Thursday, October 2, 2014

Construction boom in Swedish forensic psychiatry


Since 2000, a large number of new public facilities for inpatient forensic psychiatric care have been built in Sweden. Total nation-wide project costs were estimated at more than 3 billion SEK in 2009, and now far exceed this amount. Some of these facilities represent far superior quality to older, often run-down, services that were generally located in old asylum areas. Nevertheless, some aspects of this “construction boom” are especially problematic and surprisingly little debated. We have published an overview of construction projects run by the regions 2000-2009 here.
  1. No, or very little, national planning and allocation of resources was conducted. Instead, each independent region has created its own solution, leading to the construction of a larger number of high-security places than needed.
  2. Even if the main legislation for forensic psychiatric care has been in place since 1992, a distinct tilt towards more static security and less “home” or “hospital” character came in 2006. The use of electronic surveillance has become routine and, more and more, every person entering the facilities will have to pass through airport-like security control.
  3. There is no regulation mandating that patients should not be treated at a higher security level than they need, even if individual risk assessments are to be performed. In many places, the same patients are transferred from old facilities in residential areas, without obvious security arrangements, to hypermodern buildings behind fences, walls and perimeter safety adaptations. This is a waste of resources, which could be used for treatment purposes instead, infringes on the integrity of patients and staff alike and may contribute to a more prison-like atmosphere.
  4. The hypermodern architecture often has high ambitions, like creating a “therapeutic”, even “healing”, environment. To those naïve to this type of architecture, in need of care, a hospital stay, or sent to the clinics by courts, the impression may be different. Repression is what first comes to mind. Mikaela Aspelin wrote an eloquent piece in the largest Swedish national medical journal Dagens Medicin, providing examples of how security needs had overtaken a new general psychiatric clinic in Lund. Patients presenting at night were met by a video-camera, those hospitalized could not regulate their own curtains, several rooms were allocated for keeping patients in physical restraints and the ECT room was visible from the patients’ yard. In forensic psychiatry, political steering documents have spoken of creating a “Captain Nemo’s submarine” that isolates patients from society, which they could safely regard through bay windows. Other documents have wished for a “no-mans’ land” to surround what is basically a hospital. A “speaker’s balcony” on the administrative building facing the patients’ recreational area was added in one project. And all this has happened while a basically unchanged legislation stresses rehabilitation and reintegration in society.  
   

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