Back to Peter
Lehmann Publishing
Published in: Michel
De Clercq / Antonio Andreoli / Suzanne Lamarre / Peter Forster (eds.),
Emergency Psychiatry in a Changing World. Proceedings of
the 5
th World Congress of the International Association
for Emergency Psychiatry, Brussels, Belgium, 15-17 October 1998
(International Congress Series No. 1179). Amsterdam / Lausanne /
New York / Oxford / Shannon / Singapore / Tokyo: Elsevier 1999,
pp. 95-104 /
PDF
Peter
Lehmann
Psychiatric Emergency-treatment: Help Against One's Will
or Action of Professional Violence?
European
Network of (ex-) Users and Survivors of Psychiatry, Berlin,
Germany
Abstract. Treatment with toxic psychiatric drugs and electroshocks,
bearing risks of irreversible brain damage, are dangerous interventions
into the bodily intactness. Especially neuroleptics, the atypical
ones included, can cause diseases and death. In general psychiatric
treatment doesn't deal with the causal problems that lead to the
commitment. Often human and civil rights are offended in psychiatry.
Funding for user-run or user-controlled alternatives are necessary.
The Berlin runaway-house, beside other alternative institutions,
shows that psychic crises, which usually lead to commitment and
forced treatment, can be managed without psychoactive drugs and
means of coercion. Psychiatrists asked what they would want for
themselves in psychic crises were afraid to be treated as their
patients are. "Participation of the users" and "innovative
approaches" should be the key words of reforms, new approaches
should be based on the needs and interests of clients and users.
Information, prevention and activities focusing on the major threats
to health should have high priority, human beings in psychosocial
emergency should have choices. Especially the withholding of choices
turns psychiatric emergency-wards into dictatorial institutions,
undignified in a society understanding itself as free and democratic.
Key words: alternatives, forced treatment, human rights' violation,
refuge, treatment-damages, user-participation.
Emergency treatment and the European Network of (ex-)users
and survivors of psychiatry
In general psychiatric emergency-treatment is to equate with
oppression of disturbing and uncomfortable ways to live and feel
by means of psychotropic substances or electroshocks without informed
consent. Based on their position of power, guaranteeing the status
quo, there is a tendency by helpers/professionals to interpret
emergency-treatment as help against one's will. Many treated persons
however conceive of this treatment as withholding of human support
and of professional violation of human rights, especially the
right of freedom of bodily insult.
A wide range of perspectives to enhance the situation of the
(ex-)users and survivors of psychiatry have been highlighted by
the European Network of (ex-)Users and Survivors of Psychiatry.
By the way, the term "user" refers to people who have
mainly experienced psychiatric diagnosis and treatment as helpful
in their specific situation. The term "survivor" in
turn refers to those who have mainly experienced psychiatric diagnosis
and treatment as posing a danger to their health and life. These
definitions are often misunderstood: to "survive psychiatry"
does not mean that psychiatrists are being accused of trying to
intentionally maltreat or kill people; but it does mean that diagnoses
such as "schizophrenia" and "psychosis", which
very often have a depressing and stigmatising effect, leading
to resignation and chronic hospitalisation, must be prevented
and that drug-effects such as neuroleptic malignant syndrome,
tardive dyskinesia, febrile hyperthermia, pneumonia, asphyxia
and other dystonic or epileptic attacks, which can pose a danger
to health and sometimes even cause death, have to be survived.
The unifying element in the European Network is dissatisfaction
with the psychiatric system. This again does not deny problems
that have to do with psychosocial stress or with mental ill-health
and mental disorders; nor does it deny that some of the treated
persons are fully satisfied with the treatment.
Dangerous treatment forms
Many actual forms of professional action even if they happen
in the framework of health promotion might even unintentionally
enhance marginalisation processes, so the report "Promotion
of mental health on the European agenda" is stating [13].
According to thousands of reports, psychiatric treatment, especially
electroshock and psychiatric drugs such as neuroleptics and antidepressants,
can cause a deterioriation of mental health. Neuroleptic drugs
can lead to apathy, a state of absolute emotional deadness, depression,
suicidal states, confusion, delirium and intellectual disturbances.
