When the caregiver locks up the patient: How the mental hospital becomes a prison

Annamalai (name changed) is almost 70 years old. He has been an inmate in the ward designated for prisoners in the Institute of Mental Health for about three decades. Diagnosed with schizophrenia way back in the 1970s when he was in his 20s, Annamalai who originally hails from Thanjavur, was lodged at the facility in 1990, as a remand prisoner after committing a murder.

He was sent here as he needed specialised care under the watchful eyes of the specialists at the facility. Cleared of all the charges, Annamalai awaits family support. No one has come to see him. With none to push the wheels of the bureaucracy, cases like Annamalai’s get stuck in some dog-eared file at a court.

For Annamalai and many other inmates, the IMH will likely be the last stop. The mental health facility is worse than a prison for them. There is no release even if they are legally eligible and few care.

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The double stigma that haunts patients

Annamalai has no recollection of his past or his crime. He insists that recently, a nephew had visited him at the facility. Annamalai is not alone as there are other inmates who carry the double stigma — one of mental illness that is beyond the comprehension of many including their families and of a crime that they committed.

Among the 22 of them in the ward is 24-year-old Manikkam (name changed) from Nagapattinam who is suffering from bipolar disorder. When he was taken to the Ervadi dargah for offering prayers to get his condition cured, he killed the attender of another patient who was visiting the religious place of worship. Manikkam speaks coherently and he says his folks would soon take him home. A staff explains that the family has moved for his bail.

While both Manikkam and Annamalai have been united at the ward due to their mental condition and the crime they committed due to the condition, the support they have received from their families have been different.

K Mohan, a social worker, who has been working with the prisoner inmates, following up on the legal status of their cases, says that most often families are unwilling to take them home. “They run into trouble with landlords who do not want their houses being occupied by a person suffering from a mental condition and that too someone who has committed a murder. That explains why someone like Annamalai is not wanted by his own relatives,” he says. He adds that when the victim is a relative, the chances of a reunion are remote.

Legal hassles

Mohan says when a person’s condition is certified as unlikely to improve, the court has to be approached for the withdrawal of the case and there are several others like the inspector at the local police station, where the case was filed, and the district collector’s office that are also expected to work in coordination to release them. He adds, “There is a considerable delay due to this. We have now seven such cases that are pending for court hearing.”

KR Raja, who has worked as psychiatric counsellor in Palayamkottai prison for a few years, and runs an NGO Global Network for Equality that addresses the needs of prisoners’ children, says that human approach is missing from the system. “It is not possible to have it in prisons as authorities are keen on making them function like traditional prisons. When the prisoners get back to society after treatment and therapy from hospitals, there is a lot more need for an interlinked system that includes their family, legal system, prison authorities and mental health specialists. It is team work that will help them integrate,” he adds.

Prisons no antidote to mental ailments

As remand prisoners who spend their initial days after the crime in the prison, they face the worst as they are clueless and disoriented, says Raja. He explains that in prisons like the one in Palayamkottai and Puzhal, the medicines for mentally ill kept in separate blocks are either referred to as dabba mathirai (tablet in bottles) or robot mathirai (robot tablet) handed over to them by psychiatrists who visit them. The tablets are administering them without any understanding of the condition of the patients.

Raja says that even wardens do not try to reach out to those lodged in isolation. “They have older prisoners supervising them in shifts and they in turn report to these wardens. From what I have observed, there is poor hygiene among them and there is a need for a regular staff to engage with them regularly,” he adds.

Laws are great on paper

The Mental Healthcare Act, 2017 specifies that ‘A person with mental illness shall be entitled to receive free legal services to exercise any of his rights given under this Act. (2) It shall be the duty of magistrate, police officer, person in charge of such custodial institution as may be prescribed or medical officer or mental health professional in charge of a mental health establishment to inform the person with mental illness that he is entitled to free legal services under the Legal Services Authorities Act, 1987 or other relevant laws or under any order of the court if so ordered and provide the contact details of the availability of services. He adds that going by evidence, the person is put under trial and is convicted and if he has to move the higher court, he finds little support, with the family backing off.

Raja also says that the only government hospital for all the prisoners who need treatment and therapy as in-patients is the Institute of Mental Health. He adds, “According to a Right to Information query I filed, the hospital had treated as many as 396 patients in the period between 2011 and 2016. That is burdening the government facility whenever any prisoner from any of the nine prisons in the state are sent.”

‘Prisons equipped to handle mental ailments’

In the larger picture of depression, substance addiction and anxiety being reported among prisoners, R Natraj, MLA, and former Director General of Police, who brought about major reforms in prisons says that meeting the mental health needs of prisoners is challenging but an effective system is in place to meet them. He also points out that studies show that that there is a link between committing a crime and mental imbalance.

“However, we have designated psychiatrists in all the prisons. Prisons are not just incarceration centres and there are efforts taken to ensure that they are able to integrate society. Health rights are as important as their spiritual and social rights. Care is taken to spot people who need mental help and segregate them.”

More government infrastructure for meeting needs

Strengthening district psychiatry wards can go a long way in reducing the burden on one set up like the IMH, say experts. Dr P Poorna Chandrika, director, IMH, adds, “Now, we have prisoners from across coming to the IMH, for inpatient support. They can be in the safe custody in their own districts.”

Dr TV Asokan, a senior psychiatrist, says that a pre-trial investigation by a psychiatrist can ensure that there is no delay. “We are often asked by the legal experts if we think the person was capable of committing the crime in the given mindset, two years ago. In fact, Norway has a pre-trial investigation for people who exhibit symptoms of mental illness. These can be picked by the prison authorities and referred for psychiatric assessment. It would reduce the delay in the trial period for them. Studies have shown that there is more than 70 per cent concordance between pre-trial and final report,” he points out.