Atlas›Domain XVI · Historical, discredited & harmful›Guide 104
Guide XVI-104

Chaining and shackling of people with psychosocial disabilities

A 30 · L 60 · M 1020 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: chaining and shackling of people with psychosocial disabilities as documented by Human Rights Watch (HRW) in Living in Chains: Shackling of People with Psychosocial Disabilities Worldwide (October 2020), read with HRW's country reports on Ghana (2012, 2023), Indonesia (2016, 2018) and Kenya (2023), WHO's Guidance on community mental health services (2021), and the Supreme Court of India's January 2019 order on chaining under the Mental Healthcare Act 2017. Prayer camps as such are covered in Domain XI 069, which carries their own harm account; this guide covers chaining and shackling in every setting and does not repeat that material.

Chaining and shackling (in Indonesia called pasung) is the practice of chaining people with real or perceived mental health conditions, or locking them in sheds, cages, cells or rooms, sometimes for weeks, months or years, with no way to challenge the confinement. HRW documented it in 60 of the 110 countries it studied, in Asia, Africa, Europe, the Middle East and the Americas, and estimates that hundreds of thousands of people have been shackled at least once in their lives; no global statistics exist [source: HRW 2020 report]. It happens in family homes, in state and private institutions (including social care homes and psychiatric hospitals) and in traditional or faith-healing centres [source: HRW 2020 report; HRW 2020 news release].

This is a harmful practice, not a therapy. The UN Special Rapporteur on torture has said shackling amounts to torture even when non-state actors carry it out [source: HRW 2020 report; HRW 2023 Ghana]. It is listed here so that psychotherapists can recognise it, work with people who were shackled and with the families who shackled them, and act on safeguarding and advocacy.

Core idea of how change happens: HRW and WHO both locate the drivers in stigma, beliefs that the condition comes from spirits, witchcraft, curses or sin, fear that the person will run away or cause harm, and a lack of accessible services, so that families "feel they have no alternative" [source: HRW 2020 report]. Change, as these bodies describe it, comes from bans that are enforced and monitored, voluntary community-based services (crisis support, outreach, supported living, peer support, housing, education and work), follow-up support for people freed from chains, and work with families and faith leaders [source: HRW 2020 report; WHO 2021 guidance; PAHO/WHO 2021 news release]. The psychotherapist's part is recognition, trauma-informed care, work with explanatory models and families, safeguarding and advocacy [synthesis].

2. Framework

Historical and current phases of the practice (outline).

  • Long-standing family and institutional practice: chaining and locking up people with mental health conditions in homes, institutions and healing centres; families often consult faith or traditional healers first and confine the person when that fails [source: HRW 2016 Indonesia release; HRW 2020 report]. (The chains and cages of the early European asylum are covered in guide 018 of this domain and the asylum-era guides that follow it.)
  • Bans and programmes: Indonesia banned pasung in 1977; its anti-pasung effort later included a 2017 agreement among five government bodies to enforce the ban and a family-based health programme with home visits that screen for mental health [source: HRW 2018 Indonesia update; HRW 2020 report]. WHO's 2006 Chain-Free Initiative freed about 1,700 people in Somalia between 2007 and 2010 [source: HRW 2020 report]. Ghana's Mental Health Act 2012 prohibits shackling, and Ghana moved to enforce the ban in 2017 [source: HRW 2020 report; HRW 2023 Ghana]. India's Mental Healthcare Act 2017, section 95(1)(d), prohibits a person with mental illness being "chained in any manner or form whatsoever"; in January 2019 the Supreme Court of India called chaining at a faith-based facility in Uttar Pradesh "inhuman" and contrary to Article 21 of the Constitution [source: The Leaflet, January 2019].
  • Persistence: HRW reported in 2018 that shackling had fallen in Indonesia but persisted, including in faith-based and social care institutions, and that some people freed from chains were re-shackled for lack of community support [source: HRW 2018 Indonesia update]. In October 2023 HRW found ten people held in chains in two prayer camps in Ghana's Eastern region and reported that the monitoring bodies required by the 2012 Act were largely not in place [source: HRW 2023 Ghana]. COVID-19 disruption led some families to re-shackle relatives [source: HRW 2020 report].
  • Campaign: in October 2020 HRW, with advocates with lived experience and anti-torture groups, launched the global #BreakTheChains campaign [source: HRW 2020 news release].

Phases of the psychotherapist's own work [synthesis; drawn from the HRW recommendations and WHO 2021 guidance where cited in section 4].

