The new Danish psychiatric law which has been under development for a while has just been passed by the government and is due to be implemented on 1st June 2015. However the road to this new law, ostentatiously to improve the rights of the patients, has had an interesting history. Among other things:
This was the headline of a featured article in one of our more serious national newspapers. The purpose of the article was to highlight that the Danish state wishes to reduce the amount of forced treatment found within its psychiatric hospitals, something that has been a goal, albeit an unsuccessful goal, for many years. In fact the latest statistics were in some areas the highest ever particularly with regards to children. Denmark was on its way to achieving the dubious title of European champion in the number of people subjected to physical restraints according to the European Committee for the Prevention of Torture.
Yet for me the wording of the newspaper title was extraordinarily offensive. A national newspaper was asking the non-compliant patients, on behalf of the government, which kind of ‘torture’ they would prefer. Yet incredibly, this is not what will be seen. What the general public will see is something so normal as to be banal, in fact many probably think it is actually an act of kindness to enquire as to whether the patient would prefer being put in belts, force medicated, forced ECT, secluded or other types and combinations of involuntary treatments. Few will pause to question and think, perhaps we need to seriously start looking into alternatives. Such is the power of psychiatry that the very language of its human rights abuses has been medicalized, neutralized and normalized, rather like the euphemistic term ‘collateral damage’ meaning civilians, men, woman and children have been killed.
At the same time as opening up for choices as to which kind of forced treatment patients can choose, some now also have a new choice force treatment available to them. From the 1st of June shackling will officially be allowed. This practice colloquially known as “Guantanamo style belts” has been allowed on a trial basis for the last 4 years in forensic psychiatry and will now be made permanent. Sadly, forced community treatment which has also been trialed for the last 4 years has been granted a further 4 years trial.
Likewise, in the wake of the massive critic for putting so many people in restraints, Denmark has initiated a policy to reduce the number and open some restraint free wards. Though they have not been in existence long, our fears that belts will be replaced with forced medication is already being fulfilled as could be seen in the newspapers a few days ago. A 9% reduction in restraints but a 12% increase in forced medication.
Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment of Punishment Juan E. Méndez couldn’t make it clearer when he in a statement to a session of the United Nations Human Rights Council in Geneva on March 4, 2013 called for a ban on forced psychiatric interventions including forced drugging, shock, psychosurgery, restraint and seclusion, and for repeal of laws that allow compulsory mental health treatment and deprivation of liberty based on disability, including when it is motivated by “protection of the person or others.”
However, just recently I discovered that in the preparation for this up and coming new psychiatric law, the Danish Psychological Association an association to which I belong also had a recommendation…
“The Danish Psychological Association recommends a more far-reaching legislation in this area [forced treatment], which allows the special psychologists* in psychiatry to prescribe non-medical force treatment on an equal footing with the psychiatrists.”
(*Special psychologists are authorized psychologists who have taken a further 4-year course specializing in adult or child psychiatry. The course is virtually identical to the one doctors take to become psychiatrists.)
I was stunned! At the same time I was convinced that this desire to be a mini-psychiatrist must belong to a small handful and that the majority had, like me, not been aware of such a wish. It turned out it was me who was naïve.
It is important here to state that what you are about to read is not necessarily representative and there can be many reasons for why those who chose to express themselves, expressed themselves in the way they did. I will at the end of this blog try to reflect over possible explanations.
I wrote to a couple of forums reaching potentially 1000’s of psychologists (though some overlap is likely) saying “I am shocked to my core! Do we really want this?” quoting the above text.
This initiated an extremely long group forum discussion,* as apparently me being ‘shocked to the core over psychologists wanting to prescribe non-medical forced treatment’ turned out to be provoking.
*(Personal communications 2015)
“Yes, we want it…”
“But it would be absurd if the [UN handicap] convention overrules what is best for the individual patient.”
“It is as if every time the word force treatment is mentioned, then those who have no experience in this area get a picture of evil psychiatrists with a perverse smile on their lips, stuffing pills down the throats of fixated patients… that’s not how it is in 2015… the change in the law that we want will equate us even more with psychiatrists and thus give psychologists a greater voice in psychiatry.”
“Olga Runciman you have a patient who starts to eat himself… what do you do…?
“Olga, have you ever worked in a psychiatric ward? I ask because I have difficulties imagining that you would be in any doubt if you had.”
“Of course uncomfortable ethical dilemmas arise in our professional work but it is no good hiding our heads in the sand over this. Psychologists have to, literally, enter into the battle. That we at the same time want to work for a more holistic, recovery orientated and less medical model psychiatry –also to reduce force treatment – is in my a opinion not a contradiction”
These are just some initial examples of what my fellow psychologists were thinking with regard to my shocked outburst. I was truly saddened. But then I decided to try and explore why they would want to be prescribers of force asking a series of questions based on the many initial comments.
- [Do you] see mental distress and criminality as related, for example genetically? And just to be clear where I stand I do not accept violence or abuse. If you believe there is a relationship then I am very interested in hearing your thoughts regarding this.
