Forced or brutal treatment: the fundamental question


(Sylvain Rousselot) #1

A priori, the Open Dialogue excludes forced or brutal treatment. You can not brutalize someone to force him to dialogue “openly” with you.

But in severe psychotic crisis, forced or brutal treatment is the norm in many institutional services.

For example, in the Morel unit of the psychiatric hospital of Rennes (France), the protocol includes:

_ Undressing by force, putting in pajamas (possibly by gorillas in white blouses),
_ Massive dose of neuroleptics,
_ Prohibition of communication with the outside world. Prohibition of visits. Incoming mail intercepted silently (the patient does not even know someone tried to write to him).

There is also a personalized treatment. For example, if the patient refuses to eat:

_ Isolation in cell (10m2). Bed screwed to the floor. Hygienic pot. No other furniture. Prohibition to seeing the fellow inmates.

In case of failure:

_ Contention in bed. Feeding by tube.

In case of failure:

_ ELECTROCHOCS.

The psychiatric protocol continues until the patient fully submits or is wiped out. The protocol may be interrupted if a member of the family says “stop!”, otherwise … it goes all the way, until the “success”.

I believe the Open Dialogue should be defined not only by “what it is”, but also by “what it is not”.

A firm position on forced or brutal treatment should be established, perhaps in association with other therapeutic schools: the person-centered approach, psychoanalysis…


(Georgia Mylonaki) #2

I would like to inform you that in Greece, in a couple of cases in conferrences I heard about a “new” concept, which is Forced Treatment at Home. In a nutshell the idea is that when in crisis you are not hospitalized but a doctor calls in home and force the medication to you. It is not yet regulated and it should never be. If, IF, they start promoting it for real, we will be needing global psy support here!

PS: @sylvain-rousselot your article I find extremely usefull


(Rex Barker) #3

I am sure there is not a single country where such actions are not committed against those who need care, and I am aware of some where the conditions and care borders the barbaric. As R D Laing said, there no crazy people, just sane people trying to make sense of a crazy world. Some of these people are overwhelmed by the insane world our societies have created and withdraw, yet there are cases where even they have been reached by people willing to go beyond the norm to establish communication and offer support. I wonder if the reason why such activities survive is because the management culture encourages it; such culture these days being predominantly a bullying impersonal one. What has always appealed to me is the utility and value of dialogue in any communication. As I understand it the difference between conversation and dialogue is that one seeks to “win” or convince another of a point of view, the other seeks to find the common ground. The most disappointing element of this is that many people leave this area of care because they are not prepared to work within a culture that tolerates such behaviour. The saddest aspect is that governments and authorities seem to think that throwing money at the problem will solve it. Targets and schedules to deal with the issues won’t help because it needs a change in behaviour encouraged by a more compassionate and creative culture founded on beliefs and values that enable everyone involved, staff and sufferers. I am amazed that Finland itself hasn’t embraced OD more widely, and yet is this an indication of how deep the dis-ease goes when considering the plight of those overwhelmed by our societies? I want to help OD become more widely used and become an agent of change across society. Any suggestions/offers to help do this?


(Oli) #4

In the UK it is called community treatment order or compulsory treatment order (CTO).

http://www.mind.org.uk/information-support/legal-rights/community-treatment-orders-ctos/

http://www.mwcscot.org.uk/the-law/mental-health-act/compulsory-treatment-orders/

In Germany our law forbids compulsory community treatment and it’s unlikely that we will get such laws, because they would be against the constitution (German Basic Law).

Some years ago forced treatment was not legal at all, when our supreme court ruled a federal law and several state laws unconstitutional.

Of course and unfortunately patients are treated without proper informed consent all the time.


(Sylvain Rousselot) #5

@georgia-mylonaki

In France, this is already the case.

I quote the article of law:

The psychiatrist who takes part in the management of the patient may propose at any time to modify the form of management referred to in Article L. 3211-2-1 [full or out-patient hospitalization, or “another form”] to take account of the evolution of the condition of the person. In this respect, he shall draw up a detailed medical certificate.

The psychiatrist who takes part in the care of the patient immediately transmits to the director of the host institution a detailed medical certificate proposing a full hospitalization when he finds that taking care of the person decided in another form no longer suitable, in particular because of the behavior of the person, to provide the necessary care to his condition. When the patient can not be examined, he sends a notice based on the person’s medical file.

Article L3211-11 du Code de la Santé Publique.

In practice, this happens when a patient does not come to a mandatory appointment, in particular to receive a neuroleptic injection. Then gorillas in white blouse come to your home to take you. Your parents open the door. And you are carried away.

But in theory, any other psychiatrist can cancel this legal condition, but most patients (and psychiatrists) ignore it. It is enough to use article L3211-1, §2 of the same code, which authorizes to change of practitioner or change of establishment. Then the procedure restarts from scratch, and the new practitioner may decide to not subject you to this degrading legal regime.

There is a good and healthy aspiration of many psychotics to freedom, the demand exists and it is legal in France to satisfy it: there is no law in France that forces psychiatrists to force a patient to undergo treatment.

There is a social aspect of psychiatry, but there is also a political and economic aspect: if the therapists of the Open Dialogue engage themselves to not practice, not order or not even accept forced or brutal treatments, they will have clients.


(Georgia Mylonaki) #6

Thank you all for your feedback. It is even worse than I thought…


(Sylvain Rousselot) #7

Note that this is an example, true, but only an example. Brutal treatment is not systematic. There are no statistics on the subject.