  1. Recognition and history-taking. Goal: notice that confinement or chaining is part of the client's or family's history, without leading questions. Format: ordinary assessment, with an interpreter where needed. Move on when the client has been able to say what happened at their own pace, or has chosen not to.
  2. Safety and safeguarding. Goal: establish whether anyone, including the client, a child or a relative abroad, is at current risk; act on mandatory duties; route physical health concerns to medical care. Move on when immediate risks are addressed or a safeguarding plan is in place.
  3. Assessment and formulation. Goal: assess trauma responses, mood, suicide risk and physical sequelae; understand the family's and community's explanatory model of the illness; identify supports. Move on when there is a shared, culturally grounded formulation.
  4. Processing and repair. Goal: trauma-focused work, restoring autonomy and decision-making, family repair where wanted. Move on as the client reports regained control and connection.
  5. Advocacy and follow-up. Goal: link to community-based and peer services, support the client's own advocacy if they wish, and plan for relapse without confinement.

Session number and length follow the client's needs and the setting; pace by the client's safety and readiness [synthesis].

3. Guiding principles

  • Chaining is never care. Practical meaning: never frame confinement as treatment or a lesser evil; the UN Special Rapporteur on torture treats it as torture [source: HRW 2023 Ghana].
  • Disability never justifies loss of liberty. Practical meaning: anchor rights talk in the CRPD line HRW quotes: "the existence of a disability shall in no case justify a deprivation of liberty" [source: HRW 2020 report].
  • Understand families without excusing the act. Practical meaning: HRW finds families are the main perpetrators, often struggling to cope with no services; hold both the harm and the context [source: HRW 2020 news release].
  • Respect faith; separate it from coercion. Practical meaning: prayer and belief are respected; chaining, forced fasting, stopping prescribed medicine and detention are not part of anyone's faith that you endorse [source: HRW 2020 report recommendations to faith-healing centres; synthesis].
  • Rights-based, voluntary care. Practical meaning: offer choices; follow WHO's call for "a much faster transition" away from coercion [source: PAHO/WHO 2021 news release].
  • Legal capacity and supported decision-making. Practical meaning: the client decides about their treatment and life; your role is support, not substitution [source: PAHO/WHO 2021 news release; HRW 2012 Ghana].
  • Trauma-informed and paced. Practical meaning: the client controls what is told, when, and how much [synthesis].
  • Medical routing for the body. Practical meaning: HRW documents malnutrition, infections, nerve damage, muscle wasting and cardiovascular problems; refer for medical review; never advise on medicines [source: HRW 2020 report; synthesis].
  • Children first. Practical meaning: any child at risk triggers your child-protection and mandatory-reporting duties [synthesis].
  • Avoid re-enacting confinement. Practical meaning: no locked rooms, blocked exits or physical holding in your practice; the client can always leave the session [synthesis].
  • Cultural humility. Practical meaning: use the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions to learn the client's model rather than correct it [synthesis; DSM-5-TR wording uncertain].
  • Nothing about us without us. Practical meaning: link to peer and lived-experience organisations as HRW and WHO recommend; never use a survivor's story publicly without consent [source: HRW 2020 report; WHO 2021 guidance; synthesis].
  • Even-handed, non-moralising language. Practical meaning: describe what happened plainly; avoid labelling whole communities or faiths [synthesis].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis].

None of these interventions involves restraining, confining or holding anyone. If a client is ever at risk of harm to self or others, follow your service's emergency and crisis procedures; never improvise physical restraint [synthesis].

4.1 Historical and human-rights literacy (the clinician's own preparation)

  • Purpose / when: before working with clients from, or with family in, places where shackling has been documented, or with any client whose history includes confinement.
  • Steps: (1) Read the HRW 2020 global report and the relevant country material (e.g. Ghana, Indonesia, Kenya, India) so you know the settings (homes, institutions, healing centres), the beliefs that sustain the practice and the current law [source: HRW 2020 report; HRW country pages]. (2) Learn the rights framework: the CRPD's equal legal capacity and freedom from torture and from disability-based deprivation of liberty, as HRW summarises it [source: HRW 2020 report]. (3) Learn that shackling is not confined to poor or rural families: HRW found it across socioeconomic classes [source: HRW 2020 report]. (4) Note that the practice also occurred in Europe's own asylum history, which helps avoid framing it as a problem of "other" cultures [synthesis].
  • Example language (illustrative): "Some families in many countries, including in Europe in the past, have chained or locked up relatives when they had no other help. I know a little about this, and I would like to hear how it was for you."
  • Watch for: exoticising or blaming a culture or faith; assuming the client sees it as abuse; checking dates and laws against current sources, because laws and enforcement change [uncertain: legal status may have changed].