Antidepressants and lithium can lead to apathy, depression, suicidal
states, loss of creativity and lack of concentration. Antiepileptics
(administered as psychotropic drugs, e.g. carbamazepin) can lead
to apathy, paradoxical agitation, lack of creativity and epileptic
attacks. Psychostimulants (administered to children in order to
subdue them) can lead to apathy, depression, paradoxical agitation
and memory problems. Tranquillisers can lead to lethargy, suicidal
states, paradoxical agitation, sensory problems and memory gaps
[9].
Even if many individuals feel that they cannot continue to exist
in their present life-conditions without taking psychiatric drugs,
the treatment may still cause a deterioration of their mental
health by, among other things, lowering their emotional resilience,
impairing the conditions for psychosocial development and life
skills, reducing their capacity to deal with the social world
and to recruit the support that could be provided by other people,
and diminishing their capacity to participate in the common effort
to improve the environment and other conditions of life. Drug-caused
receptor changes cause other mental-health-problems, making the
life of many patients even worse and preventing them from having
equal opportunities in life. The treatment may, thus, result in
increased risk of marginalisation, disability and death.
Indeed, as a result of suicide and other causes of death, the
mortality of psychiatric patients is markedly higher than that
of the population in general.
Neuroleptics, antidepressants, lithium, antiepileptics (administered
as psychotropic drugs), psychostimulants (administered to children
in order to subdue them) and tranquillisers can have severe, permanent
and even lethal effects. The psychologist David Hill from the
British organisation MIND has estimated that, by 1992, 190,000
people were known to have died from the neuroleptic malignant
syndrome, a so-called side-effect of neuroleptics without
taking into account the huge number of unrecorded cases [cf. 10,
p. 98]. Another example is the above average incidence of breast
cancer among female psychiatric patients: the rate is 3.5 times
higher than among patients in medical hospitals, and 9.5 times
higher than in the average population [5; 10, p. 98]. This obviously
has to do with increased production of the hormone prolactin,
another so-called side-effect of psychiatric drugs. This effect
you can see at all kind of psychiatric drugs, of course at the
modern atypical neuroleptics too. Especially these drugs are suspected
to produce chronic psychosis and blood diseases in a higher rate
than the conventional neuroleptics. The risk of clozapine, an
older atypical neuroleptic, to cause agranulocytosis, leading
to death in a rate of 50%, is well-known. Remoxipride, a modern
atypical neuroleptic, was introduced in the German market in 1991
as "rose without thorns", that means neuroleptic without
side-effects; three years later it had to be withdrawn from the
marked again because of deadly blood disorders [10, p. 133). Since
1978 it has been mandatory in the USA to make information available
on the fact that rats which receive neuroleptics in maintenance
treatment and in comparable dosages may start to develop neoplasm
in breast glands that may result in tumours. All literature is
showing that especially neuroleptics, even so-called low-potent
neuroleptics, can produce irreversible and life-threatening damages
already after a short time of application and principally dosis-independently,
and sometimes one so-called mini-doses can lead to a life-threatening
bodily disease (for example asphyxia as a result of aspiration).
This emphasises the necessity of receiving informed consent when
administering psychiatric drugs. It is the perspective of the
European Network to implement or strengthen users', ex-users'
and survivors' rights to self-determination at all levels of the
psychiatric system.
A controlled survey on quality of care
A quality-of-care-survey, made in 1995 by the German Bundesverband
Psychiatrie-Erfahrener e.V. (German association of human beings
who have experienced psychiatry) shows the catastrophic situation
for the people treated in emergency psychiatry. Over 100 members
of the organisation had participated in the survey, which was
suggested by the psychiatric magazine 'Sozialpsychiatrische Informationen'.
The results:
"Mainly 'no' was answered to the question asked, whether
they dealt with the special problems, which lead to admission
into the madhouse. Only in about 10% of the cases they obviously
dealt with the causal problems. (...) To the question, whether
human dignity was respected without limit, there was a similar
shameful result. We can assume in only 10% of the cases that
this is correct, many a person came by his respective her own
will, but the psychiatrists put them on the closed ward and
forced them to take psychiatric drugs. Partly (10%) of the ill
people were tied up on the bed and were given injections in
a too high dosage. 'They laid me in a cell without a bed on
the naked floor and locked me in over night.' The term 'cell'
instead of 'patient's room' often appears. Complaints about
authoritarian and indifferent staff, arrogance instead of ability
to empathise, fixation, injecting down, isolation, beating indicate
almost in all cases humiliating treatments. According to the
answers the patients' will was ignored in 90% of the questioned
people. (...) To the question, whether psychiatrists gave complete
information to the persons suffering about the risks and side-effects
of treatment-measures, in not one case was the answer 'yes'.
