In Pakistan, those accused of crimes while experiencing mental illness can experience new pressures to recover despite the impact of incarceration itself on wellbeing. This has to do with the requirement to be mentally sound in order to successfully participate in a trial to contest or to plead guilty for a crime. The medical recognition of psychosis during a criminal act can be taking as a mitigating factor, resulting in reduced punishments. In such a context, individuals are also perceived by the state as invoking signs of mental illness. Such proceedings and approaches by state officials as well as attitudes in familial and community contexts shape claims and counterclaims about the presence of mental illness. Within state institutions, mental illness, beyond its biomedical reality, is also bureaucratically produced in documents and files. Symptoms are often described and erased in documents as they move through various institutes like the police, the courts, and the psychiatric ward. Despite the introduction of psychiatric discourses in state penal institutions with the passing of the Punjab Mental Health Ordinance in 2001, the attitude toward prisoners is still punitive, representing colonial-era asylum policies, and involves pressuring ‘patient-prisoners’ to show compliance and improvements in mental health in order to stand their trials, even when they experience symptoms of acute psychosis, which are interpreted variously by state officials and patients themselves as signs of divine intervention and inspiration.1
In the 2016 Imdad Ali Case, the Supreme Court of Pakistan dismissed Imdad's appeal to halt his execution, stating that schizophrenia did not fall within the legal definition of a mental disorder that would preclude execution (Tripathy 2016).2 Then in 2021, the Supreme Court annulled the sentence of execution for each defendant and stated that no death sentence should be carried out ‘if a condemned prisoner, due to mental illness, is found to be unable to comprehend the rationale and reason behind his/her punishment’ (Safia Bano v. Home Department 2021: 38; Hashim 2021; Munir and Wright 2023).
Without the Supreme Court decision, undoubtedly many individuals with mental illness would have received their death penalties, but the provision to psychiatrically evaluate individuals has often led to the accused invoking mental illness to delay court proceedings, as in the case of Zahir Jaffer in the Noor Mukadam Case.3 One of the reasons why invocation of mental illness as grounds of incarceration—both by the victim or the accused—is so politically fraught is because, since colonial times, mental illness in the Indian Subcontinent has been treated as accusatory, especially given the central role of magistrates in ordering the institutionalization of men and women (Mills 2001). Before the Mental Health Ordinance of 2001, patients could be involuntarily admitted, without having any right to appeal. Even now, detention can be extended with the magistrate's order for up to thirty days (Tareen and Tareen 2016). Given the stigmas around psychiatric care, families often try to conceal symptoms of illness when there is a threat of bringing dishonour to families or when mental illness could reveal neglect toward a person within wider family networks (Wheeler 1998; Qureshi 2013; S. Khan 2023). But patients themselves also challenge the diagnosis by arguing how they have been deliberately accused and targeted by rivals—neighbourhood, family, or even political—as was evident during my ethnographic research, with many examples of such situations.
Within state-run psychiatric hospitals, some of the patients created public spectacles by challenging their families and denying family attempts to portray them as sick to exclude them from familial inheritance. This has shaped attitudes toward psychiatric hospitals more generally in the context of Pakistan, where inpatient care is often perceived by some family members as a form of abandonment. During my interviews with interlocutors who had been coming to the state hospital to receive medicines, memories of past institutionalization were frequently described through forms of familial abandonment. Patients who had been rushed through emergency services, particularly for symptoms of delusions, frequently became spectacles for families and bystanders in the outpatient department (OPD), as they hurled accusations at their caregivers for abandoning them.
Separately, those who may be symptomatic can be accused of making up their symptoms to avoid punishment by correctional officers and sometimes judges. The inclusion of psychiatric discourses in court proceedings has meant that even petty offenders are forced to be examined for mental issues. In this context, individuals with mental illness experience a sense of ‘stuckedness’ (Hage 2009) which is part of the larger experience of bureaucratic violence, as patient-prisoners await recovering or regaining ‘mental soundness’ to stand their trials. In addition to the treatment of mental illness by state functionaries, the treatment of mental health diagnosis as accusatory draws on the perception that documents describing symptoms, improvements, and diagnoses are manipulable and ever evolving, thus giving mental health diagnoses a fluid position in the eyes of patients.
Understandings about accusatory and political uses of mental health diagnosis become especially prominent in the context where there are three major state-run inpatient hospitals and only 400 psychiatrists for a population of over 220 million (Bashir 2018). Notably, some forty psychologists were there for all the prisons in Punjab, as the head psychologist of correctional facilities once shared with me. The history of involuntary incarceration, the dearth of psychiatric care, and the provisions of screening prisoners for psychiatric problems have led to challenges for the state about whether the person is making up symptoms or is actually mentally ill. In Pakistan, a prevailing perception about the falsification of symptoms and diagnosis among families and patients is viewed as linked to views that evidence can be constructed and manipulated by certain state personnel, allegedly in collusion with families, or through the patient's own attempts to bribe state officials to change evidence about their illness.
In prisons and in psychiatric hospitals, patients continue to be viewed as making up symptoms or engaged in a ‘moral economy of lying’ (Beneduce 2015) and hence their illness is dismissed as an attempt to manipulate the system, whereas patient-prisoners view diagnoses as politically motivated and turn to interpreting symptoms through supernatural experiences. I conceptualize bureaucratic violence experienced by patient-prisoners as consisting of a combination of delays in court proceedings, arbitrary court decisions, and transfers to prisons where prisoners may receive adequate psychiatric care. This experience of delays is further compounded by complications and contestations occurring around diagnoses. Some patients experience a lack of psychiatric care while, conversely, others may experience an excess of psychiatric care viewed as punitive rather than empathetic.4 Such treatment is combined with carceral violence and frequent experiences of accusations about malingering. Overall, bureaucratic violence is marked by differential attitudes toward mental illness among the state agents and patients. The experience of being stuck indefinitely in bureaucratic procedures occurs alongside attempts to manipulate such patients to access care expediently. Diagnoses shift in official documents as these are manipulated or revised by correctional officers, psychiatrists, and physicians. In such instances, it is often the ambiguity in symptoms and judgments by state officials and patient-prisoners around whether symptoms are psychiatric at all that marks such experiences of bureaucratic violence.