4.2 Recognising a history of chaining or confinement

  • Purpose / when: at intake and during assessment with clients who mention being "kept at home", taken to a healer or prayer camp, or "tied up" during an episode; with clients whose relatives have had serious mental health conditions.
  • Steps: (1) Ask open questions about what happened during past episodes of illness and who helped. (2) If confinement is mentioned, ask gently where, by whom, for roughly how long, and whether they could leave, bathe, eat and use a toilet. (3) Note the observable signs HRW reports: people chained to trees, beds, walls or other people, kept in sheds, cages or rooms, eating, sleeping and toileting in the same small space, unable to bathe or change clothes [source: HRW 2020 report; HRW 2020 news release]. (4) Ask about fasting, herbal "treatments", ritual baths, beatings, being stopped from taking prescribed medicine, and sexual violence, as these are documented alongside shackling [source: HRW 2020 report; HRW 2012 Ghana]. (5) Record in the client's words.
  • Example language (illustrative): "When you were unwell before, what did the people around you do? Was there ever a time you were not allowed to leave a place, or were tied or locked in?"
  • Watch for: shame and minimisation ("it was for my own good"); physical signs or complaints at wrists or ankles, mobility problems or weakness, which need medical review; dissociation when describing it [synthesis].

4.3 Exploring the explanatory model (cultural formulation)

  • Purpose / when: whenever the family or client understands the illness through spirits, curses, witchcraft or sin, which HRW identifies as a main reason families go first to healers [source: HRW 2020 report; HRW 2016 Indonesia release].
  • Steps: (1) Use the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions [uncertain: DSM-5-TR wording not verified]. (2) Ask what the client and family believe caused the illness, what they hoped the healer or confinement would do, and what they think helps now. (3) Where the difficulty centres on faith, a shrine or a healer, consider the DSM-5-TR category "Religious or Spiritual Problem", code Z65.8 [source: ICD-10-CM Z65.8 (Unbound Medicine)]. (4) Build the formulation so that faith-based meaning and mental health care can sit together, while coercion is named as harm [synthesis].
  • Example language (illustrative): "What did your family believe was happening to you? What did they hope the prayer camp could do? What do you believe now?"
  • Watch for: arguing with beliefs; the client feeling their faith is under attack; differences between the client's and family's models [synthesis].

4.4 Trauma and mental health assessment

  • Purpose / when: after a history of shackling is disclosed. HRW reports post-traumatic stress among the health consequences [source: HRW 2020 report].
  • Steps: (1) Assess for post-traumatic stress, depression, anxiety, sleep problems and dissociation using validated measures your service licenses [synthesis]. (2) Assess the underlying condition that led to the confinement, and whether current care is in place. (3) Ask about triggers linked to the experience, such as confined spaces, sounds of metal, being watched, hunger or being touched at the limbs [synthesis]. (4) Assess substance use and self-harm. (5) Share the findings with the client in plain terms.
  • Example language (illustrative): "Being chained or locked away is a frightening experience. Many people have nightmares or feel panicky in small spaces afterwards. Does any of that fit for you?"
  • Watch for: symptoms of the original condition being misread as trauma or the reverse; under-reporting because of fear of being admitted or confined again [synthesis].

4.5 Suicide and self-harm risk assessment

  • Purpose / when: at assessment and whenever hopelessness, shame or a return home is discussed. Abusive institutions and coercive practices are linked to suicidal distress [synthesis].
  • Steps: (1) Ask directly and calmly about suicidal thoughts, plans and past attempts, following your service's standard risk assessment. (2) Build a safety plan with the client, including people and places that feel safe and are not associated with confinement. (3) Give crisis numbers: 988 (US); Samaritans 116 123 (UK and Ireland). (4) Discuss any lethal-means safety in terms of storage and removal only. (5) Note that a client may fear that disclosing suicidal thoughts will lead to being locked up; explain what would and would not happen in your service [synthesis].
  • Example language (illustrative): "Sometimes people who have been through this feel there is no way forward. Have you had thoughts of ending your life? If you tell me, my aim is to keep you safe with your agreement, not to lock you away."
  • Watch for: hidden ideation driven by fear of confinement; anniversaries; pressure from family to return to a healer [synthesis].

4.6 Physical health routing

  • Purpose / when: any history of shackling, prolonged confinement or forced fasting. HRW documents malnutrition, infections, nerve damage, muscle wasting, cardiovascular problems and restricted ability to stand or move [source: HRW 2020 report; HRW 2020 news release].
  • Steps: (1) Ask about current pain, numbness, weakness, walking, weight, appetite and skin problems. (2) With consent, refer to the client's GP or primary care for medical review. (3) If forced fasting has left a disordered relationship with food, refer to medical care and, where an eating difficulty is suspected, to a registered dietitian or eating-disorder service; a support option is the National Alliance for Eating Disorders. (4) If the client was stopped from taking prescribed medicine, or is unsure about it now, route to the prescriber; never advise starting, stopping or changing any medicine [synthesis].
  • Example language (illustrative): "Being kept in one position or without enough food can affect the body for a long time. Would you be willing for me to ask your doctor to check how your legs and your health are now?"
  • Watch for: reluctance to see doctors because of past forced treatment; unaddressed pain affecting mood [synthesis].

