Life of people with mental illness behind bars

15 years ago, Chit (alias) used a homemade rifle to shoot his sleeping stepfather in the head. Chit’s stepfather had looked after him since he was 2 years old and loved him like his own son. There were no disagreements between them. Chit shot his stepfather because he wanted to help him. He saw flashing lights near his stepfather’s head and he wanted to chase them away. At that time, he really believed that he should have done what he did. After Chat (alias) took Chit to turn himself in, he was held in prison for almost 2 years while the case made no progress, and no relatives wanted to bail him out.

In Chit’s case it is clear that he is ill. Article 65 of the Criminal Code allows offenders to receive no punishment or lesser punishment than is prescribed by the law. Nevertheless, we cannot allow anyone to use illness as an excuse without examination. Galya Rajanagarindra Institute is a psychiatric hospital whose main role is treating forensic psychiatric patients, which means people with mental illness involved in legal procedures or social justice, and so has the duty of proving whether the alleged offender is really ill or pretending to be sick (malingering) by relying on an interdisciplinary team consisting of psychiatrists, nurses, psychologists, occupational therapists and social workers.

The 5 professions operate step by step, through continuous cooperation, information exchange and consultation, for example, by collecting information on psychiatric patients from many sources, closely observing their condition, and using psychological tests to evaluate if they are pretending to be ill or not.

When Chat, the closest bother to Chit, started to understand that his little brother’s actions stemmed from illness and were not intentional, he studied the law and took legal action to pull his brother out of prison for treatment. It would take many more years before the court allowed Chit to receive treatment in hospital and be under his care, until his condition improved so that he could return to fight his case in the justice system.

One important duty of the interdisciplinary team that looks after psychiatric patients is to provide treatment and therapy so that the patients are able to go back into the justice system, because if their condition does not improve, the accused or defendant does not have the ability to fight their case. They will be stuck like that. Or if they have no relatives to bail them out, they will become prisoners on remand in jail until the time allowed to bring charges runs out. Therefore, getting psychiatric patients back into the justice system as quickly as possible is also a way to protect their rights.

Chit received continuous treatment until in 2016 the court eventually gave its verdict. Chit was guilty, but with reason for mitigation – his sentence was suspended for 3 years. Meanwhile he has to report to the court every 3 months. Chit’s case is resolved, but going back home has more details than that.

“Don’t play near their house. If he comes back he’ll shoot you. He’ll kill you.” Chat hears these words from people in the community so often he has become used to it. It wasn’t unexpected and he understands the community’s fear, wariness and dissatisfaction towards Chit who killed his own stepfather by shooting him while he was sleeping. Being a “crazy person” isn’t a mark that can be easily erased.

It is also the interdisciplinary team’s duty to rehabilitate patients so that they can return to their communities. The team has to make preparations right in the community, including the community leaders, local public health officials, the patients’ families, the patients themselves, as well as the victims of violence and the victim’s families. This means, for example, creating knowledge and understanding of the patients’ psychological condition, not provoking the patients, observing the symptoms, and treating and curing the victims’ fears. In some cases it is found that someone in the patients’ families are also mentally ill. In these cases the team has to coordinate with the local authorities to provide treatment to the newly discovered patients too, to prevent these conditions from having an effect. In other words, it is an exploration and preparation of various resources in the psychiatric patients’ locality so that they can return to the community.

A study of the prevalence of mental health issues and psychiatric illness among prisoners by the Galya Rajanagarindra Institute collected statistically random data from 600 detainees, 520 males and 80 females, from 10 prisons and penitentiaries across the country with various security levels. The data was collected from April to August 2017. Results revealed a total of 274 detainees (45.67%) had mental health issues and psychiatric illnesses, 246 males (47.31%) and 28 females (35%). The three most prevalent illnesses are alcohol and drug addiction (29.83%), risk of suicide and depression (both 15.83%).

Note that the Galya Rajanagarindra Institute survey is considered to be the latest, and is a “statistical” survey, something that we should be aware of at all times. The latest figures given to us by Thepsuda Fumueangpan, an expert clinical psychologist of the Department of Corrections, come from officials treating and collecting statistics on psychiatric patients and medicinal prescriptions from 1 to 30 April 2018. Results show that there are 3,947 detainees who are mentally ill. The data was collected from 130 of the 142 prisons under the Department of Corrections. These figures are not categorized by diagnosis. 

