International Journal of Law and Psychiatry 41 (2015) 95–104

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International Journal of Law and Psychiatry

Forensic psychiatry in Pakistan Tariq Hassan a,⁎, Asad Tamizuddin Nizami b, Sarah Hirji c a b c

Department of Psychiatry, Division of Forensic Psychiatry, Queen's University, Kingston, Ontario, Canada Institute of Psychiatry, WHO Collaborating Centre for Mental Health, Rawalpindi Medical College, Rawalpindi, Pakistan Queen's University, Kingston, Ontario, Canada

a r t i c l e

i n f o

Available online 27 May 2015 Keywords: Forensic psychiatry Pakistan Criminal responsibility Criminal offender Mental health ordinance 2001 Compulsory psychiatric admission

a b s t r a c t This article reviews existing forensic psychiatric services in Pakistan highlighting the role played by the judicial and the medical fraternity in managing the legal and forensic issues of the population of patients with mental illnesses. Until 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 Sub-Continent at the time. The Mental Health Ordinance of 2001 could not sustain following the 18th constitutional amendment in 2010, whereby psychiatric healthcare was devolved to the provinces from the previous federal authority. The article also highlights the difficulties and the barriers in implementation of the forensic psychiatric services in Pakistan at various levels within the healthcare system. This article also delves into 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. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction The definitions of forensic psychiatry vary, however the Accreditation Council of the Graduate Medical Education (2013) in the United States provides a comprehensive definition: Forensic psychiatry is the psychiatry subspecialty that focuses on interrelationships between psychiatry and the law (civil, criminal, and administrative law), that include: 1 the psychiatric evaluation of individuals involved with the legal system, or consultations on behalf of the third parties such as employers or insurance companies; 2 the specialized psychiatric treatment required by those who have been incarcerated in jails, prisons, or special forensic psychiatric hospitals; 3 active involvement in the area of legal regulation of general psychiatric practice; and 4. related education and research efforts. From this definition the sub-specialization of forensic psychiatry seems to be based on the institutions and administrative pathways that are different to general psychiatry, rather than any difference in the clientele. The role of the forensic psychiatrist also differs ethically.

⁎ Corresponding author at: Providence Care, 752 King Street West, Kingston, Ontario K7L 4X3, Canada. Tel.: +1 613 548 5567x1136; fax: +1 613 540 6113. E-mail address: [email protected] (T. Hassan).

http://dx.doi.org/10.1016/j.ijlp.2015.05.001 0160-2527/© 2015 Elsevier Ltd. All rights reserved.

In the US the forensic psychiatrist has the duty to tell the truth and assume either an ‘assessor’ role or a ‘treating’ role. In Canada, their roles largely include both the ‘assessor’ as well as ‘treating’ roles but there is a trend of moving to a US model. 2. Evolution of judicial system in Pakistan Pakistan is located in South Asia with a geographical area of approximately 800,000 km2 and a population of 180,808,000. The population is projected to reach 210.13 million by 2020 and to double by 2045. It is the sixth most populous nation in the world. Pakistan is a federation of four provinces (Sindh, Punjab, Baluchistan and Khyber-Pakhtunkhwa), a capital territory (Islamabad) and a group of federally administered tribal areas in the north-west along with the disputed area of Azad Jammu and Kashmir (World Health Organization, 2009). Pakistan's average population density is 229 individuals per km2. This averages from 1000 per km2 in the major cities of Karachi and Lahore to 1 per km2 in the remote northern and western mountainous areas. The judicial framework in Pakistan has evolved over approximately one millennium. It has passed through three prominent eras the Hindu rule, the Muslim rule, the British colonial rule. The fourth and current era began in 1947 with the partition of British India and the establishment of Pakistan as an independent state (Hussain, 2011). The Hindu era spanned from 1500 BC until approximately 1500 AD. The King discharged judicial functions and was the final judicial authority and court of ultimate appeal. Ministers and counselors assisted him in this task. Besides the King's Court, there existed the Court of the

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Chief Justice. Judges were appointed based on qualifications and scholarship; however they were predominately restricted to the Upper Caste, i.e., Brahmins. At the village level, justice was dispensed by tribunals of the village elders (Law Commission of India, 1958). Decisions were appealed in higher courts, with the final appeal in the King's Court (Hussain, 2011). The Muslim period in the Indian sub-continent began roughly in the 11th century A.D. This period can be divided into two eras. The first by early Muslim rulers who ruled Delhi and other parts of India, and second the Mughal Dynasty, which began in 1526 AD until the middle of the 19th century. During the period of the Muslim rulers, the religion of Islam was the cornerstone in settling civil and criminal disputes. Common traditions and customs continued to operate in parallel in settling secular matters. The Office of the King's Court continued in this period and exercised original and appellate jurisdiction. The Mughals created an organized system to administer justice throughout the country. Each administrative unit in the country had a court. The village level of the Hindu system of Panchayats (Council of Elders) continued to settle petty disputes of civil and criminal nature using conciliation and mediation. At the town level courts were presided by the Qazi-e-Parganah and similarly, Courts of Qazis were established at the district (Sarkar) and provincial (Subah) levels. The highest court at the provincial level was of the Adalat Nazim-e-Subah. The highest court of the land was the Emperor's Court exercising original and appellate jurisdiction (Hussain, 2011). During the British rule, the East India Company was authorized by the Charter of 1623 to decide the cases of its English employees. The Company, therefore, established its own courts. The President and Council of the Company decided all cases of civil or criminal nature. Subsequent charters further expanded these powers and thus the Charter of 1661 authorized the Governor and Council to decide not only the cases of the Company employees, but also of persons residing in the settlement. In deciding such cases, the Governor and the Council applied the English laws. As the character of the Company changed from one of a trading concern into a territorial power, newer and additional courts were established for deciding cases and settling disputes of its employees and subjects (Hussain, 2011). Following Pakistan's independence in 1947, the Government of India Act of 1935 was retained as a provisional Constitution. In 1956, through constitutional amendments, the Chief court of North West Frontier Province (NWFP), later renamed Khyber-Pakhtunkhwa, and the Judicial Commissioner Court of Baluchistan were declared full-fledged High Courts. The Federal Shariat Court was created in 1980 to ascertain whether or not a certain provision of law is ‘repugnant to the injunctions of Islam’. The Federal Shariat Court has the power to examine and determine whether or not a certain provision of law ‘is repugnant to the injunctions of Islam’. If it is determined to be repugnant to the injunctions of Islam, then the government is required to take necessary steps to amend the law and bring it into conformity with the injunctions of Islam (Hussain, 2011). In Pakistan, the judiciary is divided into ‘superior’ and ‘subordinate’ judiciaries. The superior judiciary consists of the Supreme Court of Pakistan, five High Courts (one for each of the four provinces and one for the Islamabad Capital Territory) and the Federal Shariat Court. The Supreme Court is at the apex of the judicial systems in Pakistan. It possesses exclusive original jurisdiction in settling intergovernmental (federal/provincial) disputes and also acts as the final arbiter of appeals from all other courts in Pakistan. The subordinate judiciary comprises the civil courts and criminal courts. The present judicial system has therefore evolved and acquired some elements of past dynasties, though not entirely transplanted from the British rule, as is commonly alleged (Hussain, 2011). The current judicial system in Pakistan is an amalgamate of the remnants of British law and fundamental Islamic principles. Irrespective of government involvement to Islamize legislation, Islamic law is very much part and parcel of the judicial fabric of Pakistan.