4.7 Safeguarding and mandatory reporting where you practise

  • Purpose / when: whenever a child or an adult at risk in your jurisdiction may be chained, locked up, starved or confined, including in a home or a faith setting.
  • Steps: (1) Know your local adult-safeguarding and child-protection routes and mandatory-reporting duties before you need them. (2) If a child is at risk, follow child-protection procedures immediately; children as young as 10 have been shackled in homes, institutions and healing centres [source: HRW 2020 news release; HRW 2020 report]. (3) For an adult, discuss with the client where possible and follow adult-safeguarding procedures; where there is immediate danger, contact emergency services. (4) Record facts, your concern and actions. (5) Consult your supervisor and service safeguarding lead [synthesis].
  • Example language (illustrative): "What you have told me makes me worried that your cousin's child is not safe. I have a duty to share this with the child-protection service. I would like to tell you what I will say and do it together if I can."
  • Watch for: pressure to keep it secret to protect family honour; interpreters who are part of the community; delay while seeking certainty [synthesis].

4.8 Concern about a relative held abroad

  • Purpose / when: a client tells you a relative is chained or confined in another country.
  • Steps: (1) Clarify facts and the client's wishes; your legal powers abroad are limited [synthesis]. (2) Help the client find the official routes in that country: HRW points to national bodies such as Indonesia's Ombudsman, Komnas HAM and Komnas Perempuan for monitoring, Ghana's Mental Health Authority and the Visiting Committees and Mental Health Tribunal under its 2012 Act, and in India the protections of the Mental Healthcare Act 2017 [source: HRW 2018 Indonesia update; HRW 2023 Ghana; The Leaflet 2019]. (3) Suggest local disability-rights and lived-experience organisations that HRW names, such as the Mental Health Society of Ghana and MindFreedom Ghana [source: HRW 2023 Ghana]. (4) If a child or a national of your own country is involved, take advice from your safeguarding lead and, where relevant, consular services [synthesis; uncertain]. (5) Support the client with the distress of being far away.
  • Example language (illustrative): "We can't act directly in that country, but we can look at who there has the power to visit and help, and what you would want to happen."
  • Watch for: the client putting themselves at risk; family conflict; guilt about sending money that pays for a healer [synthesis].

4.9 Psychoeducation on mental health conditions and rights

  • Purpose / when: for clients and families who see confinement as the only option.
  • Steps: (1) Explain, in the family's terms, that mental health conditions are common and can be supported in the community; HRW cites WHO's estimate of about 792 million people with a mental health condition [source: HRW 2020 report]. (2) Describe the community services WHO highlights: crisis support, mental health units in general hospitals, outreach, supported living and peer support [source: PAHO/WHO 2021 news release]. (3) Explain the person's right to decide about their own treatment and life [source: PAHO/WHO 2021 news release]. (4) Explain that chaining is prohibited by law in many countries, including India and Ghana, and was banned in Indonesia in 1977 [source: The Leaflet 2019; HRW 2023 Ghana; HRW 2016 Indonesia release].
  • Example language (illustrative): "Many families have locked someone in because they were frightened and had no help. There are other ways to keep someone safe that also let them get better and stay part of the family."
  • Watch for: lecturing; information that the family cannot act on because services are absent where they live [synthesis].

4.10 Working with family members who shackled a relative

  • Purpose / when: a parent, sibling, spouse or adult child discloses that they chained or locked up a relative, now or in the past. HRW finds families are the main perpetrators, often struggling to cope and fearing the person will run away or cause harm [source: HRW 2020 news release; HRW 2020 report].
  • Steps: (1) If the confinement is current, safeguarding comes first (4.7, 4.8). (2) Listen to the fear, exhaustion and lack of services behind the decision without endorsing it. (3) Name clearly that chaining causes serious harm and is prohibited in many countries. (4) Explore guilt and shame; help the person take responsibility without collapse. (5) Plan practical alternatives: crisis contacts, community services, respite, peer and carer support [source: PAHO/WHO 2021 news release; synthesis]. (6) If the relative is willing, offer facilitated family work focused on repair (4.15).
  • Example language (illustrative): "You were frightened and alone with this, and you did what people around you said would help. It hurt them, and it hurt you too. Let's work out what you can do now, and what help you need so it never has to happen again."
  • Watch for: justification hardening into denial; overwhelming guilt and suicidal thoughts in the family member; a risk that the relative will be confined again in the next crisis [synthesis].

