The forensic ward of Hospital Bahagia Ulu Kinta in Tanjung Rambutan, near Ipoh. - NSTP/Abdullah Yusof

IPOH: Mental assessment of those charged with criminal offences can be done only at four hospitals. They are Hospital Bahagia Ulu Kinta (HBUK) in Perak, Hospital Permai (Johor), Hospital Mesra Bukit Padang (Sabah) and Hospital Sentosa (Sarawak).

HBUK consultant forensic psychiatrist Dr Ian Lloyd Anthony said these were the approved psychiatric hospitals under the Mental Health Act 2001 to admit and detain individuals under Sections 342, 344 and 348 of the Criminal Procedure Code (CPC).

“The charges can range from a simple case of urine testing positive for drugs, stealing a motorbike, to serious offences, such as rape, sexual offences against children, child abuse and crimes involving the death penalty,” he said in an interview with the New Straits Times.

He said judges who suspected that an accused suffered from a mental disorder would refer him to one of the four hospitals for mental assessment under Section 342 of the CPC.

“The hospital is given a period not exceeding one month (which can be extended to two months) to observe, evaluate and send a report on the mental state of the accused before he is allowed to plead or go on trial.

“The court wants to know whether the accused has a mental disorder. Whether he is of sound mind or unsound mind at the time of the alleged offence and following a period of assessment, whether he is fit to stand trial.

“These are three important questions that the court requires us to answer.”

Dr Anthony said out of the 420 cases referred by the courts to the hospital last year, fewer than 15 were either found to be of unsound mind or unfit to stand trial.

He said the threshold for legal insanity under Section 84 of the Penal Code was high.

“Although the standard of proof for an insanity defence is on the balance of probabilities, just by merely having a mental disorder per se may be insufficient.

“It must be clearly shown to the court, with reasonable medical certainty that the accused was rendered cognitively incapable of understanding the nature and wrongfulness of his action as a result of his mental disorder."

He said when assessing the accused, the forensic psychiatrist had a duty to the court to assist it in coming to a just decision.

“For forensic cases that come for mental assessment, the obligation to the accused goes only as far as ensuring they receive an independent and unbiased assessment. We have no obligation to any party, be it the prosecution or defence. In this respect, the principle of forensic psychiatry differs from the ethics of general psychiatry.

“The forensic psychiatrist has to balance competing duties to the accused and society.”

An assessment of the accused under Section 342 of the CPC is done at the acute forensic unit, a high-security facility in the hospital. The hospital,famously referred to as Tanjung Rambutan Hospital, receives between 40 and 50 cases monthly.

“Once they are sent to us by the police, the handcuffs are taken off because this is a hospital, we do not cuff them. They are treated like ordinary patients. Although most of them are perpetrators of serious crimes, being arrested and interrogated by police, taken to court multiple times and living in a prison can be traumatic.

“If we add to that, it would be difficult to get into their minds and for them to tell us what transpired.”

Dr Anthony said without access to crime scene evidence, psychiatrists would have to rely completely on the accused to recall and reconstruct the alleged crime, step by step.

“We gather information from family members or other individuals who had observed the patient’s behaviour prior to the offence, or if they were present during the offence and at the time of the arrest, as well as policemen who made the arrest.”

Closed-circuit television (CCTV) recordings of the alleged crime and medical reports of prior psychiatric admissions and treatments in other hospitals are referred to.

“The patient’s mental state at the time of the crime is as important as the period preceding the offence and immediately after. This constitutes the entire picture of the mental state of the accused.

“Sometimes, when they come in, their mental state isn’t so stable, so it takes time for us to build a rapport, engage and slowly get them to recall things, to reconstruct the entire scene,” he said, adding that those who turned violent and aggressive would be medicated to keep them calm.

REHABILITATION PROGRAMME

Once the trial is over and the court finds the accused not guilty by reason of insanity, on most occasions, the court will order the accused to be kept in safe custody at the hospital at the pleasure of the ruler of the state under Section 348 of the CPC.

“They are no longer seen as the accused, but as patients. The aim of Section 348 is to treat and rehabilitate them with the goal of releasing them back into society.”

He said there were currently 17 female patients and 108 male patients confined to the long-stay forensic ward of the hospital under Section 348, with the majority of them having been found not guilty by reason of insanity for murder.