Thepsuda talked about the Galya Rajanagarindra Institute’s high figure of 45.67% of detainees in the country that are suffering from mental health issues and psychiatric illnesses.

“This number is weighted heavily to the problem of drug addiction, with other psychiatric issues in descending order. I think this number is possible, because detainees use fairly large amounts of drugs and addictive substances. In some prisons we may find groups of remand prisoners who are in for less than one year, still having issues concerning drugs and addictive substances, but when we look at prisoners with long sentences who have been inside for a long time, the illnesses we find are different.”

According to the Department of Corrections, all remand detainees must go through a mental health screening process using an evaluation set by the Department. The test includes a mental health evaluation for Thai detainees, depression and suicide assessment evaluation/screening and a mental illness screening, but they are not able to screen out patients 100% since there are many factors that allow loopholes. For example, mental symptoms that are hard to discover, the lack of proficiency of the personnel that do the screening, and the overcrowding in prisons, which is a chronic problem for Thai prisons, only make screening and treatment more difficult.

In addition, psychiatric symptoms are another factor why referrals to doctors are delayed. For example, if there are 4 detainees waiting to be taken to hospital, and the first has cancer that requires radiation therapy, the second needs kidney haemodialysis, the third needs surgery and the fourth is a psychiatric patient that has to be examined and prescribed medicine, when they are ranked by level of urgency, the psychiatric patient will be placed last. In some large prisons, sometimes 10 detainees have to be taken to hospital each day and have to stay overnight, such as for surgery that requires patients to be hospitalized for at least 7 days. This means other sick detainees have to have their appointments pushed back because there are not enough officers to escort prisoners to hospital since there must be 2 officers to look after 1 detainee outside prison. This is a consequence of prison overcrowding and the insufficient number of officers.

Presently, the Department of Corrections has a total of 1 psychiatrist posted at the Correctional Hospital. There are 29 psychologists: 7 stationed at the Department of Corrections, 3 stationed at the Correctional Hospital and the other 19 spread out in different areas. In total there are 30 public health psychiatric personnel, in comparison to about 300,000 prisoners. This means 1 person has to look after 10,000 prisoners.
With the overcrowding of prisons and limited resources, the system in place to look after psychiatric patients cannot move forward efficiently.
According to the testimony of Jib (alias), a former detainee in one of the female prisons in Bangkok, when she was in prison, the zone she was kept in was where they kept patients whose conditions were not too severe, the elderly that cannot take care of themselves, crazy people (her word) and those whose sentences are lighter than 5 years. Psychiatric patients that are suffering from depression or others that do not make trouble are allowed to stay with other prisoners, distributed across different sleeping cells at about 3 people per cell. Psychiatric patients that make trouble, harm others or make loud noises have a separate sleeping cell. In Jib’s sleeping block there are about 27 such psychiatric patients isolated together in another cell, where about 10-12 people can sleep.

Regarding the steps for psychiatric patients to access medicine, Jib said that you first need to inform the “cell mother” (mae hong) or the head of the sleeping cell. The cell mother will then write up a request. Officers stationed in that zone read the requests and call for you to speak with them. If they see that you should be sent to hospital, you will be sent. After that you’ll have to wait for a psychiatrist to examine you. Jib says they sometimes come, sometimes they don’t. If you are able to see a psychiatrist and are diagnosed as sick, you’ll be able to access medicine. However you need to wait about 3 more days for the medicine, then you’ll have to take the medicine for forever, or if you think you’re getting better and want to stop taking the medicine, you have to write up a request again according to the same procedure.

“It’s not good. For me, having them here is fun,” Jib expressed her opinions on the treatment of psychiatric patients in prison. “But is it fair for them? It’s not fair. And in jail there are many fights. Those that aren’t crazy are always fighting for power anyways, but the crazy ones don’t have that same patience. There are also those that like to tease, bully, and provoke. For these people, when they do something wrong they have to take stronger medicine, but it didn’t happen because of them. It happened because others provoked them. But the prison decides to increase their dose, and makes the provokers clean up. I think that increasing their medicine affects their whole body. There is also only one type of medicine, sedatives. It makes you drowsy. No matter what illness they have, they take the same medicine. Once they take it, they’ll feel sleepy and go to sleep so that they won’t cause any more trouble.

“Those that were crazy on the outside should receive proper treatment. I don’t know what process they should use to get them into psychiatric hospitals, get treatment first, then receive their sentence. But it’s not very fair. After all they’re crazy, how would they get better if they receive treatment like this?”