3. Legislation and mental disorder in Pakistan All offenses in Pakistan are enshrined in the Pakistan Penal Code (PPC; 1860). The Code drew its origins in 1860 by Lord Macaulay on behalf of the Government of British India as the Indian Penal Code. Subsequent to partition in 1947 Pakistan inherited the same Code. However over the years, amendments by successive governments led the PPC to be an amalgamation of British and Islamic Law. The Act V of the Code of Criminal Procedure (CCP) refers to the rules that govern criminal procedure in every court in Pakistan (Code of Criminal Procedure, 1898). The purpose of the Code of Criminal Procedure is to provide a mechanism for the punishment of offenders, against the substantive criminal law embodied in Pakistan Penal Code (1860). 3.1. Capacity to defend One of the fundamental gatekeeping roles of the criminal justice system is assessing the accused's Competency to Stand Trial (US), or Fitness to Stand Trial (Canada and UK) (Nussbaum, Hancock, Turner, Arrowood, & Melodick, 2008). In Pakistani law this is defined as the ‘capacity to defend’. Section 464. Procedure in case of accused being a lunatic: (1) When a Magistrate holding an inquiry or trial has reason to believe that the accused is of unsound mind and consequently incapable of making his defense, the Magistrate shall inquire into the fact of such unsoundness, and shall cause such person to be examined by the Civil Surgeon of the district or such other medical officer as the Provincial Government directs, and thereupon shall examine such surgeon or other officer as a witness, and shall reduce the examination to writing. (1-A) Pending such examination and inquiry, the Magistrate may deal with the accused in accordance with the provisions of Section 466. (2) If such Magistrate is of the opinion that the accused is of unsound mind and consequently incapable of making his defense, he shall record a finding to that effect and, shall postpone further proceedings in the case.

Section 464 (Code of Criminal Procedure, 1898, p. 163) describes how a person who is incapable of making a defense as a result of a mental disorder should be assessed. If a mentally ill offender is found to be ‘capable of making his defense’ he will be taken to the Magistrate or Court. The evidence of fitness is provided either by the Inspector General of Prisons (in case of a person detained in prison) or two visitors (if the person is detained in an asylum). A friend or relative of a mentally ill accused offender may apply to the provincial government for this person to be under their care. The mentally ill accused must be detained under Section 466 or 471 of the CCP and the friend or relative must confirm to the provincial government that the mentally ill accused will be taken care of and abide by conditions put forward by the provincial government and/or the Court (Code of Criminal Procedure, 1898, s.475, p. 166). At first glance this may seem advantageous in permitting the accused a familiar environment during the process of assessment. Unfortunately there are no checks and balances that assures the State that the patient is being well cared for. Unlike most Western and European countries, the test for incapacity to defend in Pakistan is not laid out in the Code of Criminal Procedure (1898). For example in Canada, Section 2 of the Criminal Code of Canada (1985, p. 14) gives clear instruction on the test for finding a person ‘unfit to stand trial’, which states: ‘unfit to stand trial’ means unable on account of mental disorder to conduct a defense at any stage of the proceedings before a verdict is rendered or instruct counsel to do so, and, in particular, unable on account of mental disorder to

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a. understand the nature or object of the proceedings, b. understand the possible consequences of the proceedings, or c. communicate with Counsel.

Justice in Islam demands that the defendant has the same access to the judge as that a plaintiff would. If this cannot be achieved for the mentally ill individual then a trial cannot be conducted (Chaleby, 1996). There are several differences and similarities between the legislation in Pakistan, the UK and Canada, a few of which are highlighted in Table 1. A major obstacle in the implementation of assessing ‘capacity to defend’ is a lack of resources in the rural settings where most cases are found. The legal and psychiatric community requires a process of ongoing education on the utilization of these legal provisions. Unfortunately the lack of inpatient facilities for assessing the mentally ill offender translates into such patients being wrongly shunted into the criminal justice system. 3.2. Criminal responsibility The PPC (1860) also clarifies to an extent on how the law applies responsibility to the mentally ill offender. This law has its roots in the historic ‘McNaughton Rules’ of the UK from which many western and European countries have developed their ‘criminal responsibility’ statue. Article 84 (p. 17) of the Pakistan Penal Code (1860) refers to the ‘act of a person of unsound mind’, which states: “Nothing is an offence which is done by a person who, at the time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act, or that he is doing what is either wrong or contrary to law.” On the issue of criminal responsibility while intoxicated, Article 85 of the Pakistan Penal Code (1860) separates intoxication of an individual unknowing to the individual or against his will from other instances of intoxication. It refers to an ‘Act of a person incapable of judgment by reason of intoxication caused against his will’, which states: ‘Nothing is an offence which is done by a person who, at the time of doing it, is, by reason of intoxication, incapable of knowing the nature of the act, or that he is doing what is either wrong, or contrary to law; provided that the thing which intoxicated him was administered to him without his knowledge or against his will.’ The level of responsibility for a mentally ill offender to their crime is either full responsibility or no responsibility. A guilty verdict usually

