lack of mental health services in el salvador lack of mental health services in el salvador

El Salvador is divided politically into 14 departments and 262 municipalities, Accessibility means that health services should be affordable, situated within easy physical reach, and be offered to everyone without discrimination. Res. Many think disability is a curse resulting from evil spirits. The deadline was extended to 2019. [134] WHO, Building Back Better Sustainable Mental Health Care after Emergencies, https://apps.who.int/iris/bitstream/handle/10665/85377/9789241564571_eng.pdf?sequence=1, p. 73. [145] African [Banjul] Charter on Human and Peoples Rights (ACHPR), adopted June 27, 1981, OAU Doc. [50] Human Rights Watch interview with a volunteer in a local organization providing services to people with disabilities, Buea, Cameroon, January 2019 (name and details withheld). While much attention is focused on the humanitarian crises at the U.S. border, researchers, clinicians and activists are also working to address problems at their source in Guatemala, Honduras and El Salvador. A/61/49 (2006), entered into force May 3, 2008; Optional Protocol to the Convention on the Rights of Persons with Disabilities, adopted December 13, 2006, G.A. In state-run or private institutions, as well as traditional or religious healing centers, they are often forced to fast, take medications or herbal concoctions, and face physical and sexual violence. Human Rights Watch researchers interviewed more than 350 people with psychosocial disabilities, including those who were shackled at the time of research or had been shackled at least once in their lives, and more than 430 family members, caregivers or staff working in institutions, psychiatrists, psychologists, nurses and other mental health professionals, faith healers, lawyers, government officials, representatives of local nongovernmental organizations (NGOs), including organizations of persons with disabilities, and disability rights advocates. In a privately-run social care institution in Russia, staff regularly brought people with psychosocial disabilities to the dining hall chained to each other and forced them to eat in handcuffs. [19], Governments have long neglected to invest in mental health services. Of the 60 countries where Human Rights Watch found evidence of shackling, only a handful have laws, policies or strategies in place that explicitly ban or aim to end shackling of people with mental health conditions. In Somalia, Islamic faith healers are called sheikhs, an honorific title given to an Islamic scholar or elder. [69] In 2019, large prayer camps such as Mount Horeb detained dozens of people in chains. [70] Nigeria: People With Mental Health Conditions Chained, Abused, Human Rights Watch news release, November 11, 2019, https://www.hrw.org/news/2019/11/11/nigeria-people-mental-health-conditions-chained-abused. They have already told him that it is better not to go to get the catheter, that it is better not to go out, that there is no equipment to treat to him. [117] Human Rights Watch, Like a Death Sentence, https://www.hrw.org/report/2012/10/02/death-sentence/abuses-against-persons-mental-disabilities-ghana; Chained Like Prisoners," https://www.hrw.org/report/2015/10/25/chained-prisoners/abuses-against-people-psychosocial-disabilities-somaliland; Living in Hell, https://www.hrw.org/report/2016/03/20/living-hell/abuses-against-people-psychosocial-disabilities-indonesia; "Nigeria: People With Mental Health Conditions Chained, Abused," Human Rights Watch news release, https://www.hrw.org/news/2019/11/11/nigeria-people-mental-health-conditions-chained-abused. As psychologists, it is our professional ethical duty to get involved with this crisis, Beckley says. For the purpose of this report, shackling is used in a broader sense to refer to the practice of confining a person with a psychosocial disability using chains, locking them in a room, a shed, a cage, or an animal shelter. A World Health Organization (WHO) video describes it as a black dog that follows you everywhere, does not let you sleep or eat well. "The lack of community-based mental health solutions, the lack of civil beds, the lack of walk-in centers and crises centers all of that has resulted in the last resort: the emergency. However, legal capacity is a universal attribute inherent in all persons by virtue of their humanity and people can therefore not be stripped of it. UNICEF is working with municipal governments and other authorities to develop and implement programs that support and protect vulnerable kids in El . Areas are designated as having a shortage if they meet certain criteria: the ratio of mental health providers (e.g., psychiatrists, clinical social workers, therapists, etc. Even when people seek mental health services, the quality of care in many countries is substandard. [89] Human Rights Watch teleconference interview with Felipe Orozco, man with a psychosocial disability, August 4, 2020. She began learning about services provided by the state, including "the list" for HCS services. These beliefs are driven by several perceived barriers in Americans ability to seek mental health treatment, including: Several individuals blamed the U.S. government and insurers for not providing enough funding and support for access. In Nigeria, boys as young as 10 were chained together in rooms with adult men, leaving them at risk of abuse. [75], It is even more complex to account for chaining in small institutions and homes in which people are shackled behind closed doors. [138] Until 2018, people with mental health conditions being admitted to the psychiatric hospital were asked to pay for a padlock and chain prior to admission. People in the neighborhood say that Im mad [maluca or nlhanyi]. The ACRWC has been ratified by Benin, Burkina Faso, Cte dIvoire, Egypt, Ethiopia, Ghana, Kenya, Liberia, Mozambique , Nigeria, Senegal, Sierra Leone, South Africa, Sudan, Tanzania, Togo, Uganda, and Zimbabwe. Explain to me, how is that part of a healing process? In the eastern metropolitan area of San Salvador, an increasing number of people are dying at home. Share this via Printer, Shackling of People with Psychosocial Disabilities Worldwide. [104] Human Rights Watch visit to an NGO-run institution in Herat, Afghanistan (name and details withheld). pone.0162305 (accessed September 17, 2020), p.3; J. Edwards, Ghanas Mental Health Patients Confined to Prayer Camps. The Lancet 383: 9911 (2014), doi: 10.1016/s0140-6736(13)62717-8 (accessed September 17, 2020), pp. Rodriguez supports the Shelter City Network, which relocates human rights defenders forced to move because of threats to their safety and provides psychotherapeutic treatment to Honduran survivors of torture, sexual violence and other crimes as they seek recourse through national and international justice systems. This report estimates that 45% of those with mental health needs in the seven departments farthest away from the National Psychiatric Hospital departments are still not accessing services compared to the seven departments nearest the hospital. 14: The Right to the Highest Attainable Standard of Health, U.N. Doc. [69] Helena Selby, Prayer Camps and Mental Illness, The Chronicle, undated, http://ghanaian-chronicle.com/prayer-camps-and-mental-illness/ (accessed March 28, 2012). We partner with the government, NGOs, . The . [103] Colectivo Chuhcan A.C., Disability Rights International, EQUIS Justice for Women A.C., Information Group on Elected Reproduction (GIRE), Transversal, Action on the Rights of People with Disabilities A.C., and the Mexico Childrens Rights Network (REDIM), "Alternative Report by Mexican Civil Society Organizations Submitted to the Committee on the Rights of Persons with Disabilities: 2014-2019," 2019, https://www.driadvocacy.org/wp-content/uploads/Joint-Shadow-Report-CRPD-Jul2019-FINAL.pdf (accessed September 24, 2020), p. 19. [85] In June 2020, the Ministry of Interior proposed a draft Public Order Law, which will further entrench discrimination against people with psychosocial disabilities as well as against other at-risk groups in society and add to existing deep concerns of the continuing practice of shackling in Cambodia. [13] WHO, Mental Health, https://www.who.int/news-room/facts-in-pictures/detail/mental-health); The World Bank, Mental Health, https://www.worldbank.org/en/topic/mental-health). 18 (4) and 28; ACHR, art. On a larger scale, the nonprofit International Justice Mission (IJM) works to end impunity for slavery and other human rights violations through legal and justice reform. [33] The WHO has found that spending $1 on mental health services can yield a return of $4 in the form of improved productivity and health. This was the first time that Jos Enrique, helped by staff from Mdecins Sans Frontires (MSF), had been able to cross the . A 2019 evaluation conducted by the Institute of Mental Health, University of Nottingham found that people who completed the QualityRights e-training course showed significant improvements in attitudes and practices towards a human rights based approach to mental health, including the need to end force and coercion in mental health services and to provide information and choice as well as respect peoples decisions concerning treatment. CRPD/C/GC/1 (2014), http://daccess-ods.un.org/access.nsf/Get?Open&DS=CRPD/C/GC/1&Lang=E (accessed May 15, 2015), pp. [52] This, in part, contributes to the acute shortage of mental health professionals. In certain cases, people with disabilities and their family members are identified with pseudonyms and identifying information, such as location or date of interview, has been withheld in order to respect confidentiality and protect them from reprisals from family or staff in institutions. The United States, by comparison, spends about 8% of its health-care budget on mental health (Dieleman, J.L., et al., JAMA, Vol. [55] In some countries, Human Rights Watch also found evidence of people with intellectual disabilities being shackled. The treaty further obligates governments to provide support as may be required to exercise their legal capacity. In some cases, the children were fully wrapped in bandages, duct tape or clothing, like mummies. The largest occupational group is substance abuse, behavioral disorder, and mental health counselors, which generally require a bachelors degree and had a median annual wage of $47,660 in 2020. 