These were Jib’s opinions towards psychiatric patients that commit crimes and end up in prison. This is a large gap in the system. Article 36 of the Mental Health Act B.E. 2551 (2008) states ‘Under Article 14 Paragraph 2 of the Criminal Procedure Code, treatment centres shall accept the accused or defendant for control and treatment without the need for the consent of the accused or the defendant until the accused or defendant is cured or recovered enough to defend their case, except where the investigating officer or court has issued an order or the law prescribes otherwise.’ 

The law uses the word ‘until the accused or defendant is cured or recovered enough to defend their case’. This has 2 problems. The first is that detainees do not receive treatment in treatment centres all the time, but switch between prison and treatment centre. While they are in prison, is the treatment effective enough to cure the prisoner and reduce the symptoms enough to quickly return to court to fight the case? The second issue is if the detainee’s illness cannot be cured in any way (not to mention improvement), then how will they return to the judicial process?

The law only specifies ‘cure’ and ‘recovery’ sufficient to fight the case in court, but does not say what to do if they cannot return to court.  
“There was one person called Grandma Prapha. The court said that she was crazy but they didn’t take her for treatment at a psychiatric hospital. They left her in prison and forgot about her, with no verdict and no date of release set, since she is still no better. But she shouldn’t be in prison. If the court says she has to be treated, the prison must send her to hospital, not put her in prison,” Jib said.

Thepsuda said that in the Detainees Fight Cases project, it is found that there are patients held in prison up to 10, 20 years but still unable to fight the charges against them, even though if they had been able to defend themselves, they would have already been released. The statistics of the Department of Corrections found that detainees that have been sentenced to a maximum of 20 years on average will in fact stay in prison for about 10 years due to reductions of sentence, parole or pardons. To receive these privileges, they must be convicted prisoners with fixed sentences. However, psychiatric patients that have not recovered and are unable to fight their cases in court have no way to receive these privileges.

The Department of Corrections is aware of this situation and is trying to find a solution by, for example, creating the Tele Medicine system or receiving medical advice through long-distance communication, pairing prisons and local hospitals, or moving detainees to prisons near psychiatric hospitals, etc.

The study by the Galya Rajanagarindra Institute suggests that the efficiency of screening and the skills of nurses, officers and volunteers to evaluate preliminary mental health illness should be increased, volunteers should be trained to help observe and monitor symptoms, and an accurate and up-to-date database shared between the Department of Corrections and Department of Mental Health should be created for the continuous care of patients before, during and after imprisonment.

Psychiatrist Kamonchanok Montasevee of the Galya Rajanagarindra Institute said that personally, she sees that the problem of psychiatry in prisons is something people rarely think about. Imprisonment is a punishment. But at the same time, patients have the basic human right to receive treatment which increases safety for the patients and society.

“But society’s attitude is that prison is a place where evil people gather, and that’s it. Everybody is happy, but then they forget that it’s a twilight land.  In fact it is a correctional facility. It changes those that have wronged to become good again, and cures their behaviour; it is a long-term solution to create no more risk, but these kinds of thoughts do not occur to Thai people.”

Prison overcrowding of puts pressure on every part of life behind bars; food and eating, bathing, sleeping. In some prisons that are very crowded, you can only sleep on your side or insert yourself into free spaces between others with your feet together head-to-toe. If you wake up to go to the toilet, your sleeping place will disappear. In crowded cells there are one or two toilets without doors. During unlucky days or nights, if the water is not flowing or not enough, in a stuffy or freezing room, 14 hours a day, without even a book to read, with violence inside which officers aren’t able to fully control, and many other things, whether you were sick or not before, life behind bars is always ready to push you into madness or become even madder than before.

And then the budget and staffing are out of line with the number of detainees. Each prison doesn’t have many choices to improve the work system and internal environment. So looking after detainees that are mentally ill mainly becomes passive care.

Kritaya Archavanitkul, coordinator of the project aiming to develop a health security system for detainees in Thai prisons says “Overcrowding is a basic problem of all prisons in Thailand. It is the most basic of problems.”

About 80% of detainees are inside because of the Narcotics Act. Therefore, amending the law, creating alternatives to imprisonment, decriminalizing some drug offences, separating drug users and sellers, etc. are the first doors that will help solve Thai prison problems.
However, the largest key keeping these doors locked is Thai society’s attitude towards drugs.