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Hans Schanda

PSYCHOTIC PATIENTS AS VICTIMS. OF NEGLECT AND VIOLENCE. Hans Schanda. Vienna, Austria. Treatment and Management of Psychosis. 3 rd Bergen International Conference on Forensic Psychiatry 17th – 19th September 2014.

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Hans Schanda

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  1. PSYCHOTIC PATIENTS AS VICTIMS OF NEGLECT AND VIOLENCE Hans Schanda Vienna, Austria Treatment and Management of Psychosis 3rd Bergen International Conference on Forensic Psychiatry 17th – 19th September 2014

  2. VIOLENCE AGAINST THE SEVERELY MENTALLY ILL Physicalviolence Violence Neglect, rejection, humilation, deprivationofliberty Individual Against individual patients Against ‘thementallyill‘ in generaloragainstparticulargroups Collective

  3.  Looking back  The present  A hypothesis

  4. SOCIETY AND THE MENTALLY ILL 1750 1800 1850 1900 1950 2000 2050 Philippe Pinel [1745-1826] Jean Etienne Esquirol [1772-1840] John Conolly [1794-1866] ‘Treatment oftheinsanewithoutmechanicalrestraints‘ (1856) Robert Gardiner Hill [1811-1876]

  5. SOCIETY AND THE MENTALLY ILL Mental hospitals 1750 1800 1850 1900 1950 2000 2050 Philippe Pinel [1745-1826] Jean Etienne Esquirol [1772-1840] John Conolly [1794-1866] ‘Treatment oftheinsanewithoutmechanicalrestraints‘ (1856) Robert Gardiner Hill [1811-1876]

  6. SOCIETY AND THE MENTALLY ILL NS-regime, systematickillingofmentallyillsubjects Mental hospitals 1750 1800 1850 1900 1950 2000 2050 Philippe Pinel [1745-1826] Jean Etienne Esquirol [1772-1840] John Conolly [1794-1866] ‘Treatment oftheinsanewithoutmechanicalrestraints‘ (1856) Robert Gardiner Hill [1811-1876]

  7. PSYCHIATRIC CARE IN THE PRE-REFORM ERA ◈ Treatment and care mainly in big mental hospitals. ◈Long-terminpatienttreatment, high ratesofinvoluntaryadmissions, lack ofsomatictreatmentoptions, physical restraintin caseofviolent/ disruptivebehaviour. ◈Bothpatientsandpsychiatristsweretargetsofprejudices: ★ The severelymentallyill – in particularthosesufferingfrom schizophrenia – wereregardedaspotentiallydangerous. ★ Mental hospitalswereconsideredasplacesofsocialcontrol, wherepsychiatrists high-handedlyexertcoercionon vulnerable anddefencelesspatients. !

  8. SOCIETY AND THE MENTALLY ILL NS-regime, systematickillingofmentallyillsubjects Mental hospitals 1750 1800 1850 1900 1950 2000 2050 Philippe Pinel [1745-1826] R e f o r m s Jean Etienne Esquirol [1772-1840] John Conolly [1794-1866] ‘Treatment oftheinsanewithoutmechanicalrestraints‘ (1856) Robert Gardiner Hill [1811-1876]

  9.  Improvementofthesituationofthementallyill  Normalizationoftheirspecialpositionofthe mentallyill (andofpsychiatry!) Removalofthestigmatizingsymbolsofrepressionandsocialexclusion. Nodifferencebetween mental andsomaticdisorders. Medicalization Ideology Chlorpromazine [1952] Imipramine [1957]  Quality of life  Insight, Compliance   Coercion   Stigma, social exclusion 

  10.  Looking back  The present  A hypothesis

  11. PREVALENCE OF MENTAL DISORDERS AMONG THE HOMELESSNESS Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in Western countries: Systematic review and meta-regression analysis. PLoS Med 20085(12):e225. doi:10.1371/journal.pmed. 0050225

  12. MENTAL HEALTH OF PRISONERS Prevalence in US-jails 23.9%  ‘The largest facilities housing psychiatric patients in the United States are not hospitals but jails.‘ (p 2081)  ‘Five states now spend more on corrections than they do on higher education.‘ (p 2082) Rich JD, Wakeman SE, Dickman SL. Medicine and the epidemic of incarceration in the United States. NEJM 2011;364:2081-2083 Fazel S, Baillargeon J. The health of prisoners. Lancet 2011;377:956-965