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tends to confine the mentally ill offender to jail, with scarce resources for in-treatment or rehabilitation. A sentenced mentally ill offender may be transferred to a medical facility for treatment for part of or the remainder of their sentence under Part VI (removal of prisoners), Section 30 of the Prisoners Act (1990). The provincial government will direct this: If a mentally ill offender is acquitted on ‘grounds of lunacy’ then ‘the finding shall state specifically whether he committed the act or not’ (CCP, 1898, s.470, p. 165). If it is mentioned that the accused committed the alleged act, then the Magistrate or Court can ‘order such a person to be detained in safe Custody in such place and manner as the Magistrate or Court thinks fit,’ unless the patient is not detained under the Lunacy Act 1912 (CCP, 1898, s.471, p. 165). In Canada, for example, subsequent to a mentally ill offender found ‘not criminally responsible on account of mental disorder’ (NCR-MD) the patients' judicial jurisdiction is transferred to the respective provincial ‘Review Board’. It then becomes the responsibility of the review board to determine whether to detain or discharge the patient from their warrant. In Pakistan there is no comparable statutory body that oversees the ongoing assessment of risk as well as the balance of freedoms and restrictions of such individuals. Patients are transferred to inpatient facilities for the duration of the assessment and may be kept in these facilities if ‘not criminally responsible’. However, the courts recognize the individual role of the expert witness. The expert opinion is provided to the court with the psychiatrist present. Relatively minor offenses can be tackled through this mechanism. However more complex offenses involve a mentally ill or intellectually impaired individual burning or desecrating the Koran (Islam's Holy Book). This invariably leads to reactions in the community and press reports have documented such accused individuals seized from police custody and killed. This is one reason why in these cases the expert opinion given from a consensus of professionals is favored over that of an individual who will be more likely targeted with violence and even death. At present there are no specific criteria in the Pakistan Pakistan Penal Code (1860) reflecting these Islamic laws. Future challenges to the current law will allow for clarification and possibly amending current statute in relation to the mentally ill offender (Abbasi & Khan, 2009). 3.3. The role of the police The Pakistan Police Order 2002 replaced the Police Act of 1861 and accords an augmented set of roles and responsibilities for Pakistani police. As part of their remit to manage the mentally ill in public, the Police

Table 1 Similarities and differences between the Mental Health Ordinance 2001, the Mental Health Act UK (1983) and the Canadian (Ontario) Mental Health Act (1990). Category

Mental Health Act UK, 1983 United Kingdom

Mental Health Ordinance, 2001 Pakistan

Mental Health Act, 1990 Ontario, Canada

Admission for involuntary assessment

Section 2 Up to 28 days Application made by approved mental health practitioner (AMHP) with 2 psychiatrists

Section 10 Up to 28 days Requires 2 medical practitioners, at least 1 approved psychiatrist

Admission for treatment

Section 3 Up to 6 months Application made by approved mental health practitioner (AMHP) with 2 psychiatrists

Section 11 Up to 6 months Application done by 2 medical officers, at least 1 approved psychiatrist

Admission for psychiatric assessment in urgent situations

Section 5(2) Doctors Holding Power, up to 72 h Application made by responsible clinician (RC) or deputy

Section 12 Assessment in case of urgency, up to 72 h Requires approved psychiatrist or nominated deputy

Form 3 Up to 14 days Requires 1 M.D. Cannot treat only detain in Hospital, need to make patient incapable of consenting to treatment which comes under the health care consent act (Form 33), must have a substitute decision maker. Form 4, treatment clause similar to form 3 Up to 1 month Certificate of renewal, requires 1 M.D., following form 3 Subsequent forms available for 2 months and 4 months Form 1 Application for assessment for up to 72 h Application made by physician

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Order 2002, Chapter II (responsibilities and duties of the police, s.4q, p. 5) directs the police to ‘take charge of lunatics at large to prevent them from causing harm to themselves or other members of the public and their property’. However as part of their training there is no mention in the Police Order 2002 on police needing basic mental health training on triage of mental health symptoms of offenders with mental health problems as well as how to manage this vulnerable group with respect and dignity. 3.4. Public perception A systematic review of risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan found that the overall mean prevalence of these disorders in the community was 34% (range is 29%–66% for women and 10%–33% for men) (Mirza & Jenkins, 2004). Islam plays a major role in determining the value system of Pakistani society, and the good treatment of individuals who are mentally ill is deemed greatly desirable under the society's strong religious and ethical values. There are a number of non-government organizations that provide mental health support and treatment in Pakistan (Pakistan NGOs Directory & Guide, n.d.). However, society can still be biased against individuals who are mentally ill (Naeem et al., 2005; Qidwai & Azam, 2002). According to Pakistan and Islamic laws it is an offense to either defile Islam's holiest book — The Qur'an, or to mock or defame the Prophet Muhammad (peace be upon him). These are described as the ‘blasphemy laws’. The Pakistan Pakistan Penal Code (1860) makes reference to both offenses. Article 295-B forbids ‘defiling’ the Quran and additionally and article 295-C forbids using ‘derogatory remarks’ against the Prophet Muhammad (peace be upon him) (Pakistan Pakistan Penal Code, 1860). These offenses usually tend to receive the most international coverage when the accused is suspected of having a mental illness (Ali, 2012). In some cases a fringe section of the public demand their own form of justice against the accused which, unfortunately, can have fatal consequences (Jillani, 2012). There can be immense public pressure on psychiatrists when assessing criminal responsibility for blasphemy offenses. A ‘medical board’ is then constituted comprising of at least 3 to 5 members, belonging to the administrative and clinical cadres. This committee includes mental health professionals to assess criminal responsibility. By establishing a committee as such it allows a unanimous opinion of criminal responsibility to be finalized. This could be argued to improve diagnostic clarity and credibility of an opinion given to the court. 4. Mental Health Ordinance, 2001 4.1. Implementation of the Mental Health Ordinance, 2001 In Pakistan, until 2001 the major source of laws relating to mentally ill individuals was the Lunacy Act of 1912. This was enacted by the colonial government at the time for the whole of British India. The use of terms e.g., “lunacy” is a classic example of a term being shunned by the psychiatric profession for being inhumane and imprecise. Lunatic was defined as “an idiot or person of unsound mind” (s.4) Following independence, jurisdiction for the mentally ill continued to be based on the Lunacy Act of 1912 (Ahmed, n.d.). As the country matured, other laws changed but the Lunacy Act of 1912 persisted. The Institute of Psychiatry, WHO Collaborating Centre at Rawalpindi, took the initiative and in collaboration with the international and national mental health fraternity, formulated the Mental Health Ordinance, 2001, which was promulgated in February 2001 (Government of Pakistan, 2001). As a consequence, the Lunacy Act of 1912 was repealed. Most of the laws in the Mental Health Ordinance 2001 have been adopted from the laws in the Mental Health Act of the UK (Gilani, Gilani, Kasi, & Khan, 2005). The Mental Health Ordinance, 2001 (s.2n, p. 3) defines a ‘mentally disordered prisoner,’ in context with other Acts and Ordinances as:

