here are moments in a nation’s moral life when a single document forces us to confront what we have allowed to happen in our name. The National Commission for Human Rights report, Caged in Care, is one such document. It is not merely an investigation into malpractice at rehabilitation centres in Islamabad; it is a mirror held up to a system that has quietly normalised coercion, humiliation and the erasure of autonomy under the language of treatment.

The report opens with a stark truth, stating that “across Pakistan, rehabilitation centres have morphed into spaces of confinement, where patients are stripped of dignity under the guise of care.” This single sentence captures the ethical crisis at the heart of our mental health landscape. What follows is a catalogue of practices that violate not only international human rights standards but also the most basic principles of psychological care.

Consent is the cornerstone of ethical mental health practice. Yet the NCHR found that every surveyed centre offered involuntary pickup services requiring no medical evidence, no psychiatric assessment and no legal authorisation. One facility director told investigators, “We do not need any tests. Just let us know the address where we should pick the patient up.” This is not care; it is abduction with paperwork.

The report documents case after case in which women were sedated, dragged from their homes and confined for months. A practicing lawyer was taken from her bedroom, injected into unconsciousness and held for eight months without diagnosis. Another woman described a man climbing on top of her and injecting her while she lay in her nightclothes. These are not therapeutic interventions. They are violations of bodily autonomy that would be criminal in any other context.

American activist Dorothea Dix campaigned for care rooted in dignity rather than punishment. French philosopher Michel Foucault later warned that mental institutions often served as instruments of social order, where confinement was justified through medical language but driven by deeper anxieties about deviance and disobedience. British psychiatrist RD Laing challenged the assumption that psychosis must always be subdued with force or medication. At Kingsley Hall in London, he attempted to create a space where people in extreme states could live without coercion; Mary Barnes became the most well-known example of someone who emerged from such an environment with renewed creativity and purpose. American psychiatrist Thomas Szasz, though frequently misinterpreted, did not deny the reality of suffering; his critique was directed at the misuse of psychiatric authority and the danger of turning social conflict into medical diagnosis.

The report makes clear that many admissions are triggered not by psychiatric emergencies but by domestic disputes, inheritance conflicts, refusals to marry or perceived disobedience. One woman was confined because she filed for khula’; another because she argued with her sister-in-law. A 90-year-old man had been institutionalised for over twenty years because he once smoked marijuana. This is not mental health care; it is the privatisation of patriarchal authority.

In a society where mental health literacy remains limited, families become vulnerable to exaggerated claims about risk and diagnosis.

Perhaps the most disturbing finding is the near-total absence of qualified psychiatric or psychological care. The report notes that many centres operate without psychiatrists, without diagnostic protocols and without treatment plans. In one case, the owner of a centre stated that a psychiatrist was “not relevant” to a woman’s case. Instead, treatment consists of sedation, isolation, religious instruction, humiliation, and in some cases, electroconvulsive therapy without anaesthesia. One resident told investigators,“We get up at five in the morning and spend the whole day praying. There was no treatment for my illness.” This is not rehabilitation; it is ritualised control.

The absence of psychotherapy is particularly alarming. The Islamabad Healthcare Regulatory Authority standards require that psychotherapy services be provided as prescribed and that treatment be based on assessment and diagnosis. Yet the NCHR found no evidence of structured psychotherapeutic input in any of the centres visited.

The report also echoes what many trainee psychologists have quietly shared for years: pressure to participate in ethically questionable practices. Early-career clinicians, often working without supervision, are expected to endorse decisions with profound consequences for patients. They operate in environments where the medical model is monopolised by psychiatrists, psychotherapy is undervalued and their role is reduced to compliance rather than care.

One of the most chilling findings is the absence of complaint mechanisms. The report states plainly that “none of the rehabilitation centres visited had a helpline, email address, or external reporting channel.” Patients cannot call for help, appeal their detention or speak freely to lawyers or family. In one case, a woman hugged her husband and whispered, “Get me out of here. This is hell.” A staff member immediately intervened and threatened to cancel the meeting. This is not treatment; it is captivity.

The question now is not whether reform is needed, but whether we have the moral courage to confront the system we have allowed to grow in the shadows. Three ethical imperatives emerge clearly.

First, involuntary care must be exceptional, time-limited, medically justified and subject to legal review. Anything less constitutes detention.

Second, rehabilitation must be grounded in psychotherapy, evidence-based practice and multidisciplinary care. Sedation, surveillance and spiritualisation cannot substitute for treatment.

Third, Pakistan urgently needs licensure for psychologists, accreditation of training programmes, mandatory supervision and regulatory bodies with enforcement powers. Without these safeguards, the field remains vulnerable to exploitation and institutional abuse. As state-run residential facilities remain scarce and under-resourced, a parallel network of private centres has expanded unchecked.

The report concludes with a sentence that should haunt us: “the women we rescued were not sick. They were simply unwilling to live a lie.” That is the ethical heart of this crisis. If this report is to mean anything, it must mark the beginning of a national reckoning—one that restores dignity to those who were silenced, accountability to those who failed them and humanity to a system that has lost sight of its purpose.

Dr Akhtar Ali Syed is a principal clinical psychologist in Ireland. He can be contacted at [email protected]

Zaofishan Qureshi is a clinical psychologist based in Islamabad. She can be contacted at zaofishan.qureshi@gmail.com