in Pakistan by Challenging its Western Roots

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Psychiatrist Yousaf Raza details the problems with psychiatric health care in Pakistan and shows how to find a way forward.


“She was half-conscious when she was brought to me,” our psychiatry professor said, “and this is what she had been prescribed.” He showed us an image of a local psychiatrist’s prescription. The prescription included a total of eight medications, two of which were injections, for a 16-year-old girl who had presented with a two-day history of vague physical symptoms following a stressful event. By all professional standards, she did not even require a single medication; yet here she was, disoriented by eight drugs.

This was unquestionably an unethical practice. However, as I endeavor to demonstrate in this article, this episode is but an exaggerated display of issues deeply ingrained in the mental health profession itself. Precisely because the issues are usually not as exaggerated as in this case, they are far more pernicious. Before delving further, a few disclaimers are in order:

I am not an outsider critiquing these problems to wholly condemn the profession. Rather, I am a practicing psychiatrist, committed to my professional community, who views it as my responsibility to shed light on these issues. My aim is to encourage fellow practitioners to address these challenges and to alert service users to be more cautious. I understand that in a field lacking resources and battling stigma, such a critical stance further complicates matters. However, I believe that critical reflection is as vital for the growth of a discipline as it is for individual development. Additionally, as a rather costly private practitioner by Pakistani standards, it’s important that I openly declare a conflict of interest: the more my views are heeded, the more clientele my associates and I may attract. Nonetheless, I am hopeful that any potential benefit will be counterbalanced by the critical scrutiny that my views and practices will inevitably undergo. I invite my critics to hold me accountable, ensuring that my deconstructive analysis is followed by reconstructive efforts.

Illicit ties with pharmaceutical industry 

Prescribing more medications than are justified is the number-one crime of which a shamefully large number of psychiatrists are guilty. If psychopharmacology is all there is to psychiatric practice, should we not at least get that right? Most people with mild-to-moderate symptoms who present to psychiatrists do not need a prescription. Unfortunately, many of my colleagues, despite recognizing this, rationalize by saying that if they don’t prescribe, the patient will think they are not good psychiatrists. If the ludicrous standard of “more medications equals a better doctor” has become popularized, why do we feel compelled to conform to it?

The answer is simple: it is also the standard that pharmaceutical companies hold us to. This is where the kickbacks come from. From international tours (for the entire family, mind you) to “scientific conferences” (my son learns more science from YouTube Kids than most of these conferences ever teach anyone), to tissue paper boxes, pharmaceutical companies cover it all. They only ask you to prescribe their specific brand. The more you prescribe, the more you get.

Even the more severe conditions usually do not warrant more than two medications. I can see the justification for three at times. Four medications are reserved only for really severe and resistant cases. Unfortunately, however, prescribing 4-5 medications has become the criminal norm even for mild-to-moderate cases.

Over-Diagnosis: Medicalization and Marginalization

Life is hard. Suffering is an indispensable part of life. Fear and sadness are normal responses to difficult life situations. Not everyone who walks into a clinic presenting with life challenges needs a DSM/ICD diagnostic category attached to them. Google searches already provide such self-diagnosis checklists; professionals are not needed to exacerbate the situation.

The labels we attach become an indelible part of people’s identities and significantly alter how other physicians, their families, and their employers will interact with them. The patients themselves will see themselves in a different light and behave accordingly. This treatment, for the most part, has significantly negative consequences. The diagnostic guidelines we follow are not scripture, and they are definitely not based on unquestionable science. They are useful and can be significantly helpful in a number of cases, but they need to be employed with extreme caution.

10-minutes per patient? 

When your prescription practices are dictated by pharmaceutical companies and diagnostic practices focus on checking off specific catch-phrases from a list, 10 minutes is far too much time. Our patients tell us about experiences in which they received only a couple of minutes of attention. If you are the only doctor on duty in a public hospital with over a hundred patients to be seen in less than 3 hours, the time constraint is understandable. It is not excusable at an administrative level, but it is understandable at the level of the junior doctor. But it does not apply to private practice!