‘a person, who is a prisoner for whose detention in or removal to a psychiatric facility or other place of safety, an order has been made in accordance the provisions of section 466 or section 471 of the Code of Criminal Procedure, 1898 (Act V of 1898), section 30 of the Prisoners Act, 1900 (III of 1900), section 130 of the Pakistan Army Act, 1952 (XXXIX of 1952) section 143 of the Pakistan Air Force Act, 1953 (VI of 1953), or section 123 of the Pakistan Navy Ordinance, 1961 (XXXV of 1961)’. Chapter X, section 55 (p. 34) of the Mental Health Ordinance 2001 deals with forensic psychiatric services, it states:Forensic psychiatric services— (1) Special security forensic psychiatric facilities shall be developed by the Government to house mentally disordered prisoners, mentally disordered offenders, as may be prescribed. (2) Admission, transfer or removal of patients concerned with criminal proceedings in such facilities shall be under the administrative control of the Inspector General of Prisons. (3) The Board of Visitors shall have an access to such persons admitted in forensic psychiatric facility in accordance with the provisions of this Ordinance.

4.2. Federal Mental Health Authority (FeMHA) The Federal Minister for Health is the chairperson of the Authority and has the following fourteen members: (i) Health Secretary, Federal Ministry of Health, Government of Pakistan (ii) Director General Health, Federal Ministry of Health, Government of Pakistan (iii) Health Secretaries, Provincial Ministries of Health, Government of Pakistan (iv) Advisor in Psychiatry, Medical Directorate, General Headquarters (GHQ); and (V) Seven eminent psychiatrists of at least ten years in good standing. The Federal Mental Health Authority (FeMHA), in consultation with the Government concerned, establishes the Boards of Visitors comprising of the following (Gilani et al., 2005): (a) A Chairperson who is a sitting or retired High Court Judge; (b) Two psychiatrists, one having a minimum experience of ten years in Government service; (c) One prominent citizen of good standing; (d) Two medical practitioners of repute with a minimum standing of twelve years, one of whom shall be a nominee of Pakistan Medical and Dental Council; and (e) Director General Health Services of the Province, or his nominee. The Chairperson and members of the Board are appointed for tenure of two years. The Board of visitors may, at any time, enter and inspect any psychiatric facility within its limit and require the production of any records and documents for inspection to ensure transparency and accountability. They have the power to view patient records and review progress made since the last visit by the Board (Mental Health Ordinance, 2001, p. 5) as well as make recommendations to psychiatric facilities. Additionally, the Federal Mental Health Authority can order the Board to visit any patient in case it appears necessary, for the purpose of investigating any particular matter or matters related to the capacity of the patient to manage his property and affairs. To comply with this order the Board may visit the facility or nominate a sub-committee of

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not less than two members. Through a visit in this regard, the Board or the sub-committee may interview and examine a patient in private and may require the production and inspection of any documents and/or medical records relating to the patient. Whenever the sub-committee visits a facility, it reports to the Board and the Board makes its final report to the Authority. In the case of the Board or a sub-committee visiting a mentally disordered prisoner, the Inspector General of Prisons, or his nominee, will be a member of the Board or sub-committee (Mental Health Ordinance, 2001, p. 7). Where the Board assesses that any patient in a psychiatric facility is not receiving proper care or treatment, it may report the matter to the Federal Mental Health Authority. FeMHA may issue directions to the medical practitioner, or psychiatrist in charge of the psychiatric facility. These individuals are then bound to comply with FeMHA's direction (Mental Health Ordinance, 2001, p. 7).

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Table 2 Number of medical professionals graduated last year in Pakistan (per 100,000). Medical profession

Number of graduates (per 100,000)

Medical doctor (not specialized in psychiatry) Psychiatrist Nurse (not specialized in psychiatry) Nurse (with at least 1 year of training in mental health care) Psychologist (with at least 1 year of training in mental health care) Social worker (with at least 1 year of training in mental health care) Occupational therapist (with at least 1 year of training in mental health care)

2.1 0.002 1.5 0.008 0.07 0.005 0.002

WHO (2009).

4.3. Current trends in forensic psychiatry provisions Following independence, Pakistan inherited three asylum hospitals for the mentally ill in Hyderabad (Sindh), Lahore (Punjab), and Peshawar (KPK) with a total of 2000 beds. These were very poorly managed with a skeleton staff of medical officers to provide treatment and support. This continued for another two decades until the government established the first psychiatric units in Karachi and Lahore. The first psychiatric unit at the Jinnah Postgraduate Centre in Karachi came into being in 1965 and the second at the Government Mayo Hospital in Lahore in 1967. This gradually led to psychiatric units being established in most teaching hospitals around the country (Gadit, 2007). There are 3729 mental health outpatient facilities, which treat 343 users per 100,000 general population. The average number of contacts per user is nine, with 46% of outpatient facilities providing follow-up care in the community, while 1% has mental health mobile teams. There are 624 community-based psychiatric inpatient units available for a total of two beds per 100,000 population; 1% of these beds in community based inpatient units are reserved for children and adolescents. Females account for 75% of admissions to community based psychiatric inpatient units diagnosed predominately by mood (46%) and neurotic (32%) disorders. There are five mental health hospitals in the country for a total of two beds per 100,000 population. Involuntary admission accounts for 1% of admission to community based inpatient units and 30% to mental health hospitals (World Health Organization, 2009). Some mental health hospitals have ‘beds’ for forensic psychiatric patients (World Health Organization, 2009). Unfortunately these ‘beds’ are usually prison rooms shared by multiple patients. In the forensic inpatient units 76% of patients spend less than one year; 24% of patients spend 1–4 years, and 0% spend 5 years or more. Given the large population of Pakistan, the number of graduating medical professionals last year is quite low, and even lower for those with at least one year of training in mental health care (Table 2) and at present there are only approximately 300 psychiatrists, 125 psychiatric nurses, 480 mental health care psychologists and 600 mental health care social workers for the overall population of over 180 million (Gadit, 2007; World Health Organization, 2005). More than 39% of the population in Pakistan is below the poverty line (Gadit, 2007; Government of Pakistan, 2006). This is more than neighboring India (30%) and China (13%) as well as significantly more than other Western countries like the US (15%) and the UK (14%). The first point of contact for any health related matter for the vast majority of these people is to their local ‘healer’. Irrespective of educational and ethnic backgrounds, a significant amount of time is spent in utilizing the healing rituals that they have to offer (Bennett-Jones, 1998). They are then taken to psychiatric doctors, after the route through the ‘healer’ has been exhausted. In spite of this, the ‘healer,’ to this day, enjoys an abundance of patients; they are able to offer a low cost and easy

