New working group on involuntary treatment

At this year’s EFPT Forum in Porto a new working group was initiated with the focus on involuntary treatment in psychiatry. This topic is gaining more and more importance in many European countries, as a reduction of such involuntary treatments (including mechanical restraint, seclusion, forced medication, etc.) are considered a common goal.

In psychiatry, we experience the dilemma between the assignment of our society to take care of the mental ill, the necessity of medical treatment of certain mental states and human rights regarding each patient’s free will. In psychiatric hospitals to deal with aggression and violence on one hand, or self-harm on the other hand in such exceptional mental conditions are every day practice for the medical staff and sometimes leads to involuntary treatment. But patient’s advocacy is getting stronger and stronger putting more pressure on the already existing dilemma, accusing psychiatrists of violation of the patient’s rights and bringing more and more cases to trial.

From my experience as a psychiatric trainee in Vienna (Austria), I cannot remember ever having been instructed on how to behave in such extreme situations. There is no course on mental health legislation, no course on how to write an involuntary treatment order or how to fill in correctly the monitoring protocols etc. As trainees we just try to copy the way more experienced psychiatric trainees and our senior psychiatrists handle the situations, hoping that it’ll work. De-escalation courses exist, but they are only obligatory for the nursing staff, not free of charge for psychiatric trainees and are always taking place during working hours. So, no psychiatric trainee manages to get such a course.

An interesting development this year in Austria was the abolition of net-beds (see picture), which were still in use in some psychiatric clinics. This final change in legislation was initiated by the Austrian patients’ advocacy. Although my personal opinion is, that as a patient I would prefer to lie in a net-bed, rather than being put in a bed with belts around arms and feet incapable to move or sit up. Quite a lot of psychiatrists were very unhappy about this change in practice. But after six months of working without net-beds we realize that they are not missing. Psychiatrists are used to work under certain conditions and to use certain forms of restraints and stop thinking how it would be, without them. For example in Vienna, only, after World War II atrocities in psychiatry all psychiatric wards are open. There are no closed doors! This “open-doors-policy“ seems unthinkable for most colleagues in Europe, who have closed units for acute patients.

In Porto at our first working group session I appreciated a lot the exchange of thoughts and experiences with colleagues from all over Europe. The intense and interesting discussions showed that all