WHOCC conference on coercion – Paris 2017

On Tuesday 14 March 2017, I got up early in my hotel near the Eiffel tower in Paris. After a breakfast, I joined some other speakers in a taxi to the French Ministry of Social Affairs and Health in Paris. At 8.30 in the morning, the registration for the international conference on coercion in psychiatry started.

The conference: “Force and freedom in psychiatry: experiences and results” was organized by the World Health Organization Collaborating Centre (WHO-CC) in Lille (also see: http://www.ccomssantementalelillefrance.org/?q=journ%C3%A9e-sur-la-contrainte-le-film-et-les-pr%C3%A9sentations ) There were about 300 participants.

I was invited to give a presentation on behalf of ENUSP (European Network of (Ex) Users and Survivors of Psychiatry, http://www.enusp.org )

A full video of the entire conference is available on Youtube: https://www.youtube.com/watch?v=dBdKwVGwtYE&feature=youtu.be&t=4235
(my presentation starts at 3.08)

*
The conference on coercion in psychiatry in Europe, started around 9 AM.
Jean-Luc Roelandt, director of WHO CC Lille, welcomed us, and outlined the current mission of WHO CC Lille to improve the practices regarding coercion in French psychiatry. This conference serves to learn from international initiatives.

Then Thierry Kurth (DGOS) spoke about the current French situation of coercion in psychiatry, wand mentioned several law reforms (1990, 2011, 2013 and 2016), incomplete monitoring and registration, and recent research showing big differences in the use of coercion between various locations. Increasing attention is now being given to the topic of coercion in psychiatry. Mr Kurth stated that coercion can be “necessary” and needs to be “limited and registered”.

Anne Lecourbe, controleur of places of deprivation of liberty in France, explained that the “controleur” visits places of detention, as part of the independent framework to prevent torture and ill-treatment. She aims to stimulate discussion on human rights. “Seclusion and restraints are not always justified, even when professionals say so” she said.

Then, Matthijs Muien, consultant for WHO Europe, highlighted that coercion in psychiatry presents a tragedy for all actors, and that there is huge opposition between persons who believe coercion is necessary, while others believe this is not necessary. Fact is that repression is increasing in our societies, and also in psychiatry. Changing legislation alone may not be enough to change practices and mind-sets.

After these introductions, the first panel started on Deprivation of liberty in France and in Europe, chaired by Gilles Vidon, psychiatrist. He expressed his sentiment that “healthcare can never be torture”, and it was “not a funny joke” to say otherwise.

The first speakers, Magali Coldefy and Coralie Gandre, presented their research on the use of coercion in French psychiatry. The data and statistics were incomplete due to a lack of registration and monitoring, yet it showed big differences between practices at various locations: In some institutions or wards, coercion is practiced widely, while at other places it is hardly used. More research is needed.
(The exact numbers of coercion in French psychiatry can be found in the presentation, see the link in the programme-table at http://www.ccomssantementalelillefrance.org/?q=journ%C3%A9e-sur-la-contrainte-le-film-et-les-pr%C3%A9sentations )

The second speaker was Anu Putkonen, psychiatrist, Nuivanniemi Hospital, Finland. She mentioned that also in Finland there is a huge variety in practices across different places and regions. In 2008, an RCT-study on the safety and efficacy of Seclusion and Restraint Prevention, showed that it is possible to decrease coercion without increase of violence. 6 Core Strategies were identified,and a task force was established for the “reduction of coercion and increase of safety in psychiatric care”. The 6 Core Strategies seem to have better results in reducing coercion, than the legislative changes in Finland.

Then it was my turn. First I spoke about my personal experiences: how coercion didn’t help, but it only made all problems worse. Eventually a transfer to a “psychiatric intensive care unit” made the difference and gave options for recovery. I survived because of respect, not because of coercion. ENUSPs position on coercion is similar: Coercion is the full opposite of actual support for mental health and wellbeing. The UN CRPD and several torture-prevention mechanisms call for an absolute prohibition of coercion in mental health care. This means that registration of coercion is actually: registration of human right violations, which need to be remedied.
A process of “Truth and reconciliation in psychiatry” could be a hybrid model to remedy the human right violations in mental health care, combining “remedies for victims” with “analysis of the situation/ research and development” at the same time. This may be the most effective way to discover and learn more about concrete failures, concrete improvements, concrete compensation, and concrete remedies to the human rights violations.

