1.

INTRODUCTION

Mental health is an integral part of our well-being, yet mental health issues have been
woefully neglected in our country. Even worse is the fact that serious mental illnesses are
not treated early and the treatment gap even for such disorders is very large. It is well
known that people in disadvantaged situations have high levels of mental morbidity and
poor access to treatment. Prisons and other custodial institutions are locations which see
high levels of mental distress and morbidity.

Mental distress may occur in otherwise normal individuals in response to the stress of
imprisonment. They may occur in vulnerable individuals who have pre-existing illness
that gets exacerbated in prisons, or develops anew in prisons as a result of stress or other
factors. Persons with certain types of personality disorders are also more likely to enter
prisons. Given that many of these vulnerabilities are associated with the use of both licit
and illicit drugs, it would be expected that these pre-dispositions would also enter the
prison along with the prisoner. This adds to the already high burden of substance use
(tobacco, alcohol and other drugs) encountered in prison.

In India, we do not have a clear understanding of the extent and patterns of mental health
problems in prisons. Apart from instances of non-criminal mentally ill in prisons which
captured the attention of the judiciary, and occasional reports of prison suicides, which
attract the attention of the media, relatively little is known about the mental health needs
and extent of mental illness in the prison population.

It is in this context that an evaluation of mental health problems in the Central Prison,
Bangalore, was undertaken. This initiative was the result of a joint collaboration between
the National Institute of Mental Health and Neuro Sciences, Bangalore, the Karnataka
State Legal Services Authority and the Department of Prisons, Government of Karnataka.
The results of this study have been published in Mental Health and Substance Use
Problems in Prison: Local Lessons for National Action.

As part of this initiative, we also undertook a review of the prevalence of mental illness
and substance use in prisons all over the world. In this publication, we discuss the
prevalence of a range of mental illnesses including psychotic disorders, mood disorders,
other common mental disorders and substance use in prisons from different countries. We

1
also discuss the range of high risk behaviours commonly encountered in prisons, from
violence to self-harm and suicide. The review of literature on these issues, while not
exhaustive, attempts to illustrate the kinds of mental disorders and behaviours that are
over-represented in prison settings, and what intervention approaches have been found
useful. The guidelines developed for mental disorder management in many countries may
serve as a template for the development of mental health services in developing countries,
with the necessary modifications relevant to local issues and needs.

The findings of mental health morbidity from prisons in other countries are compared
against the findings of the Mental Health and Substance Use Problems in Prisons: Local
Lessons for National Action. In this study, 5024 prisoners from the Central Prison,
Bangalore, India were evaluated for psychiatric morbidity. The objectives of this study
were to estimate the prevalence and patterns of major and minor psychiatric morbidity
and substance use in the Central Prison Bangalore; assess their mental health needs and to
develop guidelines for mental health care in prison settings. The prisoners were
interviewed confidentially on a semi-structured questionnaire, a lifestyle questionnaire
and a needs questionnaire, all specially developed for the study. The MINI Plus
interview schedule was used to assess mental health morbidity. A random sample of
resident prisoners and new entrants underwent physical evaluation and urine testing for
sugar and protein, as well as testing for drugs of abuse. Prison staff (201) was also
evaluated for mental health morbidity and their needs were assessed. A series of
recommendations were developed based on the findings.

In this review, in the comparison of mental health morbidity between other countries and
India, Indian comparisons are mostly drawn from the above study referred to variously as
the Central Prison Mental Health Study, the Bangalore Prison Mental Health and
Substance Use study or simply, the Bangalore Prison Study.

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 2. PRISON AND HEALTH

Health is one of the key indicators of wellbeing of a society and prisons serve as mirrors
of society. Understanding health conditions in prisons would help us to improve our
public health system. The World Health Organization‟s definition of health (as adopted
by the International Health Conference in 1946) encompasses physical, mental and social
dimensions. “Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity” (World Health Organization 1946). This
definition clearly emphasises two commonly neglected aspects namely a) mental and b)
social well-being, apart from physical health as being integral components of health.

Prison and jail environments are increasingly being recognised as settings in which
society‟s diseases are concentrated (Fazel and Danesh, 2002). At any given time, over 3.5
lakh people are imprisoned in correctional institutions in India (NHRC 2008). Prisoners,
who enter prison with history of drug use (such as alcohol, nicotine, cannabis, cocaine,
opiates, volatile substances and so forth) or other health-related problem often leave
without having received proper medical attention. In fact, their problems may often
escalate in prison. Prisoners who are healthy on entry have a considerable risk of leaving
prison with HIV, tuberculosis, skin diseases, drug problems or poor mental health. Many
of the prisoners also have a history of high risk behaviour such as unprotected sex,
violence, aggression, theft, or domestic violence. A single drug user upon entry into
prison may become a multiple drug user; a person with HIV may contract TB. Thus,
prisoners may be in a worse state of health upon exiting the prison than they were upon
entry, and may carry the health problems back into the community. While in prison, they
are completely at the mercy of the state for their basic needs and medical care. All health
and behavioural problems need to be assessed and intervened before discharge from the
prison, so that they do not recur in the community. Rehabilitation and reformation of the
prisoners should occur at multi-dimensional levels, from physical, mental, spiritual,
vocational and social perspectives.

Dual challenges

Developing countries like India face challenges of both communicable diseases

(especially Tuberculosis, HIV, Malaria, Dengue, Diarrhoea, Amoebiasis, Cholera,
Hepatitis and Sexually Transmitted Diseases), as well as non-communicable diseases

3
(commonly hypertension, diabetes, obesity, cancer, substance use and mental disorders)
(Boutayeb, 2006; World Health Organization, 2002). Both communicable and non-
communicable diseases add not only to mortality but also morbidity in society. These
issues are more prevalent in the prison population than in the general population (Taylor,
2010). The most commonly occurring and most widely studied communicable diseases
inside correctional settings are tuberculosis and HIV. These two conditions have received
so much attention because they are the most challenging in terms of prevention,
treatment, control and social stigma. At the same time, research and prevention in
correctional settings with regard to non-communicable diseases is meagre when
compared to communicable diseases.

COMMUNICABLE DISEASES IN PRISONS

Tuberculosis

Correctional facilities have often been cited as reservoirs for tuberculosis (TB),
presenting a potential threat to the general population, and to public health. World Health
Organization (WHO) estimates that tuberculosis (TB), a contagious airborne disease
caused by Mycobacterium tuberculosis, infects one third of the world‟s population. In the
European Region alone, TB causes 49 new cases and kills 7 people every hour. A
survey was done to collect data on TB in prisons of the WHO European Region during
2002. Only twenty-two (42.3%) countries completed the questionnaire. Survey results
reported that prisoners had up to 83.6 times more TB than civilians (Aerts et al., 2006).

In a study to estimate the prevalence of tuberculosis in Zambian prisons, a total of 1080

prisoners were recruited. Sputum from 245 (22.7%) prisoners yielded M. Tuberculosis.
Resistance to at least one anti-tuberculosis drug was detected for 40 (23.8%) isolates,
while MDR-TB was identified for 16 (9.5%) isolates (Habeenzu et al., 2007). A study
among prisoners of central jail, Hindalga, Belgaum, Karnataka, India, reported 2%
prevalence of TB (Bellad et al., 2007). A Karachi central prison study from Pakistan
reported that pulmonary tuberculosis was 3.75 times more common among prisoners than
in the general population (Rao, 2004). Lower rates from developing countries can be
attributed to the sampling procedure, case detection methods employed and high rates of
tuberculosis in the general population. Although correctional facilities are recognised as
ideal settings for interventions, little is known about the TB epidemiology within prison
settings of India.

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Figure 1: The continuum between the community and prison

Prisoners come from the community and they return to the community. People
entering prisons are at high risk for mental health problems and vulnerable to
human rights violations. They may develop mental illnesses secondary to stress.
They may come with or initiate drugs/substance use in prison. They may suffer
from physical illnesses or have high risk behaviours such as unprotected sex,
aggression/violence, low frustration tolerance and contact with anti-social groups.
If appropriate interventions are not provided, they carry these problems back into
the community upon release. This scenario is particularly relevant in the current
prison system in India.

Various factors play a crucial role in leading to high prevalence of TB in prisons. These
include overcrowding, illiteracy, poor knowledge, stigma, fear of isolation, drug non-
compliance, and non-availability of screening as well as inadequate health services inside

5
the prisons (Coninx et al., 2000). The problem is particularly acute for tuberculosis (TB)
and is exacerbated by crowding and HIV infection (The Lancet Infectious, 2007).
Infections and stress related disorders contribute majorly towards morbidity in prisons
(Massoglia, 2008).

Human Immune-deficiency Virus

Rates of Human Immunodeficiency Virus (HIV) are five times and Hepatitis C virus
infection (HCV) 17-28-times higher in prisons than in the general population (Flanigan et
al., 2009). People in prison are at risk of contracting HIV through injecting drugs,
unprotected sex and tattooing (Polonsky et al., 1994; Strike and Sutherland, 1994). Non-
availability of conjugal rights and long stay in prison increases homosexual activities.
However, there are studies that argue that most inmates with HIV infection acquire it
from the outside community; prisons do not seem to be an amplifying reservoir
(Spaulding et al., 2002). A majority of persons, who enter a correctional facility today
will return home in the near future. Hence, the present challenge is how correctional
health services deal with the HIV-infected person and this has important implications on
the overall care of HIV-infected people in the community.

A systematic review of published and grey literature of Nepal was carried out by the
National HIV Strategy of Nepal. Results of the study reported that prison conditions are
poor and there is no accurate information regarding HIV prevalence or risk behaviours
among prisoners. HIV prevention interventions have largely been limited to ad hoc
training workshops. Antiretroviral treatment is not available to HIV infected prisoners.
HIV prevention and care remains largely non-existent in Nepal's prisons (Dolan and
Larney, 2009).

A qualitative exploration of the state of health care services with regard to inmates with
HIV/AIDS was prepared from narratives obtained through face-to-face, in-depth,
unstructured interviews, in three correctional facilities in the state of Maharashtra. Results
of the study highlighted that high-risk behaviour among prisoners, inadequate access to
health care services for HIV-positive inmates, and lack of HIV/AIDS prevention
programmes are some of the major areas of concern. The study emphasised the urgent
need for active collaboration with the National Aids Control Programme (Guin, 2009).
Anonymous unlinked volunteer testing was offered to 15000 jail inmates across nine jails
in six cities of Sindh in Pakistan. Only 4987 (33%) agreed to be tested, using a rapid

6
testing kit for HIV. The overall HIV prevalence was 1% (n = 49) in the study sample
(Safdar et al., 2009).

Challenges in implementing HIV prevention programmes in prisons

Whether:

a) HIV and STI testing should be mandatory or voluntary in prisons,

b) urine drug screening of the new entrants should be made mandatory,
c) prisoners must be integrated or segregated by HIV serostatus,
d) condom promotion programmes need to be implemented in prisons,
e) needle exchange programme/availability of clean needles should be ensured,
f) conjugal rights needs to be granted to the prisoners and
g) opioid replacement therapy must be provided in prisons
These issues often have conflicting responses from the judiciary, prison officials and
public health officials.

A screening of incarcerated populations of the Los Angeles County Men's Jail,

particularly men who have sex with men (MSM), for the identification, treatment, and
prevention of sexually transmitted infections (STI) and HIV was carried out recently. A
total of 7004 inmates participated in the screening programme. The overall positivity rate
for chlamydia was 3.1% (127 of 4157) and 1.7% (69 of 4106) for gonorrhea. In addition,
early syphilis was identified in 1.6% of inmates (95 of 6008) and the overall prevalence
of HIV was 13.4% (625 of 4658). This Los Angeles study revealed a high prevalence of
STI and HIV infection in prisons (Javanbakht et al., 2009). Another group of incarcerated
people who are at high risk of developing HIV are drugs users (Strike and Sutherland,
1994). Injection drug users (IDU), crack smokers, and commercial sex workers engage in
illegal activities that place them at risk for HIV infection and also getting arrested
(Carpenter et al., 1999). The potential for HIV transmission by contaminated equipment
(needle and syringes) still exists in prison, where IDUs do not have access to new needles
and syringes (Davies et al., 1995). Though needles and syringes are not available easily,
the availability of drugs inside prisons is common world over. The correctional setting
provides an excellent opportunity to screen for and treat sexually transmitted infections
(STIs) and HIV. Along with the opportunity, there are certain obstacles that correctional
institutions are faced with such as legal, ethical and moral issues. Though there are many
unanswered questions regarding HIV prevention programmes, at least education and risk-

7
reduction counselling are the least controversial modes of prevention. These modes must
necessarily be implemented by the government without fail. Another prevention
programme which can be considered for implementation is opioid substitution treatment.
A recent systematic review of the evidence on opioid substitution treatment (OST) in
prisons reported that OST should be implemented in prisons as part of comprehensive
HIV prevention programmes. Opioid substitution treatment has played a significant role
in decreasing sharing of needles and syringes by intravenous drug users. This helped in
keeping some control over HIV incidence in prisons (Larney, 2010). Drug substitution
treatment and needle exchange programmes in German and European countries have
been found to be effective (Stoever, 2002).

There is an urgent need to address the issues of HIV in prisons. A link between area HIV
specialists and correctional health care providers is an important partnership for ensuring
that HIV-infected patients have optimal care both inside prison and after release.
However, most countries have largely neglected HIV prevention and care in prisons.

Other Communicable Diseases

Prisons in India are plagued with various communicable diseases as shown in the
accompanying box.

Overcrowding, unhygienic environment, malnutrition and non-availability of health

facilities play a crucial role in the health of prisoners. Hence, prisons are known for
frequent out-breaks of illness (Wolfe et al., 2001). Unfortunately, none of them come to
the notice of the civil society or the concerned health authorities.

Communicable diseases can be intervened against easily and effectively, if we understand

the modes of transmission. Figure 2 depicts the modes of transmission of communicable
diseases in prisons. Though sexually transmitted diseases are a known phenomenon in
prison population, minimal efforts are taken to address them. Simple measures such as
health education and counselling on healthy behaviour can curtail and prevent many
communicable diseases (Bick, 2007). Modes of transmission of communicable diseases
are similar to those in the community, but are amplified several times in prisons because
of overcrowding and unhealthy environments. Unfortunately, non-availability of timely
medical interventions contributes to both morbidity and mortality.

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 COMMUNICABLE DISEASES IN PRISONS

Food or Waterborne Diseases:

Typhoid fever -In this bacterial disease the patient usually exhibit sustained high fevers; left
untreated, mortality rates can reach 20%.
Food poisoning -This may be either bacterial or viral and patients exhibit abdominal pain, vomiting,
diarrhoea and sometimes fever.
Cholera -Bacterial disease presenting as painless diarrhoea in patients
Amoebiasis -Occurs because of entamoeba histolytica parasites and causes abdominal pain,
diarrhoea and loss of appetite
Hepatitis A & E - In these viral diseases, the patient usually exhibits fever, jaundice and diarrhoea.

Blood borne diseases:

Hepatitis C & B -Typically present with jaundice, tiredness, upset stomach, fever, loss of appetite,
diarrhoea, light-coloured stools and dark yellow urine.
HIV -Immunodeficiency virus disables the immune system and affected persons contract
infections easily.

Vectorborne diseases:
Malaria - Caused by single-cell parasitic protozoa Plasmodium; transmitted to humans via the
bite of the female Anopheles mosquito; patients exhibit in cycles of fever, chills, and
sweats.
Dengue fever - Mosquito-borne (Aedes aegypti) viral disease; manifests as sudden onset of fever
and severe headache; occasionally produces shock and hemorrhage leading to death
in 5% of cases.
Chikungunya - Mosquito-borne (Aedes aegypti) viral disease, similar to Dengue Fever;
characterised by sudden onset of fever, rash, and severe joint pain usually lasting 3-7
days, some cases result in persistent arthritis.
Japanese
Encephalitis -Mosquito-borne (Culex tritaeniorhynchus) viral disease can progress to paralysis,
coma, and death; fatality rates 30%.

Airborne diseases:
Upper respiratory
tract infection - Bacterial or viral diseases characterised by cough, fever, sneezing, sore throat,
fatigue and nasal discharge.
Lower respiratory
tract infection - Bacterial or viral diseases characterised by shortness of breath, weakness, high
fever, coughing and fatigue
Meningococcal
meningitis - Bacterial disease transmitted from person to person by respiratory droplets causing
stiff neck, high fever, headaches, and vomiting; facilitated by close and prolonged
contact resulting from crowded living conditions; death occurs in 5-15% of cases.

Sexually Transmitted Diseases:

HIV, Hepatitis A & B, Syphilis, Gonorrhoea, Chlamydia and Genital Herpes.

9
There are horrifying incidents of deaths in closed care settings. A retrospective study was
conducted in Nagpur to investigate the cause of deaths of people in custody from the year
2000 to 2004 (Rajesh et al., 2005). Findings of the study clearly indicated that 43%
(n=30) of the deaths occurred because of infections. Tuberculosis contributed to 30% (21)
of the total deaths followed by ischaemic heart disease 17% (n=12). Furthermore, 7.14%
of inmates had anaemia and 5.71% had hypertension (Rajesh et al., 2005). Another
similar study from Maharashtra prisons reported that tuberculosis related deaths were
maximum at 52% (n=34), followed by coronary artery disease 34% (n=22) (Sonar, 2010).

Figure 2: Common modes of transmission of communicable diseases in prisons

The Central Prison Mental Health study of Bangalore (Math et al., 2011) clearly depicted
the morbidity and mortality because of communicable diseases. There are 4500 to 7000
consultations each month, and the most common consultations are for skin disease (40%),
and gastrointestinal problems (20%). HIV seropositivity in 2008 was 3% which is much
higher than seroprevalence figures for Karnataka at 0.69% (figure from NFHS 3 2005-
2006). Deaths due to HIV related infections are also on the rise in many other Indian
prisons.

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NON-COMMUNICABLE DISEASES (NCD)

Non-communicable diseases (NCD) are those disorders which do not spread from one
person to another. NCDs are now recognised as a major cause for mortality (Murray and
Lopez, 1997b) (death), and morbidity (burden, dysfunction, or impairment in the quality
of life) (Boutayeb and Boutayeb, 2005; Lopez et al., 2006; Murray et al., 1996). Though
these disorders are recognised worldwide, they continue to be ignored by the policy
makers investing in health. Most common NCDs are depicted in the accompanying box.

Non-communicable diseases:

 Cardiovascular Diseases – Hypertension, Coronary vascular disease

 Mental disorders- Depression, Obsessive compulsive disorders, Psychosis and
Mental retardation
 Substance use disorders – Alcohol, Nicotine, Cannabis, Opioids, Cocaine
Inhalants and Amphetamine. Intoxication, harmful use or dependence syndrome.
 Neurological disorders – Epilepsy, Stroke
 Injuries -Road Traffic Accidents, Fights/wars, Disasters
 Endocrinological Disorders- Diabetes Mellitus
 Cancers - Oral, Lung and Cervical,
 Respiratory Diseases – Chronic obstructive pulmonary diseases, Asthma

World Health Report 2001 has indicated that non-communicable diseases accounted for
nearly 60% of deaths and 46% of the global burden of diseases (Murray et al., 1996).
Risk factors such as a person's lifestyle, high blood pressure and high blood cholesterol,
tobacco and excessive alcohol consumption, overweight, obesity and physical inactivity,
genetics and environment are known to increase the likelihood of certain non-
communicable diseases (Ezzati et al., 2002; Murray and Lopez, 1997a). These risk
factors raise the risks of coronary heart disease, stroke, diabetes mellitus and many forms
of cancer (Daar et al., 2007).

Along with the challenges of contagious diseases, India is also facing the challenges of
NCDs (World Health Organisation, 2002). Prison health system also faces similar
challenges but in an accentuated manner. The factors contributing to NCDS in prisons are
summarised in the accompanying box.

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Among the non-communicable diseases, coronary artery diseases contribute to 17-34% of
the total deaths in the Indian prison population (Rajesh et al., 2005; Sonar, 2010).
Percentage of deaths due to suicide was 5-8% in prison (Sonar, 2010). Custodial deaths in
India awaken the judiciary and attract media attention. Unfortunately, many a time,
deaths due to inadequate medical facilities or medical attention in prisons rarely reaches
the media. Available data suggests that deaths due to medical illness account for 80-90%
of all deaths (Rajesh et al., 2005; Sonar, 2010).

Factors contributing to the development of NCDs in prison

 Physical inactivity, idleness, boredom and poor motivation to do work
 Being overweight and obese
 Unstructured daily activity
 Stressful environment
 Unhealthy food
 Physical violence, intimidation and bullying
 Sexual violence
 Mental health problems such as depression, anxiety, adjustment problems and
psychosis
 Tobacco, cannabis, opioid, cocaine and other use
 Deliberate self harm and suicide

Mental disorders and substance use problems in prison

Mental disorders are major public health problems. They are present in all cultures and
societies. The prevalence of mental disorders in the Indian population is found to be 8-
12% (Math et al., 2007). It is a sad reality, that at any point in time, a high proportion of
those with mental health problems are incarcerated in the prisons of each country (Møller
et al., 2007). Prisoners have greater physical and mental health needs compared to the
general population (Hammett et al., 2001). The prevalence of mental disorders in prisons
is high, but access to services to treat them is often very low (Fazel and Danesh, 2002;
Steadman et al., 2009; Taylor, 2010).

The National Commission on Correctional Health Care in the US found that on any given
day, between 2% and 4% of inmates in state prisons were estimated to have
schizophrenia or a psychotic disorder and between 2% and 4% were estimated to have a
manic episode. Between 13% and 18% of prisoners were estimated to have experienced a

12
major depressive episode during their life time (Veysey and Bichler-Robertson 2002).
Similarly, prison rates of mental illness were higher than the rates reported in a nationally
representative population used in the National Comorbidity Survey (Kessler et al., 1994).

A systematic review by Fazel and Danesh of 62 studies from 12 countries, in 2002,

included 22790 prisoners. The overall prevalence of psychiatric disorders in prison
populations was as follows: 3.7% of men had psychotic illnesses, 10% major depression,
and 65% a personality disorder; 4.0% of women had psychotic illnesses, 12% major
depression, and 42% a personality disorder (Fazel and Danesh, 2002). The rate of current
serious mental illness for male inmates was 14% and for female inmates it was 31%
(Steadman et al., 2009).

In an Australian study, the 12-month prevalence of any psychiatric illness in the previous
year was 80% in prisoners and 31% in the community. Substantially more psychiatric
morbidity was detected among prisoners than in the community group after accounting
for demographic differences, particularly, symptoms of psychosis, substance use
disorders and personality disorders (Butler et al., 2006). Drugs are related to crime in
multiple ways. Most directly, it is a crime to use, possess, manufacture, or distribute
drugs classified as having a potential for abuse (such as cocaine, heroin, marijuana, and
amphetamines). Drugs are also related to crime through the effects they have on the user's
behaviour and by generating violence and perpetuating illegal activity. Hence, it is said
that violence, crime and drug use go hand-in-hand (US Drug Enforcement
Adminstration). Use of substances such as alcohol, nicotine, cannabis, cocaine, opioid
and amphetamines are very common among prisoners (Fazel and Danesh, 2002).

Available data indicates that a) the prevalence of mental illness in prison settings is
significantly higher than the prevalence in the general population and it is approximately
3-6 times higher than the general population (Andersen, 2004; Fazel and Danesh, 2002;
Lamb and Weinberger, 1998; Taylor, 2010; Wilper et al., 2009); b) substance use
disorders (alcohol, nicotine, cannabis, opioid, cocaine, benzodiazepines and other drugs)
are the most frequently diagnosed condition (Wilper et al., 2009); c) other commonly
occurring mental disorders are Depression, Anxiety disorders, Personality disorders and
Psychosis (Andersen, 2004; Fazel and Danesh, 2002; Lamb and Weinberger, 1998).
However, there is paucity of data regarding the mental morbidity in prisons from the
Indian subcontinent. To explore the mental health morbidity in Indian prisons, a study
was undertaken by the National Institute of Mental Health Neuro Sciences, Bangalore in

13
the Central Prison, Bangalore in Collaboration with Prison Department, Karnataka. This
study was funded by Karnataka State Legal Service Authority, Bangalore (Math et al.,
2011).

The Central Prison, Bangalore Study

Data from the Central Prison, Bangalore (Math et al., 2011), reported 17 deaths in 2006,
22 deaths in 2007, 38 deaths in 2008, and 29 deaths in 2009 (until November). During
this period, there were 9 deaths from suicide, mainly hanging. Analysis of the 38 deaths
in 2008 indicates HIV as the cause in 26%, cardiac causes in 23%, cancer in 17%, TB in
9%. Four deaths were from suicide (11%) and in one case, use of ganja (cannabis) was
recorded. All the patients who had died in 2008 had died following transfer to general or
specialised hospitals. This study also indicates that 55% of deaths are due to NCD and
35% of the deaths were due to infections.

About 5% of the resident prisoners and 4.5% of new entrants tested randomly had
positive urine sugar. On interview, only 3% had reported having diabetes, but urine
screening helped to double the diabetes detection rate in prison. Nearly one in three
prisoners was underweight with a BMI below 18.5 and one in 10 resident prisoners could
be classified as being overweight or obese. According to the MINI psychiatric diagnosis,
79.6% (n=4002) individuals could be diagnosed as having a diagnosis of either mental
illness or substance use. Recent studies suggest similar rates of mental morbidity in
diverse countries such as Australia (80%) and Iran (88%).

A large part of the mental morbidity is contributed by substance abuse and its related
consequences. 67.3% of the prison population reported ever using (lifetime) tobacco in
some form in their lives and 43.5% of resident prisoners fulfilled diagnostic criteria for
lifetime alcohol dependence and 14% for current alcohol dependence (year prior to prison
entry). After excluding substance abuse, 1389 (27.6%) prisoners still had a diagnosable
mental disorder. 2.2% of the prison population had a diagnosis of psychosis, primarily
schizophrenia (Severe mental disorder). This is twice that of the general population.
Considering that only 2% of the prison population self-reported any mental illness, it can
be understood that a systematic assessment improves identification of diagnosable mental
disorder by fourteen times.

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 Drug related
3%
Others
Suicide HIV
11%
11% 26%

TB
Cancer 9%
17%
Cardiac causes
23%

Figure 3: Causes of deaths in Prison

Despite increasing evidence that addiction/substance use is a treatable disease of the

brain, most individuals do not receive treatment. Involvement in the criminal justice
system often results from illegal drug-seeking behaviour, intoxication related violence,
and participation in illegal activities. Treating these substance using offenders provides a
unique opportunity to decrease substance abuse and reduce associated criminal
behaviour.

Factors in prison that adversely affect mental health

Factors in prisons that may adversely affect mental health include overcrowding, dirty
and depressing environments, poor food, inadequate health care, physical or verbal
aggression. Lack of purposeful activity, lack of privacy, lack of opportunities for quiet
relaxation and reflection aggravate mental distress. The availability of illicit drugs can
compound emotional and behavioural problems in prison. Reactions of guilt or shame,
anxiety of being separated from family and friends and worries about the future also
compound such mental distress. Timely identification, treatment and rehabilitation are
almost non-existent in many prisons, particularly in the developing countries. In some
countries, mentally ill people are inappropriately locked up in jails because of inadequate
mental health services. In many others, people with substance abuse problems are often

15
sent to prison rather than for treatment. In developed countries where institutional care
for the mentally ill has declined and community care is not optimal, prisons have become
custodians of persons with mental illness, which is also called as
„transinstitutionalisation‟ (Priebe et al., 2005). In such countries, is well known that
persons with mental illness languish in prisons for several years as they are unfit to stand
trial. Prisons in the developing world, in addition to having many of the problems faced
in prisons of the developed countries, have special challenges. These include inadequate
penal and judicial systems and prison resources, with resultant delays in access to justice
and speedy trial. Inadequate attention to the human rights of persons in prison, including
the right to decent living, clean and congenial existence, speedy trial, information and
communication and right to health care, particularly mental health care, further
aggravates the situation.

High-Risk behaviours

High-risk behaviours such as violence towards self (suicide and deliberate self-harm) and
others (homicidal behaviour), sexual violence, substance use, bullying, intimidation and
gang fights within the prison are also well known. Physical and sexual assault are part of
the prison experience. Approximately 21% of male inmates are physically assaulted
during a 6-month period. Sexual assault is estimated at between 2% and 5%. The high
prevalence of sexual activity in prisons not been fully acknowledged (The Lancet
Infectious, 2007). Although evidence of the prevalence is growing, less is known about
the circumstances surrounding and resulting from these incidents (Lopez et al., 2006).

Suicide, deliberate self-harm and violence towards others are difficult behaviours to
handle in the prison settings. These behaviours need to be addressed by various
behavioural techniques such as counselling, anger management techniques, family
therapy, de-addiction counselling, therapeutic community and life skills training (Day
and Doyle, 2010). The World Health Organization has advocated life skills training
programme for offenders so that possibility of reoffending (Greenwood, 2008; Krug et
al., 2002; MacKenzie, 2006; World Health Organization., 1997), as also substance use
decreases (Botvin and Kantor, 2000). Lifeskills are abilities for adaptive and positive
behaviours that enable individuals to deal effectively with the demands and challenges of
everyday life (World Health Organization., 1997). A list of 10 lifeskills, described as
generic lifeskills for psychosocial competence, was identified by WHO as core lifeskills
and these skills have been successfully implemented to curtail sexually transmitted

16
diseases, HIV prevention programmes, rehabilitate sexual offenders, prevent mental
illness, in the management of substance use, school mental health programme and anger
management. Integrated rehabilitation from both a physical and mental health perspective
is a distant dream in developing countries.

Health Research in Prisons

In India, attempts to identify priority diseases in prisons and manage them effectively are
very few. There have been no systematic studies examining these issues. Health related
interventions in prisons have not been scrutinised or evaluated. Challenges like prison
security, ethical and legal considerations in studying prison populations, non-availability
of trained man power and lack of funding, are critical challenges in conducting research
in prisons. Another important issue is that the public health system accords a low priority
for prisons and prison policies have focused little on improving health services within the
prison. Rapid turnover and frequent movement of undertrials in Indian prisons makes
them difficult settings in which to quantify the prevalence of various diseases.
Intervention based studies are minimal. Research on efficacy and cost effectiveness of
rehabilitation programmes is hardly possibly in the absence of any worthwhile
rehabilitation programmes in prison settings.

In the proposed model (see in figure no-1) the following interventions are required:
creation of awareness, education and protection of human rights in prisons. Prison
health needs to be considered as a public health priority and implementation of all
the national health programmes inside the prison must be mandatory. Identifying
and treating mental illnesses must be a priority. Availability of de-addiction
treatment inside will provide an opportunity to the prisoners to recover from
addiction. Identifying and treating contagious illnesses will improve health within
the prison and prevent the prison from being a reservoir of infection for the
community. Creating self-help groups within the prisons can help in creating
awareness about AIDS, HIV, domestic violence and human rights. Availability of
counsellors will help in training in life skills, anger management, family
counselling and modifying high risk behaviours through various behaviour
therapies.

17
In conclusion, prison health is often neglected and continues to be ignored despite
accumulating objective evidence supporting the need for rational health policies in
prisons. Politicians, policy makers, bureaucrats and community leaders have ignored this
area, citing various reasons such as „prisoners need not be treated‟, „let them suffer‟,
insufficient funds, non-availability of trained manpower, the presence of other pressing
needs, and that the law does not permit such interventions. Many prisoners with serious
physical and mental disorders fail to receive care while incarcerated. Furthermore, public-
health strategies adopted in the community are ignored in the prison setting (The Lancet
Infectious, 2007) Despite the high prevalence of tuberculosis, drugs use and HIV in
prisons, screening for such diseases is rarely available on entry into prison. There is no
access to health promotion and comprehensive treatment. In India, there has been little
systematic assessment of the prevalence and patterns of mental morbidity among
prisoners. Research in prison is a need to be encouraged so that effective interventions
can be planned. Examples include systematic collection of data and evaluation of HIV
prevention strategies in prisons (Kate et al., 2007).

Unfortunately mental health needs of prisoners are completely unrecognised. Even in

situations where they might be recognised, the responses are largely individualised and
systemic response to the problem is absent. Providing treatment for substance use, mental
illness and high risk behaviours benefits both prisoners and the wider community.
Improvements are needed both in correctional health care and in community mental
health services in order to prevent crime and incarceration.

18
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 3. SUBSTANCE USE PROBLEMS IN PRISONS

World over, it has been established that prisons have a high prevalence of mental health
and substance use problems. Substance use related disorders have serious consequences
on self and others. Although they are considered under the broad rubric of mental
disorders, here they are considered separately because of their magnitude, severity and
implications, particularly in prison settings.

As in the case of mental illnesses, substance abuse (that is, the abuse of tobacco, alcohol
or other drugs) may be present either prior to prison entry, develop or get exacerbated in
prison and persist after release from prison. Prison administrators have a responsibility to
guard both against (a) new problems emerging from drug use in prisons and (b)
exacerbating problems that existed at the time of prison entry.

There is abundant literature on drug use in prison settings from several countries across
the world. However, such data is often complex and difficult to interpret. The situation in
developing countries is very different. There is hardly any published literature on drug
use in prison settings. In this chapter, a summary of selected literature from different
countries is presented to give an idea about the extent and patterns of drug use in prison.
The findings of the Bangalore Prison Mental Health Study (Math et al., 2011) findings
with respect to substance use are summarised and compared to findings from other parts
of the world. Successful prison programmes and guidelines formulated to prevent and
address substance use problems in prison are also discussed.

Problems associated with substance use

Substance uses, particularly the use of illicit drugs, injecting drug use or alcohol bingeing
are associated with high rates of mortality and morbidity. Injecting drug users carry the
risk of overdose leading to respiratory depression, seizures and death. There is a
heightened risk of infection from both injecting drug use and unprotected sexual contact
to HIV, Hepatitis B & C and other conditions. Alcohol intoxication is associated with
violence. Acute intoxication with cannabis can produce altered sensorium, disinhibition,
paranoid ideation, mood changes and hallucinatory experiences. Cocaine and stimulants
like amphetamines can also produce acute behavioural changes. Inhalants cause severe
organ damage and can seriously affect the brain.

23
Diagnosis of Substance Dependence
Dependence has been defined in ICD10 as “A cluster of physiological, behavioural
and cognitive phenomena in which use of a substance or a class of substances takes on a
much higher priority for a given individual than other behaviors that once had greater value”
The criteria for substance dependence syndrome has been influenced by the criteria laid down
by Edwards and Gross (1976) for the diagnosis of Alcohol dependence syndrome. Though
Edwards and Gross laid down the criteria particularly for alcohol dependence, this has been
used uniformly to diagnose all classes of substance dependence.

The ICD 10 criteria specifies dependence as three or more experiences exhibited at some
time during a one year period
1. Tolerance: there is a need for significantly increased amounts of the substance to
achieve intoxication or the desired effect. For e.g., an individual would have started
with 60 ml of whisky to obtain pleasure, however with continuous use, he has to
consume 180 ml of the same to obtain the same amount of high.
2. Physiological withdrawal state: characteristic symptoms experienced on
stoppage/reduction of a substance after prolonged use. The patient uses the same (or
closely related) substance to relieve or avoid withdrawal symptoms (every class of
substance produces its own set of signs/ symptoms of withdrawal. For e.g. alcohol
withdrawal would produce tremors, sweating, nausea/ retching/ vomiting, insomnia,
palpitations with tachycardia, hypertension, headache, psychomotor agitation and in
severe cases, hallucinations, disorientation and grand mal seizures).
3. Impaired capacity to control substance use behaviour in terms of its onset,
termination or level of use as evidenced by the substance being often taken in
larger amounts or over a longer period than intended; or by a persistent desire or
unsuccessful efforts to reduce or control substance use. Some researchers are of the
view that loss of control is the most important criterion determining substance use.
4. Preoccupation with substance use, as manifested by important alternative pleasures
or interests being given up or reduced because of substance use; or a great deal of
time spent in activities necessary to obtain, take or recover from the effects of the
substance.
5. Continued use in spite of clear evidence of harmful consequences, as evidenced by
continued use when the individual is actually aware, or may be expected to be aware,
of the nature and extent of harm.
6. Strong desire to use substance (craving).This craving may occur spontaneously or
induced by the presence of particular stimuli.

Criteria (1) and (4) are physiological, while criteria (3), (4) and (6) are psychological in
nature. Thus, not one domain is sufficient to diagnose dependence. For e.g. cancer patients
who are given opioids as analgesics may have tolerance and withdrawal. However they may
not be diagnosed as having a dependence syndrome unless they fulfill other criteria. The
dependence syndrome criteria are not an all or none state, rather they exist in degrees of
severity.

24
While many substance users begin use on an experimental or recreational basis, many
users progress to regular use and dependence. There are different patterns of problematic
use of substances (tobacco, alcohol and other drugs). This includes use to intoxication,
harmful use and dependence. The features of dependence are summarised in the
accompanying box.

Factors that mediate substance use initiation and progression to dependence

The dangers from substance use emerge from the unpredictable effects on the user, poor
control on the amount used, mode of use (inhaling, injecting etc), the pharmacological
properties of the substance or drug, and the biological and psychological makeup of the
user. The interactive risk and protective factors that encourage or discourage problem
substance use and dependence are summarised in Figure 1. While the initial decision to
take drugs is mostly voluntary, once drug abuse and dependence takes over, a person's
ability to exert self-control can become seriously impaired. Withdrawal, craving and loss
of control are important triggers for continuing substance use.

Community prevalence of drug use

India has a huge burden of both licit or legal substance use (tobacco and alcohol) as well
as illicit substances (Murthy et al., 2010). The National Household Survey of Drug Use in
the country (NHSDA, Ray et al., 2004) was the first systematic effort to document the
nation-wide prevalence of drug use. Alcohol (21.4%) was the primary substance used
(apart from tobacco) followed by cannabis (3.0%) and opioids (0.7%) among men. Rapid
assessment surveys are making it evident that pharmaceutical medications like
buprenorphine and benzodiazepines are increasingly being abused among both men and
women (Murthy, 2008).

