published in: Michel De Clercq / Antonio Andreoli / Suzanne Lamarre / Peter Forster (eds.): "Emergency Psychiatry in a Changing World". Proceedings of the 5th 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
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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, p. 31f.]

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 run-away-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 run-away-house. The run-away-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 run-away-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 run-away-house "Villa Stoeckle". It was named after Tina Stoeckle who had co-founded the project in its first steps and who died in 1992.

The Berlin run-away-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 run-away-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 run-away-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

  1. force: forced commitment; forced treatment; intimidation to the stay and the consent to treatment.

  2. 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.

  3. 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.

  4. diagnostics: getting reduced to a diagnosis [8, p. 37f.].

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:

  1. (ex-)users and survivors of psychiatry should be invited to hearings before legislation is enacted;

  2. (ex-)users and survivors of psychiatry should be invited to be ombudsmen and ombudswomen at a national level;

  3. 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;

  4. (ex-)users and survivors of psychiatry should be involved in the education and examination of health and psychiatric professionals in a paid capacity;

  5. 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;

  6. 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

  1. 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,

  2. 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,

  3. 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,

  4. 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 run-away-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 run-away-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.

References

Address for correspondence

Peter Lehmann, Tel. +49-30-85963706, E-mail: mail[at]peter-lehmann.de

Copyright by Peter Lehmann 1999