accessibility, as well as other things that the present day psychiatrist cannot (Gadit, 2003, 2007). There is no official data on the number of mentally ill people in Pakistan's prisons. Anecdotes from mental health professionals working there suggest that psychiatric morbidity in prisons has been steadily increasing. There is a critical problem of overcrowding in Pakistani prisons. The Government of Pakistan's statistics (Pakistan Law Commission, 1997) in 1996 showed 74,483 persons in prison nationwide against a total capacity of 34,014. This problem was most severe in Punjab, which compared a prison population of 47,835 people to a capacity of 17,271. One study of juvenile prisoners concluded that 59.7% had been subjected to major torture (severe beatings, electric shocks, cuts, and burns) and 18.9% to minor torture (slapping, verbal abuse, food deprivation, solitary confinement, and being forced to maintain uncomfortable body positions), while in police custody (Gadit, Vahidy, & Khalid, 1997). A study of female inmates in Pakistan found 62.5% to be suffering from psychiatric illnesses, 23.43% suffered with affective disorders and 10.15% with anxiety related illnesses (Bilal & Saeed, 2011). There are a number of access points to utilize forensic psychiatric services within the domains of the Mental Health Ordinance, 2001. At times, the forensic psychiatry assessments are requested directly by the courts or via an application made to the court by the defense counsel. The courts may also make a referral to the medical superintendent of an institution, which is then forwarded to the Psychiatry Department for formal assessment. The decision to which hospital a referral should be sent to is based on the availability of ‘forensic’ beds as well as expertise in assessing forensic psychiatric patients. The forensic beds are distinct to the general psychiatry ward with all administrative and security matters under the jurisdiction of Pakistan prisons. These beds are either present within the grounds of a general hospital or within the prison itself. The postgraduate psychiatry resident takes a thorough history of the patient as well as a corroborative history from the family (or a close friend). The case, along with other forensic cases, is queued for discussion. At the end of the discussion, a diagnosis and ‘criminal responsibility’ at the time of the index offense, as well as ‘defense capacity’ are collectively agreed upon. This is then forwarded to the medical superintendent of that institution, who then replies back to the court with the findings of the committee. In most central prisons, a separate block in the prison is designated for patients with comorbid psychiatric or behavioral problems. All the patients of this block are visited every week by a postgraduate trainee from a tertiary care facility for the assessment and management of the patients and records of the assessments are maintained. If the postgraduate trainee has concerns, then a senior consultant accompanies the trainee to the prison to reassess the patient. Alternatively the postgraduate trainee, in consultation with a senior faculty, may have the patient transferred to the tertiary care facility, where the patient is assessed by a

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team of 3 senior consultants. A detailed assessment is subsequently forwarded to the District and Session Judge as well as the prison authorities. With an increasing population, the need for mental health nurses trained in forensic matters requires serious consideration (Carbonu & Soares, 1997). 4.4. Barriers to the implementation of the Mental Health Ordinance, 2001 Since its promulgation and implementation, apart from some administrative difficulties, the civil society has also posed fears and apprehension in implementing the Mental Health Ordinance. There are reservations regarding the powers given to police officers, the categorization of mental health disorders and their definitions, treatment places that are outlined, as well as types of treatments that are limited in the ordinance and the people that comprise the visiting Boards. In addition to these concerns, it is also felt that some of the terminology in the Mental Health Ordinance 2001 is misused. Further concerns show some practices such as anesthesia during Electro-convulsive therapy and specific roles, have been left out of the Ordinance. Lack of the implementation of the Mental Health Ordinance has been partially blamed on the political instability of the region. Observations regarding the Mental Health Ordinance 2001 were collated from different forums. These observations have been outlined in Appendix A.

5. Sindh Mental Health Ordinance 2013 In April 2010 the 18th constitutional amendment was passed. As part of the amendment, provinces and not the federation were responsible for psychiatric healthcare provision. Mental health law too as a result was devolved to the provincial level. The southern province of Sindh took a lead in implementing the Mental Health Ordinance, 2001 as the Sindh Mental Health Ordinance 2013 (Sindh Mental Health, 2013). The central aim of the SMHO 2013 was to strike a balance between liberty and freedom of the citizen as dictated by their constitutional rights with the need to impose treatment on a select group of the mentally ill. The Pakistan Association of Mental Health consulted the opinions of a variety of stakeholders including local and international experts on mental health law, patients, advocacy groups, lawyers, and jurists in implementing the Sindh Mental Health Ordinance 2013 (Sindh Mental Health, 2013). It will be a matter of time to see how implementing the SMHO 2013 fares in the future.

6.2. Postgraduate training The College of Physicians and Surgeons Pakistan (CPSP) regulates postgraduate medical education in liaison with the PM&DC. Accredited postgraduate psychiatric training in Pakistan has been slow to adapt to the needs of the people, however it has taken a sharp increase in recent years. In 1965, the Jinnah Postgraduate Medical Centre was the first fully accredited institution to offer a psychiatry residency training program. Sixteen institutions in the last five years alone, from a total of 25, have received full accreditation for psychiatry programs in Pakistan (College of Physicians & Surgeons in Pakistan, 2012a). Graduation and completion of a one-year internship allow the trainee to be eligible to sit the first part of the Fellowship of the College of Physicians and Surgeons Pakistan (FCPS) exam. This exam covers the clinical application of basic sciences knowledge relevant to psychiatry. This is followed by a four year residency in a CPSP accredited institution. Successful completion of the second part of the FCPS exam confers a Fellowship of the College of Physicians and Surgeons Pakistan in psychiatry (College of Physicians & Surgeons in Pakistan, 2012b). The residency training program is divided into two 2-year components. The first two years of the CPSP psychiatry residency program, the ‘Intermediate module,’ requires compulsory rotations of three months each in clinical psychology, medicine and neurology. Competency levels throughout the residency are measured using the Ten Cate and Scheele ‘entrustable professional activity’ (EPA). This measures competency levels across 5 levels from 1 ‘observer status’ to 5 ‘ability to teach others and critically evaluate’ (ten Cate & Scheele, 2007). In the Intermediate module, residents must attain the competency level of 3–4 for various learning objectives. By the end of the 4-year residency an EPA of 5 must be achieved for most learning objectives (Rana, Farooq, & Afridi, 2010). Assessments during and at the end of the Intermediate module and the Final module are by means of internal assessments, in the form of a portfolio, feedback sessions and written and clinical encounters, as well as external assessments by the CPSP, in the exam format of multiple choice and short answer questions (College of Physicians & Surgeons in Pakistan, 2012a, 2012b, 2012c).