Drug use in prisons

In the European Union (European Monitoring Centre for Drugs and Drug Addiction 2004
or EMCDDA, 2004), 22% to 86% of prison populations in EU countries reported ever
having used an illicit drug. In this region, 16-54% of inmates used drugs in prisons and 5-
36% used them regularly (EMCDDA, 2004). Several studies in Europe also suggest that
between 3 to 26% of drug users report their first use of drugs while in prison and between

25
0.4 and 21% on injecting drug users (IDUs) started injecting in prison (National Report
2001).

Figure 1: Mediators of substance abuse and dependence

Fazel et al‟s (2006) review of 13 studies of 7563 prisoners estimates prevalence for
alcohol abuse and dependence in male prisoners to range from 18 to 30% and drug abuse
and dependence to vary from 10 to 48% for male prisoners and 30% to 60% for female
prisoners at the point of incarceration. In a Nigerian prison, according to Williams et al
(2005), lifetime use of any substance among the prison population was 85.5%. 27.7% of
prisoners reported current drug use, and dependent use was estimated to be 12.5%. In the

26
United States, the number of people incarcerated annually for drug-related offences in the
past 20 years has grown from 40,000 to 450,000, leading to prison populations with high
rates of drug use (Stover and Michels, 2010). Another study in Lithuanian prisons
(Narkauskaitė et al., 2007) showed that 48.7% of prisoners had ever used drugs. The
experience from Tihar Jail shows that about 8% of new entrants come with drug
addiction problems (Tihar Jail, 2009; UNODC, 2007).

Findings from the Bangalore Prison Mental Health and Substance Use study
(BPMHSU study)

In this study (Math et al., 2011) of 5024 prisoners, 79.6% of individuals could be
diagnosed as having a diagnosis of either mental illness or substance use, and a large part
of the mental morbidity is contributed by substance abuse and its related consequences.
Recent studies suggest similar rates of mental morbidity in diverse countries such as
Australia (80%) and Iran (88%).

During their lifetime, 45% of the prison population reported using some substance or
other in a dependent fashion. A majority of this is attributable to tobacco and alcohol
dependence. Lifetime dependence on all substances was significantly higher among UT
prisoners than convicted prisoners. During the last year, 15.7% of UT prisoners met
criteria for alcohol dependence. This is more than 3 times the prevalence of dependence
in the general population (Ray, 2004).

The problem of tobacco

Tobacco is a highly addictive substance. Worldwide, it is estimated that 1.9 billion people
currently smoke. The greatest proportion of people affected can be found in the
developed world, where smokeless forms of tobacco are also rampant. According to the
WHO, tobacco is the second leading cause of death in developed and developing
countries. Tobacco will eventually kill one in two users; it is responsible for the death of
one in ten adults‟ worldwide, with 4.9 million deaths occurring worldwide each year. It is
estimated that it will cause some 10 million deaths each year by 2020, assuming the
current smoking patterns continue (WHO, 2007).

27
Tobacco use in India: According to the National Family Household Survey 3 (2005-
2006), 57% of men and 10.8% of women use tobacco in some form or the other (Murthy
and Saddichha, 2010) and tobacco use is a major cause of preventable death and disease.
The recently published Global Adult Tobacco Survey (GATS, 2009-10) reports that
47.9% of men and 20.3% of women use tobacco in India. However, these figures are
lower for men and higher for women in Karnataka. An ICMR study carried out in 2001,
where the prevalence of current use of tobacco in any form in Karnataka was 32.7%
among urban men and 42.9% among rural men, 8.5% among urban women; and 16.4%
among rural women.

Tobacco use in prisons: Although few studies have been carried out on the prevalence of
tobacco use in penal facilities, American scientists admit that, according to the available
data, the majority of inmates smoke (Bobak et al., 2000). In the Nigerian prison study,
among drugs being currently used, nicotine is the most frequently (22.9%) reported
(Williams et al., 2005). In the study in Lithuanian prisons (Narkauskaitė et al., 2007)
85.3% currently smoked tobacco.

In the Bangalore Prison study (Math et al., 2011), 67.3% of the prison population
reported ever using (lifetime) tobacco in some form in their lives. This is more than
double the tobacco use prevalence in Karnataka (29.6%-figure for 2001). 60.2% reported
ever smoking tobacco and 14% ever chewing tobacco. 97% of those who smoked or
chewed tobacco had been using tobacco in the year prior to prison entry. Undertrial
prisoners were significantly more likely to have ever smoked or chewed tobacco
compared to convict prisoners. Among new male entrants into the prison, 74.3% reported
using tobacco and 71.9% reported using tobacco during the month prior to prison entry.

Tobacco use pattern after entry into prison: Undertrials had increased their smoking from
an average of 9.2 sticks per day before prison entry to 34.3 sticks per day in the last week
in prison. Convict prisoners had increased their smoking from 11.4 sticks to 44.9 sticks.
Among those who chewed tobacco, UTPs had increased their use from 8.3 sachets prior
to prison entry to 20.9 sachets in the last week in prison, and CTPs had increased
consumption from 8.7 sachets to 10.8 sachets. Thus, smoking among UTPs and CTPs
increased about four times after coming into prison. Chewing tobacco increased
marginally among CTPs after prison entry and about two and half times among UTPs.

28
The problem of alcohol

Worldwide, alcohol and illicit drug use account for 5.4% of the world's annual disease
burden, with tobacco responsible for 3.7% (WHO, 2010). Alcohol consumption is the
leading risk factor for disease (WHO, 2004). Apart from the direct effects of intoxication
and dependence resulting from alcohol use disorders, alcohol is estimated to cause about
20–30% of each of the following worldwide due to: oesophageal cancer, liver cancer,
cirrhosis of the liver, homicide, epilepsy and motor vehicle accidents. In the late 1990s it
was estimated that 4.2% of the global population aged 15 and over used illicit drugs,
causing 0.8% of the total burden of disability. While research has shown that it is difficult
to demonstrate a clear causal relationship between alcohol and violent crime, the British
Medical Association has estimated that either the offender or victim has consumed
alcohol in 65% of homicides, 75% of stabbings, 70% of assaults and half of all domestic
assaults. In the UK it has been estimated that 78% of assaults are committed under the
influence of alcohol (Prime Minister‟s strategy, 2003).

Alcohol use in India: Nearly one third of adult men and approximately 5% of adult
women use alcohol in India. Per capital alcohol consumption in India is steadily
increasing. Alcohol carries a huge health burden as well as serious social and
psychological consequences (Benegal et al., 2005; Gururaj et al., 2006; Gururaj et al.,
2011). Alcohol carries with it a high societal burden.

Alcohol use in prisons: Williams et al., (2005), in their study in a Nigerian prison found
that in terms of lifetime use of any substance, alcohol use was reportedly the highest
(77.5%) among prisoners. In France, in 2003, just over 30% reported alcohol abuse and a
third regular drug use in the past 12 months (Mouquet et al., 2005). In the Lithuanian
prison study (Narkauskaitė et al., 2007), 92.1% of prisoners reported having used alcohol
at least once in their lives.

Few studies have focused on standardised diagnoses of alcohol or drug abuse/dependence

(AAD and DAD) among prisoners, and most have been limited to incoming or remanded
prisoners: estimates ranging from 25% to 74% for DAD and from 21% to 50% for AAD
have been reported (Peters et al., 1998, Lo et al., 2000). A New Zealand study revealed
that 81% of the prisoners had a lifetime alcohol disorder, and 39% of them had symptoms
in the 6 months prior to incarceration. Half of the prisoners had met criteria for an

29
alcohol-dependence syndrome. Thirty percent had a lifetime drug use disorder with 14%
showing symptoms in the last 6 months prior to incarceration. One-quarter had been drug
dependent. Alcohol disorder was more than twice as common among prisoners as in the
general population (Bushnell et al., 1997).

In the developed world, while correctional systems have been conscious of the
relationship between alcohol use disorders and crime (Graham et al., 2001) they have
traditionally focused on providing treatment intervention for prisoners whose crimes are
drug related. While both the United States (US) and the United Kingdom (UK) have
developed National Strategies supported by significant levels of funding to address the
problems of illicit drug use, there remains a conspicuous absence of priorities in
addressing the social and economic consequences of licit substances like alcohol.

In the Bangalore study (Math et al., 2011), more than one in two prisoners (51.5%)
reported lifetime alcohol use. This is more than double the national prevalence of alcohol
use (21%). Of those who reported ever drinking, 86% had AUDIT scores above 8
indicating harmful drinking patterns. Mean AUDIT score was 17 and was comparable
between UTPs and CTPs. UTPs had started drinking alcohol at a mean age of 19.4 years
and CTPs at a mean age of 21.4 years. Among new entrants, 58% reported ever use of
alcohol and 51.9% reported use in the last month.

With regard to lifetime dependence, 43.5% of resident prisoners fulfilled diagnostic

criteria for lifetime alcohol dependence and 14% for current alcohol dependence (a year
prior to prison entry). Current alcohol dependence rates in the prison population are
nearly three times more than in the general population. UTPs were significantly more
likely to have a lifetime (p=0.006) diagnosis of alcohol dependence compared to
convicts. They were nearly twice as likely to have a diagnosis of alcohol dependence in
the previous year compared to convicts (16% and 9% respectively). With respect to
alcohol use in prison, 3.7% of the resident prisoners reported alcohol use in the last week.
However, on breath analysis of 169 male prisoners selected randomly, none was positive
for breath alcohol. This needs to be interpreted carefully because results of the alcohol
breath analysis depends upon timing of the test after last consumption and availability of
alcohol inside the prison.

30
The problem of cannabis

Cannabis is the most widely used illegal drug in the world. Cannabis is said to be firmly
established in the youth culture, particularly in developed countries. Large illicit markets
have emerged to fill the markets. Cannabis can cause behavioural problems with
excessive use and precipitate psychosis in vulnerable individuals. Cannabis intoxication
mimics a psychotic disorder with predominant changes in emotion, excitement and
hallucinatory experiences. Long-term cannabis use associated with amotivational states.

Cannabis use in India: According to the NHSDA data (Ray et al., 2004), 3% of adult
males reported lifetime cannabis use. Literature from India has shown the occurrence of
cannabis related psychotic episodes. Although cannabis use has been culturally
sanctioned during religious festivals in India, currently, much of the cannabis use occurs
on account of its mind altering properties. Various forms of cannabis are commonly used
in India and common names include bhang, hashish, ganja, grass and marihuana.

Cannabis use in prisons: Cannabis was the most frequently reported illicit drug, with
lifetime prevalence rates among inmates of 11–86% in prisons in the EU countries
(EMCDDA, 2004). Marijuana or hashish was the most common drug inmates said they
had used in the month before the offence. Among inmates who had a mental health
problem, more than two fifths of those in State prisons (46%), Federal prisons (41%), or
local jails (43%) reported they had used marijuana or hashish in the month before the
offence (James et al., 2006).

In a prison study on drug use, Lukasiewicz et al, (2007) reported that cannabis use had
overtaken opiate use as the most frequent drug used, in little over one in four prisoners,
five times more than opiate use. More than one third (35.2%) of prisoners presented
either alcohol or drug abuse or dependence (AAD or DAD) in the last 12 months. 18.4%
had presented AAD and 27.9% DAD in the last 12 months. 11.2% (N = 111) had both
diagnoses in the previous 12 months. Cannabis was the most frequently used drug in the
previous 12 months (26.7%), others drug use being marginal (2.7% for opiate to 5.4% for
cocaine/crack) (Lukasiewicz et al., 2007). The use of cannabis in the Bangalore prison
(Math et al., 2011) is discussed along with other drugs in the subsequent section.

31
The problem of other drugs

Use of other drugs in India: According to the World Health Organization (2010), at least
15.3 million persons across the world have drug use disorders. The World Drug Report
(UNODC, 2010) suggests that drug use is shifting towards new drugs and new markets.
While drug use has stabilised in the developed world, there are signs of an increase in
drug use in developing countries and growing abuse of amphetamine-type stimulants and
prescription drugs around the world.

Use of other drugs in India: Among other drugs of abuse, opioids continue to be the most
common after cannabis. Rapid assessment surveys indicate the increase of abuse of drugs
meant as prescription drugs (UNODC, 2006). Use of drugs among women has definitely
been a source of concern in the last decade (Murthy, 2002) and is growing (Murthy,
2008).

Use of other drugs in prison: Drug use disorder was eight times as common in prisons
compared to the general population (Bushnell et al., 1997). A UNODC drug report of
4343 million persons aged 15-64 years across the world in 2007 shows that, 172- 250
million had used drugs at least once in the past year; 18-38 million were „problem drug
users‟ and 11-21 million persons were injecting drugs of abuse (UNODC, Drug Report
2009). Prisoners‟ lifetime prevalence of cocaine (and crack) use was 5–57% and heroin
5–66%. In EU prisons (EMCDDA, 2004).

Fazel et al‟s (2006) review of 13 studies of 7563 prisoners estimates prevalence for
alcohol abuse and dependence in male prisoners to range from 18 to 30% and drug abuse
and dependence to vary from 10 to 48%. A British survey found that 60% of heroin users
reported use in prison and more than 25% initiated use in prison (Boys et al., 2002).

In UK prisons, cannabis and opioids are the commonest drug of abuse. Andersen‟s
review Danish prisoners on remand, shows opioid dependence is the most frequent drug
disorder with subjects using injection representing a more dysfunctional group than
subjects using smoke administration (Andersen et al., 2004). In the Lithuanian prison
study (Narkauskaitė et al., 2007), 13.8% currently used narcotic drugs and 39.8% had
first used illicit drugs in prison.

32
The problem of injecting drug use

Injecting drug use was reported in 136 of 147 countries, of which 93 reported HIV
infection among this population (WHO, 2010). Injecting drug use is also a well
recognised problem in India, with major concerns being very unsafe injecting practices
like needle sharing, inadequate cleaning and poor hygienic practices (Ray, 2003, Murthy,
2008). Mortality in injecting drug users is very high in India (Solomon et al., 2009).

A lifetime history of incarceration is common among injecting drug users (IDUs); 56% to
90% of IDUs have been imprisoned previously. Drug-using prisoners may be continuing
a habit acquired before incarceration or may acquire the habit in prison. In Europe, 16%
to 60% of prisoners who injected outside prison continued to inject while incarcerated,
whereas 7% to 24% of prisoners who injected said they started in prison. In another
study, one-fifth of prisoners injected drugs for the first time in prison (Stover and
Michels, 2010).

Patterns of drug use in the Bangalore Prison (BPMHSU) study: Six hundred and fifty
two (13%) of prisoners self-reported ever use of any other drug apart from alcohol and
tobacco. This group primarily reported use of cannabis (94%). Nine males (0.2%)
reported injecting drugs and 6 (0.1%) reported the use of inhalants. Thus lifetime
prevalence of cannabis use was 11.8%, opioids 0.6%, sleeping pills 0.6%, injecting use
0.2%, inhalants 0.1% and other ways of getting a high 0.2%. Self-reported prevalence of
drug abuse was greater among the UTPs compared to convict prisoners (Math et al.,
2011).

Urine testing improved detection: As part of the prison study, a random urine drug
screening was carried out on 721 resident prisoners in an anonymous manner. 31% tested
positive for cannabis use, 3% tested positive for opioids, 15% tested positive for cocaine,
9% tested positive for barbiturates, 43% tested positive for benzodiazepines and 6%
tested positive for amphetamines.

There were no significant differences in the urine screening results for UTPs and CTPs
with respect to detection of cannabis, opioids and cocaine. However, UTPs were
significantly more likely to test positive for barbiturates, benzodiazepines and
amphetamines. According to the prison psychiatrist at the time of conducting the
urinalysis, of the entire prison population, 40-50 persons were likely to have been

33
prescribed benzodiazepines. On testing, nearly six times that number tested positive
suggesting self-administration of these medications. Nearly a third of positive urine
sample were positive for two or more drugs.

Table 1. Detection on random urine drug screening among UTP/CTP population

(N= 721) in the BMHSU study

Sl.no Drugs use UTP CTP X2 P

(n=406) (n=315)
1 Cannabis 130 (32%) 92 (29.2%) 0.659 0.464
2 Opioids 12 (3%) 12 (3.8%) 0.402 0.537
3 Cocaine 68 (16.7%) 42 (13.3%) 1.600 0.212
4 Barbiturates 61 (15.0%) 4 (1.3%) 40.913 0.000
5 Benzodiazepines 233 (57.4%) 77 (24.4%) 78.549 0.000
6 Amphetamines 40 (9.9%) 4 (6.1%) 22.801 0.000
Source: Math et al., 2011

Among new entrants, 28.3% tested positive for benzodiazepines, 17% for cocaine, 13.2%
for cannabis, 4.3 % for amphetamines, 1.5% for barbiturates and 1.2% for opioids.
Generalising the findings among resident prisoners, urine testing was six times more
likely to pick up drug use (8.8%) compared to self-report (1.5%). On comparison of
percentages of positive urine drug tests between resident prisoners and new entrants
(Figure 2), the use of most drugs had actually increased after entry into prison. Thus use
of cannabis after prison entry had increased 2.3 times compared to use at the point of
entry into prison, use of benzodiazepines 1.5 times, barbiturates 6 times, opioids 2.5
times, amphetamines 1.4 times. Cocaine shows a similar pattern both inside and outside
prisons, with a slight decline of use, which can be attributed to its cost.

Co-morbid substance use and mental health problems in prisons

Prisoners with mental health problems have high rates of substance dependence or abuse
in developed countries. Among those who had a mental health problem, local jail inmates
had the highest rate of dependence or abuse of alcohol or drugs (76%), followed by State
prisoners (74%), and Federal prisoners (64%) in the United States (James et al., 2006).

34
Figure 2: Comparison of positive urine drug screens between resident prisoners and
new entrants in the Bangalore study

43
45
40
35 31 28.3
30
25
17 % of positive tests among new
20 13.2
15
15 9
entrants
10 6
3 4.3 % of positive tests among
5 1.5 1.2
resident prisoners
0

Source: Math et al., 2011

Anna Kokkevi and Costas Stefanis in 1995 studied opioid-dependent men recruited from
prison and treatment services, using the Diagnostic Interview Schedule (DIS). Lifetime
and current prevalence of any mental disorder, excluding substance use disorders,
reached 90.3% and 66.1%, respectively. The most prominent lifetime DSM-III axis I
disorders were anxiety (31.8% lifetime and 16.5% last month) and affective (25%
lifetime and 19.9% last month) disorders. Antisocial personality disorder (ASP) had a
lifetime prevalence of 69.3%. Psychiatric disorders seem to precede drug dependence in
the majority of cases.

Some personality features have been commonly linked to patients with SUDs, the most
salient variables being novelty-seeking, impulsivity, and low harm avoidance. Few
studies have tried to differentiate between drug preferences and none have studied this
among jailed substance users (Lukasiewicz et al., 2007).

Special prison populations

Women and juveniles comprise two very important subgroups in custodial or correctional
settings where there are serious substance use concerns.

35
Table 2: Drug use in the month before the offence among convicted prison and jail
inmates by mental status in the United States (James et al., 2006)

State prison Federal prison Local jail

Types of drug With With With With With With
used in the month mental out mental out mental out
before offence health % health % health %
problem problem problem
% % %
Any drug 62.8 49.1 57.1 45.2 62.1 41.7
Marihuana/hashish 45.7 33.3 41.2 32.0 43.4 27.1
Cocaine/crack 24.4 17.9 21.1 15.5 24.2 14.7
Heroin/opiates 8.9 7.2 7.2 4.7 9.6 4.6
Depressants 7.3 3.0 6.7 2.7 8.5 2.0
Methamphetamines 12.6 8.8 10.9 9.6 11.7 6.2
Other stimulants 5.8 2.8 4.5 2.5 5.2 2.4
Hallucinogens 8.0 3.4 9.3 3.0 7.5 2.9

Women and substance use in prison: Female offenders have a particularly high rate of
substance use problems, and substance use in women offenders is generally regarded as
one amongst multiple criminogenic needs (i.e., associates, attitudes, employment,
marital/family, personal/emotional; as assessed by the Case Needs Identification and
Analysis assessment system used in Canadian corrections). Female substance using
offenders tend to have higher overall need level ratings, and also higher risk ratings, than
non-substance using female offenders (Dowden and Blanchette, 2002). Statistics from
DPFC (Victoria‟s female prison), suggest that women prisoners had the highest use of
both licit and illicit substances for all Victorian prisons during 1999-2000 (Armytage et
al., 2000, as cited in Sorbello, Eccleston, Ward and Jones, 2002).

A report on women in prison by H.M. Chief Inspector of Prisons, (1997) argues that
substance use has different antecedents for women than men and serves different
functions (Byrne and Howells, 2002). Primarily, drugs and alcohol are argued to serve
the function of „numbing‟ emotion for women (Murthy et al., 2008). Given this, it has
been argued that traditional drug treatment programmes are inadequate in addressing the
multitude of gender-specific physical, psychological, social and welfare needs found
among female substance misusing offenders (Sorbello et al., 2002). The combination of a

36
range of traumas (i.e., physical and/or sexual abuse, psychological/psychiatric issues) is
thought to trigger maladaptive coping strategies, (including substance use) to reduce
subjective distress. Langan and Pelissier, (2001) argue that these differences suggest that
treatment programs designed for men may be inappropriate for women.

In the Bangalore Prison Study (Math et al., 2011), 17.9% of women prisoners reported
use of tobacco in some form. This is marginally more than the prevalence of tobacco use
among women in Karnataka (15.2%-figures for 2001). Chewing tobacco was more
common among women (12.7%) compared to smoking (5.1%). Among women resident
prisoners, 3% reported ever using alcohol. This is lower than the prevalence of alcohol
use among women in Karnataka, which has been estimated at 5.8% (Benegal et al.,
2005).

Only one woman prisoner reported drug use in order to get a high. None self-reported use
of any opioids, benzodiazepines or any other drugs. However, on carrying out anonymous
drug testing among 60 women resident prisoners, 18 (30%) tested positive for one or
more drug. Thirteen samples (21.7%) tested positive for benzodiazepines, 3 (5%) for
cocaine, 2 (3.3%) for opioids and amphetamines respectively and one (1.7%) for
cannabis. One person each tested positive for two drugs and three drugs respectively.

Juvenile offenders: Very high levels substance use disorders (SUDs), particularly alcohol
and cannabis have been reported among juvenile offenders from several countries (
Zilbert et al., 1994; Putnins, 2001; Teplin et al., 2002; McCleelland et al., 2004). Several
other drugs are also abused by juvenile offenders, including inhalant use. There is a close
association between substance use, severity of the committed offence and antisocial
behaviour. Further, the earlier the age of onset of substance use, the greater is the
likelihood of severe and chronic offending. Delfabbro and Day (2003) suggest that by far
the most significant area of interest in Australia has been the problem of petrol-sniffing,
“a form of addiction that has crippled many outback communities”, causing significant
brain damage, social alienation and isolation, and ultimately death for many hundreds of
young indigenous offenders (MacLean and D‟Abbs, 2000).

Gambling: A behavioural addiction

There are many non-substance use addictions that can cause problems to the individual or
to others. These include gambling, sex, eating disorder and many others. A brief

37
discussion is provided here on gambling, as this addiction often goes in hand with
substance use disorders. Gambling as a leisure activity is known to run rampant in
prisons. However, it is recognised that this behaviour may often be picked up in prisons
and carry on post release. Addiction to gambling can cause problems before entering
prison, during imprisonment (debts, fights and clashes over settlement) or continue post
release.

Recently sentenced inmates in four New Zealand male prisons (N = 357) were
interviewed to assess their gambling involvement, problem gambling and criminal
offending. Frequent participation in and high expenditure on continuous forms of
gambling prior to imprisonment were reported. Nineteen percent said they had been in
prison for a gambling-related offence and most of this offending was property-related and
non-violent (Abbott et al., 2005).

In the Bangalore Prison Study (Math et al., 2011), about one in 10 prisoners (11%) self-
reported having indulged in some form of gambling during their lifetime. The most
common form was playing cards for stakes. There were no significant differences
between UTP and CTPs with regard to lifetime gambling. Among women, a very small
number reported any form of gambling.

Risks of substance use in prison

Large numbers of entrants to the prison come with a history of drug use. If these inmates
are not recognised and treated when they enter the prison, they may develop severe
withdrawal symptoms which may be life-threatening. Violence, illegal activities and
substance use are closely related. Persons using drugs may also become violent during
this period and may also become dangerous to others in prison.

Other consequences of drug use in prison include drug-related deaths, suicide attempts
and self-harm. Drug use tends to be more dangerous inside than outside prisons because
of the scarcity of drugs and sterile injecting equipment. In a study of 492 IDUs, 70.5%
reported sharing needles while in prison compared with 45.7% who shared needles in the
month before imprisonment (P < 0.0001). Of particular concern is that sharing injecting
equipment inside prisons is a primary risk factor for human immunodeficiency virus
transmission. Additionally, hepatitis C virus infection through shared injecting equipment
in prison has been reported in studies undertaken in Australia and Germany. Drug use in

38
prison is also associated with the risk for involvement in violence. Inmates who incur
disciplinary action related to possession or use of a controlled substance or contraband
were 4.9 times more likely to display violent or disruptive behaviour than those who did
not incur such disciplinary action. Prisoners using drugs are also at risk for engaging in
further illicit activity. If discovered using illegal drugs, inmates risk prolonged
incarceration for breaking security rules and eliciting hostility among prison staff (Stover
and Michels, 2010). In the week after release, prisoners are approximately 40 times more
likely to die than are members of the general population; in this immediate post-release
period, more than 90% of deaths are drug related (Stover and Michels, 2010).

Need for treatment and its advantages

Substance dependence is now understood as a bio-psycho-social condition. Dependence

occurs because of the effects of substances on the reward pathways in the brain, through
the release of some pleasure producing, discomfort reducing neurochemicals. It also
results from repeated conditioning to drug using cues, and the association between drug
use, pleasure and relief of tension. Treatment approaches include counselling,
medication, support and follow-up.

Substance dependence is a chronically relapsing disease and only coercive abstinence in

prison may be followed by relapse immediately after release, often resulting in overdose,
drug emergencies and death. Prisoners need to be educated on the benefits of treatment of
drug dependence, which include reduction in use both in prison and following release,
less risk taking behaviour, decrease in criminal activity, less risk of death and infection
and reduced re-incarceration. In developing countries, abusing drugs has particularly high
health, social and economic costs, which must be communicated to the prisoners, to
motivate theme for change.

In a Canadian study, female substance-misusing offenders who successfully completed a

planned treatment programme were found to be significantly less likely to re-offend than
their untreated counterparts (Dowden and Blanchette, 1999 and 2002).

The United Nations General Assembly Special Session on the World Drug Problem in
1998 explicitly identified prisoners as an important group for activities to reduce demand
for drugs (United Nations, 1998). In 1999, the European Union endorsed an action plan to
combat drugs for 2000–2004 (European Commission, 1999, 2001 and 2002). Among the

39
targets set were those aiming to substantially reduce, over five years, the incidence of
drug-related health damage (such as HIV, Hepatitis C and Tuberculosis) and the number
of drug-related deaths. The WHO Regional Office for Europe (1999) issued, with
UNAIDS, guidelines on HIV infection and AIDS in prisons. WHO Health in Prisons
Project (2002) issued a consensus statement on the considerable role of prisons in
contributing to a public health strategy for dealing with the harmful effects of drugs to
public health, to the users, to staff and to the management of prisons. The principles,
policies and practices outlined in that statement remain valid and considered along with
this report.

In the United Kingdom, the prison programme (Integrated Drug Treatment System or
IDTS) is funded to provide opioid substitution treatment (OST) in every adult prison,
within an integrated clinical and psychosocial treatment approach, uniting prisons'
psychosocial drug treatment services (counselling, assessment, referral, advice and
through-care services) and clinical substance misuse management (incorporating the
option of Methadone or detoxification) services. The design of the programme took into
account the vulnerability of drug-using prisoners to suicide and self-harm in prison and to
death upon release from prison because of accidental opioid overdose, prison regimen
services that correspond to national and international good practice and the need to
provide clinical interventions that harmonise with practice in the community and other
criminal justice settings.

Treatment gap for substance use treatments in prisons

The World Drug Report, 2010 exposes a serious lack of drug treatment facilities around
the world. "While rich people in rich countries can afford treatment, poor people and/or
poor countries are facing the greatest health consequences", it warns. The Report
estimates that, in 2008, only around one fifth of problem drug users worldwide had
received treatment in the previous year, which means that around 20 million drug
dependent people did not receive treatment. „It is time for universal access to drug
treatment‟. The other themes in this report are that „Drug addiction is a treatable health
condition, not a life sentence‟, „Drug addicts should be sent to treatment, not to jail‟,
„Drug treatment should be part of mainstream health care‟ and „Just because people take
drugs, or are behind bars, this doesn't abolish their rights‟

40
The report cautions that countries are not in a position to absorb the consequences of
increased drug use. The developing world faces a looming crisis that would enslave
millions to the misery of drug dependence (UNODC, 2010). The WHO (2010) highlights
the cost effectiveness of treatments of substance use. For every dollar invested in drug
treatment, 7 dollars are saved in health and social costs. It is unfortunate that though
many prisoners would like treatment for substance use, such treatments are not available.
Brooke et al., (1998), in their study of remand prisoners, found that 23% of drug users
requested treatment - a figure far higher than might be expected prior to imprisonment. In
the Bangalore Prison study (Math et al., 2011), 85% of smokers, 73% of tobacco
chewers, 99% of alcohol users and 71% of drug users expressed the need for help in
being able to give up using these substances.

Barriers to treatment: These barriers may be classified as Prisoner related barriers

(ignorance, lack of motivation, myths and misconceptions regarding treatment), Prison
staff and other stakeholder barriers (negative attitudes, lack of understanding about the
chronic relapsing nature of drug use and the positive impact of harm reduction measures)
and Policy and Programmatic barriers (focus only on abstention without providing
services for treatment and proper support to address factors maintaining the drug habit).

Indian experience

The UNODC has recommended that the Government of India initiate a process of inquiry
in major prisons in India, and where necessary, set up the required facilities for the
treatment of drug users. The major experience from India comes from the Tihar jail,
where the oldest programme in an Indian prison for substance use was initiated. Drug
offenders received at Tihar Jail are admitted to a “de-addiction” centre for detoxification
and treatment of withdrawal symptoms. To address drug abuse, a Drug De-Addiction
Centre (DAC) with a capacity of 120 beds was established in 2007 taking into account
that six to eight per cent of the prison inmates are drug dependent at the time of
admission, out of which some were injecting drug users. After detoxification, drug
offenders are segregated from the other prisoners and placed in therapeutic communities
run by NGOs including the Association for Scientific Research on Addictions (AASRA)
and the AIDS Awareness Group.

In collaboration with the All India Institute of Medical Sciences (AIIMS), UNODC and
Non-Governmental organisations, the Tihar jail administration initiated a pilot and the

41
first-ever Oral Substitution Treatment (OST) Centre in a prison in South Asia. The Civil
Rights Initiative–Arthur Road Jail Project was started in January 2005 in partnership with
and on request from the Sankalp Rehabilitation Trust. Sankalp is given a separate barrack
for drug users who opt to undergo a rehabilitation programme. Sankalp provides users
with counselling, medicines, treatment (Tihar Jail, 2009).

The UNODC, in its regional prisons project initiated in 2005, has been working with
prison departments and civil society agencies to enhance institutional and technical
capacities of relevant ministries and civil society partners to mount effective intervention
programmes to prevent the transmission of HIV in prison settings, within a continuum of
care of evidence-based drug dependence treatment and rehabilitation programmes.
Presently this programme is underway in 21 prison sites in the South Asian region
including the prisons in Delhi, Aizawl central prison, Mizoram and the Sajjawa central
prison in Manipur. The main components of the programme include a comprehensive
HIV prevention service, capacity building to meet the needs of drug users including
opioid substitution treatment, support for the NGOs to provide linkages between prison
and community programmes, including psychosocially assisted programmes and HIV
prevention programmes.

It is a real challenge to be able to draw on some of these experiences and at the national
level, be able to set up comprehensive substance use prevention and treatment services.

Measures to address substance abuse in prisons

1. Identification of substance use problems through questionnaires, behavioural

observation and urine drug screening both at the point of entry and during
imprisonment.

a) Detoxification services and making suitable pharmacotherapy available for

detoxification.

b) For persons with dependence, making available long-term medication as

well as motivational and relapse prevention counselling.

c) Specific interventions to be made available include the following:

42
  Tobacco cessation services (behavioural counselling, nicotine
replacement therapy, other long-term tobacco cessation
pharmacotherapy.

 Alcohol–benzodiazepines for detoxification, vitamin

supplementation for associated nutritional problems, counseling
and long-term medication like acamprosate, topiramate,
disulfiram, naltrexone and others.

 For Opiates – buprenorphine or clonidine detoxification, long-

term medication including opioid substitution(methadone/
buprenorphine; opioid antagonists like naltrexone).

 All drug users need to be evaluated for injecting use, for

HIV/STI (including Hepatitis B and C screening) and
appropriately treated.

2. Prisoner education to inform about the health and other adverse effects of
substance use, the benefits and support available for quitting, training of prison
staff in motivating prisoners‟ desire for change, psychosocial counselling in
individual and group settings, involvement of family members of prisoners.

3. Ensure availability of personnel and services to the extent possible within the
prison, network with the community to establish linkages for effective counselling
and aftercare. NGO‟s and self-help groups can be a valuable part of this network.

4. Sensitise and train all stake holders regarding the problem of substance abuse in
prisons, helpful responses and barriers to effective care. Stakeholders include
prison officials, state health departments, judiciary, police, and service providers
for other health programmes (like HIV, tuberculosis etc).

5. Identification of vulnerability factors is an important part of substance abuse

prevention, particularly important to prevent recidivism. A life skills approach to
address these vulnerabilities, linked with other psychosocial approaches seems to
be the most pragmatic approach.

43
 6. In addition to reducing HIV transmission among intravenous drug users (IDUs),
opioid substitution therapy (OST) reduces criminal activity among heroin users.
Providing OST in the community is a crime control measure that can lead to
reduction in the prison population (UNODC, 2006).

7. Engagement of family members to provide support for abstinence during

incarceration and after release.

In conclusion, in India, we are gradually becoming aware of the magnitude of substance

use and its impact on prisons. From the global experience, it is very clear that much has
to be done, and that a lot of time and opportunity has already been lost. The prison system
must take up this issue very seriously, and provide integrated services for the prevention
and treatment of substance use in prison settings.

44
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49
 4. SEVERE MENTAL DISORDERS: IMPLICATIONS IN PRISON
SETTINGS

Psychotic disorders are mental illnesses that cause impairments in a person’s judgement
and ability to carry on with the tasks of day to day life. Schizophrenia and bipolar
disorders are some of the most common types of psychotic disorders. Schizophrenia
generally affects individuals in their early adulthood, thereby in their most productive
phase of life. Typically, this disorder affects the individual’s thought processes,
perceptions, emotions and behaviours. Bipolar disorders (or affective psychoses) are
characterised by periods of, elated mood, expansive ideation and over activity (mania),
alternating with sadness and being withdrawn (depression). It is not uncommon to find
prisoners with these disorders, which may develop before entry into prison or during
imprisonment. In this chapter, the prevalence of psychotic disorders in prisons globally is
reviewed, and the findings of the Bangalore Prison mental health study are discussed in
this context. For the purpose of this review, both schizophrenia as well as bipolar
disorders are included. Both have been subsumed under the category of ‘severe mental
disorders’.

Prevalence of schizophrenia and bipolar mood disorders

A study by Birmingham et al, (1996) defined the prevalence of mental disorders and the
need for psychiatric treatment in new remand prisoners (akin to under trial prisoners) in a
Durham prison for men. A semi-structured interview schedule (incorporating well
validated psychiatric instruments) was designed specifically for the study. Schizophrenia
and other psychotic disorders were present in 20 (4%) prisoners and affective psychosis
was present in 4 (1%) of them.

The Bureau of Justice Statistics conducted three studies in the US (James et al., 2006). In
2002, inmates from all the local jails were interviewed and in 2004, inmates from all the
State and Federal correctional facilities were interviewed. A history of mental health
problems that had occurred in the 12 months prior to the interview or any history that
included a clinical diagnosis or treatment by a mental health professional was considered
for the definition of mental disorder. This study included a modified structured clinical
interview for the DSM-IV. According to the above definition, 56% of the State prison
inmates had some mental problem, while 45% of the federal prison inmates and 64% of
the local jail inmates had symptoms of a mental problem. Symptoms of psychotic
disorders were present among 20% of the state prisoners, 12.6% of the federal prisoners

50
and 31.2% of the local jail inmates during the past one year or since admission. Life time
prevalence of manic symptoms were: 21.5%, 23.3% and 17% among state prisoners,
federal prisoners and local jails respectively.

Herrman et al, (1991) estimated the prevalence of severe mental disorders in a

representative sample of sentenced prisoners in Melbourne prisons. 189 inmates were
interviewed for this purpose using the Structured Clinical Interview for DSM-III-R. 3%
(n=6) received current diagnosis of psychotic disorder while 6% (n=11) had a lifetime
diagnosis of psychotic disorder. A lifetime diagnosis of at least one mental disorder each
was made for 82% of the respondents.

White et al, (2006) screened 621 men from the main remand and reception centre for
males for the southern region of the state of Queensland, Australia. Of the 621 screened,
65 answered yes to at least one question in the Diagnostic Interview for Psychosis (DP).
These patients were interviewed using the DP [DP is a composite semi-structured
standardized interview schedule that combines social and demographic descriptors with
measures of functioning adapted from the World Health Organisation Diasability
assessment Schedule (DAS)]. 35% were homeless for an average of 32 weeks during the
precedent year. Most of them had minimal contact with family members. 78% were
unemployed and 80% were dependent on alcohol, cannabis or amphetamines. These
rates were significantly high when compared to those of psychotic men who resided in
the community.