I use the movement of documents to explore how the diagnoses and symptoms produced within disciplinary structures evolve. I ask how, even despite acute symptoms, patient-prisoners are forced to demonstrate improvement in symptoms and compliance to carceral authorities in prisons, which serves as an example of under-psychiatrization. I then explore over-psychiatrization, in which patient-prisoners challenge the medicalization of their symptoms by state institutions and/or officials by interpreting their symptoms as supernatural in nature. There is yet another modality of over-psychiatrization, where different ramifications of medico-legal power exist. Here, psychiatric causes and motivations are sought by the state for crimes even when these are absent. This leads to some patient-prisoners experiencing extended stays in prisons, where they are required to make regular visits to psychiatrists, despite the absence of any illness. Therefore, the practices at state institutions of using psychiatric causes as mitigating factors to humanize the mentally ill patient become indistinguishable or can even contribute to carceral violence.
Methodological Considerations in Studying Prisoners withÊMental Illness
Though this study is about mental illness in carceral settings, the interviews were mainly conducted outside of the ‘prison’ proper. Interviews with police officers were conducted in administrative spaces and offices. None of the participants interviewed were experiencing acute symptoms or were under distress during interviews. Permissions for interviews with state officials were sought through official channels by the submission of study protocols and aims to the office of the inspector general. These permissions also included access to case files. Though there is no parallel to HIPAA (Health Insurance Portability and Affordability Act) (see Lawrence 2016) to protect patient privacy in Pakistan, in recent days there have been calls to improve patient privacy (Newspaper's Staff Reporter 2023). These files were held in police registries, and the ones analysed in the study were of those patients who no longer received active care and who had not been sentenced in the past ten years. In order to further ensure patient privacy in the absence of regulatory frameworks, I randomly selected case files, while anonymizing the identities of these persons in my fieldnotes. I was not allowed to scan these documents, so I mainly described my observations about the organization of data in case files by audio recording my observations from the documents for later analysis. I approached these archives ethnographically with the aim of considering how documents were added or removed over time. I triangulated my analysis of these files with my ethnographic research and interviews.
This work is part of a broader ethnographic study I have been conducting on security and mental illness in Pakistan. The article draws upon archival and qualitative data collected from my conversations with persons who had previously received institutional care while being incarcerated about their experiences, as well as with a psychologist and police officers. I interviewed five people who had previously faced court cases related to blasphemy and violence and had received treatment at the state-run psychiatric hospital in Lahore, Pakistan. These interviews contributed to my documenting of experiences of incarceration and care retrospectively. The accounts of prisoners’ retroactive experiences, especially those with mental illnesses, are useful because prisoners currently experiencing mental illness or acute symptoms cannot be expected to give consent. The prisoners’ experience of double constraints, that is, giving consent while experiencing power imbalances, results in a default position that breaches privacy and confidentiality as has been noted, for example, by Diego Silva and coauthors (2017). While keeping this aspect in mind, I am also mindful that it is necessary to explore correctional health because of the unique risks of infections and mental illnesses experienced by prisoners (Venters 2019; Pont 2008), especially when incarceration itself appears as a major health risk (Drucker 2013). I remain aware of the need to further explore ways to study people experiencing incarceration and illness at the intersections between communities and closed institutions.
As indicated, I also conducted an interview with a psychologist who headed correctional psychiatry in all prisons of Punjab and also interviewed two police persons who had prior experience accompanying patient-prisoners from prisons to the major inpatient hospital of the province, Punjab Institute of Psychiatric Care (PIPC), for their regular assessments.5 Existing work on bureaucracies and mental health demonstrates how individuals perceive the ‘mind’ of the state by interpreting the state's exemption processes to pre-empt different types of sympathetic and strict state officials with aims to manipulate the bureaucracy (Weiss 2016). Moreover, as scholars such as Jessica Cooper (2018) have considered, courts and prisons deploy and impose ideas selfhood, agency, and intentionality that fundamentally clash with fluid jurisdictions and fractal forms of agency invoked by patient-prisoners. By disciplining patient-prisoners with illnesses, researchers note that the state often seems to generate the very conditions that it seeks to control and suppress (e.g., Rhodes 2004). Yet psychiatric discourses (including the use of helplines) have been employed by states as a way of demonstrating their benevolence and as a means of making people's social conditions and experiences legible (Fassin 2011; Littlewood 1996; Stevenson 2014). Meanwhile, as in other parts of South Asia, the metaphor of ‘complaint’ shapes how mental illness is brought to public awareness and concealed, as Jocelyn Chua (2012) points out. The political uses of mental health diagnosis become particularly prominent given the widespread use of psychiatric discourses to police communities, particularly so, given the country's ongoing war on terror and the state's ongoing efforts to expand surveillance into public spaces and populations.6
Everyday Policing
My research showed that various members of communities, including families, lodged complaints to the police with the aim of having troublesome members incarcerated, especially on the charge of mental illness. This use of psychiatric screening, including frequent visits to state-run psychiatric hospitals, adds to the experience of accusatory uses of mental health diagnoses. These complaints were made under sedition or blasphemy charges, and these charges were then viewed as politically constructed, and played into broader attempts by the state to police communities. For instance, blasphemy laws are increasingly used to accuse neighbours and relatives, who would then be imprisoned and psychologically screened.7 Although mental health evaluations here serve as a mitigating factor to save prisoners from the death sentence, these prisoners were still construed indefinitely as mentally unfit to stand trials, which exposed them to new forms of bureaucratic violence.8
Blasphemy laws have been instrumentalized to police minority groups, a move in line with the state's attempt to appease right-wing religious sensibilities. Blasphemy laws have also been used as a form of witch hunt, with patients kept in prisons rather than provided with care, where they are psychiatrically screened before receiving the punishment. One patient's family in a private clinic in a low-income neighbourhood of Karachi shared their worry when the patient had the urge to do something blasphemous, like burning the Quran or insulting the prophet. The family was desperate to seek a cure, given the strict policing of blasphemy. The usual practice is to report blasphemous persons to the police. Such a complaint can result in arbitrary incarceration, and disregards that many with experiences of delusion need cure, not punishment. Such individuals then experience indefinite stays in prisons, without being bailed out by families, and in the meantime, they are exposed to brutality in prisons, unable to regain their ‘sanity’ to return to court and contest accusations (i.e., related to blasphemy). Due to the sensitivity of blasphemy cases, judges can appear unsympathetic to such cases. In the last two decades, there has been an increase in mob violence toward those opposing colonial-era blasphemy laws under the pretext of love for religion and the Prophet (Ishq-i-Rusool). The watershed moment representing this antagonism was the murder of Punjab Governor Salman Taseer in broad daylight for speaking against blasphemy laws in the country; he was murdered by his own security guard, who would then be hailed as a hero among some conservative factions (BBC 2011).