- I feel inspired to quote C. S. Lewis: “Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. [For] those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.” The CRPD exists and we as a country are obligated to follow it, which is why we are in the beginning stages of planning restraint free wards. Why then should we psychologists participate in something that is already covered by another professional group namely psychiatrists? Should we not be keeping our profession pure, ethically and morally? Is the goal to be mini-psychiatrists? I am asking because I am curious, as the desire to be able to prescribe forced treatment is incomprehensible for me and I would like to know what thoughts lie behind wanting this.
- I hope not all psychologists fully share psychiatry’s psychopathological approach to mental distress. I certainly don’t. I also find it very difficult seeing how recovery, forced treatment and psychopathology can go hand in hand. How do you see that as possible?
- Finally would you like to, in time, see special psychologists being allowed to prescribe medication in some form or other?
Hardly neutral questions I agree.
“Olga – I am so extremely tired of being foisted with the assumption that by becoming a special psychologist I become some form of mini doctor pseudo psychiatrist… I don’t; I become a special psychologist […] I really want to focus on the whole person and psychology in psychiatry – and that is why I have chosen to take the specialist education, that means I am allowed to have responsibility and shared decision making with regards to the patient’s treatment… that also includes forced treatment.”
“I have no trouble seeing how forced treatment, psychopathology and recovery can go hand in hand.”
“Olga, just for clarity’s sake do you see it as better that clients who have gone off the deep end and who are viewed as dangerous, are set free to perform extreme violence against themselves or others, or should they be secluded against their will? […] It’s unclear to me what arguments you follow, do you really, literally think that people should just be set free to do whatever they want regardless of their state of mind?”
“I will make it short. I would like to be able to prescribe forced treatment, as I would like to make independent decisions with regards to the patient that I am trying to help rather than confer with a doctor that probably does not know the patient’s case as well as I do.”
“Actually I don’t understand why it has to be only special psychologists that can in the future diagnose and use force treatment.”
Our renomé out in society amongst patients and their families will be damaged if we don’t take responsibility for making the hard and many times difficult decisions and in the end save lives.”
“Well of course psychologists should be able to prescribe forced treatment. There is nothing bureaucratic here that requires specific medical knowledge. Also, we should after a little course in psychopharmacology be allowed to prescribe certain psychotropics under the supervision of a doctor of course. It’s not that difficult to study the same (small) amount of pharmacological/biochemical knowledge that all the residents and interns in psychiatry are in possession of. […] It’s not due to lack of knowledge that has resulted in psychologists not calling the shots. The doctors just got there first, have a good union and keep a tight hold on their professional boundaries. It should be us, with only a little bit of assistance from any old doctor, when it comes to e.g., ECT, intense polypharmacy, detox etc. And yes I would rather be a psychiatrist than a psychologist. At least I would when it comes to their union, power, status, wage, responsibilities and in some situations their lab coats.”
“To use coercion can be an act of kindness. […] just like using forced treatment can be an act of kindness. I would like to take on the responsibility [of forced treatment] and use it compassionately.”
“By the way I am wondering just exactly why forced treatment in psychiatry is so awful? Coercion and violence exists in numerous forms and everyone is exposed to it. Quite often without even noticing it as belonging to the category coercion/assault. Why is it so bad when it takes place in the psychiatric hospital?”
There were very few who wrote that they, like me, did not want the power to prescribe psychiatric coercion.
“I agree with Olga. This is an area psychologists ought to keep away from. Let the doctors do it. I don’t understand at all people who have a need for or feel good about having that position of power.”
And there was one person who joined me throughout this whole discussion
“I just want to say that I understand you and what you are on about – I think. I find it uplifting that there is finally a colleague who dares to speak her mind on behalf of our profession and ask something along the lines of what the f*** are you thinking of?
Since this discussion I have really been speculating. On a personal level the fact that so very few questioned the significance, and the consequences of psychologists aligning themselves so thoroughly with psychiatry and their policy of forced treatment was alarming to me. That my association the Psychology Association that represents among others also me, has that written down as something they are working towards appalls me. And in the end I believe that this has very serious consequences for the trust between a psychologist and client. For if it is implemented it will seriously compromise psychologists in Denmark as the person one can go to for help.
On a larger scale looking at this through the lens of society I think I can see why perhaps this was the face shown by my fellow psychologists. I started out with the heading of a national newspaper asking on behalf of the government the question “what kind of forced treatment would you prefer?” a question that I was unable to wrap my mind around it. Yet it reflects society. I believe that this debate clearly embodies the face of society expressing what is acceptable and politically condoned. This is the norm and there is power and acceptance in belonging to the norm. I do not believe that this is the voice of the majority of psychologists in Denmark but I think the silence of their voices and the candidness and dominance of those psychologists who wish to prescribe non-medical forced treatment clearly mirrors the accepted societal viewpoint on how we view, deem and judge the so called ‘mad’ and sadly highlights the fear of going against the current political tide.
Therefore I want to make a promise that I as a psychologist will:
- Never participate in diagnosing a fellow human being
- Never view people through the lens of psychopathology but instead respect people’s dreadful life stories and the impact this has on their lives.
- Not support the medical model of mental distress.
- Never condone forced treatment.
Instead I will abide by the Convention on the Rights of Persons with Disabilities.