Way et al, (2008) studied the characteristics of inmates who received a diagnosis of
serious mental illness upon entry to a New York State prison. A chart review was
performed for prisoners who entered prison between May 2007 and June 2007 and
received a diagnosis of serious mental illness. Initial diagnosis was made by a
psychologist or a social worker within a few days of arrival in the prison. Few days later,
a psychiatrist reviewed the chart material, conducted a second interview and confirmed or
modified the diagnosis. 6% (172 of 2,918 inmates) received a diagnosis of serious mental
disorder. The mean (SD) age of these 172 patients was 36(9.6) years. A total of 167
(97%) had been hospitalised once earlier for psychiatric treatment and 48 (28%) had been
hospitalised four or more times. Seventy nine (46%) had their first episode of
hospitalisation ten or more years ago. A total of 107 (62%) had history of a serious
suicidal attempt, 101 (59%) had history of inpatient treatment for substance abuse, and79
(46%) had been incarcerated earlier in the state prison.

51
 Table: 1- Prevalence studies of Schizophrenia /other non-affective psychoses / Bipolar Affective disorders in
Prisons/Jails

Authors (year), Venue Sample size Sampling Diagnostic Prevalence rates

country in which method instruments
study was
conducted
Bolton (1976), USA Jail 1084 inmates Not available N/A Psychosis-7%
(N/A)
Petrich (1976), USA Jail 122 jail inmates N/A Psychiatric Schizophrenia - 31% males
referred for evaluation and 25% females
psychiatric
evaluation
(84% males)
Petrich (1976), USA Jail 529 referred for N/A N/A Psychosis-49%
evaluation;
80% males,
42% females
Schuckit et al., Jail, 199 males N/A Clinical Affective disorder-5%
(1977), USA interview
Piotrowski et al., Jail 50 pretrial N/A Psychiatric Schizophrenia -22%
(1976) detainees evaluation & Bipolar Affective Disorder -
referred for chart review 10%
evaluation when possible
(88% males)
Nielson (1979) Jail Unknown N/A Clinical Psychosis - 24%

52
 evaluation
Monahan and County jail 632 referred for N/A N/A Schizophrenia-32%
McDonough (1980) evaluation;
82% male,
James et al., (1980) Prison 409 inmates N/A Clinical Schizophrenia – 5%
referred for evaluation
medical
evaluation
Lamb and Grant County jail 102 males Random Clinical Schizophrenia-75%
(1982), USA referred for sampling evaluation Affective disorder-22%
evaluation
Lamb and Grant Jail 101 female N/A Psychiatric Severe overt
(1983), USA inmates evaluation psychopathology- 59%
referred for
evaluation
Ninzy (1984), USA Jail 50 volunteers, N/A N/A Psychosis-26%
74% males
Virginia DMH, USA Jail 171 mentally ill N/A N/A Schizophrenia-40%
as identified by Mania-21%
staff
Glaser (1985), Jail 50 inmates N/A N/A Schizophrenia-48%
Australia referred for Mania-16%
evaluation
Guy et al., (1985) Jail 486 inmates N/A Structured Schizophrenia- 11.5%
Clinical Bipolar affective disorder-

53
 Interview for 3.1%
DSM (SCID)

Valdiserri et al., County jail 769 inmates N/A N/A Psychosis-17%

(1986) referred for
evaluation;86%
males
Daniel et al., (1988), Prison 100 female N/A Diagnostic Schizophrenia – 7%
USA inmates Interview
Schedule-III
Teplin (1990), USA Prison 728 male N/A Diagnostic Schizophrenia- 2.7%
detainees Interview
Schedule-III
Maden et al., (1994), Prison 301 inmates N/A Clinical Psychosis-2%
USA interview
schedule
Roesch (1995) N/A 790 N/A N/A Psychosis-5%
Bean et al., (1988), Prison 464 inmates Two-stage Initial Schizophrenia-1.5%
USA random sample screening by Bipolar disorders-2.8%
stratified by PERI, later on
facility. used SCID
California Prison 413 Two stage DIS-III Schizophrenia- 3.4%
department of samples; general

54
 corrections (1989), population Bipolar disorders-2.9%
USA sample stratified
on institutional
security level
(n=362); random
psychiatric
sample(n=51)
Neighbors et al., Prison 1240 Two stage DIS Schizophrenia-2.8%
(1987), USA random sample administered to Bipolar disorder-2.8%
stratified by sample and
institution type SCID to
screened
sample
Motiuk and Male 2185 Random sample DIS: wide Schizophrenia-4.9%
Porporino (1991), inmates stratified by criteria Bipolar disorder-4.9%
Canada region DIS: stringent Schizophrenia-4.9%
criteria Bipolar disorder-4.4%
Teplin (1994), USA Male 728 Stratified random National schizophrenia Life-time:
detainees sampling Institute of 4%
Mental Health Current-3%
Diagnostic Mania Life-time:
Interview 2%
Schedule, Current:1%
Version III

55
 Davidson et al., Male 389 N/A Clinical Psychosis-1%
(1995), Scotland prisoners interview
schedule
Birmingham et al., Male 549 N/A Semi-structured Schizophrenia & other
(1996), UK remand pro-forma that psychotic disorder-4%
prisoners included well Affective psychoses-1%
validated
psychiatric
scales
Brooke et al., (1996), Male 750 Randomly Semi-structured Psychosis-5%
UK unconvicted selected sample interview and
prisoners across young case note
offenders and 13 review
adults prisons
Powell et al., (1997), male prison 213 Randomization Diagnostic Psychosis-2%
USA and jail interview
inmates schedule-III
Singleton et al., Both N/A N/A N/A Psychotic 7%
(1998) [Office for remand and disorder (sentenced
National Statistics- sentenced men)
Prison survey-1997], inmates 10%
UK (remand
men)
Simpson et al., Male 441 N/A N/A Psychosis-4%
(1999), New Zealand inmates

56
 James et al., (2006) State State prisons- Stratified two SCID Psychotic State
[Bureau of Justice prison, 14,449 stage sampling. disorder (life prisons-
Statistics in the US] Federal Facilities were time 11.1%
prison & Federal selected in the prevalence) Federal
local jails prisons-3686 first stage. In the prisons-
second stage, 7.8%
Local jails- samples were Local
3365 systematically jails-
selected. 16.8%
Teplin (1990), USA Male 728 Stratified random DIS Current schizophrenia-
prisoners sampling 2.94%
Current mania-1.36%
White et al., (2006), Male 621 All remandees Diagnostic Psychotic disorders-9.5%
Queensland, remandees who entered the interview for
Australia remand centre Psychosis (DP)
during the study
period
Way et al., (2008), State prison 172 N/A Clinical Schizophrenia-14%
USA interview Bipolar I disorder-13%
Unspecified bipolar
disorder-19%
Andersen et al., Male 1038 Fazel and Danesh N/A Psychosis-6%
(1996) + Schuckit et prisoners (2002) have
al., (1997) + Panhuis commented that

57
 et al., (1997) + Smith the results of
et al., (1996) + these five studies
Swank and Winer have been
(1996) + Guy et al., clubbed because
(1985) + of the smaller
Barthalomew et al., sample sizes
(1967) + Brinded et
al., (1999) +
Shoemaker et al.,
(1997) + Watt et al.,
(1993)

58
Out of the 172 patients, 14 (8%) received a diagnosis of schizophrenia; 22 (13%), major
depressive disorder; 21 (12%), bipolar I disorder; 33 (19%), bipolar disorder not
otherwise specified; and 33 (19%), mood disorder not otherwise specified.

In correctional settings, schizophrenia and bipolar disorders (severe mental disorders or

psychotic disorders) are generally found in a higher proportion of the inmates, when
compared to that in the general population. Prevalence rate is highest in the age group of
25-44 years followed by the age group of 18-25 years. Some studies show that males
have higher rates when compared to females. Rates vary between two and four percent. A
large review (Fazel and Danesh, 2002) of 62 prison surveys also showed that 3.7% of
males and 4% of female prisoners had psychotic disorder at the time of assessment. These
disorders are found both among remand as well as sentenced prisoners. The phenomena
of trans-institutionalization, re-institutionalization and substance abuse among inmates
may have contributed to these high rates.

Findings from the Bangalore Prison Study

The Bangalore prison mental health study (Math et al., 2011) examined mental health
morbidity in 5204 prisoners. According to the responses on the Mini International
Neuropsychiatric Interview (MINI), there was very low reporting of symptoms for
lifetime or current psychotic illness. Only 15 prisoners (0.4%) reported a lifetime history
of psychotic disorder. Seven patients reported symptoms satisfying criteria for
schizophrenia (0.1%). A more reliable indicator of the prevalence of psychosis was the
record maintained by the prison psychiatrist. This indicated that a total of 112 cases
(2.2%) had a diagnosis of psychosis, primarily schizophrenia. Table 2 depicts the
frequency of schizophrenia and related disorders. The prevalence of bipolar episodes
(including hypomania and mania) is depicted in Table 3.

The Bangalore Prison study (Math et al., 2011) showed the current prevalence rate of
schizophrenia to be 1.1%. When all disorders with psychotic manifestations had
considered, the prevalence rate increased to 2.3%. Almost all patients with psychotic
manifestations will come in contact with not only the prison psychiatrist but also
psychiatrists at the National Institute of Mental Health and Neurosciences, which is the
tertiary centre for referral care for the Bangalore prison. Hence these figures are more
reliable and valid than the figure (0.1%) obtained from the interview schedule. Though,
world over schizophrenia and related psychotic disorders are found in higher proportion
in correctional institutions, the same was not replicated in this study.

59
Table 2. Types of psychotic disorders

Sl No Type of Psychosis Number (%)

1. Schizophrenia and related disorders 57 (1.1)
2. Mood disorder with psychotic features 30 (0.6)
3. Substance induced psychosis 19 (0.4)
4. Organic psychosis 6 (0.1)
Total 112(2.2)
Source: Math et al., 2011

Table 3. Prevalence of bipolar episodes

UTP CTP Total Chi- P-value

[n(%)] [n(%)] square
Hypomania Lifetime 4(0.1) 2(0.2) 6(0.1) 0.30 0.58
/mania current 1(0.02) 0 1(0.01) 0.31 0.57
Mania Lifetime 3(0.1) 0 3(0.1) 0.94 0.33
current 3(0.1) 0 3(0.1) 0.94 0.33
Source: Math et al., 2011

As presented earlier, global rates vary over a high range of between two to thirty percent
across various countries. UK based studies are more towards the lower end with a rate of
less than 4 percent (Birmingham et al., 1996; Gunn et al., 1991 and Fazel and Danesh
2002). Study by Herrman et al, (1991) in Australia indicate a prevalence of 6% for a
lifetime diagnosis. Higher rates have been found in the United States according to the US
BJS survey (James et al., 2006) which reached a maximum of 31.2% in one of their
settings. The 1.1% prevalence for schizophrenia is just slightly higher than that of the
general population (Isaac and Gururaj, 2004). This variation from global rates can be
attributed to the facts that the prevalence of schizophrenia in general population itself is
much lower in India when compared to the western countries (Kessler eta l., 1994; Isaac
and Gururj, 2004); the phenomenon of reinstitutionalisation is not yet documented in our
country. Moreover, majority of schizophrenia patients live with their families, which may
protect them from both becoming homeless and getting involved in crimes. Substance
abuse comorbidity is also very low in India when compared to the western countries.

60
In the Bangalore Prison Study (Math et al., 2011), the prevalence of life-time manic
episodes was very low which makes it impossible to statistically compare this with any
other study. Moreover, there are no reliable epidemiological studies of manic episodes in
India. Nonetheless, we would like to state that issues that are discussed in the above
sections can apply to patients with affective psychosis as well.

Other important issues with patients with psychotic disorders are related to their fitness to
stand trial and the phenomena of transinstitutionalisation. Not only do these patients need
to be treated adequately, proper mechanisms should also be put in place for their effective
rehabilitation. In this context, the recent Supreme Court’s judgment on the plight of such
patients and gross violations of their human rights is an eye opener [Supreme Court, Writ
Petition (CRL.) No(s). 296 of 2005] which needs to be followed up with the appropriate
actions.

In conclusion, although the comparatively low rate of prisoners with severe mental
disorders in Bangalore prison is somewhat reassuring, we cannot afford to be complacent
and need to take appropriate actions. With globalization, fast and stressful lifestyles;
traditional value systems being replaced by short term relationships, there has been a
rapid breakdown in the culture of families acting as a protective mechanism for those
suffering from schizophrenia and other psychotic disorders. We need to be better
prepared to identify and provide appropriate facilities for the treatment of such people
when they land up in prisons. Being a small number, they could very well be ignored and
go unnoticed.

61
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eds. Psychology, law and criminal justice Berlin: De Greuter, 1995: 520–31
Schuckit MA, Herrman G, Schuckit JJ. The importance of psychiatric illness in newly
arrested prisoners. J Nerv Ment Dis 1977; 165:118-125
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Instituut, Utrecht
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psychiatric morbidity in New Zealand prisons. Department of Corrections,
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Singleton N, Meltzer H, Gatward R 1998. Psychiatric morbidity among prisoners in
England and Wales. Office for National Statistics, London
Smith C, O’Neill H, Tobin J, Walshe D, Dooley E. Mental disorders detected in an Irish
prison sample. Crim Behav Mental Health 1996: 177–183
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J Psychiatry 1976; 133:1331-1333
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Teplin LA. Psychiatric and Substance Abuse Disorders among Male Urban Jail
Detainees. Am J Pub Health 1994; 84: 290-293
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Department of Corrections 1984. The mentally ill in Virginia's jails. Final report of
the Joint Task Force
Watt F, Tomison A, Torpy D. The prevalence of psychiatric disorder in a male remand
population: a pilot study. J Forensic Psychiatry 1993; 4: 75–83
Way BB, Sawyer DA, Lilly SN, Moffitt C, Stapholz BJ. Characteristics of inmates who
received a diagnosis of serious mental illness upon entry to New York State Prison.
Psychiatr Serv 2008; 59:1335–1337
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265

64
 5. THE FETTERS OF DEPRESSION

Deprivation of liberty invariably results in deprivation of choices usually taken for

granted in the outside community. Once incarcerated, prisoners are no longer free to
decide where to live, with whom to associate and how to spend their time.
Communication with families and friends is limited and often without privacy (Blaauw
and Van Marle, 2007). Petersilia, (2003) has estimated that one in six prison inmates has
a mental illness. Depression is the most prominent among them. This chapter examines
the details and extent of this problem in prisons and compares the results of the Bangalore
mental health study in prisons with studies conducted both at the international and
national level. For the purpose of this review, the terms jails and prisons are used
interchangeably.

Prison factors that aggravate mental morbidity

There are external and internal factors that aggravate mental morbidity in prisons. The
external factors, are more to do with the environment in prisons such as overcrowding,
dirty and unhygienic living conditions, poor quality of food, inadequate health care,
physical or verbal aggression by inmates, lack of purposeful activity, availability of illicit
drugs and either enforced solitude or lack of privacy and time for quiet relaxation and
reflection. Internal factors that play a contributory role are mostly emotional in nature,
where prisoners may have feelings of guilt or shame about the offences they have
committed, experience stigma of being been imprisoned, worry about the impact of their
behavior on other people, including their families and friends, coupled with anxiety about
how much of their former lives will remain intact after release. The cumulative effect of
all these factors, left unchecked, tends to worsen their mental health and increases the
likelihood of damage to the wellbeing of prisoners and staff (Blaauw and Van Marle
2007).

Depression

While it is understandable that anybody in a prison would be generally depressed, it is

important to understand depression from the perspective of a mental illness. Depression is
one of the most common mental disorder that generally occurs as an episode or series of
episodes. People suffering from this disorder may not only exhibit depressed mood but
may also lose interest in life’s activities and easily become lethargic. They may have

65
difficulty concentrating or making simple decisions. They may develop ideas of
hopelessness, worthlessness or helplessness. Severe depression may be accompanied by
psychotic symptoms such as delusions. Persons suffering from major depression are at
increased risk for suicide and may be preoccupied with thoughts of death (Hill et al.,
2004). The fundamental disturbance in depression is the change in mood or affect to
feelings of sadness. This is usually accompanied by a change in the overall activity. Other
symptoms are either secondary to these fundamental disturbances or can be easily
understood in the context of changes in mood and activity. Most of the depressive
episodes tend to be recurrent and are often related to stressful events or situations. In
typical depressive episodes, the patient usually suffers from depressed mood, loss of
interest and enjoyment, and reduced energy, leading to increased fatigability and
diminished activity. Marked tiredness after only slight effort is common. Other common
symptoms are:

(a) Reduced concentration

(b) Reduced self-esteem and self-confidence
(c) Ideas of guilt and unworthiness
(d) Bleak and pessimistic views of the future
(e) Ideas or acts of self-harm or suicide
(f) Disturbed sleep appetite and sexual functioning
(g) Death wishes, suicidal ideas or attempts

Depressive disorders affect around 5% of the adult population at any given point of time.
Patients with a ‘mild depressive episode’ are usually distressed by the symptoms and
have some difficulty in continuing with ordinary work and social activities, but will
usually not cease functioning completely. Patients with ‘severe depressive episodes’ have
disturbed biological functioning and exhibit considerable distress. The lowered mood
varies little from day to day, and is often unresponsive to circumstances (WHO 1992,
Murthy et al., 2005).

Prevalence of depression in prisons

Independent surveys by Gunn et al, (1990; including sentenced prisoners) and Maden et
al, (1994; including remanded prisoners) conducted in the UK in the early nineties
showed a very high prevalence rate (27% and 91% respectively) of neurotic problems in
the form of disturbed sleep, depression, worry, fatigue and irritability. Co morbidity was

66
present in 25% of the men and in about a third of the women in remand prisons. Both
surveys were point prevalence studies conducted on samples of prison inmates
(Birmingham, 2003).

A study by Birmingham et al, (1996) defined the prevalence of mental disorders and the
need for psychiatric treatment in new remand prisoners (akin to under trial prisoners) in a
Durham prison for men. A semi-structured interview schedule (incorporating well
validated psychiatric instruments) was designed specifically for the study. Mental
disorders (including substance misuse) were present in 148 (26%) of the 569 inmates at
the time of reception into the prison. Major mood disorders were present in 13 (2%) and
dysthymic disorder was present in 14 (2%) of the inmates.

The office for National Statistics-Prison Survey in the United Kingdom (UK; Singleton et
al., 1998) conducted a survey that included prisoners from all over the UK. It found that
the prevalence of all types of psychiatric disorders was considerably higher than that of
the general population. Prevalence of neurotic disorders (in the form of worry, irritability,
depression, disturbed sleep or fatigue) was as follows: 40% of sentenced men, 78% of
remand men, 63% of sentenced women and 76% of remand women were affected. As is
evident, more women had these neurotic symptoms and more remand prisoners had
neurotic symptoms than their sentenced counterparts (Birmingham, 2003).

The Bureau of Justice Statistics in the United States (James et al., 2006) conducted three
surveys. In 2002, inmates from all the local jails were interviewed and in 2004, inmates
from all of the State and Federal correctional facilities were interviewed. A recent history
of mental health problems that had occurred in the 12 months prior to the interview or
any history that included a clinical diagnosis or treatment by a mental health professional
was considered for the definition of mental disorder. This survey included a modified
structured clinical interview for the DSM-IV. According to the above definition, 56% of
the State prison inmates had any mental problem, while 45% of the Federal prison
inmates and 64% of the local jail inmates had symptoms of any mental problem. Major
Depressive disorder was present among 24% of State prison inmates, 16% Federal prison
inmates and among 30% local jail inmates during the past one year since admission.

In a study by Assadi et al, (2006) in Iran, 351 inmates from one of the largest prisons in
the country were interviewed using stratified random sampling. They used the Structured
Clinical Interview for DSM-IV Axis I Disorders and the Psychopathy Checklist. 88% of
the prisoners met DSM –IV criteria for life time diagnosis of at least one Axis I disorder,

67
while 29% met criteria for current diagnosis of major depressive disorder and 1.5% met
criteria for dysthymic disorder. Depressive disorders were highly co morbid along with
anxiety disorders (26%), substance use disorders (83%) and psychopathy (23%).
Depressive disorders were more prevalent in the youngest age group. When compared to
the Iranian general population, rates of psychiatric morbidity were around three times
higher. Moreover, the prisoners were not a homogeneous group. Financial offenders had
lower rates of psychiatric morbidity than other offenders.

Teplin, (1990) reported on the prevalence rates of schizophrenia and major affective
disorders by age among a random sample of male prisoners. National Institute of Mental
Health Diagnostic Interview Schedule was used. The prevalence rates in the prison were
later compared with the general population data from the Epidemiologic Catchment Area
study. After controlling for demographic differences between prison and city samples, the
prevalence rates of current psychiatric morbidity in the prison were two to three times
higher than those in the general population (Major Depression - 3.94% Vs 1.07%; Mania
– 1.36% vs 0.12%; Schizophrenia – 2.94 vs 0.91%). The same held true even for life time
psychiatric morbidity (Major depression- 5.75% vs 3.15%; Mania-2.5% versus 0.32;
schizophrenia-3.71% versus 1.70%).

In a retrospective cohort study by Baillargeon et al, (2009), medical case records of

2,34,041 prison inmates were reviewed. Diagnosis was made according to the DSM-IV
criteria. Major depressive disorder was present in 4.2% of the study population. It was
more prevalent among females (10.3%) than males (3.5%), among non-Hispanic
Caucasians (6.3%) than Hispanic Caucasians (2.6%) and African Americans (3.6%) and
among elderly prisoners (4.5%) when compared to younger prisoners (3.2%).

Teplin et al, (1994) interviewed 728 prisoners using stratified random sampling. The
National Institute of Mental Health Diagnostic Interview Schedule was used. 3.42%
prisoners had current diagnosis of major depressive episode, while 5.04% had a lifetime
diagnosis of a major depressive disorder.

Eyestone and Howell, (1994) interviewed 102 prisoners, using the Beck Depression
Inventory and the Hamilton Rating scale. Major Depressive Disorder was found in 25.5%
of the prisoners. They also found a significant relationship between Attention Deficit
Hyperactivity Disorder and Depressive Disorder.

68
Herrman et al, (1991) estimated the prevalence of severe mental disorders in a
representative sample of sentenced prisoners in Melbourne prisons. 189 inmates were
interviewed for this purpose using the Structured Clinical Interview for DSM-III-R. 29%
(n=34) were having lifetime major depression, 12% (n=10) had current major depression.
They also concluded that prisons may apparently contain a large number of people with
untreated major depression

Hurley and Dunne, (1994) interviewed ninety-two women prisoners using the General
Health Questionnaire, the Hamilton Depression Rating Scale, a Recent Stressful Life
Events questionnaire and the Structured Clinical Interview for DSM-III-R. High levels of
symptoms of psychological distress were recorded. Distress was correlated with recent
stressful life events and was more severe in inmates awaiting trial. Aboriginal inmates
were over-represented in this sample. A follow-up survey after 4 months showed no fall
in the prevalence of psychological distress and psychiatric morbidity.

Fazel and Danesh, (2002) systematically reviewed sixty-two prison surveys to determine
the prevalence rates of serious mental disorders. Thirty-one reported major depression
among prisoners. Overall, 10% (743 / 7631) male prisoners had the illness. There was
substantial heterogeneity among these studies (x2 =64; p<0.0001) and this was only
partially explained by differences between detainees and sentenced prisoners (9 vs 11%
respectively; x2 =10.0, p=0.0002 ), between studies in which interviews were done by
psychiatrists or not (7 vs 10%, respectively; x2=14·2, p=0·0002), and between larger and
smaller studies (9 vs 11%, respectively; x2=6·2, p=0·008). Overall 12% (350 / 2898)
female prisoners were diagnosed with major depression.

Way et al, (2008) studied the characteristics of inmates who received a diagnosis of
serious mental illness upon entry to a New York State prison. Chart review was
performed for inmates who entered prison between May 2007 and June 2007 and
received a diagnosis of serious mental illness. Initial diagnosis was made by a
psychologist or a social worker within few days after arrival in the prison. A few days
later, a psychiatrist reviewed the chart material, conducted a second interview and
confirmed or modified the diagnosis. Six percent (172 of 2,918 inmates) received a
diagnosis of serious mental disorder. Twenty-two (13%) received a diagnosis of major
depressive disorder and 33 (19%) received a diagnosis of unspecified mood disorder.

69
 Table 1: Prevalence studies of Depression/Neurotic disorders in Prisons/Jails

Sample Diagnostic
Authors (year) Venue/gender Sampling method Prevalence rates
size instruments

Female prison 100 Diagnostic Interview

Daniel et al., (1988) Not available (N/A) Major depression – 21%
inmates females Schedule-III

627 Diagnostic Interview Current major depression- 3.9%,

Teplin (1990) Jail N/A
inmates Schedule-III

301 Clinical interview

Maden et al., (1994) Prison N/A Neurosis -18%
inmates schedule

Two-stage random Initial screening by

Bean et al., (1988), 464
Prison sample stratified by PERI, later on used Major depression – 12.7%
USA inmates
facility SCID

Two stage samples;

general population
California
sample stratified on Diagnostic Interview
department of
Prison 413 institutional security Schedule-III (DIS- Major depression-7.2%
corrections (1989),
level (n=362); random III) Dysthymia-3.8%
USA
psychiatric
sample(n=51)

Two stage random DIS administered to

Neighbors et al.,
Michigan Prison 1240 sample stratified by sample and SCID to Major depression-11.3%
(1987), USA Dysthymia-6.4%
institution type screened sample

Motiuk and Prison DIS: wide criteria Major depression-21.4%

2185 Random sample
Porporino (1991), Dysthymia-14.3%

70
 Canada males stratified by region DIS: stringent
Major depression-13.6%
criteria Dysthymia-7.9%
Male jail Major Depression-10%
Roesch (1995) 790 N/A N/A
detainees
Male jail Major Depression-10%
Brooke (1996) 750 N/A N/A
detainees
Male jail Major Depression-8%
500 N/A N/A
detainees
Powell (1997)
Male sentenced Major depression-12%
750 N/A N/A
inmates
Male jail Major Depression-10%
441 N/A N/A
detainees
Simpson (1999)
Male sentenced Major depression-6%
645 N/A N/A
inmates
Mixed sample
(this study did
not report results
Robins and Regier Major depression-7%
separately for 604 males N/A N/A
(1991)
detainees and
sentenced
inmates)
Anderson et al., Fazel and Danesh
(1996) + Schuckit et (2002) have
al., (1977) + Brinded commented that the
Male jail Major depression-5%
et al., (1999) + 550 results of these five N/A
detainees
Shoemaker and Van studies have been
Zessen (1997) + clubbed because of the
Watt et al., (1993) smaller sample sizes
Male sentences Major Depression-10%
Roesch (1995) 790 N/A N/A
inmates

71
 Male sentenced Major Depression-10%
Brooke (1996) 750 N/A N/A
inmates
Male sentenced Major depression-9%
De Cataldo (1995) 514 N/A N/A
inmates
Brinded et al.,
Not available for
(1999) +
majority of the
Schoemaker and
references. The
Van Zessen (1997) +
authors have Not available for
Gibson et al., (1999) Male sentenced 14%
1244 commented that the most of the
+ Bulten and inmates
results of these five references
Gevangen (1998) +
studies have been
Bland et al., (1990)
clubbed because of the
+ Hermann et al.,
smaller sample sizes
(1991)
Female jail
Randomly selected Major depression-14%
Teplin (1996) detainees 1272 DIS
stratified sample
awaiting trial
Anderson et al.,
(1996) + Wilkins N/A. The authors have
and Coid (1991) + commented that the
Poythress et al., Female detainees results of these five Major depression-9%
292 N/A
(1998) + Mohan et awaiting trial studies have been
al., (1997) + Hurley clubbed because of the
and Dunne (1991) + smaller sample sizes
Neary (1990)
Mixed
sample(these
Robins and Regier
studies did not Major depression-10%
(1991) + Denton 105 N/A N/A
report results
(1995)
separately for
detainees and

72
 sentenced
inmates)
Female
Jordan (1996) sentenced 805 N/A N/A Major depression-11%
inmates
Simpson et al.,
N/A. The authors have
(1999) + Brinded et
commented that the
al., (1999) +
Female results of these five
Hermann et al., 12%
sentenced 424 studies have been N/A
(1991) + Mohan et
inmates clubbed because of the
al., (1997) + Hurley
smaller sample sizes
and Dunne (1991) +
of individual studies
Daniel et al., (1988)
N/A. Sample included
Sentenced Neurotic problems (disturbed sleep,
Gunn et al., (1991) N/A both male and female N/A
inmates worry, fatigue, irritability)-27%
prisoners
N/A. sample included
Remand Neurotic problems (disturbed sleep,
Maden et al., (1996) N/A both male and female N/A
prisoners worry, fatigue, irritability)-91%
prisoners
Semi-structured pro-
Birmingham et al., Male remand forma that included Major mood disorder-2%,
549 N/A
(1996) prisoners well validated Dysthymia-2%
psychiatric scales
40%
Neurotic
(sentenced
Singleton et al., disorder(worry,
Both remand and men)
(1998) [Office for irritability,
sentenced N/A N/A N/A 78% (remand
National Statistics- depression,
inmates men)
Prison survey-1997] disturbed sleep,
63%
fatigue)
(sentenced

73
 women)
76% (remand
women)
State
Stratified two stage
prison- Major depression-24%
sample. Facilities
14,449
James et al., (2006) State prison, were selected in the
Federal
[Bureau of Justice Federal prison & first stage. In the SCID
prisons- Major depression-16%
Statistics in the US] local jails second stage, samples
3686
were systematically
Local
selected. Major depression-30%
jails-3365
Current major depression &
Stratified random dysthymia-31%
Assadi et al., (2006) Male prisoners 351 SCID
sampling Lifetime major depression &
dysthymia-49%
Both male &
female inmates
incarcerated in
Baillargeon et al., 2,34,031 Retrospective cohort
the Texas Clinical evaluation Current major depression-4.2%
(2009) study of all inmates
department of
criminal justice
prison system
Hamilton Depression
Eyestone and
Male prisoners 102 N/A Rating Scale & Beck Major depression-25.5%
Howell (1994)
Depression Inventory
Way et al., (2008), Major depression-13%
New York, United State prison 172 N/A Clinical interview
Unspecified mood disorder-19%
States

74
Prevalence of Depression in Bangalore prison

In the Bangalore Prison Study (Math et al., 2011), the first systematic assessment of
mental morbidity among prison population in our country, an interview with 5024
prisoners showed the prevalence of major depressive episode (lifetime) of 12.9%, and
9.1% of prisoners could be diagnosed as having a current depressive episode. 1.75% of
prisoners had a current diagnosis of dysthymia and 2.9% a lifetime history of dysthymia.
UTPs were significantly more likely to receive a current diagnosis of depression. When
‘current’ major depressive episodes were considered gender wise, we obtained the
following figures: 422/4815 (8.8%) male prisoners were affected while 31/197 (15.7%)
female prisoners were affected (p< 0.001). Prevalence rate among men in Bangalore
Prison study (8.8%) was slightly less when compared to international figures (Fazel and
Danesh 2002). But when compared to their prevalence in the general population (1.3% to
3.6%; Isaac and Gururaj, 2004), the morbidity was substantially more.

Table 2: Depression in the Bangalore Prison study

UTP [n
CTP [n (%)] Total X2 P-value
(%)]

Current 377(9.9) 80(6.7) 457(9.1) 11.04 <0.001

Major
depressive Past 314(8.2) 116(9.7) 430(8.6) 2.61 0.11
episode
Lifetime 493(12.9) 152(12.7) 645(12.9) 0.02 0.88

Current 89(2.3) 36(3.0) 125(2.5) 1.75 0.19

Dysthymia Past 34(0.9) 13(1.1) 47(0.9) 0.39 0.53

Lifetime 107(2.8) 39(3.3) 146(2.9) 0.69 0.40

Source: Math et al., 2011

Prevalence rates show wide variation across the globe depending upon the following
methodological issues: type of prisoners studied; assessment instruments used; who does
these assessments; sampling methods; current disorders vs. life time prevalence.
Notwithstanding these, one fact remains viz: In prisons, morbidity from depressive
disorders is substantial when compared to that in the general population. The finding that
significantly more UTPs and female prisoners had ‘current’ major depressive disorders is

75
also an expected one. Data from the general population unmistakably shows higher rates
of depression among females (Isaac and Gururaj, 2004). International studies also reveal
higher rates of depressive disorders among prisoners in local jails (which are locally
operated correctional facilities that receive offenders after an arrest and hold them for
shorter periods of time, pending trial or sentencing) Moreover, local jails hold inmates
sentenced to short terms (James and Glaze, 2006). Prisoners in these types of jails can be
conceptualised to be similar to UTPs in our jails. This trend was not observed with
dysthymia which had a prevalence of 2.8% among the UTPs and 3.3% among the CTPs
(p=0.4). Similar rates of dysthymia have been reported from Assadi et al, (2006).

In summary, the depressive disorders are amongst the most commonly prevalent illnesses
among the prison population. Considering that this is one of the most disabling yet easily
manageable disorders, no efforts should be spared towards identifying and treating them.
Depression causes a lot of suffering as well as long-term adverse consequences if left
untreated. Prevalence rates of depressive disorders in the prison population are high
globally, and the Bangalore Prison study also highlights this finding. Sadly, depression is
hardly ever recognised and managed in prison settings. It is important to train prison staff
in the early recognition and counselling for depression, as well as establish an efficient
network with mental health professionals for its effective treatment.

76
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Schoemaker C, Van Zessen G 1997. Psychische stoornissen bij gedetineerden, Trimbos-
Instituut, Utrecht
Simpson A, Brinded P, Laidlaw T, Fairley N, Malcolm F 1999. The national study of
psychiatric morbidity in New Zealand prisons, Department of Corrections,
Auckland

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Singleton N, Meltzer H, Gatward R 1998. Psychiatric morbidity among prisoners in
England and Wales. Office for National Statistics, London
Teplin LA. The prevalence of severe mental disorder among male urban jail detainees:
comparison with the epidemiologic catchment area program. Am J Pub Health
1990; 80: 663-669
Teplin LA. Psychiatric and Substance Abuse Disorders among Male Urban Jail
Detainees. American Journal of Public Health 1994; 84: 290-293
Teplin LA, Abram K, McClelland G. Prevalence of psychiatric disorders among
incarcerated women—pretrial jail detainees. Arch Gen Psychiatry 1996; 53: 505–
512
Watt F, Tomison A, Torpy D. The prevalence of psychiatric disorder in a male remand
population: a pilot study. J Forensic Psychiatry 1993; 4: 75–83
Way BB, Sawyer DA, Lilly SN, Moffitt C, Stapholz BJ. Characteristics of inmates who
received a diagnosis of serious mental illness upon entry to New York State Prison.
Psychiatr Serv 2008; 59:1335–1337
Wilkins J, Coid J. Self-mutilation in female remanded prisoners: I-an indicator of severe
psychopathology. Crim Behav Mental Health1991; 1: 247-1267
World Health Organization 1992. The ICD-10 Classification of Mental and Behavioral
Disorders: Cinical description and Diagnostic Guidelines. Geneva. World Health
Organization, Geneva

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 6. ISSUES RELATED TO SUICIDE IN PRISONS

Suicide in prison is a tragic event that can unsettle both inmates and staff for a
considerable length of time (Hill, 2004). Suicide remains a leading cause of death in
prisons across the globe. It is the third largest cause of death in the US jails. Although the
definitive rate of suicide is not known, estimates range from 18-188 per 100,000
population. Prison suicide rates are nine to fourteen times higher than that of the general
population. Hanging and medicine overdose are the most common methods of suicide in
prisons. The study of prison suicides has increased considerably since the past three
decades (Goss et al., 2002; Daniel et al., 2006). A combination of institutional factors,
individual vulnerabilities and poor coping skills has been consistently found to increase
suicide risk among prisoners. These elements have been well documented in suicide
prevention practices (Stuart, 2003). This chapter will present a glimpse of the findings on
the prevalence and the causative factors identified from these studies and focus on the
prevention mechanisms that need to be put in place in prisons.

Global prevalence of suicide in prisons

Anderson (2004), in his seminal paper on psychiatric morbidity in prison populations,

reviewed 11 studies across the globe on prison suicides. He concludes that there is a
massive overrepresentation of suicides in prisons. The very first phase of imprisonment,
early phase of long-term sentences, history of psychiatric illness, history of suicidal
behaviour, intoxication, isolation or solitary confinement have been identified as risk
factors for prison suicides. Imprisonment stress from the following sources could also
explain the high incidence of suicide rates: general stress of entering the prison system,
disruption of normal life and social disruption. Though the incidence of suicides has
increased over time, the intervention programmes have reduced such rates.

Daniel, (2006) reviewed the literature during the past three decades on prison suicides
and identified the following demographic, clinical and institutional risk factors. A)
Demographic: being single without job or family support; young age (below 21); upper
socio economic status and high degree of social and family integration before
incarceration. B) Clinical: Psychiatric disorders such as mood, psychotic and personality
disorders; family history of mental illness, drug abuse; mental states such as depression,
hopelessness and anxiety; personality traits such as antisocial personality and borderline
personality traits; Psychosocial stressors such as interpersonal conflicts with other

81
inmates, legal processes, issues related to parole; substance abuse especially opiate abuse;
medical conditions such as HIV infection, intractably painful conditions and epilepsy. C)
Institutional factors: first 24-48 hours of confinement; overcrowded and short staffed
prisons; maximum security facilities. Based on this review, he outlines that suicide-
prevention programmes should incorporate comprehensive mental health services and
structured psychiatric delivery system supported by the administration.

