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A resident sits with his foot chained in the courtyard of the Raywan private center in the Somaliland capital Hargeisa, on July 29, 2015. © 2015 Zoe Flood for Human Rights Watch

(Nairobi) – People with mental health conditions in Somaliland are increasingly forced into institutions, where they face serious abuses and poor conditions. The Somaliland authorities should provide oversight for all mental health facilities, prohibit chaining, and establish voluntary community-based services for people with mental health conditions.

The 81-page report, “‘Chained Like Prisoners’: Abuses Against People with Psychosocial Disabilities in Somaliland,” finds that men with perceived or actual psychosocial disabilities face abusive restraints, beatings, involuntary treatment, and overcrowding in private and public health centers. Most are held against their will and have no possibility of challenging their detention. In private centers in particular, those with psychosocial disabilities face punitive and prolonged chaining, confinement, seclusion, and severe restrictions on their movement. The findings highlight the importance of mental health services in post-conflict regions. According to the World Health Organization, Somaliland has high rates of psychosocial disability.

“Rather than providing appropriate and voluntary medical care or rehabilitation, these centers subject residents to prison-like regulations, isolation, and involuntary treatment,” said Laetitia Bader, Africa researcher at Human Rights Watch. “The Somaliland authorities should act quickly to address the abuses inside mental health institutions.”

Rather than providing appropriate and voluntary medical care or rehabilitation, these centers subject residents to prison-like regulations, isolation, and involuntary treatment.
Laetitia Bader

Africa Researcher

Human Rights Watch conducted research in Hargeisa, Berbera, and Gabiley, and interviewed over 115 people, including 47 with actual or perceived disabilities who have been placed in institutions. Most had faced abuse. Basic due process, judicial oversight, and channels of redress are non-existent. The research focused primarily on privately run residential centers in Hargeisa. As most centers hold men, the findings largely address their situations, though women with psychosocial disabilities also suffer serious abuses.

Somaliland does not keep official data on the prevalence of mental health conditions, but existing research points to alarmingly high levels because of violence and trauma from the civil war, lack of health services, and widespread use of the amphetamine-like stimulant khat. For years, people with mental disabilities have been left on their own to confront significant social stigma or have had to rely largely on relatives who have little information and understanding about their conditions and have nowhere to turn to for assistance.

In 2014, the Somaliland authorities endorsed plans that identified mental health as a priority and called for the drafting of legislation in line with the Convention on the Rights of Persons with Disabilities. But the plans have not been implemented, and international support for health services has largely overlooked mental health. Somaliland currently has only two psychiatrists for approximately 3.5 million people.

In recent years, in addition to the handful of under-resourced and dilapidated public mental health wards, privately run centers have sprung up across Hargeisa to meet the massive demand for mental health care. Voluntary community-based services are virtually non-existent.

Rather than providing appropriate medical care and counseling, with the person’s consent, these centers are largely places of detention and solitude, Human Rights Watch found. Most people interviewed had been admitted against their will by their relatives. Some had been detained for up to five years, with no means of challenging their detention. A number of residents in the centers were from the diaspora.

Guards and other staff at the private centers hold residents in a heavily controlled, at times punitive, environment and subject them to stringent timetables, protracted confinement, beatings, and chaining. Chaining is widely used on admission to control residents and as a form of punishment in the private centers and, although to a lesser extent, at the Berbera General Hospital mental health ward.

“It’s the rule for all the new arrivals to have chains,” said a 27-year-old  man who spent two months in a private center after his parents placed him there without his consent. “I was in chains the whole two months I was there. I felt as though my freedom was taken away.”

The Hargeisa Group Hospital mental health ward is the only center Human Rights Watch found to be chain-free. Other government-run mental health wards and private centers should follow its lead, Human Rights Watch said.

Guards sometimes beat residents who refuse to take their medication or follow orders or who show signs of aggressive behavior, Human Rights Watch found.

“Yesterday, one of the patients fought with the security guard – then they used a belt to hit him,” a patient in a private center said. “He wanted them to remove his chains. They hit him five or six times with the belt.”

Some residents at both public and private centers are subjected to involuntary medical treatment, through force and sedation. Psychotropic drugs are widely prescribed based on perfunctory medical assessments. Residents often are not informed of their diagnosis.

The centers largely fail to prepare and support residents’ return to the community, Human Rights Watch found. They provide few meaningful activities. In most private centers, residents spend most of their time inside their rooms, often in chains or behind locked doors and sometimes in darkness.

Addressing Somaliland’s mental health crisis will require significant efforts, Human Rights Watch said. The authorities should start by banning chaining, regulating and monitoring all mental health institutions, and ensuring that people who are institutionalized have channels for redress.

Somaliland should also focus on halting the move toward institutionalization and work with people with psychosocial disabilities, their families, and communities, including the diaspora, to tackle underlying stigma associated with mental health. The government should find appropriate ways for people with psychosocial disabilities to live in a safe, independent, and dignified manner in their community.

Given the apparent significant number of people institutionalized because of their consumption of khat, the authorities should provide similar community-level services for people who use drugs.

Somaliland and international partners are currently reviewing health plans and should take the opportunity to include mental health services in their planning and programming, Human Rights Watch said.

Somaliland, with the help of its international partners, should recruit and train more mental health professionals and social workers, include mental health in provisions of primary care, guarantee access to treatment and counseling on the basis of free and informed consent, and ensure a steady, regulated supply of psychotropic medication. The government should also strengthen its mental health policies and implement these plans, including adopting mental health legislation in line with international human rights standards. 

“Long-term warehousing of people with psychosocial disabilities is discriminatory, violates their basic rights, and doesn’t provide them with the services they need,” Bader said. “But, Somaliland has an opportunity to build a system for people with psychosocial disabilities that provides both support and autonomy.”

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