Friday, September 26, 2014

Involuntary psychiatric care in Sweden: current controversies

Young female patients with self-harm have been treated at forensic psychiatric clinics in Sweden, even if they have never been charged with crimes or convicted. Some have been as young as 16 years of age, placed in the same wards as notorious violent or sexual offenders, prevented from locking their door during the night, and at least one rape in a “high-security ward” has been reported.

Several reports, including an autographical book (End-station Forensic Psychiatry by Sofia Åkerman and Thérèse Eriksson) and an investigative TV program aired yesterday, highlight how illegal forms of restraint have been used routinely at certain clinics, including locked hockey helmets, leather gloves and forearm plasters. A study by Herman Holm and co-workers (Journal of the Swedish Medical Society, 2011) found that the largest group of patients treated under the Involuntary Care Act was indeed young women with personality disorders, and that they had been subjected to physical restraints more often than other groups of patients.

Interstingly, this has been known to the authorities in charge of over-seeing the health care system for many years, and numerous complaints have been filed to the police. Official criticism has been raised, but no doctor or hospital director has been prosecuted, and the public clinics responsible have been more or less let alone by the authorities. Instead, the treatment programmes are slowly being stopped based on “media pressure”.

This shows that psychiatric practice may run a course that is not consistent with the intentions of the legislator, even in flagrant conflict with the law. 

Unfortunately, the last decade has seen the development of a much more repressive psychiatry in Sweden. New clinics are built outside cities surrounded by walls, electronic supervision and involuntary out-patient treatment have become common, and a governmental report has proposed changes that would reduce patient autonomy even further: involuntary care would be initiated among out-patients who have never needed in-patient treatment, a mere professional opinion that the patient needs involuntary care to avoid a relapse would suffice for involuntary treatment and mentally ill persons would be subjected to special measures for “societal protection” after having served penal sanctions.

Fortunately, the only proposal that has come from the government to this day rejected the idea of a “committee for exemptions” that would be able to grant authorization for otherwise illegal measures of restraint retrospectively. According to the proposal, users would not be granted even a single seat in the committee.  

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