• Psychiatrist notes confinement, lack of rehabilitation, poor mental health support, overcrowding, and substance abuse  

BY Sumudu Chamara “Death row prisoners are locked inside most of the day. They have extremely limited freedom to engage in recreational or industrial activities that other prisoners have access to. They are not being rehabilitated. They are not being released. They are not being executed. They have just been left to die inside prisons.”  Even though most of us may be unfamiliar with the above mentioned conditions, these concerns, expressed by a leading mental health professional, resonate with a considerable number of prisoners sentenced to death. While this matter has been discussed on many occasions, Sri Lanka seems to be paying little attention to improving the living conditions within prisons, and a considerable segment of the public continue to believe that prisoners not having rights is part of their punishment.  By keeping many people in such harsh conditions, what is the country gaining, and why does Sri Lanka show a great lethargy in addressing these issues despite the fact that those have been identified as inhumane treatment? These concerns, and others, were raised by Sri Lanka College of Psychiatrists President Dr. Gihan Abeywardena, speaking with The Morning.  Prisoners’ physical and mental well-being  Speaking of the overall situation of prisoners’ mental health, Dr. Abeywardena said that prisons have become stressful environments due to a multitude of reasons, and that while some prisoners are likely to develop new psychiatric disorders after being imprisoned, the mental health of some prisoners who had psychiatric disorders before being imprisoned is likely to worsen. He stressed that despite this situation, prisoners have extremely inadequate access to mental health services. “One of the most important matters that need to receive attention is the overcrowding issue in prisons. Prisons cannot successfully manage the number of prisoners within the available space, which in turn leads to the basic human rights of prisoners not being respected, whereas in developed countries, there is a minimum requirement as far as the space available for prisoners is concerned.  “But in Sri Lanka, there is no such consideration. Once prisoners are put back in their cells at 5.30 p.m., they cannot get out and there is severe congestion within the cells. They cannot even properly lie down. They have to use the toilet which is located within the cell. With the smell of toilets, they have to be in the cell till next morning. Such conditions, among others, cause mental stress.”  In addition, the lack of freedom given to death row inmates, which was looked into through a 2005 study conducted by Dr. Abeywardena, is another major concern that has a connection to prisoners’ mental health.  He explained: “Prisoners on death row are allowed to go outside only for one hour per day. For 23 hours of the day, they are locked inside their cells with no way of engaging in any activity, while other prisoners who are not on death row, get the chance to go out and engage in various activities such as sports, handicrafts and cultivation, which take place within the prison premises. Once they are locked inside their cells, there is no way for them to get involved in any additional activity. They are not allowed to go to any workshops that they have inside the prisons such as those facilitating carpentry, and they are just locked inside.”  Adding that this leads to them going through a great deal of stress, Dr. Abeywardena said: “These prisoners’ non-involvement in rehabilitation or recreational activities may lead to high levels of stress, frustration, and the higher prevalence of psychiatric disorders.”  He further stressed that when a person with a mental health issue gets imprisoned, their mental health condition is greatly exacerbated because of the conditions within prisons.  When questioned about the present situation with regard to mental health services available in prisons at present, Dr. Abeywardena noted that even though some positive developments have been reported in a handful of prisons, this is not adequate at all, because all prisons in Sri Lanka are naturally stressful environments.  He added: “Most of the prisons in Sri Lanka have a medical officer (MO), or a Bachelor of Medicine, Bachelor of Surgery (MBBS)-qualified doctor, and all other prisons have registered medical officers. They have very limited training in mental health. So a prisoner can only obtain mental health support from these doctors.  “Only if prisoners get agitated or cannot be controlled are they sent to the main hospitals’ psychiatric clinics. That is the only way that they can see a psychiatrist. If they are referred by the prison medical officer to a psychiatric clinic, then they have to wait till all arrangements are made, and it takes some time. It may not happen on the same day when their issue was detected.” The lack of monitoring of the prisoners’ mental health status, according to Dr. Abeywardena is an alarming situation, because it affects legal action being against prisoners too.  “In developed countries, when a person is sentenced to death, or when they commit a serious crime, they have to undergo a psychiatric assessment when being imprisoned, in order to ascertain whether they have committed the crime for which they are being sentenced, due to a mental illness. But unfortunately in Sri Lanka, that does not happen. In fact, in Sri Lanka, only some judges and lawyers are sensitive about mental health-related matters among suspects and convicts while others are not.  “I found during my study that there were many prisoners who had been sentenced to death who had committed crimes due to a mental illness, especially delusions. I found four prisoners who had killed their wives due to a condition called morbid jealousy, which is a psychiatric disorder where a person, without any reason, all of a sudden, gets this delusion or the false belief that their spouse or partner is having a sexual relationship with another person.”  He also raised concerns about the lack of space for mental health-related concerns in legal proceedings, which he said could be extremely detrimental to a suspect, especially a suspect who may be sentenced to death due to the nature of their crime, which may have been influenced due to a mental health issue.  He added: “The higher prevalence of psychiatric disorders among the prisoners population is a known fact, and can be seen anywhere in the world, not only in Sri Lanka. Prison environments and the rules inside prisons can be seriously detrimental to mental health. So, if a person with a mental health problem is imprisoned, his or her mental illnesses can get much worse.  “If it is a person who does not have such issues or illnesses, the situation is serious, because prisons are a breeding ground for mental illnesses due to the living conditions. There are so many people who go in with a good mental state, but become a victim of mental health issues inside the prison. In fact, prisons are unremittingly grim places and provide conditions wholly unsuitable for those with severe mental disorders. Another issue is that there is no organised national forensic mental health service in Sri Lanka. Forensic psychiatrists are the people who deal with mentally Ill offenders, and we have only a handful of them to cover the entire island.”  