4.11 Working with a client drawn to a faith-healing centre or prayer camp

  • Purpose / when: a client or family is considering sending someone to a healing centre or prayer camp. For prayer camps specifically, see Domain XI 069.
  • Steps: (1) Explore what they hope for and respect the place of prayer in their life. (2) Ask concrete questions about the place: can people leave freely, are they chained or locked in, are they made to fast, are they stopped from taking prescribed medicine, can family visit? HRW documented each of these in healing centres and prayer camps [source: HRW 2012 Ghana; HRW 2020 report; HRW 2023 Ghana]. (3) Note that HRW's recommendations to faith-healing centres are to end chaining and non-consensual fasting and to let residents leave freely; these can be the client's own tests of a safe place [source: HRW 2020 report]. (4) Support spiritual care that is voluntary and alongside, not instead of, mental health care [synthesis]. (5) Route medication questions to the prescriber.
  • Example language (illustrative): "Prayer can be a real source of strength. Before you decide, it would help to know: would your brother be free to walk out, eat normally and keep taking the medicine his doctor prescribed?"
  • Watch for: a plan to send a child or a person who cannot consent (safeguarding); medication being stopped; the client hiding the plan from you [synthesis].

4.12 Working with faith leaders and community figures

  • Purpose / when: when the client wants their faith community involved, or a faith leader is part of the support network. HRW recommends that faith-based organisations publicly oppose shackling and engage communities, and that health and faith-based staff be trained [source: HRW 2020 report].
  • Steps: (1) Obtain the client's explicit consent for any contact and agree what will be shared. (2) Approach the leader as a partner in the person's wellbeing. (3) Agree a shared position that care is voluntary and that chaining, confinement and forced fasting are excluded [synthesis]. (4) Be alert to role overlap if you share a community with the leader or client; APA Ethics Code Standard 3.05 (Multiple Relationships) applies [source: APA Ethics Code]. (5) Document agreements.
  • Example language (illustrative): "We both want her to be well and close to her faith. Could we agree that she will always be free to come and go, and that her medical care continues?"
  • Watch for: the leader taking control of decisions; confidentiality breaches in tight communities [synthesis].

4.13 Trauma-focused processing with survivors

  • Purpose / when: after stabilisation, when the client wishes to work on memories of shackling or confinement.
  • Steps: (1) Use an evidence-based trauma therapy in which you are trained, following your national guideline [synthesis]. (2) Agree stop signals and the client's right to stop at any time; avoid any exercise involving physical restriction, closed rooms or holding [synthesis]. (3) Work first on safety and grounding in the present, then on the meaning of the experience (helplessness, humiliation, being treated as less than human), then on reconnecting with valued roles. (4) Attend to body-based memories such as stiffness, pain or startle and coordinate with medical care [synthesis]. (5) Review progress with the client.
  • Example language (illustrative): "You decide how much we go into this today. If you want to stop, just say so, or stand up, and we stop."
  • Watch for: flooding, dissociation, increased self-harm; deterioration of the underlying condition, which needs prescriber review [synthesis].

4.14 Restoring autonomy and supported decision-making

  • Purpose / when: for people who were denied any say in their care. WHO's guidance includes legal capacity, a person's right to make decisions about treatment and life [source: PAHO/WHO 2021 news release]; HRW criticises laws that favour guardianship over supported decision-making [source: HRW 2012 Ghana].
  • Steps: (1) Ask the client what decisions they want to make for themselves now. (2) Help them identify trusted supporters. (3) Help them write down, in their own words, what they want to happen in a future crisis and what they never want to happen, and share it with services and family if they choose; use your jurisdiction's formal advance-statement route where one exists [synthesis]. (4) Practise saying no and asking for help.
  • Example language (illustrative): "If you became unwell again, what would you want people to do, and what must they never do?"
  • Watch for: family overriding the plan; the client deferring to you; plans that the local system will not honour [synthesis].

4.15 Family repair work

  • Purpose / when: when both the survivor and the family members who confined them want to rebuild the relationship.
  • Steps: (1) Meet separately first to assess safety, wishes and readiness. (2) Agree ground rules: the survivor can pause or leave, no one is pressured to forgive. (3) Support the survivor to say what it was like, and the family to listen and acknowledge harm. (4) Help the family explain their context without using it to excuse. (5) Agree concrete commitments for future crises (4.14) [synthesis].
  • Example language (illustrative): "This meeting is to understand each other, not to decide who was right. Anyone can ask for a break."
  • Watch for: the survivor being silenced, pressure to forgive, re-traumatisation; signs of ongoing control [synthesis].