People bring very personal and deeply disturbing problems from their lives to us with really high expectations. Part of the reason they come to us, unfortunately, is that the rapid spread of individualism in our society means they don’t have people to talk to. And end up making them feel unworthy of being heard.

Public/Private Collusion

Public hospitals are, in many ways, comparable to garbage dumps, while private practices could easily be mistaken for five-star hotels. Consultants in public hospitals routinely arrive late and leave early. Why? They need to get to their private practices, of course. Public hospitals are tolerated by these superstar consultants because they enhance their image; private practice is where the real money lies.

Neglecting Psychosocial and Cultural Context

Despite touting the “biopsychosocial” model to our non-psychiatry colleagues, and despite this being another reason why less than ten minutes might suffice, we often exhibit a complete disregard for psychosocial aspects in diagnosis and treatment. If mastering three major classes of diagnoses and four categories of medications is our primary skill set, then why do we need an elaborate four-year training program and a series of grueling examinations? If we cannot develop the basic psychological expertise to address existential concerns, do we even deserve the title of “doctors of the mind”? Or should it be “doctors of the brain”? Then how are we different from neurologists?

And this will be a sore point for most of us: aren’t there alternatives within our cultural context to which people can turn for better mental health? Do we have any acknowledgment, let alone a relationship, with those indigenous resources?

The Colonial Mindset: The Core of the Crisis

All these issues converge at a singular point: the colonial mindset that continues to pervade psychiatric practice in Pakistan. This trap prevents us from examining alternative frameworks that could offer more comprehensive, just, and culturally appropriate mental health solutions. There is far more to this malady, but I will limit myself to just a few ways in which the problems I enlisted above relate with a colonial mentality. 

Why do we over-prescribe, over-diagnose, and ignore psychosocial and cultural aspects? It is because we are intent on reducing everything psychic to the body/brain. In technical terms, this is biomedical reductionism. What is that? It is an archaic, essentially Western model that believes reality is mechanical and is best understood by breaking it down into its most fundamental parts. As promising as this model was for early developments in science, it is no longer tenable, even in the West. Mere lip-service to a biopsychosocial model, which has failed in its own country of origin, rather than being a remedy, only worsens the problem.  

Why are money and long life central to all our concerns? Of course, these are basic human yearnings, but they are yearnings that have found exclusive priority and focus in Western lifestyles. The much-envied Western healthcare system, with capitalism running through its veins, epitomizes this prioritization. Despite its magnificent and jaw-dropping achievements, the glaring shortcomings and unsustainability of these models have become patently obvious. In the UK, NHS employees are almost routinely on strike due to low pay, and the public complains of egregiously delayed access to specialist care. In the US, people drive to Canada or fly to their home countries to undergo surgeries. If the Western economy can’t sustain these models, how in the world are we expected to?

Conclusion and Future Directions

To decolonize psychiatry in Pakistan is not just a deconstructive act—it is also a reconstructive one. It offers us an opportunity to redefine the philosophical foundations upon which our psychiatric institutions stand. It is linked with a similar process in other institutions, but our scope is limited to mental health profession. As we acknowledge our colonial past, we must simultaneously imagine and work toward a future that is more reasonable, relational, and culturally resonant. This was part of Allama Iqbal’s dream for our role in the world. We identify him as a founding father and a national poet-philosopher. However, his warnings against getting deceived by the “dazzling exterior of Western civilization” have fallen on deaf ears. His was a nuanced relationship with Western intellectual resources, one in which appreciating and contributing to scientific developments did not necessitate forsaking our own traditions. This was the reconstructive task for Pakistan. 

It is beyond the scope of one article to detail what that reconstructive task entails for the field of mental health in Pakistan. The first step in that direction would be a deeper appreciation of these and other problems. Following that appreciation, we will be in a position to articulate meaningful alternatives. It is our hope to articulate that in a series of articles on Mad in South Asia.