Conversely, there were also cases where the supernatural experiences of prisoners were not treated as blasphemy, but instead evoked the awe of police officers as possible signs of divine apprehension. In a curious combination, blasphemy laws and the remnants of the Lunacy Act of 1912 have been used to screen any signs of disrespect toward Islam and the Prophet Muhammad.9 Among patient-prisoners caught on charges of blasphemy most notably, symptoms were construed as having supernatural causes, such as afflictions by jinns or delusions of being part of a divine plan (although frequently patients also referred to being chosen by God when they had committed a crime, such as murder, under the influence of delusions). As Jessica Cooper has noted elsewhere, patients can invoke multiple identities and cyclical time against the linear time and singular self of mental health courts (Cooper 2018: 104; see also Lester 2017). As I will show, when the ‘state’ is disaggregated and examined ethnographically at different levels, specifically through courts and police stations, there are notable differences in how state officials including judges respond to mental illness. Certain judges may support the official line about diminished responsibility in the case of mental illness, but in the eyes of observers, they do not always convincingly account for medical evidence when formulating their judgements. Such contradictions are considered to have direct impacts and implications for patient-prisoners and the care they receive.
Files, Bribes, and Manipulation of Illness
In the context of the lack of resources and suitable facilities, state officials frequently order the transfer of patient-prisoners between different prisons and medical and legal institutes in order to help them access medical care. This directly increases the number of people who evaluate patient-prisoners. In these processes, expert as well as nonexpert observations are added to the patient's file. In the interviews with various police officers who had previously been responsible for bringing prisoners to their psychiatric evaluations, I learnt about the process through which the prisoners were brought to the psychiatric hospital for their routine checkups. One police officer (PO-3) said the patient-prisoners he worked with had mainly been incarcerated for crimes such as murder.10 This was a junior police officer, who was friendly and described the entire process very mechanically: ‘These prisoners brought in chains had been kept in the district prison instead of the central jail’. He added,
Once they were taken to the district prison, the judge could not call them for a hearing until they had returned to their senses. The judge actually required the patient to admit or refute the claim so the court proceeding could begin and witness testimonies could be collected. If this did not happen, the patient's trial or punishment could not begin. However, before giving a decision, the judge would take into account whether the patient's behaviour had begun to improve or not. If the prisoner complied, then his sentence could be reduced. For instance, if the punishment was for forty-eight months, this could be reduced based on good behaviour.
He told me that during a person's stay in the district prison, there was adequate treatment provided by the doctor. In many other prisons though, due to the lack of specialized knowledge, the doctor referred the patient either to the general hospital or to the psychiatric hospital. The officer added, ‘Compared to civilians, treatment provided to these prisoners was much more expedient. Whenever they get unwell, they are taken to the hospital immediately where they are checked, discharged, and taken back to the prisons’. Improvement had two meanings: first, that the person could be disciplined to accept authority; and second, that the person followed a regimented lifestyle, in which he had fixed waking and sleeping hours. Discipline was thus targeted toward helping the mentally ill regain the order that had been impacted by his illness. The prisoners were also given roles within the prison, such as mowing the lawns and making food. The prisoner could be placed in situations where they could disobey, given the structures of power, but the true test of improvement was not to get into scuffles with other inmates or the officers. Being able to comply with authority was the test of improvement. Otherwise, patients would remain in the district prison and come to PIPC endlessly for their monthly appointments. These provisions crucially ignored the fact that the person could actually develop an illness during his time in prison. There was little or no evaluation of the impacts of prison itself. Resulting behaviours were treated as ‘disobedience’, which led to further intensification of punishment and the extension of such patients’ time in the prison. The differential attitudes toward mental illness among courts, prisons, and the psychiatric hospital also have to do with the different perceptions among state officials toward psychosis, as discussed subsequently.