Frottier et al, (2002) have shown the relationship between suicide risk and the duration of
incarceration. Using sophisticated statistical methods, they arrived at three different
periods of high suicide risk: immediately after admission and 2 months thereafter for
under-trial prisoners. The risk correlated with the length of the sentence.

Suicides are frequent in prisoners (Weinstein, 1989). Higher rates of psychiatric disorders
among the prisoners contribute towards this high risk. Majority of prisoners who commit
suicide have a treatable psychiatric illness, many of them communicate their intent before
they succeed in their attempt. Rates of completed suicides among inmates with past
histories of attempts are 100 times the rate in the general population (Durand et al.,
1995).

A study by Durand et al, (1995) examined factors that increase the risk of suicide in a
representative jail in Detroit. Over a period of 25 years, there were 37 suicides. Inmates
charged with manslaughter and murders were 19 times more likely to commit suicide
than were prisoners with other charges. All suicides were by hanging and most occurred
at night within 31 days of admission into the prison. Many of the victims had made
previous suicide attempts while incarcerated. The authors concluded that the important
risk factor in jail suicide was the charge of murder or manslaughter.

Suicide may be another consequence of putting seriously mentally ill individuals in

prisons. New York State data, collected between 1977 and 1982 revealed that 50% of all
suicide victims were previously hospitalised for mental disorders. Another study found
that more than 75% of suicide attempters had past histories of mental illness and
treatment (Torrey, 1995).

Shaw et al. (2004) described the clinical and social circumstances of all self-inflicted
deaths in prisons in England and Wales between January 1999 and December 2000.
Information was collected from the prison governors and prison health care staff. A total
of 172 suicides occurred during that period. 85 (49%; 95% CI 42-57) were remand

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prisoners; 55(32%; 95% CI 25-39) suicides occurred within the first week of
imprisonment; 159 (92%; 95% CI 88-96) prisoners committed suicide; 110 (72%; 95%
CI 65-79) had history of mental illnesses. 89 (57%; 95% CI 49-64) had symptoms of
mental illness at the time of entry into the prison. They concluded that suicide prevention
measures should be concentrated in the period immediately following entry and also that
potential ligature points from cells should be removed.

Fruhwald and Frottier, (2005) demonstrated significant increases in suicide rates in

correctional systems over the preceding two decades in Austria. They argue that this
increase could be explained by the phenomenon of ‘new era institutionalisation’ which is
a negative consequence of the shift of care from psychiatric hospitals to community-
based services: Most disadvantaged patients will not be able to cope with the new
situation and eventually enter the correctional system. They note that prisoners should to
be assessed for suicidal risk immediately upon entry into the system using simple
screening instruments so that preventive measures could be implemented. The gap
between scientific knowledge and preventive strategies and the need for further research
has also been stressed.

Blaauw et al, (2005) reviewed 19 studies and identified demographic, criminal

characteristics and psychiatric risk factors for suicide inside correctional settings. The
following factors were identified: age 40+, homelessness, history of psychiatric care,
history of drug abuse, prior incarceration, violent offences and history of suicidal
attempts. Past history of psychiatric care had the maximum odds ratio [10.98; 95%
CI=4.59-26.40]. They opined that these indicators are easy to identify, unambiguous,
require no special knowledge from the assessor, may be useful for categorizing inmates
who need further specialist assessment and intervention. Segregation housing (Bonner,
2006) has an independent association with suicidal ideation.

WHO, (1994) defines para-suicide as an act with non-fatal outcome, in which an

individual deliberately initiates a behaviour that, without intervention from others, will
cause self-harm. This behaviour includes attempted suicide and non-repetitive self-harm.
Although para-suicide, by definition, is nonfatal, it has the potential of being fatal.
Parasuicide is often used as an indicator of suicidal risk. These behaviours are highly
recurrent and up-to seven percent will die by suicide within the next decade. Moreover, a
history of parasuicide increases the risk of suicide by 40 times than that in the general
population (Black et al., 2007). This conclusion is supported by a recent review (Daniel,
2006) that states that 45-60% of inmates who commit suicide have attempted it before. Of

83
those with a history of prior attempts and who eventually complete suicide, majority use
lethal methods such as hanging, immolation, swallowing sharp objects and drug
overdose.

A study by Black et al, (2007) used a cross-sectional design to examine the association
between mental illnesses and parasuicides in a sample of male prisoners in UK (n=51).
They found that the unadjusted odds ratio for having a self-reported history of parasuicide
was 15.6(95% C.I=2.96-82.16). After adjusting for age, homelessness, living alone, drug
and alcohol problems, the odds ratio was 11.32(95% C.I=1.80-71.13). They concluded
that their study provided good evidence of an association between history of mental
health problems and a history of parasuicide in a group of male prisoners in UK.

Fruehwald et al, (2006) conducted a methodologically sound case-control study to

investigate risk factors for prison suicides. For each suicide that occurred in any of the
Austrian correctional institutions between 1975 and 1999, two controls that matched for
correctional institution, gender, nationality, age, custodial status and time of admission
were chosen. Past suicidal behaviour, criminal histories, current psychiatric histories were
compared. The most important predictors for pre-trial prisoners were, a past history of
suicidality, psychiatric diagnosis, psychotropic medication, violent index offence and
solitary confinement. For sentenced offenders, the most important predictors were
psychiatric diagnosis, solitary confinement, past suicidal attempts, last offence of a highly
violent nature and psychiatric medication prescribed while in custody.

As part of an effort to improve an already existing suicide prevention programme in

Washington prisons, a quality improvement committee was formed in the department of
adult and juvenile detention. From the data that ensued, Goss et al, (2008) reported on the
characteristics of suicide attempts. First time suicide attempts were studied among
inmates over a 33-month period. The prevalence of mental illness among first time
attempters was 77 % compared with 15% in the general jail population.

Jenkins et al, (2005) analysed the prevalence of suicidal ideation and suicide attempts in
the National Prison Survey of the UK, and their association with the presence of
psychiatric disorders. These data were compared with data from a national survey of
psychiatric morbidity in adults living at home. Both surveys used a two phased
interviewing procedure covering general health, mental health, activities of daily living,
socio-demographic data, substance abuse, life events, substance use and intelligence.
Suicidal behaviours were commoner in prisons than in the general population and these

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were significantly associated with various psychiatric disorders. In addition, demographic
factors such as being young, single, school drop outs, poor social supports and social
adversities were important factors for suicidal thoughts. The following were the adjusted
odds ratios (95% confidence intervals) for selective variables: moderate lack of social
support- 1.37(1.02-1.86); female gender-1.91(1.43-2.56); 16-20 years of age-3.00(1.80-
4.98); remand prisoner-1.56(1.20-2.02); depressive episode-1.68(1.2-2.35); psychosis-
4.87(3.53-6.72); personality disorder-1.98(1.26-3.11). All values were statistically
significant at p < 0.05.

Patterson and Hughes (2008) reviewed all 154 suicides that occurred in California prisons
between the periods 1999 and 2004 and examined several factors related to the suicide.
Among the prisoners who committed suicide during this period, 149 (97%) were males
and 73 (47%) were aged between 31-40 years. The methods utilised by prisoners
included hanging (n=131; 85%), lacerations (n=5; 3%), drug overdose (n=5; 3%) and
others (n=9; 6%). 87(56%) had mental illnesses. They concluded that although suicide is
not predictable, there could be clues to recognise inmates at elevated risk and identify
some of the health care practices and conditions of confinement to consider for provision
of adequate suicide prevention programmes.

Suicide Prevention Programmes in Prisons

The American Correctional Association (ACA) has developed suicide prevention

standards that require the following (Bonner, 2000):

 A written policy and procedures to ensure that all special management inmates are
directly observed at least every 30 minutes
 More frequent observation for inmates who are violent or have a mental illness
than for inmates who are not violent and do not have a mental illness
 Continual observation for actively suicidal inmates
 A written suicide prevention programme that has been approved by mental health
professionals
 Training for all correctional staff in suicide prevention and intervention
programme
 Intake screening, identification and supervision of inmates who are prone to
suicide

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Like the ACA, the National Commission on Correctional Health Care (NCCHC)
standards of the US requires a written suicide prevention plan. Essential components of
such a programme include (Hill, 2004):

 Identification through screening

 Training the staff
 Assessment by a qualified mental health professional
 Monitoring inside the facilities
 Housing: Suicide inmates should not be isolated unless under constant supervision
 Referral
 Effective communication between the correctional and health staff about an
inmate’s status
 Intervention: Staff should develop procedures on how to handle a suicide attempt
in progress
 Notification: Development of procedures for notifying family, prison
administrators and other authorities regarding potential, attempted or completed
suicides
 Reporting: Staff should document in detail all potential, attempted or completed
suicides
 Review: The facility should perform administrative and medical reviews of
completed suicides.

NCCHC also provides recommendations for the assessment, housing and observation of
suicidal prisoners through a level system that allows for a more individualised approach
to the problem of suicidal potential and behaviour. Similarly, the Federal Bureau of
Prisons’ Five-step programme for suicide prevention (of the US) includes:

 The initial screening of all inmates for suicidal potential

 Criteria for the treatment and housing of suicidal inmates
 Standardised record keeping, follow-up procedures, and collection of data
relevant to suicides
 Staff training
 Periodic reviews and audits

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After the implementation of these procedures, research has documented a considerable
decrease in suicidal rates in US prisons (Hill, 2004).

Hall and Gabor (2004) examined an innovative suicide prevention programme in cannada
in which prison inmates acted as volunteers to identify and refer individuals with suicidal
risk. Peer volunteers were trained in issues of befriending, effective and active listening,
non-verbal communications, schizophrenia, bipolar disorder, depression, suicide
prevention and suicide intervention. These volunteers were expected to have a minimum
of 200 people utilise the service per year. After establishing contacts with suicidal
inmates, they were supposed to assess the risk and make appropriate referrals. At the end
of three years of this programme, the volunteers had exceeded their target number of
contacts by 27%. Since the absolute numbers of completed suicides was very low in the
institute where the study was carried out, no statistical comparisons were possible though
they demonstrated numerical reductions in the number of completed suicides.

In contrast to the enormous literature about completed suicides, para-suicide has not
received much attention. The Indian scenario is even worse. To our knowledge, we did
not find any study that had examined prison suicides.

Findings from the Bangalore Prison Study

The Bangalore Prison Mental Health study (Math et al., 2011) carried out a secondary
data analysis of the prison records examining the details of completed suicides. There
were 6 completed suicides during the years 2008 (six out of thirty-eight total deaths) as
well as 2009 (six out of thirty total deaths). Suicide rate was 119 per 1,00,000 for each of
the years considering the prison population to be 5024.

Table 1 shows the details of suicidal/DSH attempts. Table 2 shows details of the current
suicidal risk based on the MINI scoring. 290 inmates with suicidal risk (defined as those
with MINI Suicidality score of at least one) were compared with the rest of the sample
with the aim of knowing correlates of suicidal ideation. 5.8 percent of inmates had a
current suicidal risk. Details of this are given in Table 3.

The commonest method of suicidal attempt among suicide attempters was consuming
organophosphorous compounds (68% of UTPs and 46% of CTPs). Deliberate self-harm
methods among those that attempted DSH was mainly by making cuts on the hand (65%
UTPs and 10% CTPs) and slashing the face (27% UTPs and 17% CTPs).

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Table 1. Details of suicidal/DSH attempts

UTPs CTPs df/chi- p-

square value
Suicide attempt-life time *
@
Total number of inmates 3822 1195 NA NA
[n(%)] 65(1.7) 13(1.1) 2.23 0.1
Persons who have attempted DSH-lifetime [n(%)] *
Total number of inmates@ 3823 1195 NA NA
Total number 111(2.9) 18(1.5) 7.09 <0.01
Number before coming to prison 85(2.2) 10(0.8) 9.43 <0.01
Number after coming to prison 58(1.5) 10(0.8) 3.16 0.05
DSH/Current suicidality [mean (SD)]
MINI score^ 16.67(14.2) 16.57(12.5) 288 0.1
Total number of DSH attempts 4.96(7.1) 2.63(1.96) 126 0.2
DSH attempts before coming to 4.68(7.6) 2.50(1.3) 93 0.4
prison
DSH attempts after coming to 2.78(3.3) 1.60(0.8) 66 0.3
prison
Source: Math et al., 2011
NA-Not applicable;
DSH-deliberate self harm;
UTP-under-trial prisoner;
CTP-convicted prisoner;
* Figures are for a minimum of one attempt;
@
information available for these many inmates;
MINI-Mini International Neuropsychiatric Interview;
^ scores are for 290 patients who displayed suicidal ideation at the time of assessment.

Between 45-63 percent of suicide victims would have had past history of attempts
(Daniel, 2006; Anderson 2004). Hence it is vital to identify and intervene in persons who
harbor suicidal risk. In the Bangalore Prison study, a total of 5.8% of inmates harboured
current suicidal risk. In comparison with those who did not harbour such risk, these
individuals were slightly older; had no spouses (p<0.001); had significantly more past
suicidal attempts (p<0.001) and psychiatric disorders (p<0.001). Moreover, UTPs were
significantly more likely to have suicidal risk when compared to the CTPs (p<0.001).

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Table 2. Current suicidal risk based on the MINI scoring [n (%)]

Suicide Risk UTPs CTPs df/chi- p-value

square
Total number of inmates* 3827 1197 N/A N/A
Low 41 (1.1) 03(0.3)
Moderate 121(3.2) 36(3.0) 8.38 0.06
High 72(1.9) 17(1.4)
Total 234(6.1) 56(4.7) N/A N/A
Source: Math et al., 2011

NA-Not applicable; UTP-under-trial prisoner; CTP-convicted prisoner; MINI-Mini

International Neuropsychiatric Interview; * information available for these many inmates.

Table 3. Comparison of prisoners with suicidal risk present and absent

Suicidal Suicidal df/chi- p-value

Variables risk risk square
present absent
(n=290) (n=4722)
Mean (SD) age in years 31.7(12.0) 30.6(10.4) 5010 0.08
Mean(SD) years of education 5.8(4.8) 6.2(4.7) 5005 0.2
Mean(SD) number of prior 1.7(4.7) 0.02(0.4) 5009 <0.001
attempts
Males [n(%)] 274(94.5) 4536(96.1) 3.1 0.2
Single/widowed/divorced [n(%)] 165(56.9) 2554(54.1) 30.5 <0.001
Under trial prisoners [n(%)] 234(80.7) 3583(75.9) 3.5 0.06
Any mental disorder [n(%)] 276(95.8) 3723(79.0) 48.0 <0.001
Source: Math et al., 2011

Bangalore Prison Study essentially confirmed the findings regarding prison suicides. The
rates are exceedingly high when compared to those of the general population. Compared
to the national average of 10.8 suicides per 1,00,000 population (National Crime Records
Bureau, 2008), Bangalore prison study found a rate of 119 per 1,00,000 which is eleven
times higher. Moreover, this figure is comparable to many of the international findings
which show similar rates (Daniel, 2006).

89
Many of the following factors might have led to such high suicide rates: expression of
mental suffering, despair, axis-I mental disorders including substance abuse, personality
disorders, individual coping styles and institutional factors such as stress due to
imprisonment, delay in trial and injustice. Since psychological autopsies were not
conducted, exact reasons or methods for suicides cannot be commented upon. Needless to
say, thorough reviews of all prison deaths (including suicides) should form an essential
part of the prison health care delivery system.

The findings with respect to deliberate self-harm are also comparable to the findings from
the western literature (Daniel, 2006). These are the persons who need to be targeted
through suicide prevention programmes. Identification of suicidal risk should be part of
the intake medical examinations. In this context, it is noteworthy that risk factors for
suicide can be easily identified by non-specialists using simple checklists (Hill, 2004).
Moreover, inmate volunteers have been successfully used in prison suicide prevention
programmes (Hall and Gabor, 2004).

In conclusion, while individuals end up in prison as a result of going against a legal

system, prisons should be an opportunity that would help them reform themselves and get
back to the mainstream in society. However the deplorable conditions in prisons only
adds to the negativity and enhances the sense of hopelessness that contributes to
individuals’ choosing the biggest escape route by taking their own lives. Preventive
mechanisms should not stop only at the identification of high risk individuals for suicide
and intervening with them, but rather focus more broadly on positioning prisons as
reformative centres in the true sense of the term so that individuals are motivated to
change and can hope to a second chance of a normal life style.

90
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study of Danish prisoners on remand. Acta Psychiatr Scand 2004:110: 5–59
Blaauw E, Kerkhof JFM, Hayes LM. Demographic, Criminal and Psychiatric Factors
Related to Inmate Suicide. Suicide Life Threat Behav 2005; 35: 63-75
Black D, James M, Evan R, Rogers P. The association between a self-reported history of
mental health problems and a history of parasuicide in a sample of UK male
prisoners. Int J Nurs Stud 2007; 44: 427-434
Bonner RL. Correctional Suicide Prevention in the Year 2000 and Beyond. Suicide Life
Threat Behav 2000; 30: 370–376
Bonner RL. Stressful segregation housing and psychosocial vulnerability in prison
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Daniel AE. Preventing suicide in Prison: A collaborative Responsibility of
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165-75
DuRand CJ, Burtka GJ, Federman EJ, Haxcox JA, Smith JW. A quarter century of
suicide in a major urban jail: Implications for community psychiatry. Am J
Psychiatry 1995; 152: 1077-1080
Frottier P, Fruhwald S, Ritter K, Eher R, Schwarzler J, Bauer P. Jailhouse Blues revisited.
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control study. Br J Psychiatry 2004; 185: 494-498
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Jenkins R, Bhugra D, Meltzer H, Singleton N, Bebbington P, Brugha T, Coid J, Farrell
M, Lewis G, Paton J. Psychiatric and social aspects of suicidal behaviour in
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health and substance use problems in prisons: Local lessons for national action.
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Patterson R, Hughes K. Review of completed suicides in the California Department of
Corrections and Rehabilitation. Psychiatr Serv 2008; 59: 676-682
Shaw J, Baker D, Hunt IM, Moloney A, Appleby L. Suicide by Prisoners: National
Clinical Survey. Br J Psychiatry 2004; 184: 263-267
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 7. PERSONALITY DISORDERS WITH SERIOUS IMPLICATIONS
IN PRISONS

Are people who commit crimes different from those who do not? How are they deviant?
What are the social and economic factors that influence these behaviours? Are the
stressful situations they face very unlike what others face? These are the common
questions which come up. Answers to these questions can be provided from various
perspectives. A sociological perspective might look at factors like discrimination; role of
media; illiteracy; law and order in the society etc., An economic perspective would focus
more on aspects like poverty, scarcity of resources; rise in prices etc., A psychological
perspective would be from internal factors such as personality, temperament, emotions,
greed, jealousy and impulsivity of a person. While sociological and economic factors
have been studied in depth, factors such as personality and temperament have not got
much attention. This chapter looks at criminal and deviant behaviour as a product of
dysfunctional personality and focuses more on problematic personality disorders in
prisons and how they can be managed.

Personality

Everyone in this world has their distinctive personality that makes them unique. There are
many definitions of personality. In simple words, personality consists of ingrained,
pervasive, enduring and habitual ways of psychological functioning that characterise
one's style. It is a tightly interrelated organisation of attitudes, perceptions, habits,
emotions and behaviours that characterise a person's distinctive way of relating to others
and to self (Millon, 1981; Millon, 1987). Each person has a unique personality moulded
by his/her past experiences, attitude, culture, religion, lifestyle, mood, relationships,
energy levels and hobbies. Normal personalities are productive at work, well-adjusted
socially, cope well with stressful situations and operate well within the social and cultural
norms. Similar to personality, „temperament‟ does not have a consensual definition. A
temperament refers to a distinctive profile of feelings and behaviours, rooted in biological
systems and emotion is basic to temperament (Rothbart, 1989; Goldsmith et al., 1987).
Personality is made up of a combination of distinguishing qualities and characteristics
called traits. Traits refer to a distinctive set of attributes such as thinking, feeling, attitude
and behaviour.

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Personality Disorders

The combined and consistent patterns of emotion, thought and behaviour that make an
individual unique comprise personality. However, when this pattern interferes and
impairs the day to day functioning of the individual, it is referred to as “personality
disorder” (Hales et al., 2008). In other words, they are patterns of inflexible and
maladaptive personality traits and enduring behaviours that cause subjective distress,
significant impairment in social or occupational functioning, or both (American
Psychiatric Association, 2000). These patterns deviate markedly from the culturally
expected and accepted range and are manifest in two or more of the following areas:
cognition, affectivity, control over impulses and need for gratification, and ways of
relating to others (American Psychiatric Association, 2000; Hales et al., 2008). The
symptoms are pervasive and they are exhibited across a broad range of contexts and
situations rather than in only one specific triggering situation or in response to a
particular stimulus or person. Finally, the patterns must have been stably present and
enduring, since adolescence or early adulthood (American Psychiatric Association,
2000).

According to the International Classification of Diseases -10 guidelines, “personality

disorders are deeply ingrained and enduring behaviour patterns, manifesting themselves
as inflexible responses to a broad range of personal and social situations. They represent
either extreme of significant deviations from the way the average individual in a given
culture perceives, thinks, feels and particularly relates to others. Such behaviour patterns
tend to be stable and encompass multiple domains of behaviour and psychological
functioning. They are frequently, but not always, associated with various degrees of
subjective distress and problems in social functioning and performance (World Health
Organization, 1992). People with personality disorders believe that the world should
change to accommodate them and view their own features as being acceptable and not in
need to change.

People with personality disorder constitute up to 10-15% of the general population

(Torgersen et al., 2001; Reich et al., 1989). They are the frequent visitors to the
emergency departments at hospitals , as a result of social crises, relationship breakup,
violence, injuries, self-injurious behavior, suicide, over intake of drugs, impulsivity and
sudden violent death (Warren et al., 2002; Verona et al., 2001; Watzke et al., 2006). They
are also at a high risk of getting into conflict with the law because of self-injurious
behavior, sexual offences, violence, substance use, murder and recidivism (Dunsieth et

94
al., 2004; Watzke et al., 2006; Black et al., 2007). As per the International Classification
of Diseases, there are ten different types of personality disorders seen in the general
population. However, there are many people with temperamental problems within the
general population, which is also reflected in the prison population. In this chapter, we
focus more on problematic personality disorders, which are commonly seen in prison
population and are very difficult to manage.

Prison populations are known to house certain personality disorders

The common saying about prison is that it houses the „SAD, MAD and BAD‟ of the
society (Rotter et al., 2002). Sad indicates that at least 50-75% of the prison population
suffer from depression, Mad depicts that at least 30-15% of them have mental illness and
Bad suggests that 20-10% of them are psychopaths (Rotter et al., 2002). Persons
suffering from personality disorders have their reasoning powers fully intact; hence none
of the countries have granted insanity defence to those with personality disorders.
However, they have been provided with an opportunity for treatment and rehabilitation.

Prevalence of personality disorders is high in prison population when compared to the

general population (Brink, 2005; Andersen, 2004; Butler et al., 2006). In a systematic
review of 62 surveys, it was reported that 65% of the men had personality disorders with
47% having anti-social personality disorder. 42% of the women had personality disorder
and 21% had anti-social personality disorder (Fazel and Danesh, 2002). In another study,
prevalence of alcohol and drug addiction was 90%, personality disorders were 80% and
antisocial personality disorder was 60% (Langeveld and Melhus, 2004).

In a recent study, personality disorder was observed in 30% of the prison inmates. The
distribution of personality disorders was as follows; 12% with Antisocial Disorder, 12%
with Borderline Disorder, 3% with Paranoid Disorder, 2% with Narcissistic Disorder, and
2% and Schizoid disorder (Arroyo and Ortega, 2009). Presence of anti-social personality
disorder is a high risk for developing mental illness (Andersen, 2004) and suicide
(Verona et al., 2001). Studies have reported that 50% of the mentally ill patients also
have personality disorder. Men had a higher prevalence of alcohol abuse and antisocial
personality, while women more often showed depression, anxiety disorders and
borderline personality disorders (Watzke et al., 2006).

Emotionally unstable personality disorder was present in 30% of the inmates. The
percentage of women meeting criteria for borderline personality disorder was more than

95
twice that of men (Black et al., 2007). A more recent study reported that personality
disorders, especially antisocial and unstable personality disorders are strongly related to
the manifestation of violent acts (Fountoulakis et al., 2008). One of the possible reasons
being that both disorders have a common base in impulsive personality traits, but the
behavioural differences between them are shaped by gender(Paris, 1997). Prevalence of
antisocial personality is more common in men and unstable personality is more common
in women.

Anti-social personality disorder

Anti-social personality, usually comes to attention because of a gross disparity between

the individual‟s behaviour and the prevailing social norms. Characteristics of Antisocial
personality disorder are as follows:

Characteristics of Anti-Social Personality Disorder

(a) Callous unconcern for the feelings of others;

(b) Disregard for social norms, rules and obligations;
(c) Gross and persistent attitude of irresponsibility;
(d) Inability to maintain enduring relationships, though having no difficulty in
establishing them;
(e) Very low tolerance to frustration and a low threshold for discharge of
aggression, including violence;
(f) Inability to experience guilt or to profit from experience, particularly
punishment;
(g) Marked proneness to blame others, or to offer plausible rationalisations for
the behaviour that has brought the patient into conflict with society.

Includes: amoral, dissocial, psychopathic, and sociopathic personality

Source: World Health Organization, 1992

Conduct disorder during childhood and adolescence, though not invariably present, may
further support the diagnosis. An Iranian study reported that 23% of the prison population
were „psychopaths‟ (Assadi et al., 2006). Antisocial personality disorder is associated

96
with substance use, gambling, depression, self-injurious behavior, suicide and poor
quality of life (Black et al., 2010).

Systematically conducted study from India reported that thirteen for every hundred
prisoners could be diagnosed as having a conduct disorder in childhood and UTPs were
significantly more likely to have received this diagnosis compared to CTPs. Nearly
fifteen for every 100 UTPs received a diagnosis of antisocial personality disorder. This is
7-8 times more than the general population (Math et al., 2011).

Antisocial personality disorder does not manifest out of the blue. It can be traced back to
difficult behaviours in childhood and adolescence, in the form of externalising disorders
(characterised by impulsivity, attentional deficits, negative and defiant attitudes to
authority, conduct problems which include violation of social norms and an inability to
learn from past experience). The disorder is attributed to a combination of genetic
vulnerability, temperament, subtle brain dysfunction, learning difficulties and
environmental adversity.

Antisocial personality and psychopaths are almost the same in terms of callousness,
breaking rules, irresponsible, low frustration tolerance, lack of remorse and inability to
learn from past experience (Coid and Ullrich, 2010). However, there are researchers who
argue that they differ in the severity of the antisocial behaviour. Psychopaths form the
most severe form of antisocial personality. They are characterised by low anxiety,
egocentricity, selfishness, violent behaviour, sexual aggression, promiscuousness, high
pleasure seeking and lack of emotional regulation. They deceive, manipulate, smart and
destroy the lives of others for their gratification. Persons suffering from antisocial
personality disorders are very difficult to treat. Most of these individuals are referred for
treatment by the judiciary. However treatment options in our prison systems are poor to
nonexistent. Once they understand the prison system and mental health service, they
manipulate the system using several techniques, include malingering. There are high
chances that they will be placed in forensic mental hospitals rather than in prisons. Such
facilities are non-existent in India. Till date no medicine or therapy has been found to be
effective. Recidivism continues to be high in this population because of the key
personality characteristic that they do not learn from past experiences.

97
Emotionally unstable personality disorders

This personality is more common among young women. People with this personality
often have difficulty in forming and maintaining long lasting relationships and can be
particularly vulnerable for impulsive and aggressive acts such as self-harm, suicide, wrist
slashing and so forth. There is a marked tendency to act impulsively without consideration
of the consequences, together with mood instability. The ability to plan ahead may be
minimal. Outbursts of intense anger may often lead to violence or "behavioural explosions".
Two variants of this personality disorder are specified, and both share this general theme of
impulsiveness and lack of self-control.

Characteristics of Emotionally Unstable Personality Disorder

There are two variants of emotionally unstable personality.

Impulsive type characterised by:

 Impulsivity
 Emotional/mood instability
 Inability to plan ahead
 Outbursts of violence or threatening behaviour which are common
particularly in response to criticism by others.

Borderline type characterised by:

 Often unclear or disturbed self-image, aims, and internal preferences

 Chronic feelings of emptiness.
 Series of suicidal threats or acts of self-harm
 Liability to become involved in intense and unstable relationships
 Repeated emotional crises and may be associated with excessive efforts to
avoid abandonment
Source: World Health Organization, 1992

Clinical signs of the disorder include emotional dysregulation, impulsive aggression,

repeated self-injury, and chronic suicidal tendencies, which make these patients frequent
users of mental-health resources.

98
Management of personality disorders

The behaviour management plan presented here is a guideline to address the issues of
personality problems in prisons. The population with personality disorder pose a big
challenge to any correctional and mental health staff. They tend to take up a huge amount
of time and resources. Working with offenders with personality disorders can be
emotionally very draining and stressful. The reasoning power of those with personality
disorder is well preserved; hence treating them against their will is not recommended.
However, treatment for personality disorder against their will is advocated with the
permission of the court, in certain conditions where the individual is dangerous to self
and/or others. The best policy is to work in partnership with people with personality
disorder and help them develop their autonomy and promote choice by ensuring they
remain actively involved in finding solutions to their problems, including during crises
and encouraging them to consider the different treatment options and life choices
available to them, and the consequences of the choices they make (NICE, 2009).

Treatment for any comorbid disorders should happen regardless of whether the person is
receiving treatment for personality disorder or not. For, example a prisoner with
personality disorder using alcohol and cannabis on a daily basis needs to undergo de-
addiction before the personality disorder is addressed. Developing a good patient and
doctor relationship is a crucial part of the individual therapy. A recent literature review
to know the effect of personality disorder on mental illness revealed that the presence of a
personality disorder is a poor predictor for response to treatment of mental disorders
(Bieling et al., 2007).

The prison behaviour management plan consists of six essential elements:

1. Assessing the risks and needs of each inmate at various points during his or her
detention.
2. Assigning inmates to housing.
3. Meeting basic needs of the inmates.
4. Defining and conveying expectations for inmate behaviour.
5. Supervising inmates.
6. Keeping inmates occupied with productive activities
Source: Hutchinson et al., 2009

99
Implementing a prison behaviour management plan requires clear directives, in the
form of written policies and procedures for each step of the plan. Availability of trained
staff and supervising them to ensure that the plan is implemented according to the
adapted policies and procedures is crucial. Systematic documentation and
recordkeeping of all activities related to the prisoner‟s behaviour management plan is
necessary (Hutchinson et al., 2009). Another essential area that is required to be
addressed is needs of the staff to be trained in crisis management.

People with personality disorders are at high risk for pressing panic buttons for crisis
management. Each staff in prison needs to be trained to face the challenges of crisis
management. Following are the broader aspects to be considered during a crisis
situation.

Skills required in crisis management

 Ensure your safety first, before you intervene

 Quick response is the key
 Maintain a calm, relaxed and concerned look
 Use of non-threatening attitude and posture
 Investigate the reason for crisis quickly
 Try to understand the crisis from the prisoner‟s point of view (empathy)
 Use open ended questions during the interview
 Use counselling skills to calm the patient down
 Avoid blaming or scolding
 Avoid instigating them
 Refrain from offering solutions before receiving full clarification of the
problems and know your limitation and explain them
 Provide support and short-term help until medical team/ appropriate crisis
team is available
 Documentation of the incident and action taken is also essential for legal
purpose

Source: Modified and adapted from Chandrashekar et al., 2007

100
Management of antisocial personality disorder

Individuals with antisocial personality disorder rarely seek psychiatric help for the
disorder. These individuals who seek care do so for other problems such as injuries,
sexually transmitted diseases, demanding sleeping medicines, alcohol or drug abuse, and
suicidal thoughts. Usually, the court or the prison staff refers them to a mental health
counsellor for evaluation. They lack insight into their problems. They also reject the
diagnosis and help offered. Often they use these opportunities to complain against the
medical officers for wrong diagnosis or else manipulate transfers to better inpatient
medical facilities. Hence, antisocial personalities who seek help (or are referred) can be
offered evaluation and treatment as outpatients. Inpatient care needs to evaluated and
considered if there are suicidal ideas/attempts. In fact, people with antisocial personality
can be disruptive in inpatient units, whenever their demands are not met. These
personalities go to any extent to manipulate the environment including deliberate self-
harm (wrist cutting). There are incidents when antisocial prisoners have lost their life by
suicide.

To date, there is no treatment available. The failure to cure or even treat such individuals
has divided the medical and legal communities, as well as society in general. They are
known to manipulate the situations, be litigious and bear grudges. They are well known
to split the staff by complaining to one staff against the other. Generally, complaints
received by these individuals against the staff are of malicious intent. Hence, such
complaints need to be thoroughly verified and investigated before proceeding against the
staff.

Though there is no cure for this disorder, it is crucial to identify and manage these
individuals inside the prison to ensure that they do not create trouble for others in the
prison. A large part of the problems inside the prison are attributable to this group. Staff
should learn to handle these prisoners. These prisoners do well in structured and high-
security prisons. However, psychotropic medicines are found to be very useful in
emergency and certain inevitable situations such as violence, aggression, suicide,
deliberate self-harm, demanding behaviours and illicit drug intoxication related abnormal
behaviour. The medicines are also useful to decrease their aggression in the long run.

Treatment for any comorbid disorders should be given regardless of whether the person is
receiving treatment for antisocial personality disorder or not, because such people are
often excluded from routine care (Black et al., 2010). Suicidal threats and deliberate self-

101
harm are very common in prison population. The tendency to rationalise irresponsible
acts, minimise the consequences of these acts, violence and manipulative behaviour,
needs to be confronted on a daily and immediate basis. Close supervision with structured
activity have been recommended. The most effective treatment may at times be simply to
consider high-security prisons. Many antisocial behaviours do tend to dissipate (or
burnout) with time (Kay and Tasman, 2006; Frosch, 1983). There are studies done in the
community which reported that cognitive behaviour therapy for violent men with
antisocial personality disorder in the community did not show any improvement
(Davidson et al., 2009).

Various countries have adopted different policies to manage prisoners with antisocial
personality disorder. Majority of these policies are an immediate aftermath of certain
incidents. In 1998, England was shocked by the apparently motiveless murders of a
mother and two of her children by a person with personality disorder. He was convicted
of their murders. Later, the government was determined to prevent this type of offence
from recurring. Hence, in 1999 the UK government introduced a new concept called
dangerous and severe personality disorder (DSPD). DSPD is a highly contentious concept
and is not a medical diagnosis; it refers to the perceived levels of dangerousness of the
individual to the society or to others. DSPD unit has subsequently become a treatment
and assessment programme for individuals who satisfy three requirements: (1) have a
severe disorder of personality, (2) present a significant risk of causing serious physical or
psychological harm from which the victim would find it difficult or impossible to
recover, and (3) the risk of offending should be functionally linked to the personality
disorder (Maden and Tyrer, 2003). Later, the UK government proposed a preventive
detention programme to those with dangerous and severe personality disorder (Kendell,
2002).

To manage these individuals, various countries have adopted closed monitoring systems
such as „supermax prisons‟ or „special housing units‟ (Pizarro and Narag 2008, Mears
2008). Supermax prisons are those with high level of security with electronically operated
doors, surveillance cameras, and no windows. Visitors are also not allowed inside (Mears
and Castro 2006). A special housing unit is a solitary confinement of the prisoners in a
closed room without windows and they are generally allowed out of their cells for only
one hour a day. These are managed by using proper protocol and for limited periods only
(Mears 2008). However, these kinds of settings are often misused by the prison
authorities and also very costly to maintain such prisons (Pizarro and Narag 2008, Mears
2008). Certain individuals with antisocial personality disorder with severe violence and

102
aggressive tendency need isolation. But the need for continuing to keep them in such
settings needs to be assessed periodically by risk assessment and the decision needs to
taken by a group of professionals such as representative of a judiciary, prison
administration, medical staff, and social worker so that human rights violations are
monitored closely. This needs to be documented. Finally, management of prisoners with
antisocial personality should be focused on providing symptomatic relief and clear
guidelines about expected behavior from them in prison. However, there is an urgent
need to do research to answer, whether supermax prions are warranted, effective, or
efficient in Indian settings.

Management of emotionally unstable (Borderline) personality disorder

Borderline personality disorder is characterised by a pervasive pattern of instability in

affect regulation, impulse control, interpersonal relationships, and self-image. Mood
disorders, substance-related disorders, eating disorders (usually Bulimia), posttraumatic
stress disorder, attention-deficit/hyperactivity disorder, suicide, deliberate self-harm and
other personality disorders frequently co-occur with this disorder (Lieb et al., 2004;
Zanarini et al., 1998; Gunderson and Ridolfi, 2001; Paris, 2005; NICE, 2009). On
comparing individuals with antisocial personality disorders with those with emotionally
unstable personality disorder, it has been found that in case of the latter, patients improve
with time. There is an evidence base for treatment using both psychotherapy and
psychopharmacology in emotionally unstable personalities (Paris, 2005; NICE, 2009).

Dialectical behaviour therapy, cognitive behaviour therapy, interpersonal therapy,

systems training for emotional predictability and problem solving (STEPPS) programmes
are effective treatments. Psychotropic medications are effective in treating emotional,
impulsive, mood swings and depressive symptoms that frequently are associated with
borderline disorder. Medicines can reduce depression, anxiety, and impulsive aggression
but need to be used judiciously used and supervised. (Lieb et al., 2004; Paris 2005;
American Psychiatric Association, 2001).