1366-1379. However, even in countries that have formally banned shackling, the practice continues to exist due to prevalent stigma and inadequate support services. In one case, a person died while tied up and locked in one of the bathrooms, which was used as an isolation room. More than three-quarters (78%) report the same or higher levels of severity as this time last year. L.J. Data shines a spotlight on racial inequities in American life. [40] Human Rights Watch interview with Ridha, family member, September 2020 (full name and details withheld). res. El Salvador's public healthcare system is considered poor. In many countries, Covid-19 has disrupted mental health services, which can put people with psychosocial disabilities at risk of being shackled. I stay in a different place from the men. [48] Karolina Kozik and Jean-Sbastien Spulchre, Disability Rights Bill Offers Hope in Congo, commentary, Human Rights Watch Dispatch, March 11, 2020, https://www.hrw.org/news/2020/03/11/disability-rights-bill-offers-hope-congo; Sophie Morgan, The country where disabled people are beaten and chained, BBC News Online, July 28, 2015, https://www.bbc.com/news/blogs-ouch-33523742 (accessed September 21, 2020); Shantha Rau Barriga (Human Rights Watch), Torture Comes in Many Forms, commentary,The Huffington Post, June 29, 2015, https://www.huffpost.com/entry/torture-comes-in-many-for_b_7691390?guccounter=1 (accessed September 16, 2020). [98] Human Rights Watch interview with Aisha [not her real name], family member, Gaza, February 15, 2020. In one case, a man with a psychosocial disability spent 37 years chained in a dark, sweltering cave in the mountains in Wadi Al-Sabab, Saudi Arabia. The lack of constitutional guarantees or specific protection mechanisms for LGBTI people in El Salvador has fostered systematic and institutionalized violence and discrimination against them. [51] Human Rights Watch interview with Ying (not her real name), November 2019 (location and details withheld). TRADEMARKS. 171, entered into force March 23, 1976; International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Nevertheless, Mexico needs at least 12,000 psychiatrists. Mental health shortages range in severity across the country. [84] Human Rights Watch visit to Adwumu Woho Herbal and Spiritual Centre, Senya Beraku, Ghana, November 6, 2019. Their analysis of data from the National Hospital Ambulatory Medical Care Survey (2005-2015) showed that rates of prolonged LOS increased from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS. For example, in 2017 India passed a landmark mental health care bill that explicitly prohibited people with mental health conditions from being chained in any manner or form whatsoever.[129] While the provision has proven challenging to implement, it enabled a lawyer to challenge in court cases of people shackled in homes and faith-based institutions in the state of Uttar Pradesh, India. [15] WHO, Gender and Women's Mental Health, https://www.who.int/mental_health/prevention/genderwomen/en/; WHO, Mental disorders, https://www.who.int/news-room/fact-sheets/detail/mental-disorders; WHO, Mental health in the workplace, https://www.who.int/mental_health/in_the_workplace/en/; WHO, Mental Health, https://www.who.int/news-room/facts-in-pictures/detail/mental-health. Specifically, younger Americans need more information on how and where to access care. 5, 21 I.L.M. On average, countries spend less than 2 percent of their health budgets on mental health. 25; ACHPR, art. In Morocco, the government released over 700 people chained in one shrine alone, about 50 kilometers from Marrakesh in the countrys southwest. [66], In India, in January 2019, the media reported that thousands of people with mental health conditions were chained like cattle, their feet tied with iron chains and padlocked for days, months and years, in the state of Uttar Pradesh. [164], The CRPD introduces strong safeguards against arbitrary detention and deprivation of liberty for people with disabilities, stating that the existence of a disability shall in no case justify a deprivation of liberty.[165], In her 2019 report, the UN special rapporteur on the rights of persons with disabilities stated that: The deprivation of liberty on the basis of impairment is a human rights violation on a massive scale. Carlos, a man with a psychosocial disability who had been chained and treated against his will in faith healing institutions in Mozambique, said: Human Rights Watch documented physical and sexual violence against people with psychosocial disabilities who were shackled in homes and institutions. When the fighting happened, we left him next to the house tied up. Its time for governments to step up so that families arent left to cope on their own. Furthermore, younger Americans (i.e., Gen Z and Millennials) are less sure about resources for mental health services, compared to older generations. In one center in northern Nigeria, Human Rights Watch found a dozen people who showed researchers scars on their arms, chests, and backs that they said were from floggings by staff. [92] It cannot be discriminatory and should never be justified on the basis of the existence of a disability.