  13. VICTIMIZATION IN SUBJECTS WITH MENTAL ILLNESS

  14. AXIS I DISORDERS IN POLICE FATALITIES

  15. “With respect to mortality, a substantial gap exists between the health of people with schizophrenia and the general community. This differential mortality gap has worsened in recent decades.“ Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia. Arch Gen Psychiatry 2007;64:1123-1131

  16. PATIENTS DIAGNOSED WITH SCHIZOPHRENIA (ICD-10, F20) OR OTHER PSYCHOTIC DISORDERS (F21–29), COMPARED TO OTHER DIAGNOSES LayB, Nordt C, Rössler W. Trends in psychiatric hospitalisation of people with schizophrenia: A register-based investigation over the last three decades. Schizophr Res 2007;97:68-78

  17. NUMBERS OF GENERAL PSYCHIATRIC AND FORENSIC PSYCHIATRIC BEDS AND PRISON POPULATION IN SIX COUNTRIES IN 1990-93 AND 1999-03(Values are numbers per 100.000 population) Priebe S, Badesconyi A, Fioritti A, Hansson L, Kilian R, Torres-Gonzales F, Turner T, Wiersma D. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ 2005;330:123-126

  18. RATIOS OF NUMBERS OF FORENSIC PATIENTS AND BEDS IN GENERAL PSYCHIATRY

  19. MENTALLY DISORDERED OFFENDERS NGRI: DISPROPORTIONAL INCREASE OF PATIENTS WITH SCHIZOPHRENIA AND MINOR OFFENCES ANNUAL INCIDENCES 1990 vs. 2012 60% Threat, compulsion, obstructing a policeofficer 45% 25% Homicide, attemptedhomicide, (attempted) severebodilyinjury 35% 20% 15% Property offences, arson, sexual offences

  20. General psychiatry Forensicpsychiatry Homeless-ness Jail, prison

  21. General psychiatry Forensicpsychiatry Homeless-ness Jail, prison

  22.  Looking back  The present  A hypothesis

  23. “… ‘criminalization resulting from service failure model‘ of offending among persons with mental illness …alone may be insufficient as the basis fordeveloping an adequateunderstandingof the full range of that offending.“ Fisher WH, Silver, E, Wolff N. Beyond criminalization: toward a criminologically informed framework for mental health policy and services research.Adm Policy Ment Health & Ment Health Serv Res 2006;33: 544-557

  24. “… ‘criminalization resulting from service failure model‘ of offending among persons with mental illness …alone may be insufficient as the basis fordeveloping an adequateunderstandingof the full range of that offending.“ society failure model Fisher WH, Silver, E, Wolff N. Beyond criminalization: toward a criminologically informed framework for mental health policy and services research.Adm Policy Ment Health & Ment Health Serv Res 2006;33: 544-557

  25. Society Emotions, ambivalence Mentallyill

  26. Society Emotions, ambivalence Emotions, ambivalence Psychiatry Mentallyill  Suppressed, poorvs.dangerouspatients  Helplessvs.almighty, repressive psychiatrists

  27. Society Emotions, ambivalence Politics, legislation Emotions, ambivalence Emotions, ambivalence Emotions, ambivalence Emotionen, Ambivalenzen Psychiatry Mentallyill  Suppressed, poorvs.dangerouspatients  Helplessvs.almighty, repressive psychiatrists

  28. Society Emotions, ambivalence Politics, legislation Emotions, ambivalence Emotions, ambivalence Emotions, ambivalence Emotionen, Ambivalenzen Forensicpsychiatry ‘Dangerous‘ mentallyill  Suppressed, poorvs.dangerouspatients  Helplessvs.almighty, repressive psychiatrists

  29. Compulsory pharmacological treatment in mentally disordered offenders is unlawful. (Federal Constitutional Court of Germany, March 23th 2011) Absolute ban on all non-consensual medical interventions … including the administration of mind-altering drugs, for both long- and short-term application. (UN-Commission on Human Rights, Statement by Juan E. Méndez, Special Rapporteur on torture and other, inhuman or degrading treatment or punishment, March 4th 2013, Geneva) !?!?! 1856: Treatment oftheinsanewithoutmechanicalrestraints!?!?!

  30. Patients must have the right to refuse treatment. In case of committing a crime they are exculpated due to mental incapacity and admitted to forensic-psychiatric institutions for an indefinite period of time. There they must have again the right to refuse any treatment. In this way society provides forthe permanentand effective, politi- cally and formally correct social exclusionof disturbing individuals. Protection Self-determination Freewill Morality Ethics ?

  31. Thankyou!

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