In France, forced hospitalizations concern about 1 in 5 inpatients (79000 people).


(Sylvain Rousselot) #8

However, brutal therapies are well documented and taught in psychiatry.

For example, “care contracts” are common in the treatment of anorexia.

The “care contracts” are the “doctrine of the flexible response” for anorexia: for each kilo lost matches the withdrawal of a human right.

For example, below a certain weight, you no longer have the right to see your loved ones. Then you have no more right to see the other inpatients: you are placed in solitary confinement. Finally you are tied to your bed, with a tube pressed into your nose, to feed you by force.

You are no longer a person, you are a weight. A weighing scale determines how you will be treated. The protocol is followed blindly, except when you are going to die: at this time your family is allowed to see you again, in your pitiful condition; but not necessarily, you can die before.

But there is a positive side to this treatment, whenever you gain weight, you will be rewarded! You will have, for example, the right to eat in a dining-room, with other human beings, sitting at a real table, and not tied to a bed! Do you realize what progress this represents?

In addition, the “care contract” marries perfectly with the bureaucratic spirit of psychiatry: to each weight corresponds a treatment; no need to think. Even the most stupid psychiatrist can follow this protocol.

And it works! Psychiatrists maintain the “food discipline” by threat and isolation, it is very effective on anorexics: they are terrorized at the thought of agonizing and maybe dying - ALONE. And psychiatrists are happy to throw them out when they regain some weight: they have accomplished their mission.

Strangely, there are many relapses and they have to start all over again: is not that terrible?

To conclude, I would like to quote a former anorexic who was cared by this means: “I do not want to be anorexic, because I do not want to go back to the hospital.”

She was always abnormally thin, but systematically watched her weight: for not to be locked again by her parents.


(Rex Barker) #9

Two elements struck me here, the word “ab-normal”, and the sense of fear that drives so much of society. Abnormal is just that something is outside a normal range, which doesn’t automatically mean it is bad, and a fear based society will always be destructive for the majority. I feel that OD is the way forward through exploring the context and dealing with issues holistically. This, for me at least, means we need to use dialogue in a far wider context too. The political arena is the root of the problem, you argue from polar opposites and rarely occupy the common ground as that is seen as weakness. It isn’t easy to listen to an issue without feeling you are more in harmony with one explanation than another, but trying to find an area where you can agree and then build the basis for agreed action takes dialogue. This isn’t a skill well developed in our societies so far where so many give up their power to the “strongest” without understanding the implications of such actions. The reason people become powerful is that we give them our “power” instead of demanding more considered and specific agreements.


(Sylvain Rousselot) #10

This is the antithesis. The antithesis is necessary since the psychiatric thesis is omnipresent.

I do not know what the next thesis will be. What is certain is that the next thesis will rely on the antithesis. Deeper and wider (radical) the antithesis will be, more solid and durable the new thesis’s foundations will be.

The thesis is like a tree whose the root is the antithesis.


(John Robinson) #11

Gasp! The protocol of this French Hospital is breathtakingly brutal and shocking in the literal sense.
Certainly I agree with the sentiments expressed in this entry about Open Dialogue being as much defined not only as a positive description and yet also by what it is not.


(Georgia Mylonaki) #12

We can learn from Jurnalists on this one! I was one, so I know. When writting any article, in order to deliver you have to:

  1. know of it deeply
  2. change angles, even oposite ones, and widen perspectives
  3. ask all the related parties, from lowest to highest end
  4. restrict all your presumptions, likes, loaths upon the subject
  5. present the facts and your own thoughts, seperately but well interconected and illustrated
  6. be brief and clean but also attract your audience
  7. sell it well using all the means you can think of to reach your people

so, Ask the Journalists, or take some of them on board! they 'll help!


(alita) #13

This is well-stated and I agree. And even as a type those words, it occurs to me, that my mind is set to notice the similar and the different in one perspective I am hearing or in this case reading. Our evolutionary driven nervous system is motivated by innate map of locating threats. We want safety, yet also research shows we seek risk as well. They are like two sides of a teeter totter. Is it more fun however to go high and low then to just stay afloat staring at the other person on the other side on a straight line? Systemically, there are the movers and shakers of our safety, whole-heartedly seeking refuge in a trauma-filled and joy-filled mysterious world. Therefore, I do not think convincing anyone of the validity of Open Dialogue in a monologic way, or from the outside labels/language defining it as a true method that is complete or somehow legendary on its own, will work or change anything. In fact, I think it would create more polarization. I believe integrating the six principles: Immediate help, social networks, flexibility & mobility, responsibility, psychological continuity, and tolerance of uncertainty, in our own relationships (e.g., relationship to self, relationship to family, relationship to community and society), in the here and now is the first agency we can offer anyone.


(Paul) #14

The word ‘abnormal’ for me is subjective and a language of power and dominance that sees only it’s own perspective. It is not a language of dialogue which allows for other voices for shared knowledge and understanding. In our global diverse and multi facete world we should be open to enquiry for a better understanding of perspectives rather than slam the door on perspectives we least understand. Such attitude is power driven and only gives room to dominance rather than dialogue of various voices and shared understanding. What is human development if we have lost the rudimental skills of listening and hearing the other voice? Have we replaced the fundamental human skills of communication and dialogue with the opulence of power and dominance? If so we surely have lost the plot on humanity and what it is to be human.