In these processes, the diagnoses can be increasingly unstable and susceptible to personal biases and nonexpert forms of knowledge. The patients’ files were mostly heavy, with ragged corners, and were carried as precious items by the police officers whom I had seen bringing prisoners for their routine evaluations during my ethnographic research in the psychiatric hospital. Archival research brought out that these files typically consisted of handwritten notes by correctional officers about the prisoner's behaviour, information about medical treatment or symptoms provided by doctors, psychiatric and psychological evaluations in PIPC by the psychologist and psychiatrist in charge (including notes about interviews), previous court rulings, court orders (including orders from Supreme Court to lower courts) and administrative orders for transferring patients from one prison to another for treatment. The transfers frequently accompanied the production of knowledge, especially about the behaviour of the patient-prisoner, as good behaviour was frequently a prerequisite to achieve transfers to hospitals equipped with psychiatric care. This evidence that was being accumulated was medico-legal, where each file itself consisted of legal, penal, and medical documents. The pressures to improve, the experiences of delays in transfer, and the bureaucratic work of requests sent by local authorities to the Inspector General or the Home Secretary of the province generated a corpus of knowledge about these bureaucratic workings inclusive of the forms of bureaucratic violence inflicted on patients in the process.
In Figure 1, I visualize some of the institutions involved in the process of transferring patients from one prison to another to receive psychiatric assessment. The cycle also goes in the reverse direction as the patient-prisoner is returned to the home district for the continuation of trial. The district prison first corresponds with the district court for permission and then places a request with the Home Department for a transfer. The Home Department then grants permission after evaluating the evidence and orders the transfer. This prisoner is transferred to the prison in Lahore and regularly visits PIPC for assessment and treatment.
The process of transferring patient-prisoners
Citation: Journal of Legal Anthropology 8, 1; 10.3167/jla.2024.080102
In one of the administrative offices associated with correctional health, a police official (PO-1) present discussed how prisoners were moved from other prisons/jails to district prisons to assess the need of psychiatric evaluations. He said, ‘Often the respective prison writes to the Home Department, the Home Department evaluates the prisoner's behaviour and then allows him to be brought to the district prison from where he can be taken to PIPC’.
While the Supreme Court has taken the lead in ordering courts to stall death penalties, there are complex negotiations at the junctions between the mental hospital, prison, and the court (see also Garcia 2010; Harper et al. 2015). The constitution of medico-legal evidence for mental illness and its relationship with crime not only shows the negotiations between the multiple state actors, but also the arbitrariness in these workings as scholars studying the intersections between courts, rehabilitation, and carceral institutions have noted more generally (Tiger 2012; Nolan 2003; Paik 2011). In the ‘grey zones’ of bureaucracy where formal rules blend with informality (Mathur 2016), psychiatric evidence is constituted through an imbrication of care and penalty, adding to the experience that the state's empathy is far removed from the patient-prisoners’ realities.
Psychiatric Knowledge and Suspicion
Recent scholarship on colonial asylums has shown that the treatment of patients in colonial India had ramifications for how the staff and their families would be treated outside of asylums (Bhattacharya 2016). This extends to how relationships of exchange animate care in PIPC in contemporary settings. While on the one hand, the behaviour of the prisoner plays a central role in his transfer from one prison to another to receive psychiatric help, on the other hand, it was also possible to bribe state functionaries to erase misconduct from files, without which better care becomes difficult for the patient-prisoner. A usual practice is for families seeking care to rely on knowing a nurse or bribing the staff to expedite admission to the psychiatric hospital and treatment. One interlocutor who had volunteered to help village members bring their sick patients to the psychiatric hospitals in Lahore to get them inpatient treatment strongly made the case for using bribes to expedite treatment. I was also reminded numerous times to pay petty bribes (which I refrained from) to people in the administration if I had to get things done, which led me to realize the entire economy of bribes that had emerged in the psychiatric hospital. Even when bribes were not used, people actively invoked relations (taluqaat) to expedite treatment.
These networks of obligations (taluqaat) within the prison–hospital dyad meant favours could be given as well as withheld at other levels. An interview with the chief psychologist (PS-1) at the administrative office mentioned above provided a clear example. At the time of the interview, he was dealing with a case of disciplinary action of a psychologist, whose file was brought by the assistant. The assistant asked him to withdraw the disciplinary action in his capacity as the head psychologist. Given these were office spaces, such negotiations frequently unfolded in front of me even as officials knew about my presence as a researcher. In this instance, on his request, this case was allowed to be suspended and thus the document was removed from the file. This scene unfolded right in front of me, revealing how files could be manipulated in administrative spaces outside prisons as favours for various state officials.
Explaining the process of transfers of prisoners to the district prison, he said that ‘behaviour was a necessary condition for transfer’. On the specific complications faced by prisoners in seeking psychiatric care, he said: ‘The main problem is that the patient's words cannot be trusted. The reason is that the patient can either make stuff up or lie. They could be making stuff up for a transfer, so we can't trust them at all’.11
The attitude of suspicion prompts us to consider how mental illness, when managed in prisons, becomes a negotiated category. State officials engage in practices of care, suspicion, and punishment simultaneously. Here the erasure of evidence about bad behaviour could also prevent the infliction of punishment. Patients bribe correctional officers to remove problems with behaviour, but the evidence for mental illness may also be constructed in routine paperwork, even when it is missing, by manipulating evidence about behaviour in prison, adding written information or notes to patient files.
Another way to think about the construction and manipulation of symptoms may be considered in terms of the central role of the First Information Report (FIR) as part of the patient's files. In South Asia, FIR is a document prepared by the police after they receive information about a cognizable offence. However, the FIR is also the only evidence for the presence of mental illness. The chief psychologist (PS-1) continued: ‘We don't have the resources to reach out to families. The only evidence that we can rely on is the FIR, but the FIR does not provide much information. The FIR could also be faulty. You know in this country; it is not a big problem to get an FIR against someone. Some people are even wrongly accused’. When I asked him about the psychiatric cases which are currently being adjudicated, he claimed that ‘while the judge can rely on medical evidence, he often uses his own judgement’. Thus, he alleged that while judges take the necessary steps to ensure that patients have access to medical care, in the psychologist's view the judge could also frequently ignore medical opinion. This claim that, in some instances, some judges do not take medical evidence into account, contrasted with other cases in which police officers and psychologists referred to the centrality of medical testimony.