4.16 Shame, stigma and identity

  • Purpose / when: survivors often carry internalised stigma; HRW and WHO both identify stigma as a driver of shackling and of exclusion afterwards [source: HRW 2020 report; PAHO/WHO 2021 news release].
  • Steps: (1) Explore what the client believes the confinement said about them. (2) Separate the act done to them from who they are. (3) Rebuild valued roles: work, study, worship, family. (4) Link to peer groups of people with lived experience (4.17) [synthesis].
  • Example language (illustrative): "Being chained was something done to you. It does not say what kind of person you are."
  • Watch for: withdrawal from community and faith; isolation that raises risk [synthesis].

4.17 Linking to community-based and peer services

  • Purpose / when: throughout, and in discharge planning. HRW calls for follow-up support for people freed from chains, and found some re-shackled for lack of community support [source: HRW 2020 report; HRW 2018 Indonesia update].
  • Steps: (1) Map local options in WHO's categories: crisis support, general-hospital mental health units, community mental health centres, outreach, supported living and peer support [source: WHO 2021 guidance; PAHO/WHO 2021 news release]. (2) Include housing, education and employment support, which HRW says are needed beyond medical treatment [source: HRW 2018 Indonesia update]. (3) Make warm referrals with consent. (4) Check that the client actually connects.
  • Example language (illustrative): "Let's find people near you who can help on bad days, so that no one ever feels locking you in is the only option."
  • Watch for: services that are themselves coercive; gaps in rural or diaspora communities [synthesis].

4.18 When a colleague, service or institution confines people abusively

  • Purpose / when: you learn that a colleague, a facility you work with, or a faith-based partner chains, locks up, starves or confines people.
  • Steps: (1) Do not refer to, supervise or collaborate with that service. (2) Raise the concern with your supervisor and safeguarding lead; report to the relevant regulator, inspectorate or police according to your jurisdiction's procedures [synthesis]. (3) Where people are at immediate risk, contact emergency or safeguarding services. (4) In countries with national bodies that monitor institutions, these are the routes HRW names (e.g. Indonesia's Ombudsman, Komnas HAM and Komnas Perempuan; Ghana's Mental Health Authority, Visiting Committees and Mental Health Tribunal) [source: HRW 2018 Indonesia update; HRW 2023 Ghana]. (5) Record what you saw or were told and when.
  • Example language (illustrative): "I am not able to refer clients to a place where people are chained or kept in. I am raising this with our safeguarding lead today."
  • Watch for: pressure to stay silent to protect a partnership; retaliation against residents who spoke to you [synthesis].

4.19 Medico-legal and asylum support

  • Purpose / when: a survivor seeks protection, compensation or justice. The UN Special Rapporteur on torture has said shackling amounts to torture [source: HRW 2023 Ghana].
  • Steps: (1) Refer to specialist services experienced in documenting torture and ill-treatment for legal purposes [synthesis; uncertain: specific services not verified]. (2) Provide factual clinical reports within your competence, with consent. (3) Coordinate with the client's lawyer about what is needed.
  • Example language (illustrative): "If it would help your case, I can write about how you have been affected, and I can help you find people who specialise in this kind of report."
  • Watch for: repeated retelling that re-traumatises; reports beyond your competence [synthesis].

4.20 Advocacy and testimony (with consent)

  • Purpose / when: when a survivor or family wants to speak out, or you contribute to service or policy change.
  • Steps: (1) Support the client's choices; never use their story without explicit, informed, revocable consent; never identify them. (2) Point to lived-experience organisations and campaigns such as #BreakTheChains, which HRW launched with advocates with lived experience [source: HRW 2020 news release]. (3) In your own advocacy, support HRW's and WHO's recommendations: enforced bans, unannounced independent monitoring, complaint systems, and funded community services [source: HRW 2020 report; WHO 2021 guidance].
  • Example language (illustrative): "You might want to tell your story one day, or you might not. Either is fine, and if you do, you decide where and how."
  • Watch for: exposure risks to the client or family; advocacy fatigue [synthesis].

5. Handling problems

The guidance in this section is the psychotherapist's own practice; points tied to a source are cited, and the rest is [synthesis].