Adding that the situation where death row inmates live in a state of constant uncertainty due to the fact that Sri Lanka sentences people to death although it does not implement the sentence, which allows to keep such convicts imprisoned for life or until such time the death sentence is imposed, Dr. Abeywardena noted that living in such a situation is extremely stressful, and can easily worsen or cause mental health issues in prisoners.  He further said: “Those who are on death row are suffering indefinitely, not knowing whether they will be hanged or not, and that too is in adverse conditions. When I interviewed death row inmates, the majority of them said that it would be better if the Government hanged them, and that they cannot go on not knowing whether they would be hanged or not.”  Prisoners’ mental health  According to Dr. Abeywardena, there is a severe lack of local studies into prisoners’ mental health, and the most prominent study that can be used to understand the state of prisoners’ mental health is the one he conducted in 2005. The study targeted 72 (only 72 inmates had consented to be a part of the study) death row inmates, and 72 inmates who had been sentenced for a period of less than two years for minor offences, at the Bogambara Prison. All participants were male.  According to him, the study had found depression and substance dependency among prisoners, and such issues were notably prevalent among death row inmates than among the other group.  “The study found that 68% of death row inmates were clinically depressed. In the other sample, only 20% showed the same condition, and that this is a huge difference. In addition, 79% of death row inmates had some kind of a psychiatric disorder, which is a notable statistic, and in the other group, it was only 43.1%. Only 5% in both samples gave details about a past psychiatric history, and only 5% of them had been mentally ill before being imprisoned.  “It should also be noted that around 40.3% of death row inmates had been separated from their parents in early childhood, which means that they have had no parental care. What is more, 9.7% of death row prisoners had been sexually abused during their childhood, and that is also a considerable figure.”  Alcohol dependency among prisoners was another concerning matter that the study focused on. According to the study, 30.5% death row inmates had experienced alcohol dependency before being imprisoned, while only 9.7% in the other group were identified as having experienced the same before being imprisoned.  In this regard, Dr. Abeywardena said: “There are two alarming findings. One is that depression and alcohol dependence were higher among those who had committed serious crimes. So, there is a question as to whether being depressed and alcohol dependent can lead to criminal acts by men.  “The other important finding is that 25% of death row inmates were having dual diagnosis, which means two conditions being diagnosed together. Examples are depression and alcohol, or depression and heroin. In the group of death row inmates, this percentage was 25%, while in the other group, it was only 4.2%.”  Way forward  To change the current situation, Dr. Abeywardena said that Sri Lanka must take several steps in line with what developed countries have done to improve the quality of their prison systems.  He presented several recommendations: “The most important recommendation we can base on the findings of the study is that Sri Lanka should pay attention to screening criminals for psychiatric disorders prior to sentencing. Screening all sentenced prisoners who have already been imprisoned is also a necessity. So we must screen criminals who commit major crimes before they are sentenced in order to ascertain if they have psychiatric disorders.  “If that is not possible, at the very least, we should conduct such screenings after they are sentenced. At the same time, prisoners should go through a psychiatric assessment before they are condemned, because once they are condemned, that means that their appeals have been heard and there is no possibility of changing the verdict.”  According to Dr. Abeywardena, the importance of conducting a psychiatric assessment should not be neglected, because the results of such assessments may have a direct impact on verdicts, based on which a person is convicted or sentenced. Taking the condition called diminished responsibility – a condition in which a person may not have the full knowledge of the nature and gravity of their actions because their mental state is not very sound – as an example, he said that it is crucial to look into such when proceeding with a case.  He explained: “Think of a mother who gives birth to a child. In the first few days after delivery, if her mental state is not very sound and if she gets a bit disorientated or confused, she may commit a crime because of her altered mental state. In other countries, they do not sentence the mother for murder, because it is not considered a murder. It is called manslaughter. You may be given life imprisonment or a death sentence for murder, but for manslaughter, you get a lesser sentence. However, that is not being applied in Sri Lanka.”  He added: “Another recommendation is that we should have a joint prison health service in the country. At present, the health authorities act independently, while the Justice Ministry or the Prisons Department acts on their own. There is no proper collaboration, which is necessary when it comes to dealing with those with mental health issues.  “We have to have a joint prison health service inside prisons. Even though psychiatric clinics have started providing services to the Welikada, Bogambara, and Galle Prisons, only these three places have such services. When we think about the entire country, this is not at all adequate because there are many other prisons in the country.  “The other important recommendation is taking steps to ensure humane treatment for all criminals. They are also human beings, and at present, some are locked for 23 hours a day without an opportunity to get some exercises, move outside the prison cell or engage in recreational activities such as watching television or listening to the radio. They get freedom for only one hour a day, and that too is in the locked area. What is more, prisoners should be given a chance to get involved in rehabilitation programmes.”  Even though The Morning attempted to contact the Prisons Department to discuss whether the Department has paid attention to improving mental health services for prisoners, they were not reachable.  For a long time, Sri Lankans have been taught that prisons are places that are meant to punish those who commit offences, and that prisoners are a condemned community that deserve to live in harsh conditions for their transgressions. However, prisons are also places that are meant to convert those who once broke the law into law-abiding citizens – essentially, they are also rehabilitation centres. To achieve this purpose, it is crucial that the prison system, and society at large, sees and treats them as human beings who deserve another chance, and ensure their well-being while in prison.  One of the pressing concerns that have been discussed for a long time in various forums focusing on prisoners’ well-being is whether they have access to mental health services, which has become a necessity given the harsh environments that they live in. In this context, it is crucial that Sri Lanka prioritises ensuring prisoners’ mental health in prison and law reform processes.