Suicidal threats and deliberate self-harm are very common in prisoners with emotionally
unstable personality (Gunderson and Ridolfi, 2001). There is a need to sensitise staff
about the suicide threats. There are incidents when prison staff has challenged the
prisoner‟s suicidal ideas or threats by saying „your suicidal threats are just an act‟. This
has led to actual suicidal attempt by the prisoners. There is an urgent need to implement

103
suicide prevention strategies inside the prison. Staff needs to be trained in handling these
prisoners.

Personality disorders are a common form of mental health problems seen in prisons.
Managing antisocial personality disorder and emotionally unstable personality in prison
is a challenge to any staff and mental health team. The prison administration should be
aware of the symptoms of these personality disorders. Antisocial personality disorders do
well in a highly secured and structured environment. The borderline personality disorder
needs therapy. Co-morbid conditions need to be treated irrespective of the treatment
status of the personality disorder. Prison staff plays a crucial role in preventing suicide.
They need to be trained in managing suicide and deliberate self-harm inside the prison.

In conclusion, there are indeed certain groups of people who by virtue of their
dysfunctional personality are more prone to crimes. There are those who may have
committed crimes as a way of coping with stressful situations or have made an error in
judgement by taking law into their hands. While in case of the former, bringing about a
change in the personality while in prison might be a herculean task, in case of the latter,
appropriate counselling and behavioural interventions can help by preventing the
dysfunctional behaviours and thought process leading to the crime from becoming
ingrained as part of the personality.

104
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 8. COMMON MENTAL DISORDERS IN PRISONS

Common mental disorders or neurotic disorders refer to a range of mental health

disorders that cause personal distress to the sufferer but can go unnoticed by an onlooker.
Prisoners have a very high incidence of mental health problems, in particular neurotic
disorders, compared to the general population. By the criteria proffered under the
International Classification of Diseases (ICD-10), in any week, almost half the prisoners
suffer from a neurotic disorder such as anxiety or depression (Brinded et al., 2001). This
chapter examines the prevalence of these disorders in prisons across the globe based on
the available literature and proposes interventions for these disorders in the prison
settings. Table 1 presents the major categories of the common mental disorders as per the
International Classification of Diseases.

Table 1. ICD – 10: F40-F48 Neurotic Disorders (major categories)

 Phobic anxiety disorders (include agoraphobia, social phobia and specific

phobias)
 Other anxiety disorders (include panic disorder and generalised anxiety
disorder)
 Obsessive - compulsive disorder
 Reaction to severe stress, and adjustment disorders
 Dissociative [conversion] disorders
 Somatoform disorders
 Other neurotic disorders

Prevalence of common mental disorders in prison – International Experience

A report on Health Care in Prisons Directorate of Health Care of the Prison Service in
England and Wales in 1998/9 by Marshall reported that the range and frequency of
physical health problems experienced by prisoners appears to be similar to that of young
adults in the community. However, prisoners have a higher incidence of mental health
problems, in particular, neurotic disorders, compared to the general population (Marshall
et al., 1999). In male prisoners, the prevalence of any neurotic disorder in the week before
the study was, 59% in remand and 40% in sentenced prisoners. In female prisoners, 76%
and 63% of remanded and sentenced prisoners respectively had a neurotic disorder. In
prisons, as in the community, neurotic symptoms and neurotic disorders are more
common among female than the male population. The prevalence of any neurotic

108
disorder in the general population (the adult population resident in private households) in
the community in the UK at the time of the study was12% for men and 20% for women
(Marshall et al., 1999). Highlight of this study is the difference it has drawn between the
remanded and sentenced prisoners.

Neurosis and character disorders in hospital and in prison were compared among male
non-psychotic patients and male prisoners in respect of hostility and direction of hostility
(Foulds, 1967). Prison neurotics (as defined by the Symptom-Sign Inventory) scored
significantly higher on a measure of hostility and somewhat less intro-punitively than
hospital neurotics, character disorders in prison and in hospital were virtually identical in
respect to both aspects of hostility. Psychopaths scored much higher on mean hostility
and extra punitively on the direction of hostility.

A population-based study on the rates of imprisonment in different ethnic groups,

compared the criminal behaviour and psychiatric morbidity of the prisoners. Ethnic
subgroups were compared in terms of the frequency of neurotic symptoms identified
from the CIS–R [Clinical Interview Scale – Revised]. Few differences were found.
However, Black males were less likely to report forgetfulness/loss of concentration, and
South Asian males less likely to report irritability, than White males. Black women
prisoners were more likely to report worries about physical health, and less likely to
report anxiety, than White women prisoners. There were no differences between either
Black or South Asian subgroups or White prisoners, according to gender, for an overall
measure of neurotic symptoms using a CIS–R (Clinical Interview Scale – Revised) cut-
off score of 12 (Coid, et al., 2002). Implications of this study could suggest that these
aspects need to be considered in a diverse culture like ours.

Estimates of mental health morbidity in UK local prisons, HMP Littlehey and HMP
Whitemoor, show a high prevalence of personality and neurotic disorders of 64% and
40% respectively. This translates to a heavy burden of illness, with about 723 inmates
with personality disorders and 452 with neurotic disorders in the two prisons. The
prevalence rates for self-harm and suicide (7%) were also high (Joint Strategic Needs
Assessment 2008).

The Office of National Statistics survey1999 (ONS survey) was carried out in 131 of the
133 English and Welsh prisons. Of 51,834 remanded and sentenced males, 5% were
interviewed as the initial sample. 6,500 of that sample group had personality disorders,

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55% had neurotic disorders, 60% showed hazardous drinking in the year prior to
incarceration and 10% had psychiatric disorders (O’Brien et al., 1997).

In a study of psychiatric disorders among prisoners in UK and Wales, a further analysis

of data from the ONS survey, 1997 demonstrated that, among the neurotic disorders, the
most common presentations were sleep problems and worry (not including worry about
physical health), followed by fatigue, depression and irritability (O’Brien et al., 1997).
While similar symptoms were found among adults in the general population, they had a
markedly low prevalence compared to the prison population (Meltzer et al., 1995a and
1995b). While 28% of the women in the general population reported sleep problems, 62%
of sentenced women and upto 81% of those on remand reported sleep problems. While
11% of women in the general population reported depression, 54% of women prisoners
reported symptoms of depression. Obsessive symptoms panic and phobias were also
significantly more common among remand prisoners. The prevalence rate for any
neurotic disorder was 66% of the sample group as a whole. These rates are much higher
than that found in the general household population, where the rate was 16% (Meltzer et
al., 1995a).

When specific disorders were considered, the prevalence rate was higher among remand
prisoners (76%) than among those who were sentenced (63%) (Singleton et al., 1998).
The prevalence rate for phobias in the remand group was significantly higher than that
for the sentenced group. Rates of generalised anxiety disorder and panic disorder were
the same in the two groups. Post-traumatic stress disorder was present in over a third of
the women in the sample who reported experiencing a traumatic event likely to cause
pervasive distress. The proportions of each group who met all these criteria were 5% of
sentenced and 9% of remand prisoners, with 6% of the sample overall considered to be
suffering from post-traumatic stress. Women prisoners were about twice as likely as men
to suffer from post-traumatic stress than male prisoners (Singleton et al., 1998). Eating
disorders presented in over 6% of women in the sample who were diagnosed with
anorexia. Rates for bulimia were higher, at 14% for the whole sample (15% for remand
and 14% for sentenced prisoners).

Singleton et al (1998) study found that women prisoners were significantly more likely
than men to suffer from a neurotic disorder, matching the trend in the general household
population survey (Meltzer etal.,1995a). Whereas 59% of remand and 40% of sentenced
male prisoners in England and Wales had a neurotic disorder, the corresponding figures

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for women were 76% and 63%. For all six neurotic disorders (depressive episode,
Generalised Anxiety Disorder, mixed anxiety and depressive disorder, phobia, Obsessive-
Compulsive Disorder and panic), the prevalence rates for male remand prisoners were
higher than those of their sentenced counterparts.

Another study examined psychiatric morbidity and mental health treatment needs among
women in prison mother and baby units. Sixty percent of the women who took part in the
study had mental disorders; 35% had diagnoses of personality disorder; none had
psychotic disorders (such as schizophrenia for example); 35% had current neurotic
disorders (such as depression, anxiety disorders and phobias), nearly all of whom were
depressed; 13% had been drinking alcohol at hazardous levels in the year prior to
imprisonment, and 36% had been abusing or were dependent on drugs in the year prior to
imprisonment. None of the participants reported using alcohol or drugs in prison (Luke
et al., 1999). A rare dissociative disorder characterised by nonsensical or wrong answers,
other dissociative symptoms like fugue, amnesia or conversion, often with
pseudohallucinations and a decreased state of consciousness. It is also called nonsense
syndrome, pseudodementia, hysterical pseudodementia, prison psychosis or Ganser
syndrome. It may be present among prisoners in order to gain leniency from prison or
court officials. However, there are no systematic studies to explore this lesser known and
unusual disorder, but it is believed to be a reaction to extreme stress.

Assessment of common mental disorders among prisoners in India

Very little evaluation has been carried out to assess and address common mental
disorders among prisoners in India. A study commissioned by the National Commission
for women in the Central Prison, Bangalore (Murthy et al., 1998), found higher rates of
symptoms of common mental disorder among undertrials compared to convict prisoners.
Common symptoms were, unhappiness (73% versus 43%), worrying (65% versus 29%),
poor sleep and appetite (65% of undertrials).

In the recent Prison Mental Health Study (Math et al., 2011), of 197 women who were
interviewed for psychiatric morbidity, 2.5% had dysthymia (minor depression), 4.6% had
specific phobia, 1.5% social phobia and one person had a panic disorder. Among the
entire prison population evaluated for this study (5024), lifetime and current rates of

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dysthymia were 2.9% and 2.5% respectively. Prevalence of major depressive disorders
was relatively higher.

Table 1: Prevalence of common mental disorders among prisoners in Central

Prison, Bangalore

Disorder Lifetime diagnosis Current diagnosis

[%] [%]
Panic disorder 1.0 0.9
Agoraphobia 0.3 0.2
Social phobia 1.8 0.6
Obsessive compulsive disorder - 0.1
Post-traumatic stress disorder - 0.3
Generalised anxiety disorder - 0.3
Hypochondriasis - 0.1
Body dysmorphic disorder - 0.8
Somatisation 2.1 1.7
Pain disorder - 5.4
Source: Math et al., 2011

Excessive preoccupation with bodily symptoms was seen in a substantial number of both
UTP and CTP prisoners, and a lifetime and current diagnosis of somatisation was present
in about 2 out of every 100 prisoners. Current diagnosis of a pain disorder was made in
272 (5.4%) prisoners. In Asian cultures, manifestation of psychological distress through
physical symptoms is relatively more common than in other cultures. Individual
symptoms of psychological distress have not been analysed in this study.

Interventions for common mental disorders

A synthesis of the available literature on the management of common mental disorders in

prison populations suggests the following approaches in order to address these disorders
effectively:

 Assessment for common mental disorders at the point of entry into prison and
during imprisonment, particularly during crisis points

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  Induction into prisoners needs to be phased and counselled regarding the life
style, rules, regulations and rights of the prisoners
 Violence inside prison needs to be kept under check
 Prisoner education and information about common mental disorders
 Training peers and prison staff to provide support in individual and group settings
 Counselling through trained volunteers
 Non pharmacological measures to handle sleep problems, psychological
symptoms of pain
 Adequate recreational activities
 Training in problem solving
 Counselling
 Family therapy
 Cognitive Behavior Therapy
 Professional help using psychotherapeutic methods to validate the distressing
experiences, reframing of symptoms, support and counselling
 Relaxation techniques such as meditation, yoga, prayers etc.
 Stress management programmes

Only a small minority may need referral to a psychiatrist for evaluation and
psychopharmacological intervention. Psychosocial management remains the main stay of
treatment.

In conclusion, common metal disorders unlike severe mental disorders like schizophrenia
by the nature of the symptoms can very well go unnoticed especially in a prison
environment when most of the symptoms are seen as a natural reaction to a prison
environment. But the good news lies in the fact that once identified they can be
addressed and treated by adequate counselling and other behavioral interventions and
might not require formal psychiatric help. The key is to sensitise prison staff and train
them in the appropriate techniques which would not just help the prisoners but also the
society at large when the prisoners get back to the community.

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 References

Brinded PM, Simpson AIF, Laidlaw TM, Fairley N, Malcolm F. Prevalence of

psychiatric disorders in New Zealand prisons: a national study. Aust NZJ
Psychiatry 2001; 35: 166-73
Coid J, Petruckevitch A, Bebbington P, Brugha T, Bhugra D, Jenkins R, Farrell M, Lewis
G, Singleton N. Ethnic differences in prisoners: criminality and psychiatric
morbidity. British Journal of Psychiatry 2002; 181: 473-80
Foulds GA. Some differences between neurotics and character disorders. Br J Soc Clin
Psychol 1967;6:52-9
Joint Strategic Needs Assessment (JSNA) 2008, Cambridgeshire Mental Health.
Available online at
http://www.cambridgeshire.nhs.uk/downloads/Your%20Health/JSNAs/Mental%20
Health%20JSNA.pdf Accessed on 12 Dec 2010
Luke, Gregoire A, Kamal M, Mullee M, Coulson D 1999. Psychiatric morbidity and
mental health treatment needs among women in prison mother and baby units,
Prison Service, the NHS and research
Marshall T, Simpson S and Stevens A 1998/9. Health Care in Prisons, chapter is an
updated version of a report commissioned jointly by the Department of Health and
the Directorate of Health Care of the Prison Service in England and Wales
Math SB, Murthy P, Parthasarathy R, Naveen Kumar C, Madhusudhan S 2011. Mental
health and substance use problems in prisons: Local lessons for national action.
Publication, National Institute of Mental Health Neuro Sciences, Bangalore
Meltzer H, Gill B, Petticrew M and Hinds, K 1995a OPCS Surveys of Psychiatric
Morbidity in GreatBritain, Report 1: the prevalence of psychiatric morbidity among
adults living in private households. HMSO: London
Meltzer H, Gill B, Petticrew M and Hinds, K 1995b. OPCS Surveys of Psychiatric
Morbidity in Great Britain, Report 3: Economic activity and social functioning of
adults with psychiatric disorders. HMSO: London
Murthy P, Chandra PS, Bharath S, Sudha SJ, Murthy RS 1998.Manual of Mental Health
Care for Women in Custody. National Institute of Mental Health and Neuro
Sciences and The National Commission for Women, New Delhi
O’Brien M, Mortimer L, Singleton N, Meltzer H 1999. Psychiatric morbidity among
women prisoners in England and Wales: further analysis of data from the 1997
ONS survey of psychiatric morbidity among prisoners in England and Scotland
Singleton N, Meltzer H, Gatward R, Coid J, Deasy D 1998. Psychiatric morbidity among
prisoners in England and Wales TSO: London

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 9. HIGH RISK BEHAVIOURS IN PRISON: THE NEED FOR
BEHAVIOURAL REHABILITATION

The present prison system is a university with a difference. It serves as a fertile ground to
convert small time offenders and help them graduate to being a part of an organised crime
syndicate. Merely rounding people up, without offering opportunities for change in
attitude and behaviour is the biggest failure of custodial settings. In India, thousands of
persons enter prison each year, and a substantial number are periodically released on bail.
Any opportunity to offer a corrective experience is completely lost in the „prison
mentality‟, which looks at time in prison as „punishment‟ and has the attitude that
„nothing works‟. That is certainly not the case. Rehabilitation is arguably the best
approach towards correction as most prisoners are released at some stage.

There is an urgent need to explore the reasons behind the offending behaviours that lead
to people getting into prisons, so that the best remedy can be offered. For example, a
person who commits crimes when drunk but not when sober is likely to be suffering from
harmful use of alcohol. Treating the alcohol problem may diminish the chances of the
offending behaviour. Similarly, a person may become violent because of his/her difficulty
in controlling anger. Anger management techniques will help such an individual in the
long run. A person who gets into frequent fights with the family may benefit from family
therapy. Hence, there is a need to identify the characteristics which can predispose the
prisoner to commit a crime or reoffend. This is also called identifying an individual at
„high-risk‟.

High risk behaviour is any behaviour that places a person at increased probability of
suffering from a particular condition compared to others in the normal population. In
simple words, high-risk behaviours increase the possibility of negative consequences or
outcome. This chapter focuses on the prisoners with high-risk behaviours, presents brief
treatment strategies for managing each and concludes with a proposed set of
recommended goals for creating a national strategy to develop behavioural rehabilitative
and reformative programmes in correctional settings.

Prisoners with High-Risk Behaviours

Prisoners persistently engage in a range of behaviours such as violence towards others,

suicide, suicidal attempt, deliberate self-harm, substance use, unprotected sexual activity,

115
slavery and destruction of public property that increase their probability of being
involved in serious physical diseases or mental disorders. Such behaviours result in
frequent conflict with law, death, injuries to self or others.

Table 1. High-Risk Behaviours and their Consequences

High-risk behaviours Negative outcomes

Unprotected sexual intercourse Sexually transmitted diseases, HIV, AIDS and

with multiple partners Hepatitis
Alcohol use Conflict with law, crime, physical cruelty, domestic
violence, public nuisance, poor judgement, physical
and mental illnesses
Drug use Accidents, violence, conflict with law, physical and
mental illnesses
Cannabis use Acute intoxication, Psychosis
Intravenous drug use HIV, Hepatitis, septicaemia
High speed driving Accident, Death
Smoking Cancer, Hypertension
Tobacco chewing Oral cancers
Sedentary life style Obesity, hypertension, diabetes and depression
Deliberate self-harm Death, grievous injury, conflict with law
Suicidal attempt Death, grievous injury, conflict with law

Given the poor quality of assessment and lack of remedial measures in prison, most
prisoners with high-risk behaviours remain undetected and these problems remain
unaddressed. For the purpose of managing prisoners with high-risk behaviours, it is
useful to have a classification of these behaviours based on causative factors on the one
hand and consequential dangers on the other.

It is essential to know the causes of high-risk behaviours, so that effective management

can be planned. These high-risk behaviours have consequential danger and impact at
various levels. Impact can occur at personal level, on others and property. Prison
environments breed aggressive behaviours. Many prisoners get things done by expressing
their dominance through aggression and violence. This acts as a model for other prisoners

116
to try and emulate. Hence, it becomes essential to modify their behaviour before they
leave the prison. If not intervened, this may continue even in the community. Behaviour
modification needs to be considered seriously in all the correctional centres.

Figure 1: Most commonly noted high-risk behaviours in prisons

PRISONERS WITH HIGH RISK BEHAVIOURS

Causative Factors

1. Induced by Mental disorder / Substance use

2. Induced by personality factors
3. Induced voluntarily to manipulate the system

Danger to self Danger to others Danger to property

Suicidal death Homicidal death Breaking furniture

Attempted suicide Physical injury Destroying articles

Deliberate self harm Gang wars Prison property damage

Substance use Slavery Economic loss

Food refusal Intimidation/bullying

Other adverse Sexual Transmitted

impacts on health Diseases

Other adverse impacts

on health

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High-risk behaviours can occur for a variety of reasons as shown below.

Figure 2: Causes of high-risk behaviours in prisons

Mental Disorders or Substance use

• Persons with mental illness have abnormal behaviour and violence

resulting from the illness. Similarly, substance use (alcohol, cannabis,
cocaine and other drugs) can cause abnormal behaviour because of
intoxication or substance induced mental illness.

Personality Factors

• Sensation/novelty seeking, poor coping skills, ineffective

communication, impulsivity, poor interpersonal skills, low frustration
tolerance, seeking immediate gratification, release of emotional turmoil
and exploitative behaviours

Malingering /Ulterior Motive

• Behaviour with ulterior motive to manipulate the system

Unfortunately, the current correctional system works under the punishment principle and
not for reformation and rehabilitation.

DANGER TO SELF

Dangerousness to self-behaviour in prisoners is detrimental both to the individual and the

safety and morale of the prison environment. High mortality in prisoners has been
attributed to various factors such as suicide, self-injurious behaviour, substance use, TB,
HIV and other health related conditions (Kjelsberg and Laake, 2010). Media highlights
only the custodial deaths due to police excess but unfortunately forgets that more deaths
occur because of health related reasons causes, which often go unnoticed. However,

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currently, many countries have been calling for action to prevent such deaths and to
educate staff in prevention, early recognition and management of such behaviours.

“Dangerous to self” behaviours are those behaviours which have a direct effect on both
prisoners‟ physical and mental health. These behaviours are shaped by a number of
interacting factors such as mental disorders, personality factors, impulsivity, physical
illness, personal motive, financial, family, social, cultural, situational, psychological, and
biological factors. Dangerous to self-behaviours can be classified into substance use
(alcohol, nicotine, cannabis, cocaine, opioid and other substance use), self-injurious
behaviours and food refusal. Substance use related issues, because of their magnitude and
ramifications are discussed in a separate chapter.

Food refusal

Food refusal can occur for different reasons. Prisoners, singly or in a group, can refuse
food by agitating to fulfil their demands (for e.g., going on strike). The most common
reason for this in prisons is poor quality of food. Another common reason for food refusal
is ill- health (decreased appetite because of Cancers, AIDS, Tuberculosis, Depression,
Psychosis and other illnesses). In the latter, the underlying cause needs to be treated. For
all other reasons underlying this behaviour, the prison administration needs to form
guidelines and standard operating procedures to deal with such situations without
violating the rights of the prisoners.

Self-injurious behaviour (SIB)

The most challenging and problematic behaviour in prisons is self-injurious behaviour.

Self-harm among prisoners is a common phenomenon (Knoll, 2010). A study on the
prevalence of self-injurious behaviour (SIB) among Greek male prisoners revealed such
behaviour among 35% (Sakelliadis et al., 2010). The most common underlying motives
were to obtain emotional release (32%) and to release anger (21%). Psychiatric disorders,
illicit substance use and aggression seem to be powerful predictors of SIB in prison
population (Carli et al., 2010; Sakelliadis et al., 2010). Similarly, another study reported
that 42% of prisoners had lifetime suicide ideation, 13% attempted suicide and 17% were
self-mutilators (Carli et al., 2010).

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Self-injurious behaviour among prisoners poses a great challenge to the correctional staff,
mental health team, public health administrators and also to the judiciary. To address
SIB, there are many barriers and obstacles to effective assessment and treatment (Fagan
et al., 2010). Self-injurious behaviour resulting from suicidal and non-suicidal intent
needs to be distinguished to plan for appropriate management.

Figure 3: Dangerous to self-behaviours

Dangerous to self-behaviours

Substance use Self-injurious behaviours Food refusal

With intention to kill self Without intention to kill self

Suicide Attempted Suicide Deliberate self-harm

Defining self-injurious behaviours

Various definitions have been suggested for self-injurious behaviour. There is no single
standard acceptable definition and classification. Self-injurious behaviour is a very
complex behaviour with various factors contributing to it. It encompasses a range of
phenomena from fatal to non-fatal behaviours. There are ongoing debates regarding what

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constitutes self-injurious behaviour. From the prison and correctional centre‟s
perspective, self-injurious behaviour needs to be understood differently than it is in the
community. In a correctional setting, the behaviour needs to be de-codified from the
management and rehabilitative perspective.

Prison staff and the medical team in charge must ask themselves the following questions,
when they encounter SIB in a prisoner.
a) What is the medical condition of the prisoner? (For emergency medical management)
b) What is the intent of the SIB (Death or non-lethal)? (To de-codify the behaviour)

Motivation of the SIB provides clear indication of the prisoner‟s thoughts, emotions and
behaviour. This also provides an immediate management plan and also future prevention
strategies. The following classification and definitions can help in understanding and
managing self-injurious behaviour.

Defining self-injurious behaviour

Suicide is the act of intentionally taking one's own life.
Attempted suicide is an unsuccessful attempt to kill oneself.
Suicidal ideations refers to thoughts of killing oneself, in varying degrees of intensity
and elaboration
Deliberate self-harm is a behaviour in which people inflict harm upon themselves,
without intention to die and with non-fatal outcome.
Source: Chandrashekar et al., 2007; Shneidman, 1985

SIB with intention to kill oneself

Jails and prisons are responsible for protecting the health and safety of their inmate
populations, and it is the responsibility of the state to protect the prisoners. If the state is
not able to protect its own citizens under their custody, it raises serious questions about
protective mechanisms in place outside the prison. The World Health Organization
estimates that one suicide attempt occurs approximately every three seconds, and one
completed suicide occurs approximately every minute. Every year more than one million
people commit suicide throughout the world, accounting for 1 to 2 per cent of total global

121
mortality (World Health Organisation., 2000). Suicide is a serious health problem.
Suicide and attempted suicide are symptoms of emotional distress. Suicidal behaviour is
“a desperate cry for help” or a way of showing one‟s anger and frustration. This can
manifest as suicidal thoughts (suicidal ideations), and suicidal actions (suicidal attempters
and completers). Data on suicides, attempted suicides and other self-harming behaviours
that occurred from 1990 to 2002 was studied in Italian prisons. Over the study interval,
completed suicide rates in Italian prisons were constantly about ten times higher than
among the general population. Attempted suicides were about ten times higher than
completed suicides. Female prisoners were significantly more likely to attempt suicide,
whereas male prisoners were more likely to complete suicide (Preti and Cascio, 2006).

Higher rates of suicide in prison can be attributed to the following reasons.

These reasons operate in combination rather than in isolation.
 Jails and prisons are repositories for vulnerable groups that are traditionally
among the highest risk for suicide, such as young males, the mentally ill, socially
disenfranchised, socially isolated, substance abusers, or previous suicide
attempters.
 The psychological impact of arrest and incarceration or the day-to-day stresses
associated with prison life may exceed the coping skills of vulnerable
individuals.
 There may be no formal policies and procedures to identify and manage suicidal
inmates.
 Even if appropriate policies and procedures exist, overworked or untrained
correctional personnel may miss the early warning signs of suicidality.
 Correctional settings may be isolated from community mental health
programmes so they have poor or no access to mental health professionals or
treatments.
Source: World Health Organization (2000). Preventing suicide; a resource for prison
officers. Pub by; Mental and Behavioural Disorders, Department of Mental Health,
World Health Organization, Geneva (WHO/MNH/MBD/00.5)

A study conducted on Australian adolescents on remand reported that 19% had made a
suicide attempt during the previous 12 months compared to 4% in the community
(Sawyer et al., 2010). Similar results have been replicated in adolescents on remand. It
has been estimated that they is a fourfold increased risk for adolescents in correctional
settings than in the community (Suk et al., 2009). Studies have also documented that

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recently released prisoners are at a markedly higher risk of suicide than the general
population. Factors significantly associated with post-release suicide were a history of
alcohol misuse or self-harm and having psychiatric disorder (Pratt et al., 2010).

RISK FACTORS FOR SUICIDE

Risk Factors: Evidence from prison population studies
1. Previous history of suicidal attempt
2. Mental illness like-depression, bipolar disorders and schizophrenia
3. Substance use such as alcohol, cannabis, cocaine, opioid and use of other drugs
4. Poor social integration (lack of confiding relationships/long standing
relationship problems)
5. Recently sentenced/convicted/serving life sentence
6. Young or elderly male
7. Impulsive and aggressive personality traits

(Baillargeon et al., 2009; Camilleri and McArthur, 2008; Carli et al., 2010; DuRand et
al., 1995; Fazel et al., 2005; Fazel et al., 2008; Knoll, 2010; Pratt et al., 2010)

Risk Factors: Evidence from general population studies

1. Family history of suicide

2. Family discord
3. Poor family support, broken family, physical abuse by parents, feeling
neglected by parents and loss of loved ones
4. Hopelessness
5. Barriers to accessing mental health care
6. Ongoing and /or recent life events such as relationship problems, loss of
romantic relationship, financial loss, job related and social issues
7. Chronic medical/surgical illness including HIV, AIDS and cancer
8. Loss of social status / reputation in the society.
9. Easy access to lethal methods to killing oneself
10. Unwilling to seek to help because of stigma attached to mental health
consultation and substance use consultation
11. Evolving personality disorders
12. Cultural and religious beliefs

(Beautrais, 2000; Hirschfeld and Davidson, 1988; Mortensen et al., 2000; Phillips et
al., 2002; Satcher, 1999; Vijayakumar and Rajkumar, 1999)

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In many countries, there has been a call for action to prevent such deaths and to educate
staff in the early recognition of suicide risk. The best practices for preventing suicides in
jail and prison settings should include the following elements: training programmes,
screening procedures, communication between staff, documentation, internal resources,
and debriefing after a suicide (Pompili et al., 2009). There is also a need to improve the
continuity of care for people who are released from prison (Pratt et al., 2010).

SIB without intention to kill oneself

Deliberate self-harm (DSH): This is behaviour in which persons hurt or harm

themselves without the motive of suicide. Most commonly noted DSH in prisoners are:

a) Superficial cuts (wrist slashing, trying to cut their own throat, abdomen, hands
and legs) on the body parts using sharp objects
b) Head banging
c) Swallowing non-edible materials such as glass pieces, blade pieces and other
material
d) Scratching

e) Opening old wounds

Findings suggest that self-injury occurs regularly and recurrently in a subset of inmates.
The causes for DSH are mental illness, substance use, personality problems, manipulative
behaviours and as a coping mechanism (DeHart et al., 2009). It has also been noted that
many prisoners with anti-social personality, borderline personality, mental retardation
and organic brain disorders indulge frequently in DSH behaviours (Sarchiapone et al.,
2009). Many a times such behaviours occur under drug intoxication. Depression,
frustration and an avenue to release their pent up emotions also play a crucial role
(Jenkins et al., 2005). There are prisoners who indulge in DSH behaviours to seek
attention from the prison staff, co-prisoners and family members. They also do it to
manipulate the prison authorities for personal gains. Though deliberate self-harm is not
lethal, it is a strong predictor of repetition of DSH and completed suicide in near future
(Fazel et al., 2008; Skegg, 2005). Hence, each DSH attempt needs to be taken seriously
and evaluated.

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DANGEROUS TO OTHERS AND PROPERTY

Dangerousness to others in prison setting results in harm to the co-prisoners and to the
prison staff. Harming others may range from physical to verbal harm. It can be
considered as a spectrum, with bullying on one extreme and homicide on the other. It also
encompasses violence, attempts to dominate and to obtain sexual gratification.
Behavioural scientists believe that aggression is present in each of us, and can be
modified by experience in both positive and negative ways. They have defined aggression
as behaviour aimed at causing harm or pain to others or self. Human aggression can be
manifested towards self or others, can be direct or indirect, physical or emotional, active
or passive, and verbal or non-verbal (Chandrashekar et al., 2007). It may even take the
form of slavery such as forcing co-prisoners to perform activities that degrades them.
Violence directed towards others can be in the form of physical injury/harm (hitting),
psychological pain (insulting), destruction of property and bullying (shouting or
spreading rumours). Violence and aggression raises concerns about its serious impact on
the correctional system, safety of others, economic and public health issue. Violence in
prison settings is endemic but at times it takes epidemic forms if proper mechanisms are
not in place. Prevalence of aggression and violence towards others varies depending upon
the type of violence measured.

Violence in prison is a known phenomenon all over the world, but how the prison
authorities deal with such behaviour is debatable from various perspectives, including
health and human rights. Responses can be self-defence, physical restraint, physical
torture, punishment, isolation in a dark room, withholding basic needs and at times
chemical restraint. Correctional facilities have a responsibility to take "reasonable
measures" to preserve and protect inmate safety (Wolff and Shi, 2009). The problem of
aggression in correctional institutions should be recognised and effective preventive
measures need to be put in place against violent behaviours (Merecz-Kot and
Cebrzynska, 2008).

Causes for violence

Many inter-related and complex factors have been attributed to violence and include
illness, personality traits, and individual as well as environment factors. However, there
may be instances of violence without any identifiable causes. This is commonly seen in
persons with mental illness and substance induced intoxication. They may indulge in

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violence without any provocation. Often, correctional setting administration denies any
sexual encounters in prison. The unisex nature of the prison institution provides a
potentially fertile ground for sexual aberrations. Various kinds of sexual activity have
been documented such as masturbation, transsexualism, prostitution, sex between
prisoners and prison staff, consensual homosexuality and non-consensual homosexuality
(rape among prison inmates) (Awofeso and Naoum, 2002). Such behaviours are often
associated with dangers to self and others.

Causes for violence in prison settings:

Illness factors:
 Mental illness
 Substance use such as cannabis, cocaine, opioid and other drug use
Individual factors:
 Personality factors such as impulsivity and low self esteem
 Poor coping skills
 Revenge
 To show dominance
 To revolt against authority
 Stress
Pleasure:
 Sexual gratification
 Gambling
 Entertainment (bullying)
Environment:
 A response to dissatisfaction with food, water, entertainment and other
facilities
 Gang wars
 Rigid inhuman rules and torture
 Corruption

Considering the causes of violence, the question that rises in such situations is when to
intervene? How to intervene? When to seek professional help? In order to answer these
questions, other important dimensions to be considered with regard to aggressive
behaviour are the antecedents, situations, frequency, duration, intensity of the aggression

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and deviation from the cultural and social norms. All forms of violence may not require
professional help. However, there are certain prisoners at risk who require professional
help. Hence, it is essential to identify these high-risk prisoners and provide the necessary
professional help.

People at risk of having frequent aggressive behaviour: Learning to identify and

predict those at risk of developing aggression can prevent serious consequences. The
following risk factors have been identified:

People at risk of having frequent aggressive behaviour

Individual factors:
 Mental illnesses like depression, anxiety disorders, epilepsy and psychosis
 Substance use such as cannabis, cocaine, opioid and other drug use
 Personality factors
 Poor coping skills
 Childhood trauma like sexual/physical abuse

Family factors:
 Family discord
 Violence within the family (role model)
 Substance use by the parents
 Poor family support

Social factors:
 Poor social support
 Exposure to violence
 Victimisation by peers (bullying)
 Life events and stress

The notion that „nothing works‟ in offender rehabilitation has slowly faded and evidence
based behavioural interventions are being introduced in the rehabilitation programme. In
recent years, correctional administrations have increasingly identified prisoners with
high-risk behaviours as a key target group for rehabilitation programmess and a number
of such programmes have been developed.

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MANAGEMENT OF PRISONERS WITH HIGH-RISK BEHAVIOURS

‘Dangerous to self’- management in prisons

Any „dangerous to self-behaviour‟ such as suicide usually occurs as a process in which a

chain of events leads to the final act and this process is usually triggered by a precipitant.
A person may show various signals like neglecting personal care, becoming withdrawn,
eating less, showing decreased interest in almost all activities, increasing use of mind
altering substances. He or she may even verbalise „directly‟ plans of harming self (by
saying „life is not worth living‟ „I wish I had not been born‟ „I will kill myself‟) or
„indirectly‟ („everything will be all right within few days‟ „saying good bye‟ „meeting
loved ones before the act‟ „donating favourite articles/things to others‟). Suicide is
usually preceded by weeks/days of death wishes, suicidal ideas, depressed feelings, plans
and subtle warnings. Thus, it is preventable by timely identification and response to such
pre-act symptoms.

Assessment of high risk behaviours needs to be done from the first day of the
imprisonment and then periodically depending upon the situation and environment. The
influence of dynamic risk factors (for e.g., easy availability of substance use, mental
illness, stress) highlights the importance of assessment at regular interval for the risk of
imminent and repetitive violence. However, prison staff works under various constraints
such as lack of trained human resources, inadequate funding and poor infrastructure.
These factors also act as barriers in planning effective management. Low staff morale and
burnout are the most important challenges. Acknowledging the prevailing situation, a
simple assessment and management outline has been suggested here. It is essential to
have a national and regional policy to prevent high-risk behaviours rather than blaming
the correctional staff.

a) Need for Suicide Prevention Programmes in Correctional settings as a national policy

All correctional facilities, regardless of size, should have a reasonable and comprehensive
suicide prevention policy that addresses the key components noted in the following
sections. Of course, it is not the officers' but prison authorities‟ responsibility to approve
and install such programmes (World Health Organization, 2007).

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b) Training

The essential component to any suicide prevention programme is properly trained

correctional staff, who form the backbone of any jail, prison, or juvenile facility. Very
few suicides are actually prevented by mental health, health care or other professional
staff because suicides are usually attempted in inmate housing units, and often during late
evening hours or on weekends when they are generally outside the purview of
programme staff. Correctional officers are often the only staff available 24 hours a day;
thus, they form the front line of defence in preventing suicides (World Health
Organization, 2007).

c) Intake Screening

Once correctional staffs are trained and familiar with risk factors of suicide, the next step
is to implement formal screening for suicidal risk among newly admitted inmates. Since
suicides in jails may occur within the first hours of arrest and detention, screening for
suicide must occur almost immediately upon entrance into the institution to be effective.
To be most effective, every new inmate should be screened at intake and again if
circumstances or conditions change. Screening for suicide needs to be a responsibility of
correctional staff and they should be adequately trained and aided by a checklist for
assessing suicidal risk (World Health Organization, 2007). In a correctional setting
assessment, affirmative answers to one or more of the following items could be used to
indicate an increased risk of suicide and a need for further intervention by the
professionals.

d) Monitoring

Screening identifies the person at risk but does not prevent an attempt. For an effective
prevention programme, monitoring plays a crucial role. Around the clock monitoring
requires adequate communication between the staff around the shift. Communication
needs to be open, clear and precise in nature. Proper documentation is of extreme
importance. If required, help needs to be taken from other prison inmates to monitor for
suicidal behaviour. Signs such as withdrawn behaviour, crying, food refusal, sad mood,
expressing suicidal ideas and attempts, must be the indicators for immediate referral to
mental health professional care.

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e) Reducing the availability of means/modes of committing suicide

The prison environment needs to be safe. Access to hanging materials (ropes, wires) and
self-electrocution needs to be prevented. Keeping sharp instruments, potentially
poisonous items and medications away from the person is very important. A person with
a suicidal risk must never be left alone. Someone should stay with the person and keep a
close vigil. A suicide monitoring environment would be a cell or dormitory that has
eliminated or minimised hanging points and unsupervised access to lethal materials.