  • The client defends the family or healer ("they had no choice"). Do not argue. Reflect the context HRW describes (no services, fear, beliefs about spirits) and hold the harm alongside it: "Both things can be true: they were desperate, and what happened hurt you." [source: HRW 2020 report; synthesis]
  • Stuck: the client will not speak about the confinement. Respect it. Work on present safety, sleep and daily life; return to the topic only if the client invites it. Silence may protect relatives still at home [synthesis].
  • Overwhelm or dissociation during disclosure. Stop, ground in the present room, remind the client the door is open and they may leave; shorten later work and slow the pace [synthesis].
  • Fear that you will lock them up. Explain plainly what your service can and cannot do, including any legal powers of detention in your jurisdiction, and that chaining and secret confinement are never part of care. Where involuntary admission is ever being considered, be transparent, involve advocates, and follow your local legal safeguards [synthesis].
  • Rupture: the client experiences you as one more authority deciding for them. Name it, apologise for your part, and return control (4.14). Ask how they want decisions to be made between you [synthesis].
  • Non-adherence and medication conflict. If the client or family has stopped prescribed medicine on a healer's advice, do not advise on medicines; explore the reasons and connect them with the prescriber. HRW documented camps where medical treatment was forbidden even when prescribed [source: HRW 2012 Ghana; synthesis].
  • The family plans to send the person back to a healer or prayer camp. Use the questions in 4.11; if the person cannot consent, or is a child, follow safeguarding procedures. See Domain XI 069 for prayer camps [synthesis].
  • A trip home in a crisis. Plan ahead with the client: who can be called, what services exist there, and a written statement of their wishes (4.14). HRW found that during COVID-19 some people were re-shackled when services stopped [source: HRW 2020 report; synthesis].
  • Interpreter issues. Use a professional interpreter from outside the client's immediate community where possible; brief them on confidentiality and on terms for confinement and spirits; never use a family member who may have been involved [synthesis].
  • Forced fasting and eating difficulties. Describe hunger and fasting experiences qualitatively; route to medical care and, if an eating disorder is suspected, to an eating-disorder service; the National Alliance for Eating Disorders is a support option. Give no dietary or fasting advice [synthesis].
  • Suicidal crisis. Follow standard risk assessment and safety planning; crisis numbers 988 (US) and Samaritans 116 123 (UK and Ireland) [synthesis].
  • Disclosure that a child is chained now. Act on child-protection duties the same day; do not investigate yourself [synthesis].
  • Uncertain current law. Laws, bans and enforcement have changed in several countries (Indonesia 1977 ban; Ghana 2012 Act and 2017 enforcement; India 2017 Act); check current official sources before advising a client what the law is [source: HRW 2016 Indonesia release; HRW 2023 Ghana; The Leaflet 2019; uncertain: later changes].
  • The therapist's own distress or anger. Use supervision; anger at families or faiths can leak into the work and drive the client away [synthesis].

Harm account

What was actually done

As Human Rights Watch, national courts and human rights bodies report it:

  • Who and where. Families are the main perpetrators, in their own homes; faith and traditional healers, and staff in state and private institutions (social care homes, psychiatric hospitals and general hospital wards in some countries) also chain or lock people up [source: HRW 2020 news release; HRW 2020 report]. HRW found it in 60 countries, across socioeconomic classes [source: HRW 2020 report].
  • What it looked like. People were chained by the ankle or wrist to a tree, a floor, a wall, a bed or another person, or locked in sheds, cages, cells or small rooms. In homes, people were kept in backyards, animal sheds, or a purpose-built cell on family land. In Ghana's prayer camps in 2011-12 HRW found nearly all residents of the camps it inspected chained to trees in open compounds, where they slept, urinated, defecated and bathed; in 2023 it again found people chained in prayer camps, using a shared bucket as a toilet [source: HRW 2012 Ghana; HRW 2023 Ghana; HRW 2020 report]. In Indonesia HRW found people chained to platform beds and kept in overcrowded rooms or filthy sheds, with water thrown over them instead of bathing [source: HRW 2016 Indonesia release]. At a church compound in Kenya, more than 60 people were held and kept naked or partly clothed so that they could not escape [source: HRW 2023 Kenya]. In Afghanistan in 2019 HRW found men chained in pairs at an institution [source: HRW 2020 report]. In India the Supreme Court considered photographs of patients kept in chains at a faith-based facility in Uttar Pradesh [source: The Leaflet 2019].
  • How long. From days to months or years, with no way to challenge it; release often came only when a healer declared the person healed [source: HRW 2020 report; HRW 2012 Ghana].
  • What went with it. Forced or prolonged fasting, inadequate food, forced medication or herbal concoctions, ritual baths and other "treatments", prohibition of prescribed medicine, isolation as punishment, beatings and flogging, and sexual violence, including where women were chained near men; in Indonesian institutions HRW also found forced contraception and electroshock without anaesthesia [source: HRW 2020 report; HRW 2012 Ghana; HRW 2016 Indonesia release].
  • Children. Children as young as 10 were chained at home and in institutions and healing centres; HRW reports a boy chained in Nigeria, a girl in China tied to a tree for years, and children in Mexican institutions bound with bandages or tape, and boys chained alongside adult men [source: HRW 2020 report; HRW 2020 news release].
  • How it was justified. Beliefs that the condition comes from evil spirits, curses, witchcraft or sin; fear that the person would run away or harm themselves or others; punishment; and the absence of services [source: HRW 2020 report; HRW 2016 Indonesia release; HRW 2023 Ghana].