6.3. Forensic psychiatry education In the Final module, Forensic psychiatry is documented as part of the overall syllabus (College of Physicians & Surgeons in Pakistan, 2012b). It requires the resident to have assessed under supervision ten forensic patients overall and be trained in understanding:

6. Training in forensic psychiatry in Pakistan 6.1. Undergraduate education Medical education at an undergraduate level is regulated by the Pakistan Medical & Dental Council (PM&DC). Until the late 1990s, psychiatry was only offered as didactic lectures in the final year of medical school without inclusion in the undergraduate examinations. This shifted to a clinical clerkship ranging from 3–6 weeks as well as examination questions in the final year of medical school, albeit part of the General Medicine paper, rather than a separate exam in psychiatry (Gadit, 2007; Naeem & Ayub, 2004; Pakistan Medical & Dental Council, 2012). To satisfy the requirement of PM&DC, medical schools would therefore only offer a few lectures in Behavioral Sciences in the preclinical years. In the developed world significant weightage to the syllabus is devoted to Psychiatry and Behavioral Sciences during undergraduate education. In addition, many of the qualifying/licensing exams e.g., the PLAB for the U.K., the USMLE for the U.S. and the LMCC for Canada, give due weightage to assessment and knowledge in Psychiatry and Behavioral Sciences (Gadit, 2007).

1. 2. 3. 4. 5. 6.

Mental Health Act Administrative management of psychiatric cases Forensic psychiatric syndromes Psychiatrists' role in court Management of violence and risk assessment Psychiatric report.

The author TH sent a postal survey to all 25 psychiatry program directors in Pakistan. He asked whether the residencies were able to fulfill the above requirements set out by the College of Physicians and Surgeons Pakistan and received a 40% response rate. The majority of the residency programs (80%) document the need for residents to be able to assess forensic patients and 70% of respondents believed that the necessary facilities were in their area for residents to assess forensic psychiatry patients. Fifty percent of program directors indicated that there was adequate exposure to forensic psychiatry in their resident programs, however, 20% of programs were unable to provide their residents the opportunity of a single forensic assessment. Additionally, it was found that only 30% of consultant psychiatrists have had training in forensic psychiatry.

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7. Conclusions This article provides insight into existing forensic psychiatric services in Pakistan. It highlights the progress made from the archaic Lunacy Act of 1912 to the Mental Health Ordinance 2001. It shows the barriers faced by these existing services to implement the various components outlined in the newly promulgated mental health ordinance. The new ordinance, just like the Lunacy Act of 1912, leaves the crucial question of the extent of criminal and civil liability of people who are mentally ill, unanswered. This means that the law on this matter has to be derived from other sources of criminal and civil laws. Unfortunately, at present forensic psychiatry in Pakistan operates on an ‘as required’ basis in most jurisdictions in Pakistan. The demand of forensic assessments by trained individuals is grossly outweighed by the supply that can be offered. This also highlights the need for policy makers and the administrators in Pakistan to ensure implementation of the Mental Health Ordinance 2001. The challenging social landscape leads this field to be fraught with risk to both the patient and the psychiatrist. The mentally ill offender is usually met with a double stigma; first, being mentally ill and second, being a criminal (alleged or otherwise). Anti-stigma mechanisms in conjunction with religious scholars, in print or other media sources, must skillfully and boldly put forth to educate the public on mental health and its consequences. This will, in time, prevent members of the public from taking the law into their own hands. With the development of psychiatric specializations worldwide, this is an appropriate time for Pakistan to further expand on the existing forensic psychiatry specialty. The Government of Pakistan must be made aware that correctly addressing the needs of the mentally ill offender will reduce the overcrowded prison population. The Mental Health Ordinance of 2001 in Pakistan provides an appropriate platform to update and develop forensic psychiatric services. Pakistan prisons and psychiatry must begin to develop a streamlined ‘memorandum of understanding,’ for ease of assessment and rehabilitation of mentally ill individuals. Psychiatric services need to be established within the prison walls. This will cater to inmates who develop psychiatric illnesses while in prison as well. Pakistan's police force requires more training on triaging possible offenders with mental illness as well as understanding their needs. The liaison between the legal and psychiatry fraternity must progress jointly. By doing so, greater work in the field of research will help us better understand the scale of the problem at hand, in both within and outside of the prison walls. This will ultimately help the mentally ill patient and also help to shape the current law to fulfill the patients' rehabilitation needs, while at the same time protecting the public. There is a need to improve the awareness and education among residents and consultant psychiatrists by promoting national and international cooperation in this field. There is an impending need for a formalized liaison between psychiatry and the law in education and in research. A psychiatry resident's ability to assess or observe assessments is very limited, with residents required to observe ten patients during the program. This is the minimum necessary, according to the requirements of the College of Physicians and Surgeons Pakistan. If a resident is in a program with little to no access to forensic patients then the post-graduate structure training program should facilitate this access. There is also a need to develop a platform for forensic psychiatry to develop standards and promote research in this field. The author TH delivered a lecture on Forensic Psychiatry from Canada to the faculty of King Edward University Department of Psychiatry in Pakistan. This was an online PowerPoint presentation via the internet using Cisco's WebEx. The use of technology potentially linking all institutions online could be a means to provide education in this field by experts who may or may not be resident in Pakistan. There are several means by which to improve the system at work in Pakistan, and it begins with education. Not only education in the field of forensics to the psychiatrists, but also to the citizens. There have already

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been changes in the language and the laws that are used in Pakistan, and by changing perceptions of the public and training for those in the field, forensic psychiatry services in Pakistan can, again, expand and improve for the future. Acknowledgments Prof. Dr. Murad Khan, Head of the Department of Psychiatry, Aga Khan University, Karachi, Pakistan. Prof. Dr. Iqbal Afridi, Head of the Department of Psychiatry, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. Prof. Dr. Raza Rehman, Head of the Department of Psychiatry, Civil Hospital Karachi, Karachi, Pakistan. Dr. Nusrat Habib Rana, Director of Punjab Institute of Mental Health, Lahore, Pakistan Dr. Jamil Junejo, Psychiatrist, Sir Cowasji Jehangir Institute of Psychiatry, Hyderabad, Pakistan. Dr. Faqir Hussein, former registrar Supreme Court of Pakistan, Islamabad, Pakistan. Dr. Khalid Saeed, Assistant Professor, Queen's University, Kingston, Canada.