This psychiatrist's perception was that medical evidence on mental illness was inherently unreliable. The belief that judges do not substantively consider medical evidence reproduces suspicions shared among officials in the system toward a patient about feigning illness. The neglect of medical opinion occurs despite the provision for doctors to be present at the hearing to testify to the improvement of the prisoner, as the police official (PO-2) at the administrative office noted. According to this police official, this meant that it was impossible to give a verdict without giving due importance to the medical testimony of the doctor about the patient's illness. According to the officer, during the hearing even the patient-prisoner was asked if he had been provided with proper medical care. The police officer now posited the judges as the guarantors of care to the prisoner, contrary to claims by the psychologist that the judges frequently neglect medical opinion. Thus, such views of neglect mean that while Safia Bano legally established the precedent for taking medical testimony in adjudicating crime, judges variously disregarded information about the patient's psychiatric and medical wellbeing.
Yet there are also cases whereby patients remain in prison in the process, and until a decision is given, they continue the rounds to be assessed for psychiatric evaluation. Meanwhile, prisoners are also under pressure to demonstrate behavioural improvements so that they can access psychiatric care. Evidence for behaviour, however, can also be manipulated.
As the head psychologist explained:
The district jail was at the same time a model prison, which meant that only the best prisoners were kept there. Still, these men were kept only as model prisoners whose release was delayed due to problems in the legal system. Disciplinary action played the role of extending this period, and thus prisoners colluded with correctional officers by bribing them to remove documents from their files which could be used against them (PS-1).
Disciplining patient-prisoners even when they were mentally unwell is in some ways reminiscent of what Foucault (1973/1974) referred as a shift in psychiatry: this is where psychiatrists no longer took patients’ ideas of the ‘real’, but imposed their own ideas of reality, leaving no room to accommodate the patient's own explanations and experiences, backed by penalties.12 The prisoner's behaviour was described in files. As the chief psychologist shared, the knowledge produced by correctional officers about his behaviour could shape the benefits one received as well as, conversely, their experiences of discipline and punishment.
In prisons where there weren't any trained psychologists or psychiatrists, the assessment was conducted by general physicians. When I asked about whether the prison itself could create the conditions for mental illness, the psychologist said, ‘Then we know that the patient was predisposed to developing a mental illness’. Thus, the psychologist attributed illness to the patient-prisoner's predisposition rather than the effect of incarceration on mental wellbeing. This adds to the experience of bureaucratic violence, where patients were given multiple evolving diagnoses that generated more ambiguity around the constitution of illness, crucially ignoring the impact of incarceration on deteriorating mental health conditions.
Evolving Diagnoses
In addition to the ambivalence around the usefulness of psychiatric evidence in court proceedings, state officials also assigned multiple diagnostic categories and modified them, adding to the experience of bureaucratic violence. Ian Hacking (2006) has argued how institutions, knowledge, and experts, by classifying people with specific behaviours, together ‘make people up’, such that certain conditions shape how we recognize others and ourselves, exposing a ‘conceptual confusion’ (Hacking 2006: 8). As much as diagnostic categories encapsulate disease experiences, their usage also creates new interpretive ambiguities when people do not fit into discrete categories. I noted a similar ambiguity in the way patients and their illnesses were described. The description employed diagnosed categories, but these categories frequently changed, as correctional officers and psychiatrists collected more information about patient-prisoners.
The implications for each diagnostic category can be different—the experience of psychosis might reduce culpability as well as potentially enhance the perception about the patient-prisoner's experience of divine apprehension, as I will show below; whereas the diagnosis of bipolar disorder—while technically presenting overlapping symptoms—might simply be treated as a mood disorder. The use of bipolar disorder followed by schizophrenia, or vice versa, imbues the patient's sickness with uncertainty or ambivalence. Linguistically, each diagnosis had a different ramification and influenced the way a patient was treated—for example, the presence or absence of psychosis could have legal consequences about whether to hold a person accountable, compared to the assessment that the person lacked discipline, which could introduce him to stricter forms of discipline.
One patient-prisoner (PA-1), who had been in the district prison, originally from Gujrat, had once been brought to Punjab Institute of Psychiatric Care. On reading his file, I note that he had bipolar disorder when he was in Gujrat, but when he was moved to the prison in Lahore, the general physician referred to his condition as schizophrenia. His file also had a letter from the district jail in Gujrat to the superintendent of PIPC in which the officer requested his transfer due to the unavailability of a psychiatrist in a local government hospital. The general physician in Gujrat had assigned the diagnosis of bipolar disorder. Later, in the patient-prisoner's visit to PIPC, he was provisionally diagnosed as having schizophrenia and began to receive his medication. The most important symptom mentioned in the file was the presence of ‘loose associations’. He was initially also evaluated as being ‘disobedient’, but over time this began to improve. The possibility that the disobedience was tied to his sickness was denied.
As patient-prisoner PA-1’s file showed, his diagnosis changed over time, after several tests were conducted.13 He was eventually described as ‘ranking intellectually inferior’. Two important points arise: first, how the diagnosis changed; and second, the way he was transferred from one prison to another, so that he could receive psychiatric assessments. This file was used for legal evidence, providing information on the arrest alongside the evolving behaviour in the prison. What is useful to note here is how the file was assembled: it was constructed based on the patient's behaviour in the prison and based on psychiatric assessment. Here, improvement in behaviour could reveal improvements caused by medical care. Psychiatric knowledge drew upon behavioural knowledge, which was assessed by the prison administration and correctional officers and increasingly relied upon by the institutional psychiatrist at PIPC. This also had to do with the degree of compliance to authority demonstrated by the patient. The use of punishment despite mental illness gave the impression that if mental illness could not be cured, it could still be disciplined.