After a few questions, and an interesting discussion on ”dangerousness” and the lack of 24/7 care,
the programme continued with the second panel on “Compulsory care”.

This second session was chaired by Ron Coleman, director at Working for Recovery, UK.
Ron Coleman re-opened the debate around the word “torture”, and openly questioned why “professional” terminology is continuously used to cover up and justify human rights violations. For example: calling solitary confinement “seclusion”, or calling drug-effects “side-effects”. The sanitization and alienation of the language in mental health care is used as a weapon to cover up and justify a horrible truth. If we want a real debate on how to get out of this terrible situation, we have to start by speaking the truth.

Then, Giulio Castelpeitra and Giulio Mastrovito from WHOCC Trieste, Italy, spoke about the Community Mental Health Centres (CMHC) in Trieste, where coercion is seen as a non-therapeutic act, and no confinement is used. The Community Centres are open to anyone who requests support. During crisis situations, they aim for non-violent de-escalation. They do use “holding” (also called “manual restraints”). The number of forced medication (incl. by CTO) is relatively very low. The practice in Trieste shows that mental health care without deprivation of liberty is possible, with good results.

Mathilde Labey, psychiatrist, and Corine Noel, peer support worker, both from EPSM Lille, spoke about the importance of taking a recovery oriented approach, and to focus on empowerment and support. Problems can be overcome. Recovery is possible. Professionals need more awareness on recovery, and they should promote hope, and not give up (as they are when resorting to coercion). Recovery and empowerment can be fostered with a positive approach. Experts by experience can help to raise awareness on recovery of mental health problems. All staff at EPSM Lille is trained in non-violent de-escalation with the Omega-training.

Then Pall Matthiasson, psychiatrist at the National University Hospital of Iceland, explained the situation in Iceland. He stated: “Mechanical restraints are not used at all in Iceland”, because in 1932, Dr. Helgi Tomasson burnt all the shackles, straightjackets and belts from the mental hospital in his furnace. Dr. Helgi Tomasson then contacted the parliament, to announce that he had burnt all the belts and that he wouldn’t be tying down people anymore. Instead he would like more money to employ carers. Dr. Tomasson also collected data to show that violence and incidents didn’t increase without restraints. Since then, mechanical restraints are basically out of use in Iceland, although there have been a few cases in the past decade where persons with learning disabilities were tied down to prevent self harm. (So oddly, they claim to “not use physical restraints”, while strictly that’s not fully true…. ).
The humanitarian view of Dr. Helgi Tomasson is still fundamental to Icelandic mental health care. Nowadays, there are violence-response teams, who are trained in de-escalation techniques, and special “holding”- techniques (which in fact bears risks for all involved). Seclusion cells are now being replaced by “de-escalation-suites” where staff can support the person in calming down. Pall Matthiasson recalled from his experience: “Only when the seclusion cells were “out of order” and no longer available, the staff succeeded to find concrete alternatives, and one month later, the former cell was turned into a games room.” So, once you physically remove the instruments, alternatives will be found. And obviously there are places and countries that don’t use restraints or locked doors. People can be trained. He recommended: If you want to ban physical restraints: don’t do a 10 year plan, but just do it. “Burn the instruments in the furnace if you have to”.

*

During lunch, I met with Stephanie in the big cafeteria in the basement of the Ministry, and we just had enough time for a quick meal, and a very quick smoke-break, before the programme of the conference continued.

At 14.00 the third panel started on Changing practices, chaired by Gilles Moullec.

The first speaker was Padraig O’Beirne, clinical nurse manager of Cavan Monaghan Mental Health, Ireland, who gave another interesting presentation of a ward practicing alternatives to coercion. He presented the data on forced interventions from this Irish mental health centre, which only comprised a number of “holding”-episodes (Manual restraint), measured in minutes. They do not use seclusion or physical restraints. They have a fluent staffing system, responding to the needs, and 80% of resources are used for community based support, which enables prevention. He explained the process of reducing the use of seclusion and restraints, by taking a recovery approach, training of all staff in dealing with aggression and violence, debriefing of all incidents, and by ensuring that services are properly resourced. Also, it’s important to hold services to account, to avoid the development of “corrupt cultures of care” (ungoverned, isolated wards, exerting control by coercion, responding to any situation with coercion). The Mental Health Commission has the role to ensure that high standards are maintained.

