The sub-speciality that deals with the interface of law and psychiatry is known as forensic psychiatry. Forensic psychiatric services in Pakistan are almost non-existent, and the role played by judicial and medical fraternity in managing legal and forensic issues of the population of patients with mental illnesses is minimal. However, there are enough reasons to suggest that such a service is required.
Prisons came into existence for mainly four reasons: deterrence, retribution, incapacitation and rehabilitation. Before one can emphasise on the issue of the feasibility of forensic units, there is one question that needs to be answered. Whether people with mental disorders can be violent compared to the general population. There is increasing psychiatric morbidity amongst prisoners, and the risk of suicide also increases in prisons. There are also confounding factors within the prison environment that can exacerbate mental disorders, and there is accumulating evidence that the effects of psychosis on risk of violence are much greater for women than for men. Men are more likely to have been under the influence of alcohol or using street drugs and less likely to have been adhering to prescribed psychotropic medication prior to committing violence.
Until the Mental Health Ordinance of 2001, all legal and forensic issues were dealt with the mental health legislation of 1912, the Lunacy Act of 1912. This was inherited from the British rulers in the subcontinent at the time; however, the Ordinance of 2001 could not sustain following the 18th constitutional amendment in 2010, whereby psychiatric healthcare was devolved to provinces from federal authority. Implementation of forensic psychiatric services in Pakistan at various levels within the healthcare system remains a huge challenge, and the current framework of training in forensic psychiatry for postgraduates as well as the assessments and management schedules for the mentally ill offenders at tertiary care institutions in Pakistan has difficulties and transferrable barriers.
Psychiatrists in Pakistan are now being frequently to serve as expert witnesses in an increasing number of legal contexts for civil and criminal proceedings. The skills required to practise forensic psychiatry expand upon the knowledge, skills, and abilities developed by clinical psychiatrists. Forensic psychiatrists acquire expertise in understanding the roles and various functions of the legal system, as well as their role in addressing psycho-legal questions to assist fact-finders in making legal decisions. The required skills and the unique circumstances for clinical psychiatrists pursing forensic work are being introduced for the first time in Pakistan through the collaborative efforts of the University of Health Sciences and UK-based Pakistani Forensic Psychiatrists.
The involvement of mentally disordered offenders in the criminal justice system is currently a major public health concern. This has culminated in evolving Mental Health Ordinance 2001 over the years, with a particular focus on addressing the practice and teaching of forensic psychiatry in Pakistan. University of Health Sciences, Lahore, has taken a bold initiative to launch a masters of arts programme in forensic mental health, which would be introduced in the first Pakistan Forensic Psychiatric Conference on April 8-9 in Lahore.
Mental health legislation represents an important means of protecting the rights of persons with mental disabilities by preventing human rights violations and discrimination, and by legally reinforcing the objectives of a mental health policy. The last decade has seen significant changes in the laws relating to psychiatric practice all over the world, especially with the implementation of the Convention for the Rights of People with Disabilities (CRPD). The upcoming conference would review the existing legislation in Pakistan concerning the following areas in mental health: treatment and legal protection of persons with mental disabilities, criminal laws in relation to offenders with mental disorders, and laws regulating incapacity. Speakers will discuss these texts in comparison with international recommendations and standards on the rights of persons with disabilities, showing the recurrent contradiction between them. Throughout the two days, it will address the clinical dilemmas that Pakistani psychiatrists encounter in practice in the absence of a clear legislation that can orient their decisions and protect their patients from abuse.
“Healing the Held” aims to examine the criminal and the mental health legislations available to offenders raising fitness to stand trial issues, as well as those pleading insanity at the time of the offence known as the insanity defence. Legislations are required within a framework of reducing the overrepresentation of mentally disordered offender in the criminal justice system. In doing so, comparisons are made to similar legislations in other commonwealth jurisdictions, when necessary. Regarding fitness to stand trial, it is evident that the Pakistani legislation does not contain discrete fitness indicators. Yet it is interesting that the terminologies ‘unsound mind’ and ‘incapable of making a defence’ used in the proviso convey similar meaning and requirements to those used in other jurisdictions. The insanity defence standard, on the other hand, is also heavily influenced by the McNaughton Rules in England. The defence consists of two separate cognitive tests, each of which can result in an acquittal.
One of the tests strictly emphasises knowledge of the nature and consequences of the act while knowledge of the wrongness of the criminal act is implied in the other. However, none of the tests takes into consideration the uncontrollable impulse arising from mental disorder. Workshops in the conference are planned to propose some revisions and amendments to the Punjab Mental Health Act legislation in its current formulation and recommendations for critical areas that warrant research attention in relation to mentally disordered offenders in Pakistan.
Sparse medical care is provided to mentally disordered offenders within the prison but they do not cater to the specific needs of psychiatry. The legal system offers no real relief and such patients get lost owing to ineffective laws and inefficient law makers. There is a pathological delay in the time frame till a case is resolved. This gap in the criminal justice system can be associated with the increased incidence and further increase of mental disorders within our prisons. Pakistan is also one of the few countries in the world that has three parallel legal systems — criminal courts, tribal courts and anti-terrorism courts — which further complicates the picture. Integrated mental health and criminal justice service systems can be developed by incorporating forensic mental health services, which can prove effective and strategically important in preventing unnecessary incarceration by using legal leverage to promote treatment adherence.
The writer is a professor of psychiatry and consultant forensic psychiatrist in the UK. He can be contacted at [email protected]