The production of psychiatric knowledge also relates to reports provided: prisons send reports about behaviour to the psychiatric hospital and thus correctional officers serve the role of surveilling on the behalf of the psychiatrist. The case file mentioned the request made by the prison in the patient-prisoner's home district for his transfer to receive psychiatric care in Lahore. These assessments were added to the file after the prisoner was closely observed, and these reports were forwarded to PIPC after they were received by the Inspector General. The file was also put together on views by nonmedical personnel such as prison officers; notes were based on assumptions about whether the prisoner had been rendered docile—here docility meant not resisting prison authority and complying with rules of proper conduct with correctional officers and other prisoners (see also Foucault 1995). The patient's file also mentioned that the patient-prisoner had a problem with falling asleep. He was reported as having borderline symptoms; this suggested a diagnosis of schizophrenia. The notes were ambiguous about supporting the diagnosis of schizophrenia and insisted on considering them ‘borderline’. In borderline cases like this one, diagnoses could also be conflated, as some of the sheets also speculatively diagnosed bipolar disorder.14 Diagnostic categories were crisscrossing, and the patient was assigned a diagnosis each time for a legal purpose, i.e., to make his case legally and bureaucratically intelligible; in this instance, this patient was not reported as experiencing psychotic symptoms, mood imbalances, or suicidal ideations. Suicidal ideations often characterize bipolar disorder, given the high rates of attempted suicide among patients (e.g., Lopez et al., 2001). Its implications are different from schizophrenia, characterized by psychosis, where the patient can challenge the intentionality of the crime by attributing crime to forces beyond human control. But both of the diagnoses were mentioned in a speculative manner, followed by question marks, showing the lack of certainty around the exact medical condition. This diagnostic ambiguity was further complicated, especially when the patient experienced delusions which were variously interpreted through supernatural intervention.
Competing Ontologies of Mental illness
In psychiatric clinics and among practitioners of alternative medicine, I often encountered cases of ‘religious mania’, when people either thought of themselves as superior in terms of their piety, or people reported them due to the urge to do something blasphemous. Those who are incarcerated on charges of blasphemy were also assessed for psychiatric problems like symptoms of delusions. What is unique about the differential perceptions of illness is that while the state technically does not consider supernatural experiences as a justification for a crime, given that such forms of evidence are not admissible in rational legal courts, correctional officers nevertheless are often still sympathetic. This is because the correctional officers frequently are part of shared cultural and religious systems, and are variously sympathetic to prisoners, and sometimes even ‘recognize’ or agree that delusions are signs of divine intervention, and therefore these officers differ from other state representatives in their approaches to not treat patient-prisoners entirely for their criminal intent.
One person (PA-2) who had been held in prison for blasphemy and now came routinely to get his medications for psychosis, shared with me his interpretation of his illness,
You know there are some things which I consider normal, but the psychiatrist considers abnormal. You would know about the incident when Muhammad had a connection with Omar. They connected and communicated mentally about the enemy forces coming from behind the mountain. They were able to develop a psychic connection, but this was not considered schizophrenia. I was on the Soviet side, I refused to be on the American side. You know I was a member of the communist party and for us, we don't have much to do with religion. I say to people that I want to talk about politics and economics, you know I am more concerned with education (parhnay likhnay walay log hein).
I then asked him, ‘were you caught on a charge of blasphemy?’ He replied,
Yes, these maulvis say that the punishment of blasphemy should be lifelong imprisonment. So, what happened with me was that I had said something about how Islamic architecture resembled jins (genitalia),15 and somehow my neighbour recorded it. I had been outside one day and when I returned my wife told me that the police had come. I went to the nearest police station, and they told me about the recordings. I said that I did not recognize the voice, but they still thought it was me. I think that the dealer, the owner, and the agent had gotten together in this act, because they also wanted me to vacate the home, and keep it as girwi (collateral for a loan). This is why I had been caught. But I don't think I am mentally ill. These people continue to say it is schizophrenia, but I think that these are mental communications or ‘telephone calls’. This would often happen when you are attacked by jinns. People let these jinns loose and they attack you, and when I would be attacked, I would talk blasphemously…. so whenever I would talk like that people would think it was me, when in fact, it was the jinn.16
This person, accused of blasphemy, attributed agency to the jinn, a defence not acceptable in the court's preliminary interpretation that he committed the act while he was mentally sound. The court then ruled that he committed blasphemy because he was suffering from schizophrenia. The patient-prisoner's explanation for his act did not correspond to the medical diagnosis of schizophrenia. He believed that his condition was caused by jinns. He shared that this was a position with which police officers also sympathized, because of a common cultural and religious belief in magic or rohaniyat (spiritual health) as causes of hallucinations. Police officers occupy a liminal space between reproducing bureaucratic rationality on the one hand, and being sympathetic to the suffering of patient-prisoners, on the other. The empathetic position among police officers to the supernatural experiences of patient-prisoners is indicative of these officers oscillating between magical and scientific forms of rationality (Das and Poole 2004: 225); this was the case where magic and superstition were anathema to the knowledge–power nexus on which expert knowledge and bureaucratic functionality are based. However, police officers also understood that it was their job to approach prisoners through neutrality, irrespective of their symptoms.