Then, Delphine Moreau, senior FNS researcher, Hesav Lausanne, Switzerland, presented a research on the use of coercion in Swiss psychiatry in 2 cantons Vaud and Valais, where they had compared the situation before and after the law reform of 2013. They found that cantonal legislation, local practices and institutional cultures vary a lot across Switzerland. Some institutions have an “open-door-policy”, while others mainly have closed wards. Also data-collection is not harmonized.

Roselyne Touroude, vice president of the family organization UNAFAM, spoke about her experience of testing the WHO Quality Rights Toolkit to monitor the quality of mental health care services.
The WHO QR Toolkit highlights several parts of the UN Convention on the Rights of Persons with Disabilities (UN CRPD) and it contains several standards enabling assessment. The WHO QR Toolkit also provides guides and tools for performing evaluations in practice (including for documentation review, interviews, and reporting guidelines). Assessment via the WHO QR Toolkit is an interesting and educative exercise to identify necessary improvements. She proposed that every institution should make an action plan to ban seclusion and restraints, and referred to UNAFAMs own list of good practices (family-perspective), and stressed the need for ethical reflections on the use of coercion in light of human rights standards.

Around 15.30, the final panel of the day started: “Proposals for an Observatory of coercion and liberties in psychiatry”, chaired by Nicolas Pastour, psychiatrist of CH Charcot.

Rachel Bocher, psychiatrist at CHRU, Nantes, stated there is an ongoing discussion on the use of seclusion and restraints, and there are concerns about human rights, especially dignity and liberty. It is necessary to get an overview, get the knowledge, train people, and change the mind-sets. A national strategy to reduce coercion is needed.

Philippe Guerard, president of Advocacy France, stated that persons with disabilities, or rather: “persons in a disabling situation” are citizens, with rights and freedoms equal to others. Yet, persons with psychosocial disabilities don’t have equal opportunities in many ways. For example, they can be deprived of their right to vote, which is a blunt violation of civil rights. The French mental health law is about control and safety, and not about care. Advocacy France opposes this law, and advocates for CRPD-based reforms of mental health care.

Luce Legendre, director of ADESM, expressed support for the planned Observatory of coercion in France, and suggested that this should cover the full social domain, including social care and care for elderly, and a steering committee to guide the reduction of coercion would be useful, and should include reliable data collection, comparisons and research, and promotion of good practices, as well as introducing accountability for coercion in mental health care practices. All stakeholders need to be involved.

Alain Monnier of UNAFAM, also expressed support for the planned observatory, complementary to existing monitoring bodies. He stressed that legislation alone isn’t enough for renewal of the sector. Despite all debates, coercion is currently still on the rise, and the causes for that need to be found and addressed. An observatory should be like an independent research body, with plural management of psychiatrists and users and others actors involved.

Bernard Odier, president of French federation of psychiatry, expressed his concerns that the reduction of coercion might lead to more violence and incidents, or to trans-institutionalization (relocation in prisons or social care homes). He stated that “excessive use of coercion” in mental health care should be prevented. But he felt that “issues of psychopathology” are not addressed by the disability rights-movement, and he stated that “the content of specialized types of care needs to be developed further”.

Denys Robillard, Member of the French parliament Loir-et-Cher Region, a law-expert, stressed that the French law stipulates that coercion and restraints are considered legitimate and legal when used as a “last resort”. He claimed: “coercion is allowed by law, so this cannot be torture, otherwise it would be unconstitutional and not be justified in existing national and international laws. Also no recommendations to “govern these practices by law” would be issued if it were about torture” . He stated that “systematic over-use of coercion” needs to be addressed.