[93]. Depression is the most common mental illness in the world. MSF is working . Conduct public information campaigns to raise awareness about mental health conditions and the rights of people with disabilities, especially among alternative mental health service providers and the broader community, in partnership with people with lived experiences of mental health conditions, faith leaders, and media. In addition, the local and national governments dont have coordinated detection and hospitalization mechanisms for COVID-19 cases. These include the International Covenant on Civil and Political Rights (ICCPR), International Covenant on Economic, Social and Cultural Rights (ICESCR), Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) Convention on the Rights of the Child (CRC), and Convention on the Rights of Persons with Disabilities (CRPD) and its Optional Protocol. [41], While data disaggregated by disability is hard to come by, available evidence shows that people with psychosocial disabilities often grow up in the confines of their home or an institution, excluded from community life, rarely attending school, getting married and having children, seeking employment, or participating in society. CVN focuses on improving mental health outcomes, with a goal to build a network of outpatient mental health clinics for veterans and their families in high-need communities, in which trained clinicians deliver holistic evidence-based care to treat mental health conditions. The cost of mental health. The term psychosocial disability is preferred as it expresses the interaction between psychological differences and social or cultural limits for behavior, as well as the stigma that society attaches to people with mental health conditions. Traditional or religious healers: Traditional healers administer therapies based on theories, beliefs, and experiences indigenous to different cultures including ritual and herbal methods of treatment. CAB/LEG/67/3 rev. Families who struggle to cope with the demands of caring for a relative with a psychosocial disability may feel they have no choice but to shackle them. 2; CRC, art. Finally, we must ensure standards of care are consistent through continued adoption of evidence-based practices. However, in prayer camps and institutions, many interviewees spoke of persistent, gnawing hunger from forced fasting or inadequate food. His loving parents found him nonresponsive, with a heart rate near 200 beats per minute. [49], A volunteer from an organization providing services to people with disabilities in Cameroon said: People in Cameroon have negative perceptions about disability. A number of factors fuel the shortage, including a greater awareness of mental health problems that has spurred people to seek treatment. Even people who are released from chains or confined spaces often go back to being shackled as there is little access to support or mental health services, and stigma and bias persists. The Convention on the Rights of the Child states that under the convention, a child means every human being below the age of 18 years unless under the law applicable to the child, majority is attained earlier.[1], Disabled Persons Organizations (DPOs): Organizations in which persons with disabilities constitute the majority of members and the governing body and that work to promote self-representation, participation, equality, and integration of persons with disabilities.[2]. "We're waiting for the equivalent of a heart attack- the suicides . In the 2018-2019 academic year, 4,104 people completed behavioral health training programs funded by the HRSA. 38-39; Jasmine Bauomy, In South Sudan, Stigma and Underfunding Plague Mental Health Care, Al Jazeera, January 18, 2019, https://www.aljazeera.com/indepth/features/south-sudan-stigma-underfunding-plague-mental-health-care-190117180739562.html (accessed August 3, 2020). Exacerbated by such close and unsanitary living conditions, lice and scabies are a major problem in many institutions.[97]. In El Salvador, Beckley has trained police officers, prosecutors, judges, community leaders, social workers and psychologists in trauma-informed care for people who are seeking justice through the courts. [8] Women, given the high incidence of sexual violence they suffer, are also disproportionately affected by Post-Traumatic Stress Disorder (PTSD).