In another case, the Superintendent of DG Khan wrote to PIPC and transferred the prisoner. The police officer laughingly said that the patient kept saying, ‘I am on aman (a peace) mission. Baba Hassan sends me on missions’. The officer shared that his file mentioned he had killed his wife and daughter, thus showing knowledge of the act and alleged murder. Notably, his claim to a religious interpretation of the act provides an interpretive ambiguity that also resurfaces in the attitudes of police officers, as in the case above (PA-2). The police officer added that his file stated: ‘He saw his wife giving money to her daughter. He had just been laid off from a job in Saudi Arabia. As he saw his wife give the money, he killed them both’. The patient-prisoner's natal family brought him to PIPC. His file mentioned that when he was initially brought to the prison, he saw knives and daggers. Meanwhile, he was also being regularly taken to the court and medical opinion was used by the judge to declare him unfit to face trial. The police officer told me that the patient-prisoner thought he was justified in killing his wife. According to the police officer, the patient-prisoner ‘kept saying that his wife bewitched him and that he wanted to kill everyone who was doing magic’. In some cases, unlike the case of committing blasphemy, the police officer was reluctant to fully accept the justification that the act took place completely under the influence of supernatural entities, revealing that instead of treating all delusions in a similar manner, officers differentiated between medical causes of delusions from cases when the patient's religious piety and closeness to the divine may have caused an act. The police officer narrated while laughing that the patient had said that he was ‘on Allah's mission. He could take a spiritual flight (parwaz) and could do anything. He said that he could kill whoever stood in the way of aman (peace). He talked about some Baba Hassan who gave him orders which he followed. In his mind he wasn't human. He could fly everywhere in the world’. The police officer (PO-3) told me that the patient contested the medical report about his illness; in other words, the patient did not consider himself to be sick, and also challenged the medical view that about having killed his wife in desperation. The court opined, based on a medical view, that since he had no memory, his testimony could not be taken seriously. This emphasis on the medical diagnosis was in his favour, given that he had confessed to the murder of his wife and daughter. This meant he could be deemed unfit to stand trial; his explanation of a cultural reason was not likely to be accepted as a reason to walk free from the crime, either in the court or in his community, although this claim of bewitchment corresponded to the cultural and religious setting, allowing him to avoid or at least delay the sentencing. These deliberations by the court were attached with orders from the Supreme Court not to give decisions on any cases in which the patient-prisoner suffered from mental illness, relying upon the Safia Bano case. As I have already shown, many police officers did develop sympathy with patients with delusional conditions, viewing it as a sign of divine inspiration. Such differing religious and medical frames may raise interpretive ambiguities around illness and add to the experience of bureaucratic violence. With clear psychiatric causes, such cases still evoked ambiguous responses from state officials.
There are other cases whereby the state processes operate to expand psychiatrization by seeking psychiatric causes for a crime, even when they are missing. While technically the Safia Bano decision is meant to make mental illness a mitigating factor, such state processes now expand suspicion of an underlying psychiatric condition as the cause of crime, even for those arbitrarily incarcerated, due to family feuds or the state's policing efforts, for no actual crime. These individuals are then screened for mental illness to ensure that they pose no harm to their communities. Therefore, psychiatrization of crime is an unintended consequence of the effort to screen incarcerated people for mental illness and is expressive of the larger phenomenon of bureaucratic violence above—namely, of delays, incarceration, and conceptual ambiguities around whether the person had criminal intent or was made to commit a crime due to mental illness.
Psychiatrizing the Prisoner
One of the byproducts of the Safia Bano case has been the need to produce evidence about mental illness, even when illness does not exist, and this has had ramifications for patients’ feeling stuck in the legal process. This is a different experience of stuckedness than the cases above, in that there is an attempt to find an illness even when there is none. One former patient-prisoner (PA-4) from Toba Tek Singh claimed that he did not ‘have any problems’ but was still incarcerated and taken routinely for psychiatric assessments. He said that during his psychiatric evaluation he was asked if he consumed charas,17 and from that point on, he would be assessed routinely for his psychiatric problems. He noted that police officers agreed that there was nothing wrong with him, and that he would just need to do sullah (agreement) with the victims. When I asked about what exactly had happened, he said, ‘I used to work as a day labourer at a place. A person told me not to come to the work site. The person started cursing my mother and sister. I went back home, got a knife, and stabbed him’. The former patient continued, ‘The police kept asking if I was trying to kill him, but you tell me if someone uses curse words for your mother and sister, what would you do?’’ The file mentioned that he did not have any hallucinations. The file mentioned that when he was initially brought to the prison, ordinary responses, such as not looking others in the eye (nazar chura raha tha), were taken as signs of illness. I interviewed another former prisoner (PA-5) who said that he had been caught on the charge of possessing charas in Faisalabad. ‘The police claimed that I carried charas. The reality was that my father had some land which was originally his sister's. It had a good yield, and someone was trying to buy it. My family resisted, so the big man colluded with the police to get me arrested for possessing drugs’.18 This indicated the larger historical trend toward the accusatory use of psychiatric discourses within communities for which state institutions were coopted. This example revealed how the search for psychiatric causes could even extend one's time in prison, until enough evidence through psychiatric screening had been collected for a person to dispute the charge. One might think that the inclusion of psychiatric screening would provide relief to people with sicknesses who would otherwise receive rigorous sentencing, but frequently, this only extended a person's experience of incarceration. The patient-prisoner (PA-5) then told me, ‘The police officers felt bad that I was being screened and my time in prison was being extended’. He then added melancholically, ‘Even the strongest can become mad like this’ (aisay tou baray baray pagal hojayein).
Conclusion
The historic Safia Bano v. Home Department ruling allowed for humanitarian considerations to stall death sentences. However, the unintended consequence has also been that patient-prisoners experienced different types of bureaucratic violence alongside community policing, for example, being wrongly accused of mental illness to settle scores, or being denied an inheritance. This article takes mental illness as a negotiated category moving from communities to prisons and courts. The experiences of prisoners, patients, and state officials, inclusive of psychiatrists, police officers, and judges, show the attitudes toward the relationship between psychiatric illness and crime. Patient-prisoners continue to experience delays and neglect; in some instances, there is arguably over-psychiatrization of their conditions as state agents endeavour to find psychiatric causes for crime even when they are missing. In the official settings, this is combined with an under-psychiatrization, where state officials within carceral settings impose their own definitions of illness and its causes and also create demands for prisoners to comply and demonstrate recovery despite their illnesses. Yet the use of multiple diagnoses, especially when the patient-prisoner experiences psychosis, informs attitudes and approaches where patients’ own supernatural beliefs about illness also end up influencing the state officials’ carceral attitudes. Prisoners also seek to reinterpret the causes of their crimes in unsuccessful bids to evade culpability. This happens alongside situations where persons can be forced to become well in order to face punishment. These forms contradict the state's emphasis on humanitarian approaches following the Safia Bano ruling that made mental illness a mitigating factor, and show the complex bureaucratic arrangements that impact diagnoses and punishment.