Yousaf Raza


  1. As salaamu alaykum Yousaf.

    I assume you have read the work of Frantz Fanon, particularly his “Wrenched of the Earth”? As a psychiatrist who worked with some of the victims of ‘colonialism’ in Algeria (and interestingly some of the French torturers), his views on how to ‘throw off’ the chains are fascinating. I also found his brief comment late in the work regarding the “elegant method of overcoming resistance” particularly insightful. Confidentiality? Oh dear, “they will take their oaths as a cover” 63:2)

    You write;

    “Prescribing more medications than are justified is the number-one crime of which a shamefully large number of psychiatrists are guilty.”

    I can find no offence in our Criminal Code to suggest anyone could be charged, much less convicted of ‘overprescribing’, at least in my State. In fact, I was ‘spiked’ with a date rape drug (benzodiazepines), and had a Senior Medical Officer write a prescription for that drug making it my “Regular Medication” after being snatched from my bed by police (they were told I was a ‘mental patient’ though I did not meet the legal criteria…… not a problem, forge the statutory declarations and ‘edit’ the legal narrative [“do not conceal the truth with falsehoods 2;42] and the arbitrary detention and kidnapping disappear). I would have thought such forging of prescriptions to conceal criminal offences would be frowned upon but ….. was told I would be “fuking destroyed” by a hospital administrator for making a complaint about my ‘treatment’. Hence the ‘editing’ and release of my confidential information. And so I can agree with your comments about how the slander of a mental health label can have an effect on a persons character (“they will say you are mad” 15;6 +).

    I guess there is a lot I could discuss with you about how the Mental Health Act is being used in my Western ‘democracy’ to conceal information from the public that our ‘elected representatives’ deem unfit for public consumption (ie how to arbitrarily detain, torture and involuntarily euthanize citizens who can be made into ‘mental patients’ post hoc with some legal narrative ‘editing’ and some negligence on the part of the ‘authorities ‘ who have a duty to examine complaints about human rights abuses [ Our Chief Psychiatrist who provides “expert legal advice to the Minister” doesn’t know what the legal protections in our law are, and has removed the protection of “reasonable grounds” thus enabling people to be snatched form their beds by police and ‘treated’ against their will. Care to see his letter? Though I do believe it was forged by the people at our Mental Health law Centre at the request of the Minister [and assuming, wrongly, that police had retrieved the documented proof.] And these are the people pointing fingers at Pakistan as corrupt? lol.).

    Whilst I have had some wonderful interactions with ethical psychiatrists, some of the people surrounding your profession leave a lot to be desired. In my State it is a crime for a Community Nurse to call Police and LIE about a persons status in order to have them beaten to a pulp and cause an ‘acute stress reaction’. Particularly when it is known to that Community Nurse that the citizen has been ‘spiked’ with date rape drugs (benzos)…….. In fact I direct you to Article 1 of the convention against the use of torture.. Fortunately anyone who complains can be turned away by the Police and given ‘treatment’ for their truth speaking….. which can result in what is eupemistically called an “unintentional negative outcome” by our Chief Psychiatrist.

    So the colonial past in my country seems to be a very deep rooted corruption, which must be silenced by our ‘elected representatives’ as it is also a ‘tool’ which is highly effective in destroying anyone who blows the whistle on their corruption. You can be snatched form your bed and ECTed until your brain is mush….. and we now have ‘euthanasia laws’ and if you combine this with the “editing” of documented legal narratives post hoc?

    My illness was all well and good until I turned up with documented proof of what I am alleging…….. all that is left os for the ‘authorities’ to deny reality…. something of the ‘illness’ they claimed I was suffering from.

    I quote from the notes by the Senior Medical Officer who diagnosed me with three serious mental illnesses (and prescribing a chemical cocktail which I am told would have made me “very ill”. A ‘chemical kosh’ I have been told) after a less that three minute ‘assessment’. I had “potential for violence, but no clear intent or actual history”. Am I to be drugged for his ‘suspicions’, or is this a symptom of his paranoid delusions? And what happens when one of your ‘colleagues’ is drugging people for political purposes, and to assist corrupt police in the concealment of their human rights abuses?

    I’ll look forward to hearing your response, though oh so many run away once they realise that I have been speaking the truth, AND that I still have the documents to prove it despite the best efforts of the State to ensure I was in no fit state to continue to speak it. Something our Nabi (saw) no doubt came across all those years ago.