During discussion time, I got into a discussion with Denys Robillard. I stated: “The latest binding legal standard applies, and the UN CRPD supersedes pre-existing standards. - In all presentations we hear the need for a paradigm shift, and a call for a change of mind set regarding coercion in psychiatry. And nowadays there is a clear new mind-set available, in the form of the UN Convention on the Rights of Persons with Disabilities (UN CRPD), which in fact clearly recognizes that coercion in mental health care amounts to torture and ill-treatment. The same analysis has been made in recent years within the UN torture framework. Yet, this new mind-set now appears to be rejected by mental health professionals, which in fact very counterproductive. It would be logical and important to take the newest UN Convention, the UN CRPD, as a guidance for change”.

Just before 17.00, Jean-Luc Roelandt, director of WHOCC Lille closed the conference by thanking everyone, and expressed commitment for the realization of an Observatory of coercion and liberties in psychiatry, with the ultimate goal to eventually change these practices.

*
After the conference, I met again with Stephanie and some others, and we had a nice coffee together at a terrace close to the Ministry. Then it was time to leave, and we said goodbye to each other (smiling, what a wonderful time we had..). I went to the train station Paris-Nord, to take the Thalys high speed train. Unfortunately, this train had a small collision on the way, resulting in several hours of delay. Together with some other people who had missed their connections, I was eventually brought home by taxi, which was actually very nice and cosy, and comfortable. I reached home around 2 in the night. It had been a very long but satisfying day.

I was grateful that I had been given the opportunity to speak out against coercion at this conference, as an ambassador of all those people who are currently still subjected to restraints, seclusion and other coercion in psychiatry. As an expert with lived experience of many forms of coercion (when my voice was fully ignored), I feel so privileged to be given the floor, to be given an audience, and to deliver the same message as I did when I was locked up: Coercion is harmful, not helpful. It is inhumane, and it needs to stop!

*
Once I had arrived back home, I still enjoyed good memories of my trip to France.
Nevertheless, I couldn’t escape from some deep thoughts and questions, mainly related to my situation in the Netherlands, which has a gloomy undertone. Since in the past couple of weeks, I had to endure some very disappointing developments in the Netherlands, regarding a lack of access to justice, and some terrible law reforms which expand coercion, (contrary to the UN CRPD, and ignorant of activism and innovation). This made me feel overwhelmingly powerless and sad. (Also see an earlier post: Shocking: No access to Dutch remedies: http://punkertje.waarbenjij.nu/reisverslag/4967248/shocking-no-access-to-dutch-remedies ).

So, when I reached home, after a very nice trip to France, I noticed that the disappointment and pain over these Dutch developments have not healed yet.
Regarding the Netherlands, I feel deeply hurt, because my genuine attempts to stop harmful practices, have been basically fully ignored by Dutch authorities, and all “normal routes” to really expose or stop these injustices apparently failed, while (naively?) I really believed that the Dutch authorities would eventually do justice, and realize real care instead of coercion.
I still feel utterly sad, because I already spent the majority of my life trying to expose the injustices that happened to me in my youth in the Netherlands, and yet, these practices remain unchanged. The main momentum for Dutch change was recently wasted, and instead of a historical change, the old paradigm is still prolonged and extended in law and policy. I really had higher expectation of the Dutch authorities….

I can only consider this as a huge tragedy, and an enormous loss and disappointment. I feel like I fell short, while I actually did everything I could, as a person, and as an activist... Why isn’t that enough? I just don’t understand it. It feels incredibly unfair, and inhumane. It is re-traumatizing to be powerless towards ongoing human rights violations again. It makes me so angry.
So, lately, I have been trying hard to repair my hope for Dutch change, and to avoid becoming bitter and sour and negative (devoid of hope). Instead I try to keep my head up high, and to cling on to my firm belief that Good practices will win over Bad practices. Problems can be overcome. People can grow and gain awareness. Also corrupt systems can recover.

I find support with peers. I am surely not the only one who has been hurt by psychiatry or the authorities. In fact we are with many. Peer support is important.
I particularly also find hope in the repeated statement at the conference “legislation alone is not enough to change practices”. (So maybe, terrible legislation also won’t have too much impact?).

Anyway, returning to the Netherlands, for me also meant, returning to a current state of “broken dreams”. In fact, my motivation to keep pushing for change is actually fuelled up by this massive injustice. Nobody should have to go through such pain and suffering. Injustices shouldn’t exist. It burns, and it calls for resistance. I will definitely not cease my attempts to push for change. I am really angry at the system. My fire is only getting higher.