Acknowledgements
The research for this article was supported by the American Institute of Pakistan Studies Junior Research Fellowship. I presented parts of the article at the American Institute of Pakistan Studies Emerging Scholars Symposium held at the University of Wisconsin-Madison South Asia Conference in 2022, where I received valuable feedback from colleagues and mentors. I also presented an earlier draft of this article at the American Anthropological Association Conference in Toronto in 2023 as part of a panel co-organized with Thomas Thornton on incarceration and religion, where I received excellent feedback from discussants Jessica Cooper and Harini Kumar, and learned greatly from the insightful papers presented by Thomas Thornton and Tamara Kohn. Finally, I want to express my gratitude to Narmala Halstead, the editor of Legal Anthropology, for facilitating the review, and to the anonymous reviewers for their generous feedback.
Notes
Drawing from Garcia (2010) and Sufrin (2017: 88), I use the word ‘patient-prisoner’ to refer to the experience of punishment and care that participants experienced.
During the hearing of the review petition, Justice Manzoor Ahmad Malik stated, ‘The Apex Court of the country has been called upon, through this Larger Bench, to determine questions relating to culpability, competence to face trial, and execution of sentence in case of those accused persons and convicts who are suffering from mental illness. These determinations need to be made while considering the latest jurisprudential, legislative and medical developments on this subject’ (C.R.P. 2016).
Zahir Jaffer murdered a woman by beheading her and pled to being mentally ill with the expectation of avoiding the death penalty (Daily Pakistan 2021).
As Towghi (2012) has shown in the context of Pakistan, problems of accessing healthcare leads to physicians conducting dangerous and invasive surgeries, especially given the difficulties of following up with patients living in rural Pakistan.
The name of the state-run psychiatric hospital has been pseudonymized.
The Pakistani state has led operations against ‘Islamic militants’ since 9/11 which have consisted of several full-blown operations in the country's frontier bordering Afghanistan (previously known as the Federally Administered Tribal Areas), and more covert operations and attempts to control the risk of militancy through a protracted conflict which continues to this day. This conflict, however, has also led to increased surveillance of urban life and public spaces, through check-posts and a routine military presence in the major cities.
The administration of the British Raj enacted Hate Speech Law Section 295(A), a part of the Criminal Law Amendment Act XXV. This made it a criminal offence to insult the founders or leaders of any religious community (Nair 2009). After creation of Pakistan in 1947, anti-blasphemy laws and clauses were introduced in Pakistan's Penal Code.
The use of laws to regulate public order means that minorities such as Christian groups continue to be targeted. NGOs such as the Justice Project Pakistan have been advocating for reductions in sentencing for prisoners with mental illness and providing safeguards against many of the country's laws instituting harsh punishments, such as executions, instead of rehabilitation. This was not met with much favour by some police officers who would refer to ‘NGOs’ colloquially, and often disparagingly, when I asked them about the treatment of prisoners with mental illness.
Instead of doing away with colonial-era blasphemy laws, the country's national assembly as recently as 2023 has expanded these to include blasphemy against the companions of the Prophet, a move used increasingly by populist leaders to attract religious supporters (Kuru 2023).
In the article I use PO for police officers, PS for psychologists and PA for patients.
The treatment of patients as malingerers has a long history. The physician, Edouard Brissaud, introduced the term ‘sinistrosis’, which he considered to be a workers’ disease characterized by patients’ refusal to return to work until they received financial compensation (Fassin and Rechtman 2009); progressive legislation in Germany resulted in what has been known as ‘compensation neurosis’ (ibid). Elsewhere I have discussed histories of treating soldiers as malingerers in colonial India (S. Khan 2022).
This represented a move from an earlier mode, as highlighted by Foucault (1973/1974), under Jean-Étienne Dominique Esquirol and Phillippe Pinel, whereby the patient's as-if structures would not be dismantled but actively used for treatment (see also Das 2020).
Two of the tests mentioned in the file included the Minnesota Mental Test and Standard Progressive Tests.
Borderline cases can create new confusions and new accusations about malingering and thus new disciplinary pressures, as Lester (2009) reminds us.
Jins here used for sexual organs is used for gender also used in the words jinsi harrasa to refer to sexual harassment. The word is different from jinns used in Islamic context for spirits.
Jinns evoke ambiguous responses and are sometimes claimed to be Hindus in Pakistan, reflecting perceptions of minorities as using occult practices. They can bring both divine inspiration and misery, as they are attracted to both good and evil, with human-jinn relationships constantly evolving and offering visions intothe spirit world (N. Khan 2006). Jealousies, intertwined with religious differences, lead to bewitching of rivals. Jinns also voice historical events like partition and displacement, blurring distinctions between past and present, and allowing personal experiences of political history (Taneja 2017).
Charas is a part of the cannabis plant and a psychoactive drug.
The possession of drugs has not been decriminalized in Pakistan. Drug possession charges for a few kilograms, under 9-C of the Control of Narcotics Substance Act 1997, are frequently used as the basis of arbitrary incarceration for up to nine years; see, for example, ‘Taxila drug peddler gets nine-year jail term’ (Our Correspondent 2024).
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