Forensic psychiatry

The current objectives in Pakistan are to gain insight about the mind of the terrorist, to conduct a review of impacts on the health of the population especially as a result of terrorist attacks and to discern the role that can be played by forensic psychiatry in emergencies caused by terrorist activities. These concerns are developed at the population level and at the individual level from the point of view of a description of the terrorist and of the victim’s need for forensic intervention and representation. Dealing with terrorism is a potentially hazardous but relevant extension of the evolving role of forensic psychiatrists. Psychiatrists may be asked to act as intermediaries between terrorists and the state or as forensic experts in courts. However, to avoid being perceived as policemen, jailers or collaborators, forensic psychiatrists should seek the formal approval of the medical profession so that there is no question about their professional identity. There is much that psychiatrists can do to help victims of terrorism, including assessment, rehabilitation and providing medico-legal evidence.
Forensic psychiatry is a field that is yet to be recognised in many countries. In Pakistan, it is well-known that there is overwhelming concern for the great stigma in which individuals with mental disorders and their families live. The evidence of this is, among other things, the considerably limited access to employment for such patients. Consequently, there is much criticism regarding the denial of human rights to psychiatric patients.
There are basically two great obstacles to the acquisition of knowledge and the raising of awareness regarding forensic psychiatry in Pakistan. The first obstacle is linked with the immense heterogeneity of the country, which is due to various factors, i.e. cultural, political, juridical, religious, etc. Such heterogeneity sometimes makes it difficult to describe the term clearly. There are few other fields in psychiatry in which the cultural nature and social norms of a society have more of an impact than the field of forensic psychiatry. The second obstacle is the lack of knowledge of culturally different situations.
Pakistan has specific mental health legislation. The Mental Health Act of 2001, addressing mental health issues in Pakistan, clearly leans toward the institutionalisation of the patients rather than toward a greater involvement in their treatment. However, the revision of the mental health law promoted measures to protect forensic patients although not in a satisfactory way. In Pakistan, the mental health law is good in theory but deficient in practice. The Pakistan Mental Health Act 2001 was constructed over the course of decades and is a legitimate attempt to update humanitarian policies in psychiatry. Nevertheless, the document is still more of an ideological plan rather than a reality, due to a deficient mental health infrastructure. This, however, does not prevent forensic psychiatry from having its place. The accused person’s capacity to stand trial and the insanity defence are taken into consideration. Since there is no crime if there is no criminal intent, mens rea is well-accepted and is necessary for a person to be considered guilty.
Mental health in Pakistan has remained the subject of debate during the last few years. The incidence and prevalence of mental illness have increased tremendously in the background of growing insecurity, terrorism, economic problems, political uncertainty, unemployment and the disruption of the social fabric. Pakistan has a very low number of psychiatrists and they too are continuously being poached by developed countries, especially the western world, where they are offered attractive salary packages and lifestyles. So, the question remains: who comes back and serves the nation? In order to bring about an improvement in psychiatric education, it is important to put emphasis on the subject of the subspecialties of psychiatry and design an appropriate postgraduate training programme, in line with international modules. There is a need for the development of a research culture, especially in the areas of need assessment. Along with these efforts, the medical community can force the government to allocate a higher budget, reduce poverty, bring about social justice and harmony, and improve the political scenario.
It may be added that through the help of Professor Mohammad Aslam, the Vice Chancellor (VC) of the University of Health Sciences Lahore, the first forensic psychiatry training programme has been conceived by a team of UK-based Pakistani forensic psychiatrists and office bearers of The College of Physicians and Surgeons, Pakistan. This programme will entail a number of activities to develop forensic psychiatry and train forensic psychiatrists in Pakistan. These activities include arranging international forensic psychiatry conferences, arranging educational sponsorships and establishing links among professionals in this field. The first meeting was held in Birmingham where a special meeting was organised at the International Psychiatric Conference of the Royal College of Psychiatrists. This meeting provided an opportunity to discuss future training facilities for Pakistani mental health professionals with active support from reputed academics in the field of forensic psychiatry and mental health.
The healthcare system in Pakistan is both underdeveloped and poorly resourced. Therefore, it is not surprising that psychiatric training is in its very early stages at both the undergraduate and postgraduate levels. In order to look after the mentally ill, radical changes in the patients should be a part of the training of doctors. Medical curricula for psychiatrists need to place more of an emphasis on forensic psychiatry. This would not only help doctors understand the need for forensic psychiatry but would also help train psychiatrists, who are more than just clinicians and can be agents of change in society through health education. It is also advisable to create better incentives for mental health professionals in order to avert the brain drain from this field. Efforts to provide a favourable environment to the public to promote sound mental as well as physical health are imperative.

The writer is a professor of Psychiatry and consultant Forensic Psychiatrist in the UK. He can be contacted at fawad_shifa@yahoo.com