How it caused harm

  • Physical: malnutrition, infections, nerve damage, muscle wasting, cardiovascular problems, reduced ability to stand or move, and poor hygiene; in overcrowded settings without water and soap, higher risk of infectious disease including COVID-19 [source: HRW 2020 report; HRW 2020 news release].
  • Psychological: post-traumatic stress, isolation and loss of dignity; HRW described the conditions of many people with mental disabilities in Ghana as "inhuman and degrading" [source: HRW 2012 Ghana; HRW 2020 report].
  • Lost liberty and rights: indefinite detention with no means of release or complaint; the UN Special Rapporteur on torture treats shackling as torture even by non-state actors [source: HRW 2023 Ghana]. The Supreme Court of India called it "inhuman" and a violation of Article 21 [source: The Leaflet 2019].
  • Lost treatment: prescribed treatment withheld and the underlying condition left untreated [source: HRW 2012 Ghana].
  • Danger in emergencies: shackled people cannot flee conflict or disaster, as in Yemen [source: HRW 2020 report].
  • Cycles: people freed without community support were sometimes re-shackled or moved into psychiatric institutions [source: HRW 2018 Indonesia update; HRW 2020 report].

Recognising it today

  • The practice persists despite bans: HRW reported continuing chaining in Ghanaian prayer camps in 2023, Indonesian institutions in 2018, and a Kenyan church compound in 2020 [source: HRW 2023 Ghana; HRW 2018 Indonesia update; HRW 2023 Kenya]. National human rights bodies have also documented abuses: Kenya's National Commission on Human Rights reported systemic neglect in its 2011 report Silenced Minds [source: HRW 2023 Kenya].
  • In clinical work, signs include: a history of being "kept" at home, at a healer's or in a camp during illness; scars, weakness or pain at ankles or wrists; mobility problems; fear of small rooms or of being touched at the limbs; reports of enforced fasting or of being stopped from taking medicine; family talk of spirits or curses together with fear the person will run away; relatives who cannot say where a family member is being "treated" [synthesis drawing on HRW 2020 report].
  • In services: locked rooms or areas residents cannot leave, residents tied or chained, people kept unclothed, no complaint route, no family visits, discharge only at a leader's word [source: HRW 2020 report; HRW 2023 Kenya; HRW 2012 Ghana; synthesis].
  • For prayer camps specifically, see Domain XI 069.

What to do instead and how to help those harmed

  • Supported alternatives: voluntary, community-based, person-centred and rights-based services as WHO describes them: crisis services, mental health units in general hospitals, community mental health centres, peer support, outreach and supported living, with links to housing, education and employment [source: WHO 2021 guidance; PAHO/WHO 2021 news release]. Mental health care integrated into primary care, as in Indonesia's family-based programme and community health centres [source: HRW 2018 Indonesia update; HRW 2020 report].
  • Rights-based quality improvement: WHO QualityRights aims to improve quality and human rights conditions in mental health and social care facilities and has training used in Ghana and Kenya, among other countries [source: Knowledge Action Portal entry; HRW 2020 report].
  • Survivors' support: trauma-informed therapy, medical review, peer support and help to rebuild roles (sections 4.4 to 4.17); follow-up support after release, which HRW recommends [source: HRW 2020 report].
  • Family support: psychoeducation, crisis planning, carer support and repair work (4.9, 4.10, 4.15).
  • Reporting and legal routes: local safeguarding, child-protection and police routes where you practise; in affected countries, the bodies HRW names (e.g. Indonesia's Ombudsman, Komnas HAM and Komnas Perempuan; Ghana's Mental Health Authority, Visiting Committees and Mental Health Tribunal; in India, the Mental Healthcare Act 2017 prohibition on chaining) [source: HRW 2018 Indonesia update; HRW 2023 Ghana; The Leaflet 2019].
  • Survivor and lived-experience organisations: groups HRW names such as the Mental Health Society of Ghana and MindFreedom Ghana, and the #BreakTheChains campaign launched with advocates with lived experience [source: HRW 2023 Ghana; HRW 2020 news release].
  • Crisis resources: 988 (US); Samaritans 116 123 (UK and Ireland).

Sources

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