Appendix A

Observation

Explanation

According to section 19 of MHO 2001 (p. 131) Mentally disordered persons found in public places: — (1) If an officer in charge of a police station finds in a place to which the public have access, a person whom he has reason to believe, is suffering from a mental disorder and to be in immediate need of care or control the said officer may, if he thinks it necessary to do so in the interest of that person or for the protection of other persons, remove that (not arrest) person to a place of safety (not to a police station) which means only a Government run health facility, a government run psychiatric facility or hand him over to any suitable relative who is willing to temporarily receive the patient. 9 (2) A person removed to a place of safety under this section may be detained there for a period not exceeding 72 h for the purpose of enabling him to be examined by a psychiatrist or his nominated medical officer and for making any necessary arrangements for his treatment or care. 02 The three categories of mental health Chapter 1, definition (m) of MHO 2001 (p. 117) disorders (as mentioned in the new ordinance) cover major illnesses, but “Mental disorder” means mental illness, including mental impairment, severe depressive and anxiety disorders personality disorder, severe mental (which account for more than 5% of the population and more than 70% of impairment and any other disorder or patient population) may need a more disability of mind and “mentally disordered” shall be construed accordliberal terminology. ingly and as explained hereunder. Depression, anxiety or any other mental illness has not been excluded. 1. The title of the MHO 2001 03 The Mental Health Policy should indicates: (p. 115) emphasize that the traditional concept and practice of Mental Health WHEREAS it is expedient to consoliHospital should be replaced by more date and amend the law relating to 01 Section 19 implies that the SHO will have the discretion and power to arrest anyone whom the SHO believes is suffering from a mental illness. This ordinance may be misused by the police and may be a threat to civil liberties of citizen.

(continued on next page)

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Appendix A. (continued)

Appendix A. (continued)

(continued)

(continued)

Observation humane, community oriented treatment centers in every district.

Explanation

the treatment and care of mentally disordered persons, to make better provisions for their care, treatment, management of properties and affairs and to provide for matters connected therewith or incidental thereto and to encourage community care of such mentally disordered persons and further to provide for the promotion of mental health and prevention of mental disorder; 2. Chapter III: assessment and treatment (p. 123) This chapter starts with emphasis on community care Care in the community: — Community based mental health services shall be set up for providing mentally disordered persons, their families and others involved in their care with guidance, education, rehabilitation, after care and preventive measures and other support services on an informal or voluntary basis. 1. We still lack the scientific evidence 04 Incorporation of currently popular to support and promote most of the (though outdated) methods of “popular though outdated” treatment i.e., spiritual/magical traditional methods of treatment. should be seriously considered. An 2. “Treatment of mentally disordered in-depth survey can determine the person” means the assessment and method and manner of inclusion of treatment of a mentally disordered such centers. person and shall include assessment, care, training, habilitation as well as rehabilitation techniques or measures, as the case may be (no specified treatment is indicated and perhaps accommodate any traditional methods also). 05 The world ‘detention’ used in the new Under the Law, the word used is ‘detained’ and not lodged, admitted law for people admitted to a or staying. This causes confusion. psychiatric facility is highly objectionable. In its place terms like placed, lodged, allowed to stay or admitted should be used. 06 Section on informed consent must be 1. The right word should be rewarded and expanded. ‘reworded’ instead of rewarded in the draft. 2. The family has a lot of say in the issue of informed consent. The definition of informed consent has been taken from law books and is similar to the other Mental Health Acts of present time. This definition helps the patient management better. “Informed consent” means voluntary and continuing permission of the patient or if the patient is a minor his nearest relative or guardian, as the case may be, for assessment or to receive a particular treatment based on an adequate knowledge of the purpose, nature, likely effects, and risks of that treatment including the likelihood of its success and any alternatives to it and the cost of treatment. 3. The issue of informed consent has been discussed in Chapter VII: protection of human rights of mentally ill (p. 144) Informed consent: — (1) Before commencing any investigation or treatment a psychiatrist or nominated medical officer shall obtain written informed

Observation

Explanation

consent, on a prescribed form, from the patient or if the patient is a minor, his nearest relative or a guardian, as the case may be. (2) Where the consent of a patient to any form of investigation(s) and or treatment(s) has been given the patient or if the patient is a minor, his nearest relative or a guardian, as the case may be, may withdraw his consent in writing at any time before the completion of the treatment. (3) Without prejudice to the application of sub-section (2) above to any treatment given under the plan of treatment to which a patient or if the patient is a minor, his nearest relative or a guardian, as the case may be, who has consented, to such a plan may, at any time withdraw his consent in writing to further treatment, or to further treatment of any description under the plan of treatment. 07 In order to ensure humane treatment 1. Attention is drawn to the functions of mentally disordered persons, there of the Federal Mental Health Authority (pg 120) should be more precise and detailed 2. Chapter VIII: offences and indemnity policies regarding the methods and manner in which mentally ill patients (p. 144) In this chapter maltreatment has been are treated. severely discouraged. 08 Federal Mental Health Authority and 1. One has to question the feasibility of this suggestion. the visiting Boards must include 2. The Board has one citizen who human rights advocate. obviously would have sense of human rights. The MHO indicates; There shall be a Board of Visitors at the provincial level which shall consist of: — (pg 121) (a) A Chairperson who is or has been a judge of the High Court; (b) Two psychiatrists, one having a minimum experience of ten years in Government service; (c) One prominent citizen of good standing; (d) Two medical practitioners of repute with a minimum standing of twelve years, one of whom shall be nominee of Pakistan Medical and Dental Council; and (e) Director General Health Services of the Province or his nominee. 09 Article 54 of the ordinance specifically 1. The statement has been misinterpreted and the whole speaks of a “mentally disordered” accused person detained in jail being paragraph should be read; Inspection of mentally disordered seen by the Inspector General of Prisons to ascertain his state of mind. prisoners (p. 146 of MHO) But it does not go on to say what is to Inspection of mentally disordered prisoners: — (1) Where any person is be done to these people. Provisions ought to be made to divert them to a detained under the provisions of section 466 or section 471 of the Code mental health system. of Criminal Procedure 1898 (Act V of 1898), section 130 of the Pakistan Army Act, 1952 (XXXIX of 1952), section 143 of the Pakistan Air Force Act, 1953 (VI of 1953), or section 123 of the Pakistan Navy Ordinance, 1961 (XXXV of 1961), the Inspector-General of Prisons, if the accused person is detained in a jail, and the Board of Visitors or any two members of such board, if the accused person is detained in a psychiatric facility, may visit him in order to ascertain his state of mind and such a detainee shall be visited once at least in every six months by the