Check list for assessment of suicide by prison staff

1. The inmate is intoxicated and/or has a history of substance abuse.

2. The inmate expresses unusually high levels of shame, guilt, and worry over
the arrest and incarceration.
3. The inmate expresses hopelessness or fear about the future, or shows signs
of depression, such as crying, lack of emotions, lack of verbal expression.
4. The inmate admits to current thoughts about suicide
5. The inmate has previously received treatment for a mental health problem.
6. The inmate is currently suffering from a psychiatric condition or acting in an
unusual or bizarre manner, such as difficulty to focus attention, talking to
self, hearing voices.
7. The inmate has made one or more previous suicide attempts and/or admits
that suicide is currently an acceptable option.
8. The inmate admits to current suicide planning
9. The inmate admits or appears to have few internal and/or external supportive
resources.
10. The arresting/transporting officer believes that the inmate is at risk for
suicide.
11. Facility records indicate that the inmate had a risk for suicide during a prior
confinement.

Source: World Health Organization (2000). Preventing suicide; a resource for

prison officers. Pub by; Mental and Behavioural Disorders, Department of Mental
Health, World Health Organization, Geneva

f) Supportive Role

The prison staff must try to help the at-risk person in all possible ways, within their
limitations. Any unnecessary delay in the process of providing help must be avoided.

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Concern and support for the prisoner‟s recovery is vital. The staff must acknowledge
his/her limitations and try to assure the person of the best possible help. A person making
a suicidal attempt must never be challenged.

g) Professional Help

Availability of mental health professional for further management adds value to the
services. They can provide medications, electro-convulsive therapy, counselling and
psychotherapy.

If suicidal attempt occurs: Rapid response mechanisms

First aid needs to be administered and on a high priority, emergency hospital referral to
save the person‟s life needs to be done. Training the staff in providing first aid is also the
key to success of the suicide prevention programme. The higher authorities of the prison
must be immediately alerted. There is an urgent need to formulate standard operating
procedures to manage a suicidal attempt if it occurs. Around the clock availability of
escorts to shift the person to higher centres needs to be formalised and should occur
without any delay.

Malingering a suicidal attempt

At times suicidal attempt can be used with the motivation of gaining entry into hospital.
Suicidal behaviour because of mental illness is usually labelled as “MAD” behaviour and
with manipulative intent as “BAD” behaviour. Such a classification adopted by health
professionals and prison staff needs to be abandoned because of following reasons:

a) This dictates “MAD” requires treatment and “BAD” needs punishment.

b) It also assumes that suicidal behaviour is a static phenomenon, but in fact it is a
dynamic phenomenon. Today‟s manipulative intent of suicide may be tomorrow‟s
completed suicide.
c) Even though a suicidal attempt may have a manipulative intent, punishment and
challenging may lead to the extreme step of completed suicide.
d) 30-40% of completed suicides have a past history of attempted suicide and self-
injurious behaviour.

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Hence, for all practical purposes, every prisoner with a suicidal risk needs to be evaluated
and managed. If there are well documented, multiple, manipulative suicidal attempts in
the past, then that case definitely needs professional help for his maladaptive and poor
coping ability.

If completed suicide occurs: dealing with the grief process

Suicide committed by a prisoner can have severe psychological impact on the co-
prisoners and the prison staff. It can even become a model for other prisoners as a method
to tackle their own problems. Hence a protocol should be developed by the prison
authorities for dealing with such situations. Authorities should get adequate factual
information about the event. Then information should be given to the other inmates. To
avoid rumours, all inmates should get the same information. It is important not to keep
discussing the suicidal event with everyone. The suicidal act must not be glorified.

At times, completed suicide can provoke anger and violence inside the prison. Hence,
prisoners must be allowed to discuss their thoughts and feelings. Severely affected co-
prisoners (close friends) of the deceased should be allowed to ventilate and if required
counselling services should be offered. This opportunity should be utilised later for
discussing or brain storming sessions or seminars about suicide, help seeking behaviour,
available services, problem solving techniques and depression.

Dangerous to others and/or property - Assessment and management in prisons

The present relatively primitive level of management and treatment of violence risk needs
to be replaced by evidence based management from the health and human rights
perspective. Assessment plays a crucial role in predicting and preventing violence in
custody. Violence is a dynamic phenomenon as already discussed. Hence, assessment
needs to be done as and when required. Each assessment is relevant only for a limited
time frame of days to weeks (Simon and Tardiff, 2008). There are various forms of
assessment including clinical and structured assessments of violence.

Assessment of „dangerous to others and property‟ behaviour needs to encompass the

following issues a) nature; what kinds of behaviour might occur? b) consequences; what
may be consequences of the high-risk behaviour? c) frequency: how often might high-
risk behaviour occur? d) expecting; how soon might high-risk behaviour occur? and e)
probability; what is the probability that high-risk behaviour might occur?

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 Factors that needs to be evaluated in the assessment risk of violence

1. Nature and personality of the prisoner

2. Motivation for violence (Provoked/unprovoked)
3. Planning, means, severity, nature, place and details of violence
4. Past history of violence /Violent crime/ Domestic violence
5. Gang activities
6. Substance use such as alcohol and drugs
7. Presence of mental illness
8. Relationship instability and impulsivity
9. Ongoing stress

It is also essential to do the analysis of the behaviour in the (recent) past. This gives us a
rough picture about the person‟s personality and gravity of the risk assessment involved.
This assessment can be done by trained counsellors or a psychologist. Depending upon
the assessment, risk quantification can be done on four point scale, each indicating the
ascending hierarchy of the severity level. 0=no risk present, 1=mild risk, 2=moderate risk
and 3=severe risk. Depending upon the available resources and results of the assessments,
various actions can be initiated to curtail the current violence, to predict and prevent
future violence. Action can be shifting the person to the hospital or to a high security
area, requiring assessment from the psychiatrist and initiating the behavioural
management rehabilitation.

‘ABC’ Analysis of the behaviour

An „ABC‟ analysis of the behaviour helps to carry out a direct observation and to collect
information about the events that are occurring within a prisoner's environment. "A"
refers to the antecedent, "B" refers to observed behaviour and "C" refers to the
consequence Consequences may be positive, negative or sometimes a combination of
both (O'Neill et al., 1997). It is also important to identify the settings, events that may be
working to keep the behaviour going (what are the factors maintaining that behaviour).
This analysis can be done on an ABC analysis chart as shown in the accompanying
figure. Analysis is not one time but must be carried out over a period of days to weeks.

133
Figure 4: ABC analysis of behaviour

• Antecedent (the antecedent activity that immediately precedes a problem

A behaviour)

• Behaviour (Observed high-risk behaviour)

B
• Consequence (The consequence may be for the person involved, other
C people or on property.)

‘ABC’ analysis chart

Name (of the inmate)………………………………….. Date…………………….

Referral no………………….

Sl Date and Antecedents Behaviour Consequences Comments

No Time
Activity
1 16.12.2009 Altercation with a Physical Co-prisoner sustained Un-controlled
10.30 AM co-prisoner over the abuse of the grievous injury to the explosive violence.
Bathing availability of water co-prisoner right eye and lost his Urine analysis
in the toilet vision positive for
cannabis
2
3
4

Observer signature ……………………

Name…………………….Date…………

‘ABC’ chart analysis helps not only in understanding the behaviour in a given situation
but also the consistent pattern of behaviour and the situations in which it occurs. It also
helps to make a proper plan of management. The plan of management needs to occur
under the supervision of professionals including medical, prison staff and others
concerned. This decision needs to be a group decision rather than an individual one, for

134
several reasons. In a given case, it may be decided to refer to a psychiatrist, or to a
mandatory anger management programme or to a lifeskills programme. There are various
behavioural rehabilitation programmes that can be intiated in correctional settings.
However, there are only a few programmes which have been rigoursly researched and
found to be effective. This section has only provided a bird‟s eye view of those
programmes.

Mental Health Services and De-addiction Programme

Availability of mental health services and de-addiction services in a correctional setting is

the need of the hour (Chandler et al., 2009). There is no doubt about their need and
effectiveness. These services start from educating about mental illness, supportive
counselling, medications, de-addiction treatment, emergency services, HIV counselling,
family counselling, stress management programmes, behaviour therapy and life skills
training programmes (Edens et al., 1997). They also need to be involved in providing
training to the correctional setting staff. The staff spends more time with prisoners, hence
it makes sense to use their expertise to train them in counselling, behaviour therapy,
family therapy and other therapeutic methods of dealing with prisoners (Edens et al.,
1997). This also will help us to address the lack of trained manpower in rehabilitation
settings.

There are many countries providing mental health and de-addiction services in
correctional settings (Adams et al., 2009; Armitage et al., 2003; Blitz et al., 2006; Gorski
et al., 2008; Kolind et al., 2010). A strong linkage between substance abuse and criminal
activity among young offenders has triggered a new wave of rehabilitation by adding de-
addiction services in prison settings (Dowden and Latimer, 2006; Steel et al., 2007). In
many countries, considering the nature of risk involved, such as dangerousness to others
from the use of drugs or alcohol, A Compulsory Drug Treatment Correctional Centre
(CDTCC) has been established and this is also endorsed by the judiciary. A Compulsory
Drug Treatment facility in the Correctional Centre of Australia was established in 2006
for repeat drug-related male offenders (Birgden and Grant, 2010). Though compulsory
treatment goes against the individual rights, the high-risk behaviours of the offenders put
others at risk. This necessitates appropriate action, best done in a rehabilitation and
reformation framework. Innovative approaches of collaboration between correctional
settings with medical colleges for providing mental health services have been successful
(Appelbaum et al., 2002). Studies have also documented that providing mental health

135
care and de-addiction decreases recidivism, time spent incarcerated and successful
community integration (Case et al., 2009; Lamberti et al., 2001).

Anger management programme

Anger management is probably one of the most common forms of rehabilitation offered
to prisoners with high-risk behaviours. For this reason, it is important to determine
whether anger management works in reducing anger and anger-related problem
behaviours. Five published meta-analytic studies with at least moderate effect sizes, have
all suggested that anger management is effective, (Beck and Fernandez, 1998; Del
Vecchio and O‟Leary, 2004; DiGiuseppe and Tafrate, 2003; Edmondson and Conger,
1996; Sukhodolsky et al., 2004). Hence, anger management needs to be offered to the
high-risk prisoners.

Life skills training programme

Life skills are abilities for adaptive and positive behaviours that enable individuals to deal
effectively with the demands and challenges of everyday life (World Health
Organization., 1997). A list of 10 life skills, described as generic life skills for
psychosocial competence, was identified by WHO as core life skills applicable across a
wide range of contexts in daily life and risk situations.

Ten Life skills identified by WHO

(World Health Organization., 1997)
Problem solving Decision making,
Empathy Self-awareness
Inter-personal relationships Communication skills
Critical thinking Creative thinking
Coping with emotions Coping with stress

They are depicted in the above box. These skills have been successfully implemented to
curtail sexually transmitted diseases, to prevent mental illness, in the management of

136
substance use, in school mental health programme, in anger management and also in
correctional settings (Edens et al., 1997; Marshall et al., 1989).

Cognitive behavioural therapy for sexual offenders

A meta-analysis of 69 studies comparing treated and untreated offenders on controlled

outcome evaluations of sexual offenders reported that the majority of the studies
confirmed the benefits of treatment. Treated offenders showed 37% less sexual
recidivism than controls. Cognitive behavioural therapy approaches revealed the most
robust effect (Lösel and Schmucker, 2005). Similar results have been replicated in
another meta-analysis. This meta-analysis of 10 studies was conducted to know the
effectiveness of treatments for male adolescent sexual offenders (N = 644). Results from
the study reported that cognitive-behavioural therapy approaches were the most effective
(Walker et al., 2004).

Another interesting treatment approach called „Multisystemic Therapy‟ in young sexual

offenders has been found to be effective in a well conducted trial (Borduin et al., 2009).
„Multisystemic Therapy‟ incorporates family therapy, cognitive behaviour therapy and
individual therapy. Involving family members in the treatment process has yielded
positive results. Therapeutic benefits of „Multisystemic therapy‟ continued even after one
year of undergoing treatment (Letourneau et al., 2009). Hence, any programme having
cognitive behavioural therapy component needs to be advocated in sexual offenders.

Family therapy / Assistance programme

This programme provides assistance to the family members of the inmates. Immediately
after arrest, inmates are worried about their family members. They want to know about
their condition and safety. Families are also in a state of transition when their family
member is arrested or receives a custodial sentence. Significant reactions include shame,
guilt, physical and emotional distress, loss of social mobility and income stability,
stigmatisation, stress and anxiety (Hardy and Snowden, 2010).

Family intervention programmes focus mainly on the following issues:

a) To enhance communication between inmates and their families
b) Helping the family to cope with the incarceration of their dear one
c) Promoting family visits and parole

137
 d) Addressing issues like domestic violence in the family context
e) Involving family members in treatment of the inmate such as de-addiction and
aftercare (Gideon, 2007)
f) Family therapy or marital therapy (Henggeler et al., 1992)
g) Counselling in parenting (Thompson and Harm, 2000)
h) Providing educational support to the children of the inmates
i) Assisting in employment and rehabilitation and
j) Family re-integration (Gideon, 2007)

This programme helps the prisoners to relieve their anxiety and focus on rehabilitation.
Family therapy can thus be used to engage prisoners into the rehabilitation programme.
Adding family therapy into any rehabilitation programme gives a whole new meaning to
the life and hope for the prisoner.

Other behavioural rehabilitation programmes

There are various other behavioural rehabilitation programmes that have been suggested
but their efficacy has still not been backed by proper trials. These include: Mindfulness
therapy (Bowen et al., 2006), Social skill training, Sex education programme as a part of
HIV prevention programme, Stress management, Yoga, Relaxation, Meditation, and
Spirituality.

Educational programme

Supporting educational needs of the prisoners has been occurring since many decades.
There seems to be a general acceptance by the public and policy makers that education
has benefits in its own right. It is based on the understanding that an educated person has
a higher probability of finding a job and less recidivism. However, this surmise has never
been confirmed. Only recently, a review on correctional and vocational education
(MacKenzie, 2008), has yielded positive results leading to the conclusion that educational
programmes reduce the recidivism of offenders as well as increase employment. This
review has also raised serious concern about the content of education programmes. They
need to bring about a change in thinking and cognitions and not just in their ability to
directly impact the offender‟s ability to get employment.

138
In conclusion, rehabilitation should be the guiding principle of all correctional
institutions. It is time to acknowledge that punishment and deterrence based interventions
are ineffective. Appropriate interventions should be instituted and improved by
supporting systematic research to differentiate effective and ineffective correctional
interventions. It is also important to eradicate the idea that “nothing works” to change
offenders. Health care and rehabilitation need to be integrated, so that multimodal
approaches of public health care such as early recognition and treatment of prisoners with
high-risk behaviour (secondary prevention), behavioural rehabilitation (tertiary
prevention) and prevention of re-offending behaviour (primary prevention) occur hand in
hand.

Evidence-based treatment and rehabilitation services are an absolute need in any

correctional centre. Treatment approaches should include behavioural interventions that
are effective in changing an array of human behaviour. To achieve this herculean task,
correctional and health staff need to establish credibility, develop competence, learn
effective communication and collaborate effectively. This constitutes the bedrock of a
successful programme in any correctional setting.

139
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Suk E, van Mill J, Vermeiren R, Ruchkin V, Schwab-Stone M, Doreleijers T, Deboutte
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Vijayakumar L, Rajkumar S. Are risk factors for suicide universal? A case control study
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Walker DF, McGovern SK, Poey EL, Otis KE. Treatment effectiveness for male
adolescent sexual offenders: a meta-analysis and review. J Child Sex Abus
2004;13:281-293
Wolff N, Shi J. Feelings of safety inside prison among male inmates with different
victimization experiences. Violence Vict 2009;24:800-816
World Health Organisation 2000. Preventing suicide; a resource for prison officers. Pub
by; Mental and Behavioural Disorders, Department of Mental Health, World Health
Organization, Geneva (WHO/MNH/MBD/00.5 ). Available online at
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 10. RIGHTS OF PRISONERS

“Convicts are not by mere reason of the conviction denuded of all the fundamental rights
which they otherwise possess.”
- Justice V.R. Krishna Iyer
(Sunil Batra Vs. Delhi Administration., 1978)

A prison, jail or correctional facility is a place in which individuals are physically

confined or detained and usually deprived of a range of personal freedom. These
institutions are an integral part of the criminal justice system of a country. There are
various types of prisons such as those exclusively for adults, children, female, convicted
prisoners, under-trial detainees and separate facilities for mentally ill offenders. In this
chapter, “prisons” refer to only adult correctional facilities.

Imprisonment or incarceration is a legal punishment that may be imposed by the state for
the commission of a crime or disobeying its rule. The objective of imprisonment varies in
different countries and may be: a) punitive and for incapacitation, b) deterrence, and c)
rehabilitative and reformative (Scott and Gerbasi., 2005). In general, these objectives
have evolved over time as shown in the accompanying figure. The primary purpose and
justification of imprisonment is to protect society against crime and retribution. In current
thinking, punitive methods of treatment of prisoners alone are neither relevant nor
desirable to achieve the goal of reformation and rehabilitation of prison inmates. The
concept of Correction, Reformation and Rehabilitation has come to the foreground and
the prison administration is now expected to function in a curative and correctional
manner (Karnataka Prisons, 2009). Human rights approaches and human rights
legislations have facilitated a change in the approaches of correctional systems, and they
have evolved from being reactive to proactively safeguarding prisoners‟ rights. The
United Nations has also provided several standards and guidelines, through minimal rules
or basic principles in the treatment of prisoners (United Nations, 1977).

The State is under an obligation for protecting the human rights of its citizens as well as
to protect the society at large, and is authorised to do so. To protect the citizens from any
possible abuse of this authority, they are given certain basic privileges recognised by the
Constitution of India as Rights. Elevation of such claims to the status of Rights, gives the

145
citizens the capacity to evoke the power of the Judiciary to protect themselves against
violation of such rights, as well as to seek redressal for their restitution.

Figure 1: Evolution in the objectives of the prison system

Human Rights of prisoners: National and International Instruments

In India, the idea of rights of prisoners was long suppressed under the colonial rule and
has only recently emerged in public discourse. The Constitution of India confers a
number of fundamental rights upon citizens. The Indian State is also a signatory to
various international instruments of human rights, like the Universal Declaration of
Human Rights which states that:

146
 “No one shall be subject to torture or cruel, inhuman or degrading treatment of
punishment” (UDHR, 1948)

Also important is the United Nations Covenant on Civil and Political Rights which states
in part:

“All persons deprived of their liberty shall be treated with humanity and with
respect for the inherent dignity of the human person”. (UNICCPR, 1966)

There are many United Nations codified standards of treatment for prisoners across
different economic, social and cultural contexts in a number of documents. These
concern themselves with ensuring those basic minimum conditions in prisons which are
necessary for the maintenance of human dignity and facilitate the development of
prisoners into better human beings. International documents, which have articulated the
prisoners‟ rights, are listed in the accompanying table.

Table 1. International Conventions/Regulations on Prisoners’ Human Rights

Standard Minimum Rules for the Treatment of Prisoners (OHCHR, 1955)

Principles of Medical Ethics relevant to the Role of Health Personnel, particularly
Physicians, in the Protection of Prisoners and Detainees against Torture and Other
Cruel, Inhuman or Degrading Treatment or Punishment (UN Medical Ethics, 1982)
Convention Against Torture (UNCAT, 1984)
Body of Principles for the Protection of All Persons under Any Form of Detention
or Imprisonment. (Principles of Detention, 1988)
Basic Principles for the Treatment of Prisoners (UNPTP, 1990)
United Nations Standard Minimum Rules for Non-Custodial Measures (The Tokyo
Rules, 1990)
Declaration on the Protection of all Persons from Enforced Disappearance. General
Assembly Resolution 47/133 (UNDPPED, 1992)
United Nations Standard Minimum Rules for the Administration of Juvenile Justice
(The Beijing Rules, 1985)
Declaration of Basic Principles of Justice for Victims of Crime and Abuse of
Power, (UNVCAP, 1985)

147
Therefore, both under national as well as international human rights law, the state is
obliged to uphold and ensure observances of basic human rights.

Human rights of prisoners in India

The Indian freedom struggle played a crucial role in initiating the process of identifying
certain rights for the prisoners. After independence, the Constitution of India conferred a
number of fundamental rights upon citizens. Article 21 of the Constitution guarantees the
right of personal liberty and thereby prohibits any inhuman, cruel or degrading treatment
to any person whether (s)he is a national or foreigner.

Article 21. Protection of Life and Personal Liberty; “No person shall be deprived of his
life or personal liberty except according to procedure established by law”.

The Supreme Court of India, by interpreting Article 21 of the Constitution, has developed
human rights jurisprudence for the preservation and protection of prisoners‟ rights to
maintain human dignity. Although it is clearly mentioned that deprivation of Article 21 is
justifiable according to procedure established by law, this procedure cannot be arbitrary,
unfair or unreasonable. In a celebrity case (Maneka Gandhi Vs. Union of India., 1978),
the Apex Court opened up a new dimension and laid down that the procedure cannot be
arbitrary, unfair or unreasonable. Article 21 imposed a restriction upon the state where it
prescribed a procedure for depriving a person of his life or personal liberty. This was
further upheld (Francis Coralie Mullin v. The Administrator, 1981) “Article 21 requires
that no one shall be deprived of his life or personal liberty except by procedure
established by law and this procedure must be reasonable, fair and just and not arbitrary,
whimsical or fanciful”.

Any violation of this right attracts the provisions of Article 14 of the Constitution, which
enshrines right to equality and equal protection of law. In addition to this, the question of
cruelty to prisoners is also dealt with, specifically by the Prison Act, 1894 and the
Criminal Procedure Code. Any excess committed on a prisoner by the police authorities
not only attracts the attention of the legislature but also of the judiciary. The Indian
judiciary, particularly the Supreme Court, in the recent past, has been very vigilant
against violations of the human rights of the prisoners.

148
Role played by the judiciary

The need for prison reforms has come into focus during the last three to four decades.
The Supreme Court and the High Courts have commented upon the deplorable conditions
prevailing inside the prisons, resulting in violation of prisoner‟s rights. Prisoners‟ rights
have become an important item in the agenda for prison reforms.

The Indian Supreme Court has been active in responding to human right violations in
Indian jails and has, in the process, recognised a number of rights of prisoners by
interpreting Articles 21, 19, 22, 32, 37 and 39A of the Constitution in a positive and
humane way. Given the Supreme Courts‟ overarching authority, these newly recognised
rights are also binding on the State under Article 141 of the Constitution of India which
provides that the Law declared by the Supreme Court shall be binding on all courts within
the territory of India.

Following are the reasons cited in various case laws for which prisoner‟s rights were
recognised and upheld by the Indian judiciary.

a) “Convicts are not by mere reason of the conviction denuded of all the
fundamental rights which they otherwise possess”- Justice V.R. Krishna Iyer
(Sunil Batra vs. Delhi Administration., 1978).
b) “Like you and me, prisoners are also human beings. Hence, all such rights except
those that are taken away in the legitimate process of incarceration still remain
with the prisoner. These include rights that are related to the protection of basic
human dignity as well as those for the development of the prisoner into a better
human being” (Charles Shobraj vs. Superintendent, 1978).
c) If a person commits any crime, it does not mean that by committing a crime,
he/she ceases to be a human being and that he/she can be deprived of those
aspects of life which constitutes human dignity.
d) It is increasingly being recognised that a citizen does not cease to be a citizen just
because he/she has become a prisoner.
e) The convicted persons go to prisons as punishment and not for punishment (Jon
Vagg., 1994) Prison sentence has to be carried out as per the court‟s orders and no
additional punishment can be inflicted by the prison authorities without sanction
(Sunil Batra vs. Delhi Administration., 1978).
f) Prisoners depend on prison authorities for almost all of their day to day needs, and
the state possesses control over their life and liberty, the mechanism of rights

149
 springs up to prevent the authorities from abusing their power. Prison authorities
have to be, therefore, accountable for the manner in which they exercise their
custody over persons in their care, especially as regards their wide discretionary
powers.
g) Imprisonment as punishment is now rethought of as „rehabilitative‟ punishment.
This involves a philosophy that individuals are incarcerated so that they have an
opportunity to learn alternative behaviours to curb their deviant lifestyles.
Correction, therefore, is a system designed to correct those traits that result in
criminal behaviour. The rehabilitative model argues that the purpose of
incarceration is to reform inmates through educational, training, and counselling
programmes. This development and growth requires certain human rights without
which no reformation takes place.
h) Disturbing conditions of the prison and violation of the basic human rights such as
custodial deaths, physical violence/torture, police excess, degrading treatment,
custodial rape, poor quality of food, lack of water supply, poor health system
support, not producing the prisoners to the court, unjustified prolonged
incarceration, forced labour and other problems observed by the apex court have
led to judicial activism (NHRC, 1993).
i) Overcrowded prisons, prolonged detention of under trial prisoners, unsatisfactory
living condition and allegations of indifferent and even inhuman behaviour by
prison staff has repeatedly attracted the attention of critics over the years.
Unfortunately, little has changed. There have been no worthwhile reforms
affecting the basic issues of relevance to prison administration in India. (Justice
A N Mulla Committee, 1980-83)

Rights of the prisoners have been expressed under the Indian Constitution as well as
Indian laws governing prisons. The Supreme Court and High Court rulings have played a
crucial role in enumerating the rights of prisoners.

A land mark judgement by Justice V.R. Krishna Iyer enumerated basic human rights of
the prisoners. Mr. Sunil Batra had written a letter from Tihar Jail, Delhi to the Supreme
Court providing information about the torture and inhuman conditions of the prison. This
case has become a landmark case in prison reforms (Sunil Batra Vs Delhi Administration,
1980) This case recognized the various rights of prisoners in the most comprehensive
manner. The judgement held that: “No prisoner can be personally subjected to
deprivation not necessitated by the fact of incarceration and the sentence of the court. All

150
other freedoms belong to him to read and write, to exercise and recreation, to meditation
and chant, to comforts like protection from extreme cold and heat, to freedom from
indignities such as compulsory nudity, forced sodomy and other such unbearable
vulgarity, to movement within the prison campus subject to requirements of discipline
and security, to the minimal joys of self-expression, to acquire skills and techniques. A
corollary of this ruling is the Right to Basic Minimum Needs necessary for the healthy
maintenance of the body and development of the human mind. This umbrella of rights
would include: Right to proper Accommodation, Hygienic living conditions, Wholesome
diet, Clothing, Bedding, timely Medical Services, Rehabilitative and Treatment
programmes”.

Another land mark judgement pronounce by the judiciary is the right to compensation in
cases of illegal deprivation of personal liberty. The Rudal Shah case (Rudal Shah v. State
of Bihar, 1983) is an instance of breakthrough in Human Rights Jurisprudence. The
petitioner Rudal Shah was detained illegally in prison for more than fourteen years. He
filed Habeas Corpus before the court for his immediate release and, interalia, prayed for
his rehabilitation cost, medical charges and compensation for illegal detention. After his
release, the question before the court was "whether in exercise of jurisdiction under
Article 32, could the court pass an order for payment of money? Was such an order in the
nature of compensation consequential upon the deprivation of fundamental right? There
is no expressed provision in the Constitution of India for grant of compensation for
violation of a fundamental right to life and personal liberty. But the judiciary has evolved
a right to compensation in cases of illegal deprivation of personal liberty. The Court
granted monetary compensation of Rs.35,000 against the Bihar Government for keeping
the person in illegal detention for 14 years even after his acquittal. The Court departed
from the traditional approach, ignored the technicalities while granting compensation.

The decision of Rudal Shah was important in two respects. Firstly, it held that violation
of a constitutional right can give rise to a civil liability enforceable in a civil court and;
secondly, it formulates the bases for a theory of liability under which a violation of the
right to personal liberty can give rise to a civil liability. (Rudal Shah v. State of Bihar,
1983) The decision focused on extreme concern to protect and preserve the fundamental
right of a citizen. It also calls for compensatory jurisprudence for illegal detention in
prison.

151
In India, the courts have acknowledged and several judgements recognise a wide array of
fundamental and other rights of prisoners. Table 2 enumerates the broad categories of
rights, which are not exhaustive as this field is still developing and slowly evolving
(Sreekumar R, 2003). These rights have been drawn from various case laws (Madhurima,
2009). Though these rights are articulated in the case laws, they do not reach the poor
prisoners. There are still many rights that are not recognised by the Indian legal system.
For example, in January 2010, considering the rapid increase in the number of HIV
positive prisoners, the Bombay High Court asked the Maharashtra government to
examine the possibility of allowing jail inmates to have sex with their wives in privacy.

Table 2. RIGHTS OF PRISONERS

1. Right to be lodged appropriately based on Proper Classification.
2. Special Right of young prisoners to be segregated from adult prisoners.
3. Rights of women prisoners.
4. Right to healthy environment.
5. Right to bail.
6. Right to speedy trial.
7. Right to free legal services.
8. Right to basic needs such as food, water and shelter
9. Right to have interviews with one‟s Lawyer.
10. Right against being detained for more than the period of sentence imposed by the court.
11. Right to protection against being forced into sexual activities.
12. Right against arbitrary use of handcuffs and fetters.
13. Right against torture, cruel and degrading punishment.
14. Right not to be punished with solitary confinement for a prison offence.
15. Right against arbitrary prison punishment.
16. Right to air grievances and to effective remedy.
17. Right to evoke the writ of habeas corpus against prison authorities for excesses.
18. Right to be compensated for violation of human rights.
19. Right to visits and access by family members of prisoners.
20. Right to write letters to family and friends and to receive letters, magazines, etc.
21. Right to rehabilitation and reformative programmes.
22. Right in the context of employment of prisoners and to prison wages.
23. Right to information about prison rules.
24.Right to emergency and reasonable health care. Sources: Sreekumar 2003.

The Court for the first time noted the aspect of physical needs of the prisoners (The
Conjugal Right, 2010). This conjugal right also has a valid argument that merely because
a spouse is convicted, the innocent partner should not suffer. Another basic contention is

152
that as long as the prisoner is not executed, in line with the court‟s orders, he/she had a
right to life, which includes the right to propagate species and to a sex life.

Prisoners with mental illness: prison scenario

Human rights and mental illness are closely related. Persons with mental illness are most
vulnerable to violation of their rights in the society. They are stigmatised, isolated and
discriminated (Lewis, 2009; Thornicroft et al., 2007). A mentally ill prisoner has a double
disadvantage. Even when quality psychiatric care is provided, the inmate/patient still has
been doubly stigmatized—as both a mentally ill person and a criminal (Lamb, 2009). He
may not be able to defend his/her case. Many times, a person with mental illness may not
receive proper treatment and remains in the custody for years. This may be an account of
being unfit to stand trial, lack of support, or because the family is able but unwilling to
bail out the person because of the illness.

Human rights violation itself can have a severe impact on a person‟s mental health and
lead to a vicious cycle as shown in the accompanying figure 2 (Johnson et al., 2010;
Priebe et al., 2010).

Figure 2. The vicious cycle of mental disorder and human rights violation
violation

153
According to Penrose's law, outlined on the basis of a comparative study of European
statistics, there is an inverse relationship between the number of psychiatric beds and
prison populations within a country. Deinstitutionalisation or closing down psychiatric
hospitals has in fact led to trans-institutionalisation (Kalapos, 2009).

Figure 3: De-institutionalisation and trans-institutionalisation

Downsizing
of mental
hospital
beds

Non-availabilty of
Arrest and
community mental
imprisonment
health care

Wandering
Petty crime
mentally ill

De-institutionalisation and downsizing of mental hospital beds on the one hand,

with nonexistence of community mental health care on the other, results in many
wandering and homeless mentally ill on street. These persons are booked for
offences such as trespassing, creating public nuisance, indecent behaviour,
planning a crime/robbery and other petty crimes. This is known as „criminalisation
of the mentally ill‟ (Torrey et al., 2010). Often, they are arrested for begging and
kept in a beggars‟ home without any treatment for decades and left to perish.

Trans-institutionalisation is the movement of persons with severe mental disorders

between prisons and the mental hospital and prison or other custodial settings (Pedersen

154
and Kolstad, 2009). Persons with mental illness are likely to remain in prisons for
unnecessarily long periods of time because their illnesses go unnoticed, undiagnosed and
untreated (Priebe et al., 2005). Even if they are brought to the notice of the court, he/she
may not be fit to stand trial. Non availability of timely treatment and continuous care
further aggravates the situation. The family in many instances is unwilling to house or
care for such persons and there is no place in the community for their rehabilitation.
There is an urgent need to evolve an interdisciplinary approach to provide care and
uphold the rights of mentally ill prisoners (Jennifer Bard, 2007).

In conclusion, various judgements passed by Indian courts suggest that they are sensitised
to the need for doing justice to people to whom justice had been denied by a heartless
society for generations (Mehta and Neena Verma, 1999). Although several judgements
have recognised the rights of prisoners, these have resulted in few amendments to
legislation. While judicial sensitivity and activism is appreciable, it must be borne in
mind that the country’s criminal justice system still suffers from substantive and
procedural deficiencies; once a citizen is arrested, even if on a relatively minor charge,
he/she could be held in custody for years before his/her case comes up for trial. Those
who are affluent are still being able to negotiate their way around the numerous
obstacles that lie on the road to justice. For an ordinary citizen, an encounter with the
law is very much the stuff of nightmares. There is a long course before the Indian
judiciary to be followed in order to achieve the goal of social justice (Krishna Iyer VR,
1984).

Though various rights have been granted to prisoners, in reality, they do not reach the
prisoners. An outstanding example is the right to speedy trial. A huge backlog of cases
impedes the delivery of justice and this is a violation of the rights by the court itself.
Similarly, free legal aid is an idealistic goal, but presently far from reality. Many of the
prisoners do not know about the services and they are unable to utilise it.

155
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 11. FITNESS TO STAND TRIAL

Mental illness, mental retardation and certain neurological conditions may incapacitate
cognitive, emotional and behavioural faculties of an individual, consequently having
serious impact on the ability to defend the case. Assessment of the mental abilities of
individuals to defend their case is called, ‗fitness to stand trial‘ or ‗competence to stand
trial‘(American Psychiatric Association, 2002; Mossman et al., 2007). In law, ‗fitness to
stand trial‘ deals with the mental capacity of an individual to participate in legal
proceedings. As per the guidelines approved by the Council of the American Academy of
Psychiatry and the Law in 2007, ‗Fitness to stand trial‘ is a legal construct that usually
refers to a criminal defendant‘s ability to participate in legal proceedings related to an
alleged offence (Mossman et al., 2007).

Defendants who are ‗unfit to stand trial‘ are usually excluded from criminal prosecution
and the trial is usually postponed until such time as the person is judged competent.
People found psychiatrically incompetent for trial are usually sent for treatment and will
be treated to regain competence. Traditionally, fitness to stand trial evolved in criminal
cases, but has also been recently extended to the civil suit. In civil proceedings, fitness
for proceedings is termed the capacity to sue and be sued, and is not identical in its
requirements with fitness for proceedings under criminal law. The capacity to sue and be
sued is related to contractual capacity (Rothschild et al., 2007). Fitness also encompasses
other areas apart from trial. There are instances when the investigating officers are
threatened by the defendants that they will commit suicide if the interrogation is done. In
such cases, investigating officers request mental health professionals to assess the
individual‘s, ‗fitness for interrogation‘. Fitness for interrogation is the capacity to
understand the meaning of questions posed during police investigations and in court, and
to answer such questions meaningfully (Rothschild et al., 2007). However, fitness is
rarely used in this context.

Fitness to stand trial evaluations have profound significance because of their influence on
court decisions, court proceedings, resources utilised and the far-ranging consequences
for the defendant with regard to referral to a forensic psychiatry setting. These aspects
have been applied in day-to-day practice, and researched extensively in western
countries. This has become possible with growing awareness among the professionals
and increased frequency of evaluations of competence to stand trial in recent years
(Melton et al., 2007; Melton et al., 1997; Quinnell and Bow, 2001). In the United States

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alone, conservative estimates suggest there are 60,000 competency cases per year, with
rates of incompetency often falling in the 20- to 30-percent range. (Bonnie and Grisso,
2000; Melton et al., 2007; Melton et al., 1997) When extrapolated from the number of
actively psychotic and mentally disordered inmates, (American Psychiatric Association,
2002) the potential number of competency evaluations could easily be twice this estimate
(Rogers and Johansson-Love, 2009).

In India, there are many instances in which fitness to stand trial has delayed the
proceedings for decades. Various reasons have been attributed for the delay, such as,
ignorance, non-availability of the psychiatrist, non-availability of psychotropic medicines
and family members not wanting the person with mental illness to be released (perceived
dangerousness). This is compounded by the lack of resources to provide care and restore
such individuals to their mental competency to fight their case. This chapter reviews only
a small selection of the vast amount of published literature on fitness to stand trial. It
provides a brief overview of the concept of fitness to stand trial, assessment and its
impact.

Case Vignette

Mr. Machang Lalung, was arrested at his home village of Silsang near Guwahati in
1951 under section 326 of the Indian Penal Code for ―causing grievous harm.‖ He
was detained at the age of 23, he could secure his release only when he was 77 years
old.

