Visit to psychiatric hospital Chisinau Moldova

Today, 14 March 2013, we had the site visit to the psychiatric hospital in Chisinau, Moldova. At 8.30 we gathered in front of Le Roi Business Centre (the training venue) and a minibus came to pick us up. We went with 14 people who formed 2 groups, and I would lead one of the groups. It was the first time that I would lead a monitoring-training-team on site, and I was a little bit nervous/excited for what was to come. I knew that besides dealing with my own impressions, I would also have to be a leader, taking care of the group’s process. That made it extra special, and different from other visits to painful places.

We drove for about 45 minutes before arriving at the psychiatric hospital compounds. The hospital was founded in 1895, and there were many old buildings, some were abandoned and falling apart. The sight of that immediately raised a feeling of neglect and social unimportance. Some old buildings were in use, and also some newer buildings were placed in between. This resulted in a quite messy mix of buildings in a huge park-like area, with a rather long entrance road.

When we arrived we first had a chat with the deputy-director. The administration building wasn’t accessible for wheelchairs, so we went off to the only wheelchair-accessible building: General Psychiatry, to have a chat in the hall.
Basically we let the monitor-trainees ask the questions, and Oliver gave some extra coaching and tips. Then we split up in groups to do an actual monitoring visit (observing and interviewing).

At the third floor there were 2 psychiatric wards: one for males and one for females. My group went to the female ward. I had an interpreter on my side to be able to follow what was said. The members of my group split up further and started interviewing staff and patients. I also took a look around and talked to some persons, while “monitoring the monitor-trainees”. I felt quite responsible, but it appeared that I didn’t have to steer them in their contact-skills, so I just made sure that they could talk in private to the persons they wanted to talk to, and I talked a lot to staff, who seemed quite happy to be heard in their complaints on understaffing and lowered wages and so on. Because I was a kind of facilitator for the group, I couldn’t put my own interests or curiosity on the front, but I went from room to room, touching on every pair of monitor-trainees to check if everything was going fine. It all went well. On both wards that we visited (also the male ward on the fourth floor).

But of course, like any psychiatric institution, it was a painful place. It was actually horrible. There were 60 persons packed in 8 to 10 rooms. The rooms were filled with beds and mainly empty bedside-tables side by side. Most of the persons were in pyamas and laying in bed, severely drugged. There was this typical, disgusting smell of unwashed people in an unventilated ward. Water was cut off for so-called “safety-reasons”, and so was the electricity. The persons got to shower only once a week, in a group shower for 3 persons, which is obviously very degrading. Also the toilet was a set of 3 pots in one room, without any privacy.

The rooms seemed to correspond with a kind of step-programme: the rooms closest to the guard’s office were the rooms for admission and “surveillance” (regime 1.1). The nurse explained: “This is the room for agitated persons” : what we saw was 10 zombified persons laying in their beds… It appeared that the treatment for any mental problem is: knock-out by Haloperidol or Aminazine and laying in bed, just as in the 70s in the Netherlands. Then as a next step (next room, regime 2.1), persons were allowed to walk on the corridor of the ward with supervision of a nurse, sister or carer. The next step (regime 2.2.a) is that they are allowed to walk on the ward on their own, and (2.2.b) go to the caged balcony and go with family (without nurse-supervision). In step 3 and 4.a the persons are allowed to walk out on their own.
This appears to be the regime on all wards (except on the second floor the regime was like a general hospital, for ‘neurological illness’ which were milder, such as depressions). So treatment for any mental problem comprises getting medication and walking around.

There is not any social activity or whatsoever. There is no choice at all, and the administration of medication is often accompanied with force and full repression, including violence and physical abuse.

The place was really unbearable. Many persons told us they wanted out, and one lady was actually climbing on her bed to reach to the barred and locked window, but she was pulled down by the nurse, who was typically dressed in a white dress. Generally 99% of staff were female (only on the male ward there was 1 male corridor-guard). People asked us many things: such as cigarettes, make-up, when they would get out or see their family. It was totally heartbreaking to see people so fully deprived of everything in life, even deprived of having their own feelings - their identity is taken away by being so drugged. They are made totally voiceless, and are treated as objects without a soul. It is so utterly dehumanizing and I had to fight my tears.

The only ‘positive’ was that Moldovan system only arranges for stays of 30-60 days. So the persons might get out of there at some point (as long as they are not immediately returned by the often unwilling community). So they generally aren’t there for years - except in the wards for Forced Treatment, which are the forensic ward with court orders (of which the name suggests that all non-forensic treatments are “voluntary treatment” , but we know better… The signatures for “consent” are forced or done by the guardian, which can be the institution itself).

The entire group was moved by what we had seen in the psychiatric hospital. For some it was the first experience of visiting such a psychiatric institution. But they all learned a lot and they were grateful for getting this opportunity.

It was really great that after half a day, around noon, one member of the NPM showed up at the visit, and also the independent Ombuds-women who is specialized in psychiatry issues joined later. This really made me feel good, like there is hope on building bridges. And maybe my theory of yesterday was wrong. The NPM appeared to be volunteers, who also have another job, which may also be a reason why members weren’t participating in our training. The psychiatric-Ombudswomen is dedicated, but is rather excluded by the rest of the monitoring mechanisms, which puts her in a very hard position.

After the visit, around 14.30 we went back to Le Roi Business Centre, where we had a late lunch in the side-room of the conference-room, which was occupied by another group. We had to be quiet not to disturb the other conference, and everyone was so hungry that we ate our delivered meals in a comfortable silence. At 4 we could use the conference-room for ourselves, and we resumed the training by debriefing the visit, which we will continue to do tomorrow.

What we have seen today was disturbing and terrible. Nobody should have to live like that. Initially for me it was again quite hard and confusing to digest what I had seen, and to relate these experiences to my own experiences. Moldovan psychiatry is so clearly wrong and ill-treatment/torture. In the Netherlands it looks nice and it’s less clear that it’s a violation. It’s hard to say what’s worse: 2 months in full horror, or 2 years in ‘soft-horror’... But after all, there is no need to rank violations. BAD IS BAD, and it should be GOOD.

It’s our duty as human beings to care for another. The horrible deprivations must be stopped, and we should make it right. The devastation of human lives cannot be ignored any longer.

And after all, I find it a pity that I can’t give any substantial training to the staff of the hospital. It’s a missed opportunity, because I do think I could have brought some awareness and ideas. But as a monitoring-body, you have to be neutral. And I was a facilitator/ monitoring coach. But somehow that feels unsatisfying. I would have rather tried to improve things right away, in close communication with the staff, instead of just “noticing” what’s wrong and bringing that out. So I guess I’m not really a monitoring-type, or it should be extended with an intensive feedback-session to the hospital, in order to empower them with alternative ideas. I think it’s a missed opportunity to leave out mediation and collaboration on improvement. Pointing fingers may not result in an understanding of good practices, but rather create distance and more closed doors. I personally think that education of the staff and policy makers may be more effective to bring an actual positive change. I will surely mention this tomorrow at the evaluation.

It was an intense day, but I’m satisfied with the training we did. The skills we learned are useful to identify shortcomings, but I think we should also build bridges to the institution, in order to guide them to quality of care, and not just try to impose High Profile-demands with UN stuff, NPM’s and public reports.
Anyway, I’m done for today. I have offloaded my emotional baggage from the visit in several ways now, and I’m going to sleep. Tomorrow will be the last day of our training here. It was an intense week.