(...) Only seven of the questioned 100 people could have had
sufficient time to reflect offered treatment-forms and speak
with persons of trust about them. (...) Only 10% of ill people
could decide freely, that means without any fear of the consequences
of rejection." [18, pp. 31-32]
These results differ from published results of surviews made
by psychiatrists themselves mainly from three reasons. The questions
were formulated by people who experienced psychiatric treatment
themselves. The answers were given outside of the psychiatric
sphere of influence, so the answering people did not have to be
afraid to get punished at some time. (Ex-)users and survivors
of psychiatry participated at the analysis.
Funding and appropriate help
Funding is necessary to create effective social and emotional
support controlled by (ex)users and survivors of psychiatry themselves
and by people they trust. Therefore the European Network favours
runaway-houses, crisis spaces and communication centres combined
with self-help offers, without registration and without compulsive
methods [11]; supportive institutions to which people do not have
to be removed by police-force, but where they can go with trust
instead of fear, even when they are emotionally extremely stressed,
at their wit's end or confused.
Without underestimating the responsibilities and potentials of
health and social care institutions and of working life, we urgently
need to enhance the situation of the so-called mental patients
in emergency-situations. "Participation of the users"
and "innovative approaches" should be the key words.
New models of support in emotional crises, without the risk of
causing a deterioration of mental health or increased marginalisation
as a result of professional action, are needed. These approaches
should be based on the needs and interests of clients and users
to a greater degree than they are at present. Information, prevention
and activities focusing on the major threats to health should
also have high priority.
There is a basic need to put discussion of alternatives to current
psychiatric institutions on the political Agenda. We need a public
and open discussion about innovative approaches to the development
of better concepts, about methods of evaluation and sets of indicators
relating to mental health and its promotion, and about the development
of better methods for enhancing the visibility of the best national
and European models of promotive work.
Example Berlin Runaway-house
One example of an appropriate and user-controlled institution
is the Berlin runaway-house. The runaway-house is an institution
for people who have decided that they want to live without psychiatric
diagnoses and without psychoactive drugs. Here they can regain
their strength, talk about their experiences and develop plans
for the future without psychiatric views of illness blocking the
access to their feelings and their personal and social difficulties.
People who are addicted to alcohol or drugs or who are in forensic
care cannot be admitted. In the team ten social-workers, survivors
of psychiatry, psychologists and four short-time employed people
work around the clock. Half of the staff members are survivors
of psychiatry.
The dream of the runaway-house could come true because of a
gift of one million Marks from a relative. With this gift the
Association for Protection against Psychiatric Violence which
is of public benefit could get access to an old villa in the Northern
part of Berlin. With contributions of charitable lotteries, of
sympathizing associations and of individuals (sponsors) the building
was transformed into the runaway-house "Villa Stoeckle".
It was named after Tina Stöckle who had co-founded the project
in its first steps and who died in 1992.
The Berlin runaway-house has been opened on January 1, 1996.
The internationally highly-regarded model-project offers protection
to homeless people who want to escape from the violence of psychiatry
and the effects of revolving-door-psychiatry. The runaway-house
is the first officially run institution in Germany of its kind.
The Association for Protection against Psychiatric Violence (the
supporting foundation behind the house) has fought for ten years
to establish its antipsychiatric project; its continuation is
acutely endangered by administrative acts of caprice.
The nearly three years' experience of work in the runaway-house
has shown that psychic crises can be managed without psychoactive
drugs and without means of coercion. But such crises have put
to a hard test the tolerance of co-inhabitants and staff which
had its limit with the employment of force against others. When
contact with certain inhabitants stopped short or mutual agreements
became impossible, it was difficult. For those reasons some people
have left the project. In other cases inhabitants had to leave
because of alcohol- or drug-abuse. Those who had to go for the
above reasons often returned to living in the street or to psychiatry
because of lack of alternatives. Regularly the inhabitants had
before been treated with psychoactive drugs against their will
respectively without having been informed sufficiently. Their
problems had not been considered [7].
