TWO and a half centuries ago, a prison reformer observed that jails in Britain were crowded and offensive, because the rooms designed for prisoners were “occupied by lunatics”. Further, “No care is taken of them, although it is probable that by medicines, and proper regimen, some of them might be restored to their senses, and usefulness in life”.

Not much has changed. Global estimates suggest that nine out of 10 prisoners have at least one mental or substance use disorder. Some reasons for the high prevalence of mental disorders in prisons include higher risk of arrest for sufferers of mental disorder, inadequate services for mental healthcare, poor identification of mental disorders at entry into prison, and inefficient psychiatric assessments during legal proceedings.

The goal of mental healthcare in detention facilities is to ensure treatment for mental disorders, and to assist courts when a detainee’s mental capacity is in question. But at the intersection of these facilities and the community, the broader objective includes preventing sufferers of mental disorders from becoming victims or violators of law.

Pakistan has an estimated 80,000 individuals detained in its prisons — twice the existing capacity. Most of these detainees have yet to be convicted. The purpose of our jails is custody, control, care and correction. But the power dynamics underpinning ‘custody’ and ‘control’ are at odds with the need for ‘care’ and ‘correction’ critical for mental healthcare. These prisons are thus poor settings for psychiatric treatment.

Our jails are poor settings for psychiatric treatment.

At present, we have no mechanisms to identify mental disorders in these facilities; essential medicines are unavailable; health records are poorly maintained; medical staff is not trained; and there is lack of continuity of care. Consider the case of Khizar Hayat, who suffered from a psychotic illness but remained on death row for 16 years. He was assessed by more than 11 psychiatrists in jail over that period, but was never adequately treated and died of medical complications.

In the context of our prisons, the role of a psychiatrist needs to be divided: treating physicians for detainees and forensic psychiatrists tasked with producing independent court reports. The former should operate on establishing a patient-doctor relationship, whereas the latter should strive for objectivity to assist the legal process.

In Pakistan, both roles are filled by psychiatrists in provincial health services. They are not independent; are poorly trained to conduct forensic assessments; work in resource-scarce environments; are deprived of legal protection and vulnerable themselves to the system’s vagaries.

The process by which psychiatric assessments are conducted and court reports prepared is also far from desirable. Courts often fail to communicate their reasons for seeking psychiatric opinions. Hospitals constitute ‘boards’ comprising senior health professionals, some of whom might not even be qualified to assess mental states. In other cases, an amicable group of psychiatrists is asked to offer assessments with the basic understanding that they are there to help dispose the case at the earliest and to avoid dissent.

Such hurried assessments are nearly always incomplete and often inaccurate. The reports are brief, heavy on medical jargon, and almost always missing the essential testament of capacity ie fitness for trial or sentence.

Judges who have little understanding of the context of psychiatric morbidity are unable to interpret these reports, and conveniently disqualify mental impairment, thus depriving patients of their basic rights. Even if a patient is declared unfit for judicial proceedings, there is no formal mechanism to ensure treatment in the community to break the vicious cycle of reoffending.

Like other low- and middle-income countries in the region, Pakistan has consistently ignored the rights of incarcerated sufferers of mental disorders.

A social and behavioural paradigm shift is essential if our custodial services are to improve. Prisons must be screened for mental disorders at the moment of entry and at other critical intervals; ensure the provision of regular mental healthcare in detention facilities; and commit to an effective referral system with specialist services.

Psychiatrists need to be better trained, and courts must ensure equitable justice for sufferers. The provinces must implement mental health legislation that states that mentally unwell prisoners be assessed and provided with appropriate psychiatric care. The collective challenge for stakeholders is to help promote the recovery of the mentally ill in detention facilities by modifying present judicial processes and turning our prison environments into truly reformative opportunities.

The writer is a consultant psychiatrist.

Twitter: @AsmaHumayun

The National Academy for Prison Administration, with ICRC support, is organising a dialogue on ‘Mental healthcare in Detention Facilities’ on April 27.

Published in Dawn, April 26th, 2019