[9]. El Salvador is a republic with three branches of government: the Executive, the Legislature, and the Judiciary. Mental health professionals' skills comprise a potentially robust . The government identifies shortage areas so it can address them with proper resources. She expressed her appreciation to WHO for having focused its attention on this priority public health issue, since depression can be prevented. Anna-Catherine Brigida reports from San Salvador about a group of ambulance workers on how they cope with the In Kenya, which launched in November 2019, almost 3,260 people have enrolled and around 732 have completed the training. Once survivors attain a significant level of recovery from their initial trauma, measured using a tool IJM developed called the Assessment of Survivor Outcomes, Beckley guides some of them into leadership roles in the international global survivor network to share their experiences and advocate for other survivors. Our research indicates that most people want to work to support their families and send their children to school, says M. Brinton Lykes, PhD, a professor of community-cultural psychology and co-director of the Center for Human Rights and International Justice at Boston College. My aunt has tried her best to support them but she struggles with stigma and the lack of robust mental health services in Oman. Wendy, a doctor working for MSF's ambulance service, said that some patients die while waiting to be transferred to a hospital. It requires governments to recognize that people with disabilities are persons before the law who enjoy legal capacity on an equal basis with others in all aspects of life. 90% of our funding comes from individual donors. If we miss hygiene, they give us a punishment. And when natural disasters such as hurricanes strike, aid is not available to help residents recover. The ACRWC has been ratified by Benin, Burkina Faso, C. American Convention on Human Rights (ACHR), adopted at the Inter-American Specialized Conference on Human Rights, San Jos, Costa Rica, 22 November 1966. Human Rights Watch research across 60 countries found people with real or perceived psychosocial disabilities are arbitrarily detained against their will in homes, state-run or private institutions, and traditional or religious healing centers. The Minister of Health, Dr. Violeta Menjvar, said that in El Salvador anxiety, depression, alcoholism and suicide are the mental disorders with the highest prevalence. Moreover, it also appears that the availability of programs and services may be associated with higher reporting rates (Filmer, 2008). The offices of the first two are filled through popular elections; the president serves for five years and members of the legislature serve for three years. On the upcoming April 4 ballot, you can vote to increase funding for mental health initiatives and resources within Kankakee County. Stark Disparities in Accessibility at State and Income Levels. [145], The Latin American countries discussed here are party to the American Convention on Human Rights and the Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights (Protocol of San Salvador). A/44/49 (1989), entered into force September 2, 1990; United Nations Convention on the Rights of Persons with Disabilities (CRPD), adopted December 13, 2006, G.A. According to the latest available global estimates, 792 million people or 10.7 percent of the global population has a mental health condition. Mental healthcare is especially difficult due to lingering social stigmas and scarcity of services. MSF is also hearing worrying reports about the situation in some communities in San Salvador and Soyapango. [138] Human Rights Watch phone interview with Joshua Duncan, program manager, Mental Health Coalition of Sierra Leone, September 25, 2020. Even when mental health services are free or subsidized, the distance and transport costs are a significant barrier. In the United States, an immigrant might earn $300 per week cleaning houses, the equivalent of about a months salary in Guatemala, says Cbar Cataln. Encourage governments to collect quantitative and qualitative data on the current number of people shackled, the reasons families continue to practice shackling, and examine the support or services they would need to discontinue the practice. People are shackled in locations that are out of sight and out of the way for families: in backyards, outhouses, sheds, or animal shelters. In Latin America, 5% of the adult population suffers from it, but most neither seek - nor receive - treatment, according to the WHO. [56] Any criticism of faith-based institutions is not linked to their religious roots or spiritual nature. And we promote greater understanding of mental wellbeing as a core component of comprehensive health and health care. Families or staff in institutions often make the person who is shackled stay naked, dress in very scant clothing, or wear an adult diaper, so it is easier for them to keep the person clean and they do not have to regularly wash soiled clothing. The report also draws on Human Rights Watchs extensive research on stigma, mental health, and discrimination that people with psychosocial disabilities face around the