Rehabilitation for female patients include a bakery, a spa, a hair salon, making and selling ice-cream, selling kacang, ikan masin and ikan bilis.

For the male patients, they are enrolled in activities, such as planting vegetables, sugar cane, gardening, car wash and electrical workshops. Some also work in the hospital’s laundry and canteen. The work keeps patients occupied and they progress from a simple job to a more complex one.

BOARD OF VISITORS

Relatives of patients confined under Section 348 can request their release under Section 351 of the same Act by applying to the respective state secretariat and copying the same letter to the hospital.

The hospital will then refer the case to its Board of Visitors, who will deliberate on it.

Once they are satisfied that the patient can be safely released, the ruler may in his discretion, order the patient to be delivered to a relative.

“Since last year, we have put 20 cases before the Board of Visitors for release under Section 351. Out of that, nine successfully went back into society, while some are awaiting their release order,” said Dr Anthony, adding that there were instances where the board did not agree to release a patient and called for more time in rehabilitation.

The planting of sugar cane is part of Hospital Bahagia Ulu Kinta forensic ward’s rehabilitation activities for male patients. - NSTP/Abdullah Yusof

“It depends on the patient. If the patient’s symptoms are well controlled, his illness improved and he has successfully taken part in rehabilitation activities, and when there have been no episodes of violence or aggression during the patient’s stay in the ward, then we have no problems in facilitating his release.

“Once they have been rehabilitated, they should be released into society, with the necessary safeguards in place.”

RELEASING PATIENTS BACK INTO SOCIETY

“When we release a patient, we would want to be sure that this person has a low risk of re-offending. Risks can only be estimated to a certain extent. Let’s say we are releasing a patient, we can predict risks up to only six months.

“Subsequent risk assessments will have to be done by the hospital that’s in charge of his followup treatments. If he misses his medications, he can relapse and re- offend.

“Therefore, we have to provide him with services on the outside. If the patient is going back to Alor Star, for instance, we have to provide him with psychiatric services there, especially with a community psychiatric team that carries out regular home visits to ensure that he takes his medications.”

Dr Anthony said many patients had drug-related problems that would have resulted in some of the offences and it was a difficult task keeping them away from drugs.

In cases where there is no relative to take a patient home, the hospital will release the patient under Section 350 of the CPC, upon recommendation of the hospital director.

These patients are then readmitted to the hospital voluntarily under the Mental Health Act 2001.

For this group of patients with no relatives, the aim of release under Section 350 is for further rehabilitation by allowing them to work outside the hospital. Some of them are allowed to live independently in apartments on the hospital grounds while seeking employment outside.

Who adapts better once released, men or women?

“That depends on the support given by the family. The first six months after release from the hospital is crucial as they have to readjust to life outside the hospital.

“During this period, I will schedule appointments to see them at the outpatient clinic of Hospital Bahagia. Once I am comfortable and satisfied that, yes, this patient is doing well, only then will I refer him to the nearest hospital where he lives.

“We do not completely cut off ties with them and random checks are made with their families to ensure that they are taken cared of,” he said.

CHALLENGES

Dr Anthony said space was a problem for rehabilitation programmes as they were utilising old wards for their activities.

“Work is therapeutic. Some of these patients had good jobs before committing their offences. If you don’t give them anything to do, they become bored and boredom can trigger a lot of things.”

He said there were very few psychiatrists interested in the field of forensic psychiatry.

“There are a lot of risks involved in dealing with criminals. The workload is tremendous, compounded by the pressure of having to go to court. At present, there are only three forensic psychiatrists in Malaysia and we are training three more in the Health Ministry’s forensic psychiatry subspecialty training programme.”

He said HBUK sometimes had problems tracing family members when a patient was ready to be released back into society.

There were cases of family members being reluctant to take them home.

“Like for murder cases, they can be very reluctant. They don’t mind visiting the patient here in the hospital, but they do not want to take them home.”

He said the oldest patient in the forensic ward was an 86-year-old.

“He came here in 1960 and he is still here under Section 348 of the CPC. He was charged with voluntarily causing hurt,” he said, declining to reveal more about the patient.

He said the youngest patient was a 21-year-old who was admitted last year after being found not guilty by reason of insanity for voluntarily causing hurt.