Psychiatrists would want alternatives for themselves
Psychiatric workers know of the suffering, (ex-)users and survivors
of psychiatry experience in madhouses. Again this was a result
at the Congress "Stationaere Alternativen" ("In-patient
alternatives"), held by the Swiss psychiatry-foundation Pro
Mente Sana 1992 in Nottwil/Switzerland. In the working-group "Asylum
for (ex-)users and survivors of psychiatry" male and female
psychiatrists, social-workers and nurses presented their practises
vividly and realistically. They told of a lot of depressing reasons
to run away in case they themselves should get to know psychiatric
practise on their own bodies; in detail they told of
-
force: forced commitment; forced treatment; intimidation
to the stay and the consent to treatment.
-
lack of rights: incapacitation; no information about the
treatment's risks and damages; only the 'yes' is accepted
as legally valid, but not the 'no'; treatment in spite of
current protest at the court; dependence from psychiatric
workers; lack of freedom to decide (being forced to give reasons
for everything); lack of right to look fully at their own
treatment-records; to the choice of madhouse and key worker.
-
treatment: neuroleptics as main treatment. Treatment-setting:
dangerousness of the admission ward; imposed day's structure;
destructive time spent; hours with handicraft work getting
on your nerves; therapeutic work of expression under neuroleptic
armour-plating; forced communication; imposed sleeping neighbours;
permanent control; reduced private sphere.
-
diagnostics: getting reduced to a diagnosis [8, pp. 37-38].
Improving quality assurance in the psychiatric and psychosocial
field
In addition to supporting the development of alternatives and
human and social rights and the exchange of relative information,
the European Network makes proposals to introduce or improve quality
assurance in the psychiatric and psychosocial field. In April
1997 the European Network was asked by the World Health Organisation
to comment on the planned Declaration on Quality Assurance in
Mental Health Care. To promote human rights of people in the psychiatric
system the European Network suggested, among other things, that:
-
(ex-)users and survivors of psychiatry should be invited
to hearings before legislation is enacted;
-
(ex-)users and survivors of psychiatry should be invited
to be ombudsmen and ombudswomen at a national level;
-
there should be a body including (ex-)users and survivors
of psychiatry at a national level to monitor the human rights
of people who have, or who are said to have, mental disorders,
and to record new treatment measures and decisions of ethics'
commissions in research fields;
-
(ex-)users and survivors of psychiatry should be involved
in the education and examination of health and psychiatric
professionals in a paid capacity;
-
irreversible treatments such as psychiatric drugs, electro-
and insulin shock for mental disorders should never be carried
out on an involuntary patient or without informed consent.
Psychiatrists who treat patients without informed consent
should lose their medical licence;
-
clinical trials and experimental treatments should never
be carried out on an involuntary patient without informed
consent. Institutions carrying out any such measures should
be obliged to prove that any damage arising was not caused
by these measures [12].
As for improving of the current situation in psychiatric emergency-wards:
good will could be sufficient. Here are some minimal demands,
made to WHO and WPA by the European Network of (ex-)Users and
Survivors of Psychiatry: There should be phones-boxes for inmates/patients
in each psychiatric ward. There should be easily visible coin-operated
telephones at the entrance halls of each psychiatric institution.
In each psychiatric ward should be an notice easily visible, that
inmates/patients can get writing-paper, envelopes and stamps if
wanted. There are notice-boards in every ward, on which local,
regional and national organisations of (ex-)users and survivors
of psychiatry can put up uncensored information. For each inmate/patient
there should be the offer to have a daily walk in the open air
for at least one hour. On each ward should be a kitchen where
inmates/patients can prepare food and drinks around the clock.
On a medium and long term however the situation will change only,
if
-
you get rid of the scientifically outdated conception of
man, unilaterally dominated by natural science and medicine
that reduces the human being with psychosocial difficulties
to a faux pas of its metabolism that can be manipulated psychopharmacologically
and electrotechnically,
-
organisations of (ex-)users and survivors of psychiatry
can participate in a meaningful way in decision-making structures
and can have control functions, for example, in law-making
processes, in editorial staff of specialist magazines, in
the education and training (including the boards of examiners)
of psychiatrists, physicians, psychologists, nurses, social
workers, occupational therapists on a well-paid level, in
congresses and in bodies that register new treatment measures
and in ethics' commissions in research fields,
-
the legal position of the (ex-)users and survivors of psychiatry
is strengthened, for example, if the institutions and persons
carrying out psychiatric emergency measures are obliged to
prove that possible damages are not due to these measures,
if will declarations in advance (psychiatric wills, treatment
agreements) are acknowledged juridically effective,
-
the psychosocial system meets the needs and demands of the
(ex-)users and survivors of psychiatry, giving the free choice
for everyone whether he or she prefers to visit a psychiatric
hospital or a psychosocial institution outside the psychiatric
system, for example a nonpsychiatric runaway-house or an
institution like Soteria/California).