    Kind regards

  2. Call police and request assistance with your “patient” (‘target’) who has been ‘spiked’ with benzos without their knowledge (Offence is ‘intoxication by deception’, may also constitute the offence of “stupefying with intent to commit an indictable offence, namely kidnapping)

    Police will then assist by causing an “acute stress reaction” in the ‘target’. thus;

    Fabricate the evidence required to take the target into custody, then have police do the kidnapping for you by forging a Transport Order, and have them utter with it. Once at the hospital the person can now be ‘treated’ at your leisure………… dribble therapy by ‘overmedicating’ anyone? The slander of the ‘mental health label’ and the “editing” of their File will take care of any complaints….. that and the threats to their family members.. ask my estranged wife who I haven’t been allowed to speak to for 10 years about the threats she received from the hospital; FOI Officer after I requested my documents proving what I am saying.,


  3. In surah Al Hujurat, ayat 6, it says;

    “O ye who believe! If a wicked person comes to you with any news, ascertain the truth, lest ye harm people unwittingly, and afterwards become full of repentance for what ye have done.” (Yusef Ali)

    Whilst I do not consider myself to be a “wicked person” I have been surprised that they ‘news’ which I have spoken to my “brothers” has not been checked for fear of it being the truth. Surely the ayat refers to a duty of checking the facts when such serious allegations are made?

    I believe it is said in the Haddiths that the greatest form of jihad is to speak a word of truth to an oppressive ruler? Our Chief Psychiatrist could most certainly be described thus. His ability to rewrite the laws passed by our Parliament to remove the legal protections afforded our community would suggest an ‘oppressive ruler’? I had thought democracy involved a need for Parliament to pass changes to our laws, and not the right of a public servant who prefers a different outcome when public officers are abusing human rights by arbitrarily detaining and torturing citizens, and claiming that it is ‘medical care’?

    I have fulfilled my duty in this regard by speaking that word of truth to someone who simply ignores (and in fact the State actually threatens peoples families) any allegations he prefers “never happened”.

    So where does this leave me with my “brothers”? It says in surah Ya Sin, ayat 47;

    “And when they are told, “Spend ye of (the bounties) with which Allah has provided you,” the Unbelievers say to those who believe: “Shall we then feed those whom, if Allah had so willed, He would have fed, (Himself)?- Ye are in nothing but manifest error.””

    Will they not spend of their ‘bounties’ by taking the time to check the facts? Or is it the case that they will say that if Allah willed, He would look at the matters Himself? Does this not demonstrate the hypocrisy of those claiming to be Muslims? They prefer to remain in ignorance, and accept known lies than confront the ‘oppressive ruler’?

    An dit is the case that there is a duty in law for the Chief Psychiatrist to report suspected misconduct to the Corruption Watchdog immediately upon becoming aware …… though why would one bother if you are concealing the offending/abuses with cover ups? And why did Allah leave me with the proof of these abuses while they thought they had retrieved the documented proof, and we confident they could simply ignore and gaslight me with their vicious abuses?

    I understand your a psychiatrist and NOT a cleric. And these questions are probably best asked of someone with an understanding of the Quran…. but maybe you can see what my dilemma has become?

  4. “Public/Private Collusion
    Public hospitals are, in many ways, comparable to garbage dumps, while private practices could easily be mistaken for five-star hotels. Consultants in public hospitals routinely arrive late and leave early. Why? They need to get to their private practices, of course. Public hospitals are tolerated by these superstar consultants because they enhance their image; private practice is where the real money lies.”

    No mention of the method being used to Shang Hai ‘patients’ from the Private system to the Public in order to extort money and empty bank accounts Yousaf? You know, that system where people who are awarded large sums of money as a result of psychiatric reports by the courts, who are then subjected to forced ‘treatments’ as a result of their medical records being accidentally released, and being snatched from their beds by police and ‘treated’ until the money is transferred from the ‘patient’ to the ‘doctor’?

    THATS where the real money lies right?


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