Less than a year after he was taken into custody, Lalung was transferred to a
psychiatric hospital in the Assamese town of Tezpur. Sixteen years later, in 1967,
doctors confirmed that he was ―fully fit‖ to be released, but instead he was
transferred to Guwahati Central Jail, where he was imprisoned until 2005. He spent
his valuable 54 years of life behind bars and could secure his release only after the
intervention from the Honorable Supreme Court of India in 2005. He was able to
enjoy life outside the prison for only two years. He passed away on 26 Dec 2007

Source: Supreme Court, Writ Petition [CRL] NO(s). 296 OF 2005

http://news.bbc.co.uk/2/hi/south_asia/4712619.stm

160
EVOLUTION OF THE FITNESS TO STAND TRIAL

In 1960, Dusky v. US trial established what is usually taken to be the minimal

constitutional standard for adjudicative fitness in the United States. The appellant, Milton
Dusky, faced a charge of unlawfully transporting a girl across state lines and raping her.
A pre-trial psychiatric evaluation rendered a diagnosis of ‗schizophrenic reaction, chronic
undifferentiated type‘ A separate psychiatric report and psychiatric testimony at trial
stated that Dusky could not "properly assist" counsel because of suspicious thoughts,
including a belief that he was being "framed." Yet, the trial court found that Dusky was
competent to stand trial. He was convicted of rape, and the Eighth Circuit Court of
Appeals affirmed his conviction (Mossman et al., 2007).

The U.S. Supreme Court held, however, that the trial court's determination that Dusky
was oriented and could recall events was not sufficient to establish his competence to
stand trial. Instead, the Court stated that the test for his competence to stand trial was
"whether he [had] sufficient present ability to consult with his lawyer with a reasonable
degree of rational understanding—and whether he [had] a rational as well as factual
understanding of the proceedings against him" (Dusky v. US 1960). It is not enough to
find that the defendant is oriented to time and place and has some recollection of events,
but that the test must be whether he has sufficient ability to consult with his lawyer with a
reasonable degree of rational understanding and whether he has a rational as well as
factual understanding of the proceedings against him (Dusky v. US 1960).

The accurate assessment of fitness to stand trial depends on a good operational definition.
A good operational definition hinges on the clear identification of the criteria and
components of fitness to stand trial. Several attempts have been done to identify the
criteria and classify the components with varying degree of success. However, there are
no agreed definitions or clear cut criteria to assess fitness to stand trial. In the US, fitness
to stand trial assessment is based on three prongs of the Dusky standard. These are: (a)
factual understanding, (b) rational understanding, and (c) ability to consult with counsel
(Dusky v. US 1960; Rogers et al., 2001). As per the Criminal Code of Canada, an
individual‘s ability is defined in terms of three areas of information. First, the accused
must understand the nature or object of the proceedings. Second, the accused must
understand the possible consequences of the proceedings, and finally, he or she must be
able to communicate with counsel (Zapf et al., 2001). In the Australian legal system, a

161
person is deemed to be fit to stand trial if he or she has the ability to achieve a lay
person‘s understanding of: the court process, the charges that have been made, and how
s/he will instruct legal advisors to proceed in relation to the charges (Large et al., 2009;
Mullen, 2002).

Almost all legislations have certain common components which are used to determine the
impairment in cognitive, emotional and behavioural domains of brain functioning, with
regard to assessment of fitness to stand trial. They are as follows, a) comprehending the
charges framed against them, b) realising the seriousness of the penalties if proven guilty,
c) following the proceedings of the court, d) helping their lawyer to defend their case and
e) appropriate behaviour in the court. Hence, fitness to stand trial plays a crucial role in
persons with mental illness or mental retardation. ‗Un-fitness to stand trial‘ therefore
depends upon the presence of a mental disorder during the adjudication process (i.e either
during the initiation of the trial, continuation of the trial or else during the verdict).
Though presence of a mental disorder is obviously an important factor in determining an
individual‘s fitness, mental disorder by itself is not sufficient to determine that a
defendant is unfit. There are many mental illnesses in which individual‘s rational thinking
capacity is preserved and such a person will be deemed fit to stand trial. For example, in
the case of mild to moderate depression, individuals do not lose their rational thinking
capacity.

Invoking the fitness to stand trial assessment in court

The court may order an assessment of the defendant‘s mental condition if it believes that
such evidence is necessary to determine a) fitness to stand trial, b) whether the defendant
was, at the time of the commission of the alleged offence, suffering from a mental
disorder, c) whether that mental disorder impairs reasoning power of the defendant and d)
for placement of the individual in an appropriate place such as a mental hospital,
rehabilitation, or high security prison.

In a case in the US, (Medina v. California 1992), a defendant faced several criminal
charges, including three counts of first-degree murder. Upon the defense counsel request,
the trial court granted a hearing on his client's competence. The court clearly stated that in
every case it presumes that defendants are competent until the contrary is proven. Hence,
invoking the fitness to stand trial assessment would be by the defendant or his/her family

162
members or by his/her attorney. At the same time, burden of proof is also on the
defendant. However, the level of proof needed to show that a defendant lacks
adjudicative competence is by proving it by a preponderance of the evidence.

NEED FOR ASSESSMENT OF ‘FITNESS TO STAND TRIAL’

Principle of natural justice

The Principle of natural justice is based on two legal maxims namely, a) nemo judex in
sua causa – ‘nobody shall be a judge in his own cause‘, invalidating any judgement
where there is a bias or conflict of interest or duty; and b) audi alteram partem- ‗hear the
other side‘, giving at least a fair opportunity to present one's case. The aim of the
principle of natural justice is to secure justice and to prevent miscarriage of justice.
They do not supplant the law but supplement it (Maneka Gandhi v. Union of India 1978,
Gabriel v. State of Madras 1959). These two fundamental principles are widely held to be
legally necessary for a fair trial or valid decision in a legal system. This chapter is not
concerned with the former. The question is only in regard to audi alteram partem rule in
the lawsuit related to person with mental illness so that the trial is fair.

In a recent landmark judgement in India, the Supreme Court has voiced that each one has
an inbuilt right to be dealt with fairly, in a criminal trial. Denial of a fair trial is as much
injustice to the accused as is to the victim and the society. Fair trial obviously would
mean a trial before an impartial judge, a fair prosecutor and an atmosphere of judicial
calm. Fair trial means a trial in which bias or prejudice for or against the accused, the
witnesses, or the cause which is being tried is eliminated (Zahira Habibullah Sheikh v.
State of Gujarat 2006).

Violation of ‘Right to a fair trial’

Fitness to stand trial is to assure the autonomy and individual right of the person to
defend himself/herself. The question which is of utmost importance is whether the person
can do so, so that fair adjudication of trial is given. Hence, fitness to stand trial has a
direct impact on deciding the Right to a fair trial.

The reasons for determining fitness to stand trial are as follows (a) to safeguard the
accuracy of the proceedings, (b) to ensure procedural fairness, (c) to preserve the dignity

163
of the legal system, and (d) to achieve the objectives of sentencing (Wiener, 1985).
Bonnie (1992) identified a three-part rationale: (a) dignity, (b) reliability, and (c)
autonomy. Trying a defendant who lacks an understanding of wrongdoing and
subsequently punishing that defendant would offend the moral dignity of the legal
proceedings. The term reliability addresses the issue that the construct of competency
must be operationalised within the attorney-client relationship. That is, in order to present
an

Right to fair trial is a human right

 Article 14 of the International Covenant on Civil and Political Rights, which has
been ratified by India and is now part of the Protection of Human Rights Act
1973 recognises the right to fair trial as a human right.
 The concept of a fair trial is a constitutional imperative recognised in Articles
14, 21, 22 and 39-A
 The Code of Criminal Procedure (CrPC) 1973 (Procedure in case of accused
being lunatic, CrPC Sec 328, 329 and 330)

adequate defense, the defendant must have the capacity to appreciate the utility of certain
facts and the wherewithal to provide counsel with that information. If a defendant is not
able to provide counsel with such information, then the reliability of the criminal process
is jeopardised. Lastly, Bonnie's rationale of autonomy is based on the legal rules that
certain decisions regarding the defense must be made by the defendant (Bonnie, 1992)

ASSESSMENT OF FITNESS TO STAND TRIAL

Assessment is usually done by a forensic psychiatrist. Presence of a mental disorder is a

necessary but not sufficient condition to determine that a defendant is unfit (Roesch and
Golding, 1980). Even if a person is suffering from mental disorder, it should be assumed
that he/she has the mental capacity to decide on various matters unless the contrary can
be shown. Hence, it must be demonstrated that the mental disorder affects the defendant‘s
performance on adjudicating process. Roesch and his colleagues reported in their study
that, while nearly all defendants who had been found unfit to stand trial had some form of

164
psychosis, almost one-third of those found fit to stand trial were also considered to suffer
from psychosis (Roesch et al., 1981).

Assessment can be done on an outpatient or inpatient basis depending upon the nature of
the case. On a simple outpatient basis examination it

Figure 1: Assessment of fitness to stand trial

*It is also essential to report that ‗unfitness‘ is reversible (treatable conditions such as
schizophrenia, bipolar disorders, acute psychosis, delirium) or irreversible (no
treatment currently available such as mental retardation, dementia, irreversible brain
damage).

can be easily assessed for the fitness to stand trial. On the contrary, to report unfitness,
the forensic psychiatrist has to ascertain the nature of the illness, nature of impairment
and also reason out how the defendant‘s illness is an impediment to the adjudicating
process. It is the responsibility of the professional to inform the court regarding the
restorability of the fitness (reversible and irreversibility of the condition) and time
required for the same.

165
Inpatient assessment is a time consuming and costly affair. The time required in inpatient
assessment and treatment for restoration of fitness may require approximately 4-8 weeks.
Hence, fitness assessment is sometimes used as a strategy to delay the proceedings of the
case. Rarely, it can also be used to determine the feasibility of a later insanity defence.
Forensic psychiatrists also need to keep in mind that at least ten percent of defendants
referred for competence evaluations attempt to feign mental problems that would impair
competence (Gothard et al., 1995; Rogers et al., 1994).

Absence of forensic psychiatrists to do the assessment is a serious limitation in India.

There are only a few hospitals providing inpatient forensic psychiatry services across
India. Unfortunately, there are very few psychiatrists trained in forensic issues. There is
neither a formally approved forensic psychiatry training course in India nor a certified
course.

Ethical and legal issues regarding fitness to stand trial:

Fitness to stand trial also involves diverse ethical and legal challenges that need to be
discussed and debated. Many of them revolve around the individual rights of the
defendants.

Reversibility: It refers to restorability of fitness to stand trial in the future, whereas

irreversibility means non-restoration (eg. lack of treatment response as in refractory
schizophrenia, and absence of any effective treatment as in dementia, mental retardation).
Reversibility certification needs to be accompanied with adequate safeguards. For
example, a defendant found unfit to stand trial should not be held indefinitely for
treatment for restoration of his/her fitness. There must be a time period stipulated for
successful restoration within a reasonable time. However, irreversibility of the fitness to
stand trial raises various issues such as the need to wait for the availability of new
treatment. What should be the next legal proceedings? Where the accused should be
kept? What will happen to the legal proceedings? What is the kind of care to be provided
to the individual in prison?

Forced treatment: On assessment for fitness, if a defendant is found to be suffering from

mental illness, then he/she should be offered treatment. In certain situations the defendant
may refuse treatment and even threaten self-harm if coerced. This gives rise to a conflict

166
between an individual‘s right to refuse treatment versus restorability of the fitness to
stand trial through forced treatment. Another hot debate in forensic psychiatry and among
the legal fraternity in western countries is the use of electro-convulsive therapy in
defendants. These issues need to be addressed.

Case Vignette
Mr. R, 55 years old, was accused of killing his neighbour over a property issue. He
was arrested and charges framed against him. During his stay in prison, he started
behaving abnormally, forgetting his barrack, passing urine in his clothes. He was
unable to remember his family member‘s name and had difficulty in remembering
day-to-day events.

He was referred for assessment to NIMHANS. He was admitted and a complete

evaluation was done. Blood investigations, Cerebrospinal fluid analysis and CT scan
of the brain were also done. He was diagnosed to be suffering Alzheimer‘s dementia
(early onset), and certified as unfit to stand trial.

Self-Incrimination: During the assessment of fitness to stand trial, defendants may admit
to certain actions either spontaneously or in response to the psychiatrist‘s question.
Documentation of such self-incriminatory evidence had led to debate in the US as to
whether a court can convict a defendant based on information in a competence
assessment. This became the subject of two U.S. Supreme Court cases (Estelle v. Smith
1981) and (Buchanan v. Kentucky 1987). In the earlier case (Estelle V. Smiths 1981), the
Supreme Court upheld the right against self-incriminatory evidence, because the
defendant did not initiate the psychiatric examination or attempt to introduce psychiatric
evidence at trial. However, in Buchanan V. Kentucky, the privilege against self-
incrimination was not violated, because the defendant had requested a psychological
evaluation and the evidence gathered during the procedure was used.

Confidentiality: Forensic psychiatrists usually get into a dilemma between the ‗respect
for the individual's right of privacy‘ and ‗duty to do forensic assessment of the defendant
and provide an accurate report to the court or the investigating agency‘. Psychiatrists
should maintain confidentiality to the extent possible, given the legal context. There is a
need to disclose the role of assessment and submission of report to the court. The

167
psychiatrist also needs to inform the defendant that the collateral sources of information
will be collected, such as, past history of treatment, past history of offences, family
history, personality history from his/her family members and so forth. Hence, limitations
of confidentiality need to be disclosed to the defendant. If the defendant raises an
objection regarding the confidentiality, then it should be brought to the notice of the court
and further directions need to be as per the court orders.

Fitness to stand trial is different from Insanity defence

It is important to note that the ‗insanity defense‘ is completely different from ‗fitness to
stand trial‘. Fitness to stand trial refers to current ability to understand and participate in
the adjudicating process. The ―insanity defense‖ refers to one‘s state of mind at the time
of the alleged crime (Sec 84 Indian Penal Code). In simple, words ‗insanity defense‘ is
concerned with the state of mind during the commission of crime and is considered static.
Whereas, fitness to stand trial is the assessment of the state of mind during the
adjudicating process and it is considered dynamic since it changes over a period of time.
Therefore, it needs to be assessed periodically in vulnerable populations such as people
with mental illness. Insanity defense is the retrospective assessment of the state of mind
during the crime but fitness to stand trial is a prospective assessment of the state of mind.

A person suffering with schizophrenia may commit a crime during his/her active phase of
illness. Immediately after initiating the treatment, his/her fitness to stand trial is restored
within a few weeks. In such a scenario, the primary concern will be the insanity defence-
the state of mind during commission of the crime. In another scenario, a normal person
may commit a crime and become mentally ill after incarceration or he/she may develop
illness during the adjudication of the case. This distinction is important because of the
popular sentiment that the insanity defence it as a way of "getting away with a crime",
and avoiding accountability and culpability for a criminal action. In fitness to stand trial,
ability to understand and participate in the trial process is assessed rather than the
defendant‘s condition or functioning at the time of the alleged offence. The distinction
sounds simple but mistakes are often made by both psychiatrists and lawyers.

INDIAN SCENARIO

A person with a mental disorder should be assumed to have mental capacity to decide on
various matters unless the contrary can be shown. In many instances, persons with mental

168
illness need to undergo a medical examination called ‗fitness to stand trial‘ as per the
Code of Criminal Procedure, 1973 Sec 328, and Sec 329. Section 328 of CrPC
(Procedure in case of the accused being lunatic) states that ‘when a Magistrate holding an
inquiry has reason to believe that the person against whom the inquiry is being held is of
unsound mind and consequently incapable of making his/her defense, the Magistrate shall
inquire into the fact of such unsoundness of mind, and shall cause such person to be
examined by the civil surgeon of the district or such other medical officer as the State
Government may direct, and thereupon shall examine such surgeon or other officer as a
witness and shall reduce the examination to writing‘. If a person is found incompetent to
stand trial, the trail is usually postponed until such time as the person is judged
competent. A person found psychiatrically incompetent for trial is usually sent for
treatment to regain competence (even against his/her will).

Need for a screening instrument

Considering the lack of forensic psychiatrists in countries like India, there is a need for
developing a simple screening instrument for assessment of fitness to stand trial by a
lawyer, medical professionals or a trained psychologist. Various instruments and
screening questionnaires have been devised to assist in the assessment of fitness to stand
trial of mentally ill patients with greater efficiency and accuracy (Pinals et al., 2006).
Some of the well-known instruments are MacArthur Competence Assessment Tool-
Criminal Adjudication (MacCAT-CA) (Poythress et al., 1999), Evaluation of
Competency to Stand Trial-Revised (ECST-R) (Rogers et al., 2004) and Competence
Assessment for Standing Trial for Defendants with Mental Retardation (CAST-MR)
(Everington and Luckasson, 1992). For more information readers are requested to read
the article by Rogers & Johansson-Love (2009). These instruments are intended only as a
tool to facilitate the assessment of fitness to stand trial, so that a mentally ill person need
not wait for a fitness assessment certificate from a qualified psychiatrist. On assessment
using such a screening instrument, if he/she is found fit, the trial will proceed. If he/she is
found unfit, the defendant needs to undergo detailed evaluation, mental status
examination and diagnosis by a psychiatrist before the defendant is declared unfit to stand
trial. Hence, certification of incompetence to stand trial can be done only by a qualified
psychiatrist after thorough examination and the reason for the same should also be
mentioned clearly in writing about the diagnosis and nature of interference in the
defendant‘s mental capacity to participate in legal proceedings.

169
A brief screening instrument would save time and money because the screening
procedure could be done within a couple of hours, without placing the individual in a
costly psychiatric institution. This will help to protect their human rights, right to fair and
speedy trial and also avoids unnecessary detention in psychiatric settings. Unfortunately,
there is no validated screening instrument available at this point of time for the Indian
population.

Methods of restoration of fitness to stand trial

A brief explanation may be necessary regarding the use of the words, ―restoration‖ of
fitness to stand trial. Restoration involves the following interventions:

 Use of medication or pharmacotherapy

 Psycho-social interventions and
 Legal counselling.

Treatment of the underlying condition (schizophrenia, depression) through medication

restores the fitness to stand trial. Psycho-social interventions include cognitive behavior
therapy in depressed patients, cognitive retraining in patients with cognitive deficits,
social skill training in schizophrenia, anger management techniques, counselling for drug
abuse, relaxation training and behavior therapy for anxiety disorders. Other interventions
include stress management and teaching coping skills, so that the defendant learns to
handle stress during the litigation and also cope with possible negative outcome/
judgment of the case.

Legal counselling involves educating the defendants in the trial process, including the
roles of the courtroom personnel, pleas, charges, sentencing, and how to assist the
attorney in planning the case. Further, it also involves expected behavior in the court of
law. Guest lectures, group discussions, discussing with survivors, workshops and meeting
with the court personnel, all help the defendant in gaining knowledge of various legal
procedures. Also helpful are question and answer sessions with legal experts. Role-play
by defendants acting as actors of various courtroom personnel in a scripted mock trial,
with discussions led by legal experts, videotapes of actual courtroom proceedings
watched by defendants, with discussions led by lawyers all help in restoration of the
fitness to stand trial (Mossman et al., 2007). There are various educational modules and
programmes that have been developed and used in the competence-restoration curriculum

170
(Noffsinger, 2001; Wall et al., 2003). Further, educating their rights and mechanisms to
restore them if they are violated plays a crucial role in developing a rights based
environment inside the correctional settings.

In conclusion, fitness to stand trial is a legal construct, which discusses the issues
regarding the defendant‘s mental capacity to participate in legal proceedings. Assessment
of fitness to stand trial assures the court that the defendant has adequate mental capacity
to make a defense. Psychiatrists should clearly describe the opinion regarding the fitness
to stand trial. If the opinion is of an ―unfit‖ state, it needs to be accompanied by details
regarding psychiatric diagnosis, the causes for defective reasoning and how it interferes
with the ability to participate in legal proceedings. Fitness to stand trial is an important
area in the context of Indian law, and is only evolving. It needs to be utilised judicially to
protect the rights of the mentally ill, without becoming a tool for misuse.

171
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 12. WOMEN IN PRISON

The fact that prisoners have higher rates of psychological distress and mental health
problems when compared to the general population are well established (Fazel and
Danesh, 2002). Needless to say, the rates are much higher in the case of women in
custody. Although women still constitute a small minority of the prison population across
the world, the number of incarcerated women is increasing (Slotboom et al., 2007). In
addition to the common kinds of distress both men and women experience in prison,
women are more vulnerable for gender discrimination, neglect, violence, physical and
sexual abuse. Studies have documented that relative to their male counterparts, women
incarcerated in state prisons are more likely to have mental disorders and a history of
physical and sexual abuse (Blitz et al., 2006; Brown et al., 1999; Hartwell, 2001). Despite
the magnitude of problems, little attention has been given to the unique health concerns
of women prisoners. Mental health care and attention to the psychological distress that
occurs because of imprisonment of women, is almost non-existent.

The relevance of gender issues

Women usually lead protected lives and are good home makers. They are not exposed to
the travails of the outside world. When they come in conflict with law and are
imprisoned, they find it very difficult to cope with the prison environment. Prison isolates
the women from their family and friends. They cannot perform their usual duties. This
causes sadness, guilt and puts tremendous stress on them. The physical and mental health
needs of women are different compared to men. Traditionally, most of the prison inmates
are males, and the prison environment is therefore shaped by the needs of males
(Slotboom et al., 2007) and do not cater to the special needs of women prisoners.

Women in prison have a double disadvantage. The gender disadvantage and

discrimination gets worsened during imprisonment, which is further amplified upon their
release from prison. Gender sensitive interventions need to take into account
psychological distress in a life stage perspective.

As women in prisons are frequently victims of physical and sexual abuse, United Nations
on Human Rights Rule 53 of the Standard Minimum Rules for the Treatment of Prisoners
states that women prisoners must only be guarded by female officers (United Nations,

175
1955). Male staff continue to have unchecked visual and physical access to women in
what constitutes their rehabilitation rooms, bedrooms, restrooms and living rooms in
many Indian prisons. At times, male staff does not hesitate to do frisk search on female
prisoners. There are instances when prison staff have endorsed and supported bullying
and verbal abuse of women prisoners, if they do not listen to them (Human Rights Watch
1996).

Figure 1: Women and discrimination

International Review

Women prisoners are found to suffer from a variety of health problems in the custodial
environment. A recent study on women prisoners in the UK reported that imprisonment
impacted their health negatively. The initial shock of imprisonment, separation from
families and enforced living with other women suffering drug withdrawal and serious
mental health problems affects their own mental health. Over the longer term, women
complained of detention in unhygienic facilities by regimes that operated to disempower

176
them, even in terms of management of their own health (Douglas et al., 2009). Women
described responses to imprisonment that were also health negating such as increased
smoking, eating poorly and seeking psychotropic medication. The study avers that there
is little evidence that the UK policy initiatives have been effective in addressing the
health needs of women prisoners (Douglas et al., 2009). According to the fact sheet of
Amnesty International on women in prison, women are denied essential medical
resources and treatments, especially during pregnancy.

There are studies which have reported high prevalence of syphilis among women
prisoners as compared to general population. HIV infection is also high (M.C.De
Azcarraga Urteaga et al., 2010). Women prisoners suffer menstrual disorders, stress, and
depression. The WHO guidelines on HIV infection and AIDS in prisons (World Health
Organization, 1993) contain the following recommendations specific to women in prison.

a) Special attention should be given to the needs of women in prison. Staff

dealing with detained women should be trained to deal with the psychosocial
and medical problems associated with HIV infection in women.

b) Women prisoners, including those who are HIV-infected, should receive

information and services specifically designed for their needs, including
information on the likelihood of HIV transmission, in particular from mother
to infant, or through sexual intercourse. Since women prisoners, either upon
release or during parole may be sexually active, they should be enabled to
protect themselves from HIV infection, e.g., through imparting skills in
negotiating for safe sex. Counselling on family planning should also be
available, if national legislation so provides. It is possible that the woman
discovers her pregnancy only after incarceration. For such women, there
should be no pressure placed to terminate their pregnancies. Women should
be able to care for their young children while in detention regardless of their
HIV status.

c) The following should be available in all prisons holding women:

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  Gynaecological consultations at regular intervals, with particular
attention paid to the diagnosis and treatment of sexually
transmitted diseases;

 Family planning and counselling services oriented to women’s

needs;

 Care during pregnancy in appropriate accommodation;

 Care for children, including those born to HIV-infected mothers;

and

 Condoms and other contraceptives during detention and prior to

parole periods or release.

There is also a need to focus on the preventive health care aspects for the women
prisoners, especially with respect to cervical cancer screening, breast cancer, HIV testing
and hepatitis (Nijhawan et al., 2010). Opportunities need to be provided for sex
education, smoking cessation and drug de-addiction programmes (Jolley and Kerbs,
2010). US based studies have reported that access to substance abuse treatment for
women is necessary because at least half the women in state prisons were under the
influence of illicit drugs/alcohol at the time of their offence and most women are in prison
on drug-related convictions (Greenfeld and Snell, 2000).

Women have a considerably greater risk of contracting HIV and Hepatitis C from sexual
activity than men. Women who engage in injecting drug use have a particularly high risk
through sharing syringes and needles. They might have had unprotected sex with their
drug partners or have been engaged in sex work. Women’s cultural and societal
conditions might be such that they are not in a position to control their own sexual lives
(Bastick and Townhead 2008; Reyes, 2000; UNODC, 2009; World Health Organization,
1993). Women prisoners have important mental health and drug treatment needs. Studies
have shown that the beneficial effects of treatment components oriented toward women’s
health needs in prison sustain even after 12 months after release (Nena et al., 2010). The
majority of offences for which women are imprisoned are non-violent such as property,
dowry-harassment, drug-related offences, prostitution, bar dancing and so forth (Kumari,
2009; UNODC, 2009). Many women serve a short sentence, which means that the
turnover rate is high.

178
Figure 2: Spectrum of gender specific health care required in prisons

Specific mental health problems among women in prison: International perspective

Mental health problems among women in prisons all over the world are very high. These
include both mental disorders and a high level of drug or alcohol dependence. Women in
prisons frequently come from deprived backgrounds, and many have experienced
physical and sexual abuse, alcohol and drug dependence and inadequate health care
before imprisonment (Messina et al., 2006; Reyes, 2000). Further, women entering
prisons are more likely than men to have poor mental health, often associated with
experiencing domestic violence and physical and sexual abuse (Reyes, 2000; UNODC,
2009).

Research indicates that women in prisons have mental health problems to a much higher
degree than both the general population and male prisoners (Bastick and Townhead,
2008). A systematic review of the literature on prevalence of post-traumatic stress
disorder (PTSD) in prisoners reported that PTSD rates ranged from 4% of the sample to

179
21%. Women were disproportionately affected (Goff et al., 2007). A study conducted by
the Bureau of Justice Statistics of the United States, showed that 73% of the women in
state prisons and 75% in local prisons in the United States have symptoms of mental
disorders compared to 12% of women in the general population (Covington, 2007). In
England and Wales, it was noted that 90% of the women prisoners have a diagnosable
mental disorder, substance use or both (Møller et al., 2007). Nine out of ten had at least
one of the following: neurosis, psychosis, personality disorder, PTSD, self harm, alcohol
abuse and drug dependence. Prevalence rate of current serious mental illness for male
inmates was 14.5% and for female inmates it was 31.0% (Steadman et al., 2009). Women
were 14 times more likely to harm themselves than men and also repeat such self harm
(Møller et al., 2007).

Recognising that the public health importance of prison health is neglected, the World
Health Organization (WHO) Regional Office for Europe established the Health in Prisons
Project (HIPP) in 1995 (World Health Organisation, 1995). This continuously expanding
network of 38 Member States in Europe is committed to reducing the public health
hazards associated with prisons along with protecting and promoting health in prisons.
Published reports of the HIPP during recent years, including the widely used WHO guide
to the essentials in prison health in 2007 (Møller et al., 2007) and the Trencin Statement
on Prisons and Mental Health in 2008 (World Health Organization, 2008), have
combined the latest research and analysis from experts throughout the world and have
clearly raised the profile of prison health issues.

NATIONAL SCENARIO

In spite of several legislations and committees, the condition of jails is deplorable.

Though the hard fact is known to the administration, nothing is done to address these
issues. A prison officer listed the various issues relating to women inmates which are: (i)
Admission (ii) Classification (iii) Reformation Programme (iv) Vocational Training (v)
Health and Hygiene (vi) Psychological or emotional issues (vii) Visitors and emergency
leave (viii) Rehabilitation on release (ix) Resocialisation and acceptance. Women
prisoners on admission are in a mentally disturbed condition. He has also highlighted the
fact that nearly 60% of inmates suffer from various issues of mental health like psychosis,
major depression and personality disorder (Nataraj, 2009).

180
Imprisonment of a mother with dependent child/children is a problematic issue and it
needs to be addressed immediately (Pandy and Singh, 2006). The effects of incarceration
can be particularly catastrophic on the children and costly to the state in terms of
providing for their care, and because of the social problems arising from early separation
(Pandit Govind Ballabh Pant Institute of Studies in Rural Development, 2004).

The shocking survey on children of women prisoners, conducted by the National Institute
of Criminology and Forensic Sciences, Delhi, during 1997-2000, documents the
conditions of deprivation and criminality in which they are forced to grow up, lack of
proper nutrition, inadequate medical care, and little opportunity for education. Indian
Council of Legal Aid and Advice also filed public interest litigation in the Supreme
Court, asking that state governments to formulate proper guidelines for the protection and
welfare of children of women prisoners (Upadhyay v. State of A.P., 2006). The jail
authorities said that they were doing what they could within their limited resources to
give children the best possible facilities.

The majority of women offenders convicted for homicidal activities were poorly adjusted
to the family settings. In many cases, their offence directly stemmed from their husband
and in-law’s cruelty, rejection and humiliation. Husband’s illicit affairs with other
women, alcohol and substance use, domestic violence contributed significantly in
motivating married women to resort to crimes (Saxena, 1994).

In another study by Kumari (2009), women prisoners perceived that they would face
problems in all spheres of life in future because of their imprisonment. They were also
worried about economic and family problems. There is hope about the redemption of the
prisoners through counseling and rehabilitation. A study supported by the National
Commission for women evaluated mental health problems among women in the Central
Prison, Bangalore (Murthy et al., 1998). Among both women undertrials and convicts,
common emotional responses were unhappiness, feelings of worthlessness, worry, and
somatic symptoms. All these were aggravated during crises points in prison (entry into
prison, court hearing, around the time of pronouncement of judgment, victimization,
release of a fellow prisoner, death of a fellow prisoner, illness or death of a family
member and imminent release).

Protection and promotion of women prisoners’ health requires multidimensional

approach starting from political will, empowerment policy, police and prison reforms,

181
therapeutic approach of rehabilitation and social reforms (Kumari, 2009; Maniyar, 2004;
Mishra, 2002).

Judicial Contribution

Unfortunately, the largest democratic country in the world has a ‘very poor political will’
to improve the conditions of the women prisoners and children of the prisoners. Laudable
and commendable work regarding women prisoners has been initiated by the Indian
judiciary. In response to a public interest litigation, the Supreme Court has formulated
guidelines regarding pregnancy, antenatal, child-birth and post-natal care and child care
(Upadhyay v. State of A.P., 2006). The Apex court has clearly stated the following:

Regarding Gynaecological examination

a. Gynaecological examination of female prisoners shall be performed in the

District Government Hospital. Proper pre-natal and post-natal care shall be
provided to the prisoner as per medical advice.

Regarding Pregnancy

a. Before sending a woman who is pregnant to a jail, the concerned authorities

must ensure that the jail in question has the basic minimum facilities for child
delivery as well as for providing prenatal and post-natal care for both the
mother and the child.

b. When a woman prisoner is found or suspected to be pregnant at the time of

her admission or at any time thereafter, the lady Medical Officer shall report
the fact to the superintendent. As soon as possible, arrangement shall be
made to get such prisoner medically examined at the female wing of the
District Government Hospital for ascertaining the state of her health,
pregnancy, duration of pregnancy, probable date of delivery and so on. After
ascertaining the necessary particulars, a report shall be sent to the Inspector
General of Prisons, stating the date of admission, term of sentence, date of
release, duration of pregnancy, possible date of delivery and so on.

182
 Regarding Child birth in prison

a. As far as possible and provided she has a suitable option, arrangements for
temporary release/parole (or suspended sentence in case of minor and casual
offender) should be made to enable an expectant prisoner to have her
delivery outside the prison. Only exceptional cases constituting high security
risk or cases of equivalent grave descriptions can be denied this facility.
b. Births in prison, when they occur, shall be registered in the local birth
registration office. But the fact that the child has been born in the prison shall
not be recorded in the certificate of birth that is issued. Only the address of
the locality shall be mentioned.
c. As far as circumstances permit, all facilities for the naming rites of children
born in prison shall be extended.

Regarding child care

a. Female prisoners shall be allowed to keep their children with them in jail till
they attain the age of six years
b. After six years, the child shall be handed over to a suitable surrogate as per
the wishes of the female prisoner.
c. Expenses of food, clothing, medical care and shelter shall be borne by the
respective state.
d. There shall be a crèche and a nursery attached to the prison for women
where the children of women prisoners will be looked after. Children below
three years of age shall be allowed in the crèche and those between three and
six years shall be looked after in the nursery. The prison authorities shall
preferably run the said crèche and nursery outside the prison premises.
e. A dietary scale prepared by the National Institute of Nutrition, Council of
Medical Research, Hyderabad , for a balanced diet for infants and children
up to the age of six.
f. Jail manual and/or other relevant rules, regulations, instructions etc. shall be
suitably amended within three months so as to comply with the above
directions.

The Apex court clearly highlighted the need to uphold the fundamental rights. It
articulated the provisions under Article 15(3)-special provisions for women and children,

183
Article 21-Right to life and liberty, and Article 21A-free and compulsory education to all
children from the ages of six to 14 years.

Table 1: Women and child care in prisons

The directive principles of state policy articulated in the judgement (Upadhyay v.

State of A.P., 2006)

Article 39(f) - State to ensure that children are given opportunities and facilities to
develop in a healthy manner and in conditions of freedom and dignity,
and that childhood and youth are protected against exploitation and
moral and material abandonment.

Article 42 - Provisions for just and humane conditions of work, and maternity beliefs.

Article 45 – Provision for free and compulsory education for children up to the age of
14.

Article 47- Duty of the State to raise the level of nutrition and the standard of living
and to improve public health.

Source: (Directive Principles of State Policy)

Available online at http://indiacode.nic.in/coiweb/coifiles/p04.htm

In this landmark judgment by the Supreme court, the directive principles of state policy
(as shown in the table), were brought under the ‘legal obligation’ of the state to provide
protection, prevention and promotion of human rights and health care of marginalised
imprisoned women and children.

Specific mental health problems and needs

There are hardly any systematic studies regarding the mental health problems of women
in prison. A study conducted by Murthy and her colleagues in 1988 is the first of its kind
in India (Murthy et al., 1998). Collaborators of the study were the National Institute of
Mental Health and Neuro Science (NIMHANS), Bangalore and the National Commission
for Women (NCW), New Delhi. The objective of the study was to organise training and

184
awareness programmes for prison staff and also to bring out literature relevant to the care
of women in custody. Unhappiness was the most common psychological reaction to
imprisonment among women prisoners.
Table 2: Common psychological reactions seen in undertrials

Feelings of Percent
Unhappiness 73
Feeling of worthlessness 69
Frequent worrying 65
Poor sleep and appetite 65
Headache 56
Tiredness 52
Inability to work 52
Fearfulness 46
Thoughts of ending life 44
Source: Murthy et al., 1998

During the study, it was noted that most women are financially dependent and are not in a
position to plan, or get help, for example, to arrange for bail. It is also difficult for them
to reintegrate into society after release. In addition to the stigma of having been in prison,
women face a multitude of other problems. For example, the spouse might have
remarried and may reject her, her in-laws or parents may not be willing to keep her in
their home, her children may have grown up and may not need her, or she may feel too
humiliated to return to her place of origin. All these can come in the way of her
successful rehabilitation and reintegration into society (Murthy et al., 1998).

The study also reported that women were unable to defend themselves, and ignorant of
the ways and means of securing legal aid. They were unaware of the rules of remission or
premature release, and live a life of resignation at the mercy of officials who seldom
understand their problems. Women prisoners need to be psychologically and emotionally
supported in crisis situations such as separation from family, legal problems, during the
verdict, violence in the prison, release of a fellow prisoner, death of a fellow prisoner and
illness/death in a family member. Another important issue which needs to be kept in the
mind of policy makers is that women need to be empowered through vocational
rehabilitation and provided information on various organizations that they can approach

185
for further support so that post-release they can earn their livelihood without being
dependent on others.

Figure 3: Psychosocial care for women in prisons

Source: Murthy et al., 1998

Bangalore Prison Mental Health Study Findings

Mental health problems and substance use among women as well as their needs in prison
were assessed as part of the Bangalore Prison Mental Health Study (Math et al., 2011). At
the time of conducting the study, there were 210 women prisoners (4%) of whom 197
were interviewed for the study. Table 3 depicts that most of the women in prison were
housewives, unskilled and semi-skilled workers. The mean educational status in years is

186
3.9 years and 49.7% were illiterate. Both these factors have strong bearings in vocational
rehabilitation and integration into the community.

Table 3: Socio-demographic characteristics of women evaluated in the Bangalore

Prison Study

Variable N %

Legal status Undertrials 123 62.4

Convicts 74 37.6
Marital Single 15 7.6
status Married 160 81.2
Widowed 16 8.1
Divorced 6 3.0
Domicile Urban 93 47.2
Village 20 10.2
Semi-urban 84 42.6
Occupation Housewife 43 22.3
Unskilled work 25 13.0
Semiskilled work 54 28.0
Skilled work 14 7.3
Business 12 6.2
Agriculture 28 14.5
Others 17 8.7
Mean SD
Age 37.5 14.4
Years of education 3.9 4.7
Duration of stay in prison 20.3 21.3
months(SD)
Source: Math et al., 2011

Regarding the nutritional status of women in prison, one in four was underweight, but a
greater number were overweight or obese (26.3%) compared to males (10.9%).

187
Nearly one third of women could be diagnosed as having a mental health or substance use
problem. About one in four women had a diagnosis of either a current or past major
depressive episode. A very small number had a diagnosis of deliberate self harm or
suicidal attempt.