The right to drug-free care has to be respected both in- and
outside psychiatry. Low risk naturopathic psychotropic drugs,
specialised nutrition (healthy food, vitamins, minerals, proteins)
have to be available and offered [12].
Forced treatment: psychiatry's basic evil
The basic legal problem in psychiatry is forced treatment. Who
can count the people who give the madhouse a wide berth even in
s situation when the know that they need help? Who can count the
people who killed themselves full of fear getting committed and
then treated by force? Who can count the people who had traumatic
experiences with forced treatment? Of course physicians have the
duty to forcefully treat a person that cannot express his or her
natural will rationally and is in deadly danger but whoever
died from a syndrome characterised by a lack of haloperidol? If
people who do not work inside a psychiatric institution do not
know about the dangers and risks caused by the administration
of psychiatric drugs and electroshocks, they may not understand
that fundamental violation of the inviolable dignity which should
be guaranteed by human rights' declarations and national constitutions.
As in medicine in general treatment without informed consent
in emergency-psychiatry has to be interdicted. Only a concrete
provable acute life-threatening situation, in accordance with
the proved impossibility to express the natural will, can justify
a life-saving treatment without consent. But generally speaking
the absence of psychiatric drugs like haloperidol can neither
be a seen as causing a life-threatening illness nor can the application
of psychiatric drugs be definitely considered as a life-saving
measure. So in the emergency-psychiatry treatment without informed
consent has to have consequences based on punitive and civil law.
Patients who think it is good for them to be treated by force
in the state of emergency may make will declarations in advance
to allow forced treatment in their cases.
That forced application is not necessary, but dangerous and antitherapeutic,
is shown by a lot of experiences besides the runaway-house in
Berlin. There is a lot of literature about this issue and experiences
[1-4; 6; 14-17; 19-20]. Another example, where results are possible
if there is good will and the willingness of psychiatrists to
work without force and to communicate with the relatives and friends
of their patients and especially with themselves, is the "open
dialogue"-principle, practised in a certain area in the
northern part of Finland (covering a population of 90000 inh.).
The "open dialogue" is the fundamental treatment-principle:
within 24 hours the staff-member who receives a patient has to
arrange the first session with the patient, some relative family-member
and a group of professionals. In many cases the first session
more or less solves the problems. The session can take place in
the home of the patient, at the hospital or somewhere else. The
idea is to make the many voices speak and not to talk about the
patient without his or her participation. The language amongst
the professionals has to cope with the language of the user (how
free the will of this person ever may be to use psychiatry). In
1997 out of 64 first time diagnosed "schizophrenics"
only 16 were given neuroleptics. This positive Finnish experience
with "open dialogue" as the fundamental principle in
psychiatry should be highlighted and introduced elsewhere in psychiatry
as well as in emergency-psychiatry.
There are psychiatrists who support our demands as there are
psychiatric patients who understandably consider treatment by
force as helpful especially given the lack and withholding of
treatment alternatives. The impossibility to solve this conflict
gives evidence of the following: A positive reform of the situation
in emergency-wards is only possible under the following conditions:
with the enhancement of the legal status of the (ex-)users and
survivors of psychiatry; with a psychosocially oriented education
of psychosocial workers, integrating the treasure of knowledge
of the people who have experienced psychiatric treatment and coping
with different psychiatric problems; by means of the integration
of the (ex-)users and survivors of psychiatry into all decision-making
structures and their inclusion in treatment-teams (and not at
the bottom of the hierarchy); by financing nonpsychiatric forms
of support for human beings in psychosocial emergency in order
to create possibilities to have and make choices. Especially the
withholding of choices turns psychiatric emergency-wards into
dictatorial institutions, undignified in a changing society understanding
itself as free and democratic.
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Address for correspondence
Peter Lehmann,
E-mail: mail[at]peter-lehmann.de
Copyright by Peter Lehmann 1999