T. Hassan et al. / International Journal of Law and Psychiatry 41 (2015) 95–104 Appendix A. (continued) (continued) Observation

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Appendix A. (continued) (continued) Explanation

Inspector General of Prisons or the Board or any two members of such Board, shall make a report as to the state of mind of such person to the authority under whose order the accused person is detained and the Inspector General of Prisons or, as the case may be, the Board of Visitors or any two members of such board, shall make a report as to the state of mind of such person to the authority under whose order the accused person is detained. 2. Also 5.5 Forensic psychiatric services: — (1) Special security forensic psychiatric facilities shall be developed by the Government to house mentally disordered prisoners, mentally disordered offenders, as may be prescribed. (2) Admission, transfer or removal of patients concerned with criminal proceedings in such facilities shall be under the administrative control of the Inspector General of Prisons. (3) The Board of Visitors shall have an access to such persons admitted in forensic psychiatric facility in accordance with the provisions of this ordinance. 1. It is difficult to describe specific 10 The document should include description of specific roles attributed roles, however the sub-committees can make further recommendations. to various sectors in government, non-governmental or religious orga- Functions of the Authority: ∎Prescribe for care, aftercare or nizations in the way of promotional, rehabilitation, under supervision or preventive and rehabilitative activiotherwise; ties related to mental health. ∎Provide for and regulate the setting up of help lines and crisis centers for the general public with regard to mental health; ∎Discharge such other functions with respect to matters relating to mental health as the Government may require. 1) Psycho geriatrics has been clearly 11 Psychiatric services should be mentioned in the Functions of the reorganized to address and incorporate psycho geriatric services Authority: (p. 120). Recommend measures to improve and treatment of substance existing mental health services and abuse/addictions. setting up of Child and Adolescence, Psycho geriatric, Forensic, Learning disability and Community based services; 2) Services for substance abuse are missing and could be incorporated. Mental health ordinance gives lot of 12 There is a need to establish forensic emphasis to forensic psychiatric psychiatric services where mentally services. disordered offenders are kept Forensic psychiatric services: — (p. 146 separate from other criminals. of MHO) (1) Special security forensic psychiatric facilities shall be developed by the Government to house mentally disordered prisoners, mentally disordered offenders, as may be prescribed. (2) Admission, transfer or removal of patients concerned with criminal proceedings in such facilities shall be under the administrative control of the Inspector General of Prisons. (3) The Board of Visitors shall have an access to such persons admitted in forensic psychiatric facility in accordance with the provisions of this ordinance. That's what has been described in the 13 The board and sub-committee makfunctions of the Board (p. 121 of ing visits under the sub-section may MHO). interview and examine patients and may inspect any documents and/or

Observation medical records relating to the patients. However, they should be accompanied by the treating doctor. 14 Since the bulk of mentally ill persons in the community are treated by family physicians, the role of family physicians in the promotion of mental health and in prevention of mental illness must be address. Representation of family physicians must be ensured in the bodies established under this ordinance. 15 Chapter III (10 and 11) admission for assessment/treatment requires a written recommendation in the prescribed form of two medical practitioners when one should be a psychiatrist, if available. This clause will delay treatment to disturbed mentally disordered persons. If the admission is voluntary, the nearest relation's verbal request should be accepted for admitting and treating the patient for a limited and specified period.

Explanation

(pg 121 of MHO) 1) The Board has two doctors. 2) Doctors and not only psychiatrists have also been registered to assess for the compulsory admissions.

1) This is misinterpreting the MHO. Section 9 is for urgent admission which should ‘not delay’ at all. The nearest relative's verbal request is good enough in this case. 2) According to section 9, an urgent application may be made either by a relative of the patient or medical officer; and every such application shall include a statement that it is of urgent necessity for the patient to be admitted and detained under this section and that compliance with the provisions relating to an application for treatment, under section 11 would involve undesirable delay. Electro convulsive therapy (ECT) is a 16 ECT should always be administered life saving treatment modality for under general anesthesia (not severe mental illnesses and is used in preferably as in Section 56(2)). psychiatric practice worldwide. It is administered under general anesthesia, but in our health system adequate services for anesthesia are not available even in the major centers. The provision of ‘preferable’ is kept in consideration of the seriously ill patient who otherwise would not get an effective life saving treatment. 17 There should be a liaison or watchdog The FeMHA already provides the committee to monitor the ‘treatment’ same service; ∎Advise the Government on all meted out to patients at mazars, matters relating to promotion of shrines and other ‘voluntary’ mental health and prevention of institutions. mental disorder; ∎Develop and establish new national standards for care and treatment of patients. ∎Recommend measures to improve existing mental health ∎Prescribe procedures with respect to setting up and functioning of the mental health services and facilities; ∎Prescribe a code of practice to be implemented for achieving the purposes and objects of this Ordinance as well as to be followed by all the mental health personnel involved with the care of patients under this Ordinance. The FeMHA already provides the 18 Immediate orientation programs same service; should be held in major institutions, Arrange and organize such courses and for those who are likely to be and training programs as may be involved in comprehensive mental necessary for carrying out the health care, including family purposes and objects of this physicians and the police. Ordinance. 1) The cost matters have been a 19 Liability to meet the cost of maintenance of patients admitted in a serious consideration while drafting the ordinance. It is quite minimal psychiatric facility rests with the so far. government, unless the patient is affording. Non-affording patients will be the responsibility for the government. 20 A central monitoring system ought to 1) There should be liaison with the (continued on next page)

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Appendix A. (continued) (continued) Observation be set up to safeguard the interests and rights of mentally disordered persons envisioned in the new ordinance with the active involvement of bar associates and the Bar Council. 21 The undergraduate psychiatric training of medical students in the state sector should be standardized nationally. An adequate number of training facilities for psychiatrists should be ensured before any new approach to mental health care is adopted. 22 The clinical training of psychologists and their utilization in mental health services should be given due importance. 23 A written mental health policy, with provisions of integration into the primary health care system, can help the implementation of MHO 2001.

Explanation FeMHA.

The functions of FeMHA indicates; 1) Arrange and organize such courses and training programs as may be necessary for carrying out the purposes and objects of this Ordinance. 2) Register psychiatrists for the purposes of this ordinance, in such manner as may be prescribed. The MHO does not stop the psychologists from working, rather they have an effective role in care, and rehabilitation. That has been the basis of MHO 2001.

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