world, including in Australia, Brazil, Cameroon, Croatia, India, Iran, Kazakhstan, [23] ngela Carbonell, Jos Javier Navarro Prez, Maria Vicenta Mestre, Challenges and Barriers in Mental Healthcare Systems and Their Impact on the Family: A Systematic Integrative Review, Health and Social Care in the Community vol.28:5, September 2020, https://doi.org/10.1111/hsc.12968 (accessed September 25, 2020), pp. One of their most surprising findings was that deported children did not experience greater psychological harm than a control group of Salvadoran children who remained in the country (El Salvador, in Childhood and Migration in Central and North America: Causes, Policies, Practices and Challenges, 2015). The large majority of Americans (76%) also believe mental health is just as important as physical health. A person who is shackled can be affected by post-traumatic stress, malnutrition, infections, nerve damage, muscular atrophy, and cardio-vascular problems.[106]. In Mexico, for example, Disability Rights International documented children with psychosocial disabilities in cages or tied down with bandages. If a person does manage to get to a health facility, they are often turned away. Many of MSFs ambulance calls in recent months have been related to respiratory diseases. Provide counseling and other forms of support to people with psychosocial disabilities and their families. [74] Why Pakistans Poor Seek Mental Health Cure at Shrine, BBC News Online, September 29, 2016, https://www.bbc.com/news/world-asia-37495538 (accessed March 23, 2020). In El Salvador, for instance, an underfunded and corrupt police force, unable to maintain public safety, has helped spur the formation of gangs as de facto authorities across most of the country (Life Under Gang Rule in El Salvador, International Crisis Group, 2018). 31, no. [53] Human Rights Watch, Treated Worse Than Animals, https://www.hrw.org/sites/default/files/report_pdf/india1214.pdf, p. 38. Track how COVID-19 is spreading in the US, plus key indicators for pandemic recovery. The objective was to combat stigma by raising awareness on mental health and put an end to chaining in homes as well as in hospitals. The HRSA manages the Behavioral Health Workforce Education and Training program, which provides training funding for colleges, universities and training schools preparing people for behavioral health jobs with an emphasis helping people from underrepresented minority or disadvantaged backgrounds. Help us! [173], According to the UN Committee on Economic, Social and Cultural Rights, the international expert body charged with monitoring compliance with the ICESCR, access to health facilities, goods and services should be non-discriminatory, especially for the most vulnerable or marginalized sections of the population, including individuals with disabilities. In Indonesia, 57,000 people with mental health conditions have been in pasung (shackles) at least once in their lives. We are seeing an increase in the number of people dying in their homes before our ambulance services arrive, said Luis Romero Pineda, MSF project coordinator in El Salvador. As a result, they urinate, defecate, eat, and sleep in a radius of no more than one to two meters. [140] Partners in Health, Celebrating New Possibilities at Sierra Leones Only Psychiatric Hospital, June 5, 2020, https://www.pih.org/article/celebrating-new-possibilities-sierra-leones-only-psychiatric-hospital (accessed September 17, 2020). [27] For example, there are 0.19 psychiatrists per 100,000 people in Kenya and 0.12 The bill, in its current draft, provides the authorities with unfettered powers to arbitrarily strip people with mental health conditions of their civil liberties. [29] WHO, Mental Health, https://www.who.int/news-room/facts-in-pictures/detail/mental-health. CAB/LEG/24.9/49 (1990), entered into force November 29, 1999, art 14. In some instances, people or their families had fashioned bamboo beds and grass-thatched shelters under a tree to get protection from the sun, but many slept on cold, hard concrete floors with no mattress or bedding. There are currently over half a million people working in mental health roles like psychiatry, psychology, counseling, and therapy. [109] When his community went into lockdown and Sodikin lost access to community-based mental health services, his family was unable to support him and locked him in a room. There are only 4,600 psychiatrists, 60% of them are in Mexico City, the state of Mexico, Jalisco, and Nuevo Len. Combined, medical and behavioral health costs $37.6 to $67.8 billion (yes, with a B) a year in lost productivity. 2200A (XX1), 21 U.N. GAOR Supp. (No. So stressful, in fact, that the migration route with all its perils barely registers above the daily pressures children and their families face here.. A doctor working at a psychiatric hospital in southern Nigeria said: We have to use chains in some cases.[59] In eastern Indonesia, Human Rights Watch witnessed a woman being tied around the waist with a twisted cloth and restrained to her