Table 4: Prevalence of diagnosable mental disorders among women in the Bangalore

Prison study

Mental Disorders N %

Major Depressive Episode (current) 33 16.7

Major Depressive Episode (past) 18 9.6
Dysthymia 5 2.5
Deliberate self harm 3 1.5
Lifetime suicidal attempt 4 2.0
Panic disorder (current) 1 0.5
Social Phobia 3 1.5
Specific Phobia 9 4.6
Source: Math et al., 2011
Tobacco and alcohol use

More than one in ten women reported chewing tobacco use in their lifetime and 5%
reported smoking. As in the general population, prevalence of smoking is much higher
among males than females. However, in comparison to smoking tobacco use among
women in Karnataka, the prevalence is higher among women prisoners. Smokeless
tobacco prevalence among women in prison is also higher than among women in
Karnataka. Six women (3%) reported ever use of alcohol. This is lower than the
prevalence of alcohol use among women in Karnataka, which has been estimated at 5.8%
(Benegal et al., 2005).

Urine drug screening among women in the Bangalore Prison study

Sixty women were randomly screened for urine drugs in an anonymous manner. In total,
18 women (30%) tested positive for one or more drugs. Thirteen samples (21.7%) tested
positive for benzodiazepines, 3 (5%) for cocaine, 2 (3.3%) for opioids and amphetamines

188
respectively and one (1.7%) for cannabis. One person each tested positive for two drugs
and three drugs respectively.

Table 5: Urine drug screening in the Bangalore Prison study

Sl. Drug use FEMALE MALE X2 P

no n=60 n=661
1 Cannabis 1 (1.7%) 221 (33.4%) 26.050 0000
2 Opioids 2 (3.3%) 22 (3.3%) 0.000 1.000
3 Cocaine 3 (5%) 107 (16.2%) 5.325 0.023
4 Barbiturates 0 (0%) 65 (9.8%) 6.485 0.004
5 Benzodiazepines 13 (21.7%) 297 (44.9%) 12.148 0.001
6 Amphetamines 2 (3.3%) 42 (6.4%) 0.876 0.570
Source: Math et al., 2011

In summary, the Bangalore Prison Mental Health Study (Math et al., 2011) found that
nearly a third of women prisoners had a diagnosable mental disorder. Depressive disorder
was relatively more common. Lifetime smokeless tobacco use among the women in
prison was higher than that reported in the general community. Though there was a
negligible self-report of drug use, nearly one in 3 women tested positive on urine screen
for one or more drugs. This study highlights the need for gender specific mental health
interventions for women in prison.

Recommendations

The main goal of imprisonment must be rehabilitation and reformation instead of

punishment. There is a need to enable prisoners to lead useful and law-abiding lives on
their return to the community. Keeping such a focus, the negative effects of imprisonment
should be minimised; mental health should be maintained and promoted. Women
prisoners must feel safe, be treated with respect and dignity and need to be assisted
towards developing insight into their offending behavior. The Supreme Court directions
need to be implemented regarding women prisoners’ requiring assistance in pregnancy,
ante-natal, natal and post-natal care. Children of the women prisoners must be provided
care as per the guidelines.

Any intervention must start with the prisoner, the moment she enters the prison.

189
Privacy and dignity: Women prisoners’ privacy and dignity must receive the topmost
priority.

Female staff: There must be a female doctor inside the prison as well as female guards in
charge of the female prison premises.

Health check-up: Women prisoners must be routinely screened for physical and mental
health problems and provided treatment at the earliest.

Peer support group: Self-help groups among women prisoners can be of great help
during stressful situations – Entry into prison, during bail, preparation for court
appearances, unpleasant events at home like death of a family member, before, during
and after judgement.

Mental health and counselling: Considering the mental health morbidity in women
prisoners, mental health services and counselling needs to be provided. Effective
planning for mental health care after release is vital, particularly for women with severe
mental illness.

De-addiction facility: De-addiction facility should be made available to women with

substance use problems.

Family counselling: Involvement of family members in counselling is an essential

component to good health of women prisoners.

Vocational Rehabilitation: Adequate opportunities must be provided to work and keep

them busy. Adequate planning for livelihood after release, particularly for women
without family support is extremely important.

Behavioural rehabilitation: High-risk behaviors such as aggression, violence, self-

injurious behavior, impulsivity, sexual behavior and substance use need to be addressed
with appropriate techniques.

Suicide prevention strategies: Frequent meetings with prisoners will help in prompt
identification of their problems, generation of solutions and reduction in distress. Prison

190
staff requires training on how to identify mentally illness and use crisis intervention
techniques.

Adequate planning before release, safeguards against prison re-entry, halfway home
support systems for women without family support, and treatment continuation after
release are critical components of effective treatment. Life skills training and encouraging
further education in prison and health education also play a crucial role in empowering
women and preventing recidivism and poor mental health outcomes. The circumstance of
being within four walls of a prison is upsetting enough. It is important that mental health
of women prisoners is preserved and enhanced, so that the prison experience will not scar
their lives.

191
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Marriott Marquis, Atlanta, Georgia
Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S. Prevalence of serious mental
illness among jail inmates. Psychiatr Serv. 2009;60:761-765
United Nations 1955. Standard Minimum Rules for the Treatment of Prisoners. Adopted
by the First United Nations Congress on the Prevention of Crime and the
Treatment of Offenders, held at Geneva in 1955, and approved by the Economic
and Social Council by its resolutions 663 C (XXIV) of 31 July 1957 and 2076
(LXII) of 13 May 1977
UNODC 2009. Women’s health in prison; correcting gender inequity in prison health.
Pub: World Health Organisation. (Kyiv Declaration on Women’s Health in
Prison) Available online at http://www.unodc.org/documents/commissions/CND-
Session51/Declaration_Kyiv_Women_60s_health_in_Prison.pdf Accessed on 12
Dec 2010
Upadhyay RD v. State of AP & Ors. Writ Petition (civil) 559 of 1994 date of judgement
13 April 2006
Urteaga MCDe A, Rodrigues AG, Ayala JA, Allain NG, Bautista S 2010. Women in
prison settings: the need of a sexual and reproductive approach for HIV and other
STIs prevention and attention: Poster at XVIII International AIDS conference
World Health Organisation 1995. Health in Prisons Project (HIPP) Available online at
http://www.euro.who.int/en/what-we-do/health-topics/health-
determinants/prisons-and-health/who-health-in-prisons-project-hipp accessed on
12 Dec 2010.
World Health Organization 1993. WHO guidelines on HIV infection and AIDS in
prisons. Geneva
World Health Organization 2008. Trencin statement on prisons and mental health.
Copenhagen: World Health Organization Regional Office for Europe, Availble
online at http://www.euro.who.int/__data/assets/pdf_file/0006/99006/E91402.pdf
accessed on 12 Dec 2010

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 13. MENTAL HEALTH NEEDS OF PRISON STAFF

One of the key determinants of the performance of any organisation is its staff. In the
case of a correctional facility, the challenges faced by the staff are very unique. They
include a closed coercive work environment, the need to deal with violence and perform
arduous tasks, an occupation dependent on the maintenance of security and order inside
prisons, as well as more general constraints affecting, in particular, the organisation of
work, such as certain work schedules, and relationships within the prison hierarchy
(Goldberg et al., 1996). Though there is a significant body of research on the impact of
the work environment on correctional staff, there are only a few attempts that have been
made to address such issues. Burnout is a common problem among correctional staff
(Schaufeli and Peeters, 2000). Burnout can be devastating not only for the staff member
but also for the co-workers, inmates, rehabilitation programmes and the correctional
organisation itself. This chapter provides insights into the prison staff – the roles they
play, their work environment, the stressors that are around them and what can be done to
reduce such stress.

Defining the role of prison staff

The role of the prison staff is to (i) Maintain secure custody, in a context where people
are held in confinement against their will; (ii) Provide care for the prisoners with
humanity; (iii) Provide prisoners with opportunities to unlearn and correct their offending
behaviour; and (iv) Assist with day-to-day management in the complex organisational
environment of the prison" (Liebling, 2000; Price and Liebling, 1998).

In addition to the above roles, prison staff also needs to:

1. Protect, promote and endorse human rights of the prisoners

2. Take care of the needs of the prisoners to the extent feasible within the prison
environment
3. Identify patients who have health problems and get them the needed health care
4. Pay special attention to the vulnerable sections of the prison population, such as
women, children, mentally ill and disabled by ensuring that medical treatment
and counselling is made available to them.

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These additional roles are endorsed by Andrew Coyle, who in his article on ―A human
rights approach to prison management‖ emphasises the correctional aspect of the prison
inmates (Coyle, 2002). The prison is not just a place of confinement. It needs to focus on
behavioural corrections of the prisoners thereby veering them away from the path of
crime and enable them to become good citizens after their release. However prison
officers are rarely cognisant of this role. ‘Role Conflict’ of the correctional officers arises
when they have to engage in custodial responsibilities (maintaining security, such as
preventing escapes and inmate fights) as well as engage in prisoners‘ treatment functions
(helping in rehabilitation of prisoners). ‘Role ambiguity’ may be created by supervisors
who expect officers to ―go by the rules‖ and at the same time insist that officers must be
flexible and use judgement in their interactions with inmates. Such role conflict and
ambiguity arises in the prison environment because of dichotomous perception of their
role as custodial versus curative, punishment versus rehabilitative, administrative versus
treatment, segregation versus inclusion and human rights versus duties. In addition,
legislations, judiciary case rulings, human rights laws and department rules. The strict
hierarchy inside the organisation and security issues inside and outside the prison further
complicates the issue.

International Scenario

Prisons as organisations are charged with managing a complex offender population. Staff
must successfully accomplish this mission without fanfare or scandal. Obviously, prisons
are twenty-four hour operations and staff must constantly tend to the needs, concerns,
and issues of the offender population. Staff must be sensitive to the lighting, caloric
intake of inmates, food temperature, recreational needs, cell size and population density,
racial and ethnic composition of offender living areas and cells, disciplinary
requirements and personal security, health care, mail and correspondence needs, hygiene
needs, and a host of other issues on a daily and hourly basis. Their job is complex,
dangerous, stressful and it is a thankless task (Marquart, 2005). Therefore, the
relationship and interactions between staff and inmates play a crucial role on safety,
security, control and providing a rehabilitative environment (Gilbert, 1997). Staff
responses to stress include high turnover, absenteeism, psychosomatic diseases, high
levels of job dissatisfaction and burnout (Schaufeli and Peeters, 2000).

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Figure 1: Sources of stress for prison staff

The performance of prison staff is of paramount importance in the prison system. Their
approach can determine whether the experience of imprisonment is a survivable or
destructive one. The prison staff play a mediation role in addressing the needs of
prisoners, provide access to the required goods and services, help in establishing contacts
with the prisoners‘ friends and family (Mathiesen, 1965) Similar observations indicate
that the prison staff stand between humane and brutal imprisonment from a
psychological perspective (Bottoms and Rose, 1995).

A study that was done in the UK revealed that lack of training for the prison staff
contributed significantly to the development of stress and in reducing confidence in
dealing with the many traumatic situations encountered (Holmes and Maclnnes, 2003).
However, interpersonal relationships provided mutual support during crises. General
working conditions, including workload and staff redeployment, were also important
contributors to high levels of sickness-absence which, in turn, exacerbated stress. Poor

197
management practices, combined with a perceived lack of support, further aggravated
stress (Holmes and Maclnnes, 2003).

The literature indicates that working in correctional settings is a hard and often stressful
occupation (Armstrong and Griffin, 2004). The stress on correctional staff is harmful
over time, can increase medical problems; can promote substance abuse, cause divorce,
suicide, and death (Cheek and Miller, 1983). Staff attributed their problems to
administrative malfunctions which place them in a classic double-bind predicament in
relation to rule enforcement (Woodruff, 1993). The job-related stressors may include
inmate defiance, maintenance of discipline, compliance with prisoners' rights,
overcrowded conditions, and the confining nature of the jail or prison environment.
Stressors associated with organisational structure and administration include lack of
participation in decision making, lack of positive recognition, lack of administrative
support, role conflict and ambiguity, and supervisory behaviours (Woodruff, 1993).

Burnout in prison staff can have a direct effect on providing care for the prisoners. It also
affects the co-workers, prisoners and also the organisation. Impact of stress ranges from
adverse health conditions to economic consequences. Direct impact of stress on health
leads to absenteeism, which has a direct economic repercussion on the organisation.
Further, staff may attempt and at times commit suicide because of the overwhelming
stress.

Job related stress, quality of supervision, job variety, and job autonomy have been
theorised to affect the job satisfaction and organisational commitment of correctional
staff members. All four job characteristics had a significant impact on correctional staff
members‘ job satisfaction and organisational commitment (Lambert, 2004). Further, job
stress has been linked to decreased job satisfaction and absenteeism among correctional
staff (Slate and Risdon, 1997).

A meta-analysis of twenty studies on the predictors of job stress in correctional officers

revealed that work attitudes (i.e., participation in decision-making, job satisfaction,
commitment, and turnover intention) and specific correctional officer problems (i.e.,
perceived dangerousness and role difficulties) generated the strongest predictive
relationships with job stress. Furthermore, both favourable (i.e., human service/
rehabilitation orientation and counselling) and unfavourable (i.e., punitiveness, custody

198
orientation, social distance, and corruption) correctional officer attitudes yielded
moderately positive relationships with job stress (Dowden and Tellier, 2004). Role
conflict, role ambiguity, role overload, perceived dangerousness of the job, work-family
conflict, and role strain have all been found to lead to increased job stress (Lambert &
Hogan, 2009).

Figure 2: Impact of stress on prison staff

Research has also indicated that favouritism, decision making without a rational basis,
lack of empowerment for staff, lack of trust in supervisors, lack of task control, and low

199
administrative and supervisory support lead to increased job stress (Dowden and Tellier,
2004; Slate and Risdon, 1997).

In addition to the other stressors, World Health Organization (WHO) fact sheet refers to
mental disorders of inmates as stress for the staff and underscores the need for mental
health care. Good mental health care is one of the central aspects of good prison
management.

Benefits of addressing prison staff job stress

a) Saves money and time because of absenteeism

b) Decreases substance use in prison staff
c) Decreases the probability of having illnesses
d) Decreases depression and suicide in staff
e) Improves their work performance and subsequently output
f) Facilitates protection of human rights of the prisoners
g) Leads to pro-active involvement of the staff in rehabilitation
programmes
h) Improves their family life
i) Enhances quality of life

World Health Organization (WHO) advocates for training on mental health for prison
staff at all levels. It states that such training increases awareness of the mental disorders,
makes the staff adhere to human rights, reduces suicidal attempts by inmates, and helps
the prison staff to get over stigmatising attitudes. This will be a catalyst for improved
mental health of both, staff and inmates (Møller et al., 2007; World Health Organisation,
1998).

Indian Scenario

The fact sheet (table no-1) on prisons in India clearly demonstrates that the prison
population rate is 33 per 100,000, which is much lower than in many other countries in
the world. However, there is an increasing trend and in addition, the prisons are also
overcrowded by more than 132%. Such overcrowding adds to the stress levels of the
prison staff. Despite worrying statistics and call for reforms, adequate funds are not

200
provided for the prison administration. Lack of resources contributes significantly to
prison staff stress.

Table 1: Prison population of India

Ministry responsible Ministry of Home Affairs

Prison population total 385023 (30 June 2008)
(including pre-trial detainees / remand
prisoners)
Prison population rate 33 (30 June 2008)
(per 100,000 of national population)
Pre-trial detainees / remand prisoners 263108 (68%) 30 June 2008
(percentage of prison population)
Female prisoners 16145 (4.2%) 30 June 2008
(percentage of prison population)
Juveniles / minors / young prisoners 0.1% (31.12.2007 - under 18)
incl. definition (percentage of prison
population)
Number of establishments / Institutions 1,347
Official capacity of prison system 277,304 (31.12.2007)
Occupancy level (based on official 132% (30 June 2008 )
capacity)
Recent prison population trend Year Total Prison population
Population rate
1999 281,380 28
2001 313,635 30
2003 326,519 30
2005 358,368 32
2007 371147 32
2008 385023 33
Source: National Human Rights Commission, 2008; Walmsey R, 2008

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Problems faced by Prison staff

Central to the prison administration is the problem of demoralisation and lack of

motivation of the prison staff. The prison officers today are working in very hostile and
highly adverse conditions. Almost all the prisons are understaffed and residential
quarters are devoid of any security. Even senior prison officers are not provided with
fire arms for self-defense. There is no guarantee for their life either inside the prison or
outside the prison. Prison staff is the most neglected personnel and the least important in
the government sector. No steps are taken by the government to ensure their safety and
security (Reddy, 2010).

While governments and non-governmental agencies plan and implement several

programmes for prisoners, institutional training for them and for their rehabilitation, no
efforts is made to redress the problems being faced by the prison staff (Reddy, 2010). The
unhealthy work environment discourages initiative, and leadership qualities of the prison
staff. This indifference among the prison staff could get translated into aggression on
prisoners.

Findings of the Prison Mental Health Study, Bangalore

The Bangalore Central Prison exemplifies some of the major inadequacies in Indian
prisons (Math et al., 2011). It is overcrowded by 150% and this has caused problems in
health care, monitoring, and resulted in enormous stress for the staff. More suicides are
reported, violence and rampant substance use is on the rise, suicidal ideation has been
observed in some of the prison staff and there were two recent staff suicides (both died of
hanging, one of them was a senior official of the prison) and one more death is suspected
to be a case of suicide. The prison staff is overworked and the level of motivation has
been inadequate. There are incidents of supervisory abuse and staffs do not find rewards
and recognitions that are commensurate with their performance.

Prisoners tend to group together and threaten staff, including the doctors. The prisoners
sometime make unfounded allegations to Human Rights organisations and to courts. This
has caused considerable stress for the staff and has added to their reduced motivation.
The job is not just viewed as thankless – it is also seen as hazardous and risky.

202
Lack of proper security is another worry for the prison staff at Bangalore. The lady staff
has to further bear disinhibited behaviour of the male prisoners. The staff are also
threatened with violence and revenge if they do not comply with the ‗special‘ needs of
prisoners (like demands for fake certificates when they want to avoid court proceedings,
demand for admission in the prison hospital without any ailment, and refusing discharge
despite recovery). There are frequent cases of malingering of ailments, manipulative
behaviour, and abuse of prison staff. Lack of adequate numbers of prison staff has also
compounded the problems. Prison environment has increased stress levels of the staff
and little has been done to improve the situation. Training on mental health has been
inadequate and some of the staff themselves stigmatise mentally ill prisoners. There is
only one psychiatrist for the whole prison and clearly there is a need to provide more
supporting staff, train the staff on mental health related issues along the lines of WHO
recommendations.

Due to the perceived risk and dangerousness of the prison environment, many of them
present with depressive episodes, somatoform disorders and substance use, abuse and
dependence. During personal interviews with the prison staff of the Central Prison,
Bangalore, they expressed that they were not happy working in this environment at all.
They also said that ‗All the authorities are concerned with the prisoner’s wellbeing and
nobody is there to care for us’.

Prison staff spends very less quality time with their families. Their spouses, many of
them homemakers also suffer from mental health problems. The accompanying tables
give details of the Bangalore Prison study and reflect staff attitudes towards their work,
environment, and stress. The plights of smaller prisons are even worse. In such prisons,
there is no proper health care. Awareness levels of staff in such places are very low and it
is a distressing situation for both inmates and for officers.

In the Bangalore Central Prison study (Math et al., 2011), data was collected from 201
staff out of 207. Out of the 201 staff, 191 were male (92.3%) and about 16 of them were
female (7.7%). Of the 201 staff for whom available data on education was, 12(5.8%)
were postgraduates, 79(38.2%) had undergraduate degrees, 63 (30.4%) had pre-
university education, 46 (22.2%) were high school educated and 1 (0.5%) staff had
primary education.

203
General Medical Conditions among the prison staff

5 of 207 had heart related problems and about 17 reported blood pressure problems. Two
staff had chest related ailments and 16 had diabetes. One staff had epilepsy. A large
number of inmates had digestive disorders (20%). None self-reported mental illness.

Table 2: Self-reported general medical problems among the prison staff

Sl No Presence of general medical problems (Self-reported) n(%)

1 Physical disability 0
2 Heart problem 5(2)
3 Blood pressure 17(8)
4 Chest disease 2(1)
5 Diabetes 16(8)
6 Mental illness 0
7 Epilepsy 1(0.5)
8 Digestive problems 41(20)
9 Back pain 21(10)
10 Rheumatic problem 22(11)
11 Eye problems 23(11)
12 Skin disease 18(9)
13 Dental 18(9)
Source: Math et al., 2011

21 staff reported back problems and 22 complained of rheumatic problems. One staff had
shoulder, arm, and wrist/hand problems. 23 had eye related problems. 18 staff had skin
problems and a similar number had dental problems. Only one staff reported taking
regular medicine. This clearly indicates that many staff were living with their problems
and did not go for proper treatment.

Mental Health Problems in prison staff

Structured assessment of the staff on MINI instrument revealed the following mental

204
disorders in staff. Many of the illnesses noted appeared secondary to the work
atmosphere and stressful job situation.

Table 3: Mental disorders among staff

Sl No Presence of mental disorders n(%)

1 Depression current 10(5)

2 Depression past 12(6)
3 Depression lifetime 22(11)
4 Substance induced mood disorder 7(3)
5 Suicide (low risk) 1(0.5)
6 Deliberate self-harm 1(0.5)
7 Panic disorder current 2(1)
8 Agoraphobia current 1(0.5)
9 Agoraphobia lifetime 1(0.5)
10 Social phobia current 9(4)
11 Social phobia generalized 2(1)
12 Specific phobia current 3(1)
13 Post-traumatic stress disorder current 1(0.5)
14 Alcohol dependence current 23(11)
15 Alcohol abuse current 3(1)
16 Alcohol dependence lifetime 29(14)
17 Alcohol abuse lifetime 3(1)
18 Tobacco dependence lifetime (smoking) 7(3)
19 Tobacco dependence lifetime (smokeless) (2)
19 Generalized anxiety disorder 5(2)
20 Pain disorder 2(1)
21 Conduct disorder 1(0.5)
22 Anti-social personality disorder 1(0.5)
Source: Math et al., 2011
On summarizing the findings;
 About 5% of the staff were suffering from depression at the time of this study.
 6% of the staff had past history of depression

205
 11% of the staff had lifetime major depressive episodes and this calls for proper
psychiatric intervention.
 One of the staff presented with deliberate self-harm
 There were 2 staff who presented with panic disorder at the time of this study.

As evident, upon evaluation using standardised psychiatric assessment tools, conditions

like major depression, alcohol and tobacco dependence, social phobia, agoraphobia and
post-traumatic stress disorder were identified, necessitating further psychiatric evaluation
and intervention. The findings of mental morbidity are somewhat similar to other
international studies (Goldberg et al., 1996). The minor variations noted can be attributed
to differences in methodology, sampling technique and instrument used to assess the
pathology.

Improvements Suggested for Staff issues:

Adequate remuneration: Generally speaking, prison staffs are held in lower regard than
other people who work in the criminal justice field, such as the police. In order to attract
and retain high quality personnel, it is essential that salaries are set at a proper level and
that the other conditions of employment are the same as in comparable work elsewhere
in public service. Work on shifts is inevitable. Due care and proper scheduling of night
duties, apart from special incentives for doing the night duty can be of help.

Basic amenities: The following basic amenities need to be provided to the staff at the
work place;
 Clean and safe drinking water
 Provision of appropriate facilities at the place of duty
 Adequate toilet facilities / Rest room / Changing room
 Recreational room / Exercising facilities
 Self-defense training
 Security of staff
 Security for the family members of the prison staff

Periodic training of staff in counselling and self-defense: Lack of a congenial working

environment that is of a hierarchical nature, direct contact with difficult prisoners who

206
are abusive, depressed and violent can all exacerbate the stress levels of the prison staff.
There is a need to decongest the prisons, increase the number of prison staff, train the
staff on counselling, conflict resolution, and enhance the safety procedures and
mechanisms apart from ensuring that fit warders with self defence skills are employed in
prisons.

Health screening of staff and their family members: Routine screening of staff and
their family members for physical and mental health issues, and providing appropriate
interventions as and when required is important.

Health Insurance: Given the difficult, risky environment the prison staff face, they need
to get more allowances and free insurance with a good health cover.

Job Transfer: Prison staff is stressed about transfers and clear guidelines should
therefore be followed. Transparency and zero tolerance for corruption need to be the
ensured in all matters in prison settings, particularly on issues like transfers and
promotions.

Training staff in human rights approach: Andrew Coyle (2002) has exemplified the
need for improvement in staff working conditions and their remuneration. According to
him, prison staff works in an isolated environment and this can make them inflexible.
The staff needs to be open to accept prisoners without biases and be sensitive to changes
in the broader society from where prisoners come and go back.

Periodic soft skills training for the prison staff: Towards improving the prison work
environment, enhanced staff communication and conflict resolution skills are
recommended. There is a need for the following improvements in the prison environment
towards making it a more congenial and less stressful environment:

 Improve staff teamwork

 Improve interdepartmental cooperation
 Improve morale
 Reduce conflict

207
Handling allegations by prisoners: The Board of Visitors needs to be established and
active. Complaints given by prisoners need to be investigated from all possible angles.
Monitoring of the prison by using advanced visual technologies such as CCTVs etc., can
prevent untoward incidents in the prison. Adequate support and time needs to be given to
the staff to defend his/her behaviour. Regular meetings need to be held with the staff to
discuss key problems faced by prisoners. In addition, regular review meetings with the
human rights organizations can certainly foster greater awareness of human right issues
of the prison staff. Further, such interactions increase trust among the prison staff. The
meetings can address the issues of the prisoners, the allegations against the staff, and
action taken can also be shared at these meetings. Routine interviews of the staff to get
their feedback, provision of a secure environment and focus on the safety needs of
women prison staff is of paramount importance.

Stress management programmes: There is an urgent need to address the issue of stress
among prison staff. Periodic stress management programmes, adequate sanction of leave
and holidays need to be implemented.

Mental Health Promotion in Prisons: The Prison environment is stressful and can
make people depressed or can worsen their mental health problems. These can become
aggravated if staff is not aware of mental health problems and their identification and
management. This is a reality in many prisons. The presence of prisoners with
unrecognised and untreated mental disorders can further complicate and negatively affect
the prison environment, and place even greater demands upon the staff.

WHO report on mental health promotion in prisons (1998) at Copenhagen, details the
benefits of mental health promotion. According to the report, mental health promotion
can result in better emotional and physical health, confront and correct offending
behaviour, reduce the incidence of mental health disorder apart from reducing the
severity of the disorders, be an amenable place for rehabilitation and can result in
enhanced confidence and social skills. Mental health promotion improves job
environment for staff, reduces their stress levels, helps in enhanced security at prisons,
improves relationship between staff and prisoners and this can result in better family
relationships for prison staff.

208
 Stress management for prison staff:

a) Stress counselling
b) Family counselling
c) Availability of de-addiction treatment
d) De-briefing at work place
e) Anger management training
f) Problem solving and decision making training
g) Communication skills training
h) Time management training
i) Regular exercise
j) Relaxation exercise
k) Meditation, yoga, prayer and other forms of relaxation
l) Paid holiday
m) Staff redressal mechanisms

Many roles and duties traditionally attributed to clinicians can and often should be
performed not only by other mental health professionals, but by prison staff such as
correctional officers and nurses. Moreover, the optimal climate for effective treatment is
one in which mental health professionals and line staff work collaboratively, especially
since prison staff alone are in contact with prisoners all 24 hours. The specific activities
which comprise mental health treatment in prison include:

1) Counselling and psychotherapy—talking with inmates,

2) Consultation—talking about inmates,
3) Special housing, activities, and behavioural programmes, and
4) Medication.
(Appelbaum et al., 2001).

Recognition and nurturance of these activities will improve the quality of services and
reduce stress on staff and inmates alike. Consultation with onsite staff, joint training, and
use of multidisciplinary treatment teams are advocated as methods of reaching these
goals (Appelbaum et al., 2001). The training should equip prison staff in identifying and
managing mental health conditions of prisoners. Mental health training enhances the staff

209
understanding of mental disorders, increases the knowledge of human rights and
challenges stigmatising attitudes of the staff. The focus needs to be on mental health
promotion for both staff and prisoners (World Health Organisation, 2008).

In conclusion, the current international literature on prison staff and the study conducted
at Central Prison Bangalore, highlight that prison staff need better working environments
in terms of safety, reduced stress, and better relationships between themselves and the
prisoners. Their job needs greater role clarity, their needs for wellbeing in terms of
support, incentives, training thereby motivating them to better deliver their services need
to be addressed. Prison staff are not aware of mental health issues of prisoners and proper
training in this regard is required across the prisons. Appropriate measures are required
to provide psychiatric help for the prisoners and staff, to ensure all the staff are provided
training on mental and physical health issues of the prisoners. Further, the prison staff
require training on conflict resolution and also have effective listening and empathetic
communication skills. The staff should be aware that their quality of interactions can go a
long way in correctional aspects of prisoners and this is a very important job objective
for them. They should be aware of human rights and treat prison inmates with respect
and avoid stigmatising prisoners with mental illness.

210
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Development Department of Mental Health & Substance Abuse, WHO Geneva.
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http://www.who.int/mental_health/policy/development/MH&PrisonsFactsheet.pdf
accessed on 09 Mar 2010
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prisons. A report on mental health promotion in prisons at CopenHagen. Available
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accessed on 26 Sept 2010

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 14. MENTAL HEALTH CARE IN PRISON: THE WAY FORWARD

Prison health is often neglected and continues to be ignored despite accumulating

objective evidence supporting the need for rational health policies in prisons. Many
prisoners with serious physical and mental disorders fail to receive care while
incarcerated. Furthermore, public-health strategies adopted in the community are ignored
in the prison setting. Developing countries like India face challenges of both
communicable diseases and as well as non-communicable diseases. Despite the high
prevalence of tuberculosis, drugs use and HIV in prisons, screening for such diseases is
rarely available on entry into prison. There is no access to health promotion and
comprehensive treatment. Unfortunately mental health needs of prisoners are completely
unrecognised. Even in situations where they might be recognised, the responses are
largely individualised and systemic response to the problem is absent. Providing
treatment for substance use, mental illness and high risk behaviours benefits both
prisoners and the wider community. Improvements are needed both in correctional health
care and in community mental health services in order to prevent crime, incarceration and
violation of human rights.

There are many lacunae in health care in prisons in developing countries like India.
Prisons have few health care professionals delivering comprehensive health care. A few
skeletal staff like doctors and nurses is often on deputation from state health services.
Services are poorly organised and there is no adequate networking with facilities
available in the community. Prison systems tend to be closed and often do not facilitate
collaborative partnerships with other governmental and non-governmental organisation.
Prison staffs are poorly trained in identifying and dealing with health, particularly mental
health issues. Given this scenario, the following strategies merit immediate consideration
and implementation.

HEALTH CARE IN PRISONS

Access to general health care

Right to health needs to become the rights of the citizen and also the prisoners, who are
also rightful citizens. Availability of emergency health care services needs to be made
mandatory for central prisons.

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 1) Separate health personnel need to recruited for all correctional centres, rather than
deputation from the health and family welfare department
2) Local medical colleges needs to provide the specialist support for providing health
in prison
3) Telemedicine needs to be considered for obtaining specialist opinion for health
care, legal and other purposes.
4) A separate budget needs to be allotted for the health in prisons
5) Screening for health needs to be mandatory for all the prisoners when they enter
prisons
6) Periodic health screening is also required in prisons
7) Prison hospital needs to be upgraded and appropriate resources needs to be
provided. Adequate health staff needs to be provided according to the standard
prescribed in the Mental Health Prison Project report of the Central Prison,
Bangalore
8) Availability of essential medicines needs to be ensured in every prison hospital.
9) Inpatient treatment, whenever required needs to be encouraged within the prison
hospitals.
10) Maintenance of health records in prison should be made mandatory

Emergency health care

All central prisons housing more than thousand prisoners need to provide emergency
health care inside the prison. At least one ambulance needs to be provide for each central
prison.

National health programme

Prison health needs to be considered a public health priority. All the national health
programmes needs to be implemented in prisons.

HIV prevention programme

HIV prevention programme needs to be available for prisoners. Pre-test and post-test HIV
counselling needs to be done. Provision of anti-retroviral medicines needs to be ensured
inside the prisons. Protection of the human rights of HIV positive prisoners needs
attention. Segregation, isolation and discrimination of HIV prisoners must not occur. If
isolation is required as per medical advice (required only in few cases) then the person
needs to be shifted to the district hospital rather than isolating in prison. Health education

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regarding HIV transmission and prevention need to be emphasised. There is also a need
to educate vulnerable populations regarding safe sex practices.

Tuberculosis prevention programme

Screening of prisoners for tuberculosis must occur routinely. The screening needs to be
done when the prisoner is inducted into the prison and also as and when cases report to
the medical officer incharge of prison. Anti-tubercular treatment needs to available in all
the prisons. Prison authorities needs to take responsibility of procuring these medicines
and making them available to the prisoners. Periodic check for drug resistant cases and
appropriate measures need to be taken.

Health care for women and children

Women and child health needs topmost priority. Availability of a lady medical officer is a
mandatory in all the central prisons. As far as possible screening and periodic
examination needs to be done by a female doctor. In case of gynaecological examination,
only a female doctor must carry out the examination. If a female doctor is not available,
then the women prisoners needs to be referred to the district hospital for further needful.
Antenatal, natal and post-natal care needs to be made available to women prisoners.

MENTAL HEALTH CARE

Access to mental health care

Mental health care needs to be an integral part of the general health services. The District
Mental Health Programme needs to be implemented at the prison without fail. Health
services provided to prisoners should be better than or at least an equivalent level to that
in the community. However, non-availability or poor standard of health care at the
community level cannot be an excuse. Minimum essential psychiatric medicines need to
be made available as per the District Mental Health Programme. Psychiatric services
needs to be provided in the prison hospital. If the psychiatric specialist is not available,
then the services at general hospitals must be utilised. When prisoners require acute care
they should be temporarily transferred to psychiatric wards of the general hospitals with
appropriate security levels. There should also be a mechanism in place to provide care
after release.

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Access to de-addiction treatment
Prison should be a tobacco free zone and also be free from illicit drugs. De-addiction
facilities need to be available and offered to prisoners. A system needs to be in place for
clinical assessment of substance use, urine drugs screening and treatment. Psycho-social
management of substance use, such as educating regarding the ill-effects of substance
use, motivation enhancement, family counselling and stress management also needs to be
available in prisons.

Suicide prevention programme

Another essential element of mental health care in prison is prevention of suicide.
Prevention in suicide starts from training all levels of prison staff, guards, prisoners and
medical staff in the recognition and prevention of suicides. There needs to be a written
policy regarding prevention of suicide in prison. Standard operating procedure needs to
be formed in case of suicidal attempt, deliberate self-harm and death due to suicide in
prison.

Behavioral rehabilitation
Prisoners high-risk behavior needs to be addressed before they go back into the
community after release. This can be done by various methods including education,
lectures, seminars, workshops, dramas, group therapy and individual psychotherapy.
Many prisoners may require family counselling, anger management training, life skills
training, individual therapy, stress management and cognitive behavior therapy. Such
high-risk behavior management reduces recidivism.

Challenges for providing mental health care

Lack of trained manpower can be addressed by providing periodic mental health training
to prison staff, medical personnel and health workers. They need to be trained in
identification of mental health problems, counselling and referral to the medical officer in
prison. The district psychiatrist or a consultant psychiatrist, from a nearby medical
college needs to visit to prison for providing mental health care on a weekly basis.
Training of prison staff needs to focus on identification of mental disorders, treatment
and counselling. They also need to be trained in the area of raising awareness on mental
health to the prisoners and their family members. Mental health programmes need to be
owned and driven by the prison staff rather than being dependent on the psychiatrist.

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Mental Health Visiting Board
Independent inspection mechanisms through mental health visiting boards, mental health
authority, mental health welfare committee and monitoring by a disability commissioner
can also be established through legislation. Such agencies must inspect prisons as well as
other mental health facilities in order to monitor the conditions for people with mental
disorders. Strict vigilance needs to be kept regarding the violation of human rights in
prison.

Collaboration
Collaboration between various sectors such as health and family welfare department,
correctional department, health department, law department, human rights agencies and
social welfare department needs to be enhanced. Non-governmental organisation and
public-private partnership models can also provide very useful collaborations. Many
problems and issues can be solved by bringing relevant authorities and stakeholders to
discuss the needs of the prisoners.

STAFF TRAINING

Prison staff training is crucial in providing mental health care and suicide prevention. The
essential component to any programme is properly trained correctional staff, who form
the backbone of any jail, prison, or correctional facility. Identification of the cases,
counselling and referral is done by the staff. Hence, they need to be sensitised by
providing adequate training.

Module for mental health training

One day training module for prison staff

1. Introduction to mental disorders
2. Depression
3. Psychosis
4. Substance use (Alcohol, tobacco, cannabis and other drugs)
5. Suicide and deliberate self-harm
6. Stress management
7. Counselling
8. Identification and referral

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Very few suicides are actually preventable by health care staff in prisons. Most suicides
are usually attempted by inmates in barracks, and often during late evening hours or on
weekends, when health staff are not on duty. Correctional officers are often the only staff
available 24 hours a day; thus, they form the front line of defense in preventing suicides.

Need for National Correctional Centre

A National Institute of Corrections needs to be formed at the centre. Such an agency
needs to focus on research, training, innovation, policy issues, human rights, health and
legal aid issues that shape and advance effective correctional practices and public policy.
The national institute needs to contribute significantly towards research, reformation and
rehabilitation to achieve correctional goals and priorities. They also need to provide
effective policy, planning, management and operational strategies that uphold human
rights and prison safety. Access to reasonable health care in general and mental health
care in particular needs to be ensured for prisoners, who are also rightful citizens.

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