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Mental health in prisons

People with mental illnesses are especially vulnerable during war and its immediate aftermath. Red Cross Red Crescent explores this littleknown theme through the experiences of Jean Rey- Bellet, who has been on several missions for the ICRC, notably in Yemen, and Bosnia and Herzegovina.

Yemen, 1994: four years after the reunification of the royalist north and the socialist south, civil war erupted, prompting a large-scale humanitarian operation. The ICRC sent Dr Jean Rey-Bellet, a retired former director of the psychiatric hospital in Monthey (Switzerland), to Yemen to assess psychiatric needs in prisons. Two years earlier, he had carried out a mission to Tuzla in war-torn Bosnia and Herzegovina with a similar brief. There, mentally ill patients had been driven out of a hospital in a Serb area and left to fend for themselves. Urgent solutions had to be found on the spot to assist a group of people who are particularly vulnerable in wartime.

“In Yemen for 25 years, the ICRC had been receiving regular reports on the situation of the mentally ill in the country’s prisons, where they received no specific treatment,” recalls Dr Rey-Bellet. “But for a long time no action was taken. It wasn’t until the civil war in 1994 that it decided to do something.” Dr Rey-Bellet therefore went to Yemen and visited the main prisons and all the psychiatric institutions in the country. Once a month a Yemeni doctor would visit the prison in the capital Sana’a, where conditions were horrific. They were even worse in Hodeida prison, where the mentally ill were piled on top of one another. Concrete blocks served as beds. In some cases, the inmates were chained. “Overall, the hygiene conditions were appalling,” he recounts. In Aden, meanwhile, in what had been South Yemen and under Soviet influence for years, the situation was better. “Mental illness was recognized. Inmates thus afflicted were given occupational therapy, which in the West formed an important part of the treatment 30 years ago.”

Dr Rey-Bellet came up with a rapid plan of action and submitted it to the ICRC’s Geneva headquarters, which accepted it despite some reservations. And so he headed once again to Yemen to put it into effect, first in Sana’a, from 1995, and then gradually extending it to two other prisons, Taïz in 1996 and Ibb in 1997. “It would have been impossible, and pointless, to set up a psychiatric unit in each prison. From the start, the idea was to group all the mentally ill inmates in the country in these three prisons.” In the capital, the ICRC hired a psychiatrist and a nurse to follow up each case regularly and supply them with the necessary drugs, which were very costly. Their first task was to determine which of the inmates were genuine detainees and which were mentally ill people who had simply been picked up in the street. They then had to establish each patient’s identity in order to create individual medical files.

The ICRC had already substantially refurbished the Sana’a prison (installing electricity, sanitation, running water and drains). It rounded off this work with the wing for mentally ill inmates: buildings were repainted, an exercise yard kitted out and a kitchen garden created to enliven their existence. Following a training period, Yemen Red Crescent Society volunteers served as nurses. “When we started in Sana’a prison, there were 102 mentally ill inmates, of whom 14 were not proper detainees, in that they had not been through the courts. As the programme took effect, the number of ‘non-detainees’ increased because the families put pressure on the warders to let them in so that they could receive free care”, says Dr Rey-Bellet.

Today, the project is fully financed by the Netherlands Red Cross. In 2000, Dr Rey-Bellet passed the baton on to his son, a doctor at the Geneva psychiatric hospital, thus ensuring the continuity of a programme that had reached cruising speed. Looking back, he wonders why the ICRC was so reluctant to get involved in this project. “It didn’t fit into the institution’s mission, since it is more of a development issue,” he ponders.

In any case, the dynamic set in motion in Yemen has achieved is main goal. “Instead of being ‘guarded’, the patients are treated — even if the treatment is sometimes quite basic. At the same time, the different actors in the health sector in Yemen have organized themselves to work in a concerted manner,” he says.

In the psychiatric section of the Taïz central prison in Yemen.
©Till Mayer / ICRC










Sana’a central prison, psychiatricsection. Since 1995the ICRC, together with theYemen Red Crescent Society, has supported mentally ill inmates through various projects, including sports programmes.
©Till Mayer / ICRC


Samuel Gardaz
Samuel Gardaz is a freelance journalist based in Geneva.


From theory to practice

Dr Jonathan Beynon, head of prison health at the ICRC in Geneva, explains the current thinking in the field of psychiatric care in prisons, as well as the main challenges.

Does the ICRC have a specific doctrine on the subject of psychiatry?
Jonathan Beynon: Strictly speaking, no. However, psychiatry as such is only one aspect — albeit an important one — of mental health, which should be viewed as a whole. The ICRC’s concern is to promote the mental health of everyone in the prison environment — not just of the inmates, but also of the warders and the management. After that, its aim is to provide a targeted response to the mental problems suffered by detainees by finding alternatives to imprisonment: treatment outside the prison system, coordination between the prison system and the public health service, etc. With this in mind, in 2004–2005 we came up with a more formal approach, outlined in a document produced jointly with the World Health Organization, which tackles the subject from both the theoretical and the practical points of view. If we did have an official doctrine, this document would form the core of it.

What does it consist of?
It begins with a brief exposé of the current state of affairs: the rate of mental illness in prisons is proportionally higher than in the rest of society. In many countries, detention has a very damaging effect on mental health; in some cases, mental patients are kept in prison because no suitable medical alternative exists. On the practical level, the document recommends that, as a basic rule, people suffering from mental illness be directed first to ad hoc medical facilities, even if it means they are sent to prison at a later stage, provided that once there they receive appropriate treatment. For example, one country in Africa had plans to build a prison specifically for the mentally ill and asked the ICRC for its advice. We replied that it was the wrong approach. Basically, our view is that the public health system should be the first port of call and not prison.

What is the main challenge today?
It is the application of the theory rather than the theory itself, for the simple reason that in every country in the world, including in the West, prisons are the most poorly resourced. Our main challenge is therefore to change the attitude of those in power towards prisons.

Is psychiatry sometimes used for non-medical ends in prisons?
Yes, in the way it was practised in the Soviet era, it is still used in some countries to neutralize dissidents under the guise of medical diagnosis. In other cases, psychiatrists or psychologists are used during interrogation of prisoners to detect possible mental weaknesses so that they could be used to extract information. Many people have protested that this is contrary to medical ethics.

Interview by Samuel Gardaz


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