Free legal aid in hospitals for persons with mental illness: Is it helpful? An Indian prospective study.

Background: Legislative backing exists to set up free legal aid clinics in psychiatric hospitals to provide legal assistance to their patients. Aims: This study aimed to assess the utility of a free legal aid clinic running inside a mental health establishment.
Methods: In this prospective study, 71 subjects (chosen via convenience sampling) were recruited. Assessments were carried out at baseline and two months after intake. Legal needs and the legal outcomes were assessed.
Results: Most of the legal issues were either family-related (50.7%) or civil issues (28.2%). A majority of patients (64.4%) had implemented the advice given at the clinic. Those who had implemented the advice had a better legal outcome, defined as either resolution of the legal issue or that the legal issue was in an active proceeding compared to those who had not implemented the advice (P = 0.007).
Conclusion: The provision of free legal aid services in mental health establishments would benefit patients. Copyright:

INTRODUCTION

Ensuring social justice is one of the ways to provide and promote social well-being.[1] The journey toward attaining social justice has several hurdles, and an important action in this direction is the provision of free legal aid. The constitution of India emphasizes providing equal justice to all regardless of economic or other disabilities, including mental illness. This has led to the enactment of the National Legal Services Authority (Legal Services to the Mentally Ill and Mentally Disabled Persons) Scheme, 2015. The act directs the state legal services authority and the district legal services authority to set up legal services clinics at psychiatric hospitals and similar facilities to provide legal assistance to persons with mental illness (PwMI) and their family members.[2] The Mental Healthcare Act (MHCA), 2017 also mandates the provision of legal aid to PwMI by the appropriate government under section 19.[3] Hence, the provision of legal aid in India is a rights-based approach and is legally binding.

The relationship between mental illness and rights violation is bidirectional.[4] PwMI are likely to face social barriers in the form of psychosocial adversities in seeking legal help. Some of these are societal barriers, stigma, discrimination, poor legal literacy, financial constraints, and lack of access to judicial systems.[4] Free legal aid to PwMI has helped overcome some of these barriers. This has been initiated by various hospitals across India in various states such as Bengaluru, Odisha, Cuttack, Tamil Nadu, Kerala, Telangana, and union territories like Delhi.[5678] However, systematic studies evaluating the effectiveness of these legal aid services in India are lacking. One study assessed the perspectives of the beneficiaries of legal aid services and reported a high level of satisfaction among the patients.[9] Owing to the dearth of information in this area and the need for more systematic studies, this study was conceptualized.

The study aimed to assess the utility of the legal aid clinic (LAC) for PwMI. The objective was to understand the legal needs of the patients, the nature of legal help provided, and its outcome through a follow up after two months.

MATERIALS AND METHODS

Study design

The study was conducted at the LAC of the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. This was a hospital-based prospective cohort study, and the sample consisted of both the patients and their caregivers consulting with the LAC. Seventy-one subjects were recruited for this study via convenience sampling. The study period was between June 2015 and September 2016. The Institutional Ethics Committee approved the study protocol. The study sample was contacted after two months of their intake into the study. Fifty-nine subjects could be contacted during the follow up. : A LAC was initiated in the outpatient department of the mental health establishment where the study was conducted. The broad roles of the clinic were providing assistance to patients in court-related procedures, legal advice, legal counseling, legal representation, mediation, and alternate dispute resolution. All these services were being provided free of cost. Legal counseling included guidance concerning a legal matter. Legal advice included interpreting the law to a given set of facts and giving a professional or formal opinion about the situation. Legal representation included legal work that a licensed attorney performed on behalf of a client. (a) Adult patients of either gender from both the out- and inpatient settings, (b) having the diagnosis of a mental illness as per the International Code of Diagnosis-10 as assessed by a clinical interview of a psychiatrist and as per the Mini-International Neuropsychiatric Interview (MINI 5.0), and (c) those who were willing to provide a written informed consent about their willingness to participate in the study. A semi-structured interview schedule was developed for the study. The main domains of the interview schedule were the sociodemographic profile, clinical information, the source of referral and knowledge about the setting, history of the legal issue, the advice obtained at the LAC and the level of satisfaction from the LAC services at the time of the first consultation. A follow-up interview schedule that was administered after two months tapped information regarding the status of the legal issue, whether the advice given was implemented (along with reasons), the clinical condition of the patient and what was planned for the legal issues.

Statistical analysis

Sociodemographic, clinical and legal data were analyzed using descriptive statistics. A Chi-squared test was done for categorical variables. P < 0.05 was considered significant.

RESULTS

Table 1 elucidates the sociodemographic, referral and clinical profile of the patients. The mean age of the patients was 36.6 (±11.2) years. In terms of the sociodemographic profile, a majority were males (56.3%), married (42.3%) and from an urban background (63.4%). Furthermore, a majority of the patients had severe mental illnesses such as psychosis (36.6%) and mood disorders (35.2%).

Table 1

Sociodemographic, referral and clinical profile of the patients

Sociodemographic variables (n=71)	n (%)
Age in years [Mean (SD)]	36.6 (±11.2)
Gender
Male	40 (56.3)
Female	31 (43.7)
Education
No formal education	1 (1.4)
Primary	11 (15.5)
Secondary	33 (46.5)
Graduation	26 (36.6)
Marital status
Single	26 (36.6)
Married	30 (42.3)
Separated	13 (18.3)
Divorced	2 (2.8)
Occupational status
Unemployed	31 (43.7)
Employed	40 (56.3)
Background
Urban	45 (63.4)
Rural	26 (36.6)
Referral details
Need for referral
Treating team-driven	28 (39.4)
Self- or family-driven	43 (60.6)
LAC* consultation by
Patient alone	20 (28.2)
Patient with a family member	14 (19.7)
Family member alone	37 (52.1)
Referred from which department?
Outpatient department	54 (76.1)
Inpatient department	17 (23.9)
Knowledge about LAC was through
Health professionals	41 (57.7)
Self or friends	30 (42.3)
Clinical profile
Primary psychiatric diagnosis
Psychosis	26 (36.6)
Mood disorder	25 (35.2)
Others	20 (28.1)
Duration of illness
<1 year	15 (21.1)
1-5 years	26 (36.6)
>5 years	30 (42.3)

*LAC - Legal aid clinic

Table 2 elucidates the legal profile of the patients at baseline and follow-up and their opinion regarding the LAC. Legal services offered to the subjects approaching the LAC have been categorized into legal counseling (52.1%), legal advice (46.5%), and legal representation (1.4%). A majority of the subjects had family-related legal issues (50.7%), had not sought any legal help in the past (84.5%) and were satisfied with the service provided at the LAC (53.5% - very satisfied; 42.3% - satisfied). On follow up after two months, there was a significant association between those who had implemented the advice and those who had a better legal outcome in terms of either resolution of the legal issue or that the legal issues were in an active proceeding in comparison to those who had not implemented the advice (P = 0.007).

Table 2

Legal profile of the patients at baseline and follow-up and their opinion regarding the legal aid clinic

Legal details (n=71)			n (%)
Duration of legal issue	< 1 year		22 (31.0)
	1-5 years		33 (46.5)
	> 5 years		16 (22.5)
Relationship of the legal issue with the clinical condition	Unrelated		17 (23.9)
	Related		54 (76.1)
Type of legal issue	Criminal		1 (1.4)
	Civil		20 (28.2)
	Family		36 (50.7)
	Mediation		1 (1.4)
	Employment- or education-related		3 (4.2)
	Involuntary admission		10 (14.1)
Civil issues	Wills		10 (14.1)
	Property		10 (14.1)
Family issues	Divorce		10 (14.1)
	Division of family assets		9 (12.7)
	Separation and maintenance		11 (15.5)
	Domestic violence		6 (8.5)
Previous legal help sought before reaching LAC	Yes		11 (15.5)
	No		60 (84.5)
Level of satisfaction with the service provided at LAC	Very satisfied		38 (53.5)
	Satisfied		30 (42.3)
	Not satisfied		3 (4.2)
Follow up profile of patients (n=59)			n (%)
Whether the legal issue was being affected by the clinical condition?	Yes			25 (42.4)
	No			34 (57.6)
Would the subjects recommend the LAC to others?	Yes			50 (84.7)
	No			2 (3.4)
	Maybe			7 (11.9)
Relationship between the implementation of the legal aid and its legal outcome (n=59)
	Cases either resolved or in active legal proceedings (n=36)	Cases that are at the same status as at the time of first consultation (n=23)	χ 2	P
Advice implemented	28 (77.8)	10 (43.5)	7.2	0.007
Advice not implemented	8 (22.2)	13 (56.5)

DISCUSSION

The key findings of this study are that most of the legal issues were either family-related (50.7%), such as divorce, division of family assets, separation and maintenance, and domestic violence, and civil issues (28.2%), such as wills and property-related issues. A majority (64.4%) had implemented the advice given and reported that they would recommend the LAC to others (84.7%). An earlier study conducted in 2018 highlighted the perspectives of the service users.[9] In this study, a majority had reported that the LAC services were useful and that they would recommend this service to others. However, this study looks into the legal issues in greater detail.

It would be beneficial to identify legal issues at the time of admission and detailed evaluation to potentially improve legal literacy and awareness among patients and their families. On follow up after two months, the number of cases that were either in active legal proceedings or had resolved was significantly higher among people who had implemented the advice compared to those who had not. Hence this is a strong indicator of the progress of the legal issues of the patients with the help of the LAC.

Legal issues in PwMI are not uncommon as emphasized earlier.[410] Hence, the clinicians need to exercise sensitivity during assessment and evaluation to consider legal issues as a prospective factor in the patient’s treatment and recovery plan. As most of the patients benefitted from the interventions of the LAC, we have preliminary evidence to suggest that they are helpful. However, two months is a short period to assess a legal outcome and hence long-term studies may be needed.

There are LACs in law school campuses that have come into shape after the mandatory requirement from the Bar Council of India.[11] Similarly, MHCA 2017 mandates the provision of legal aid services to PwMI.[3] Mental health establishments (MHEs) can become excellent avenues for establishing and providing such services. MHEs across India such as Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) in Ranchi, Institute of Human Behaviour & Allied Sciences (IBHAS) in Delhi, Institute of Psychiatry (IOP) in Kolkata and several others have already started legal aid clinics.[1213] There is a need to generalize this to other MHEs as well to implement the provisions of the National Legal Services Authority Scheme, 2015.[2] It would be essential to collaborate with legal services authorities and other nodal agencies for the same. Also, the activities of the LAC should not be restricted to only providing legal advice and legal counseling. Other legal issues like public interest litigations or treatment-related issues might also be pertinent. The functioning of these LACs would also have to resonate with the functioning of the Mental Health Review Board that would be set up as per the MHCA, 2017. A very short follow-up period, convenience sampling method, limited range of legal aid services, and social desirability bias pertaining to questions related to recommending LACs to others are some of the limitations of this study.

CONCLUSION

Patients have sought legal intervention most commonly for family issues followed by civil and involuntary hospitalization–related concerns; invariably, in a majority of the cases, these legal concerns were related to their clinical condition. Furthermore, the use of LACs by PwMI has provided them assistance in working their way through specific legal matters in a majority of cases. The presence of such a facility in MHEs is of much utility as it is an easily accessible avenue to address the medico-legal needs of patients with mental illness.

Ethical considerations

The Institutional Ethical Committee of NIMHANS approved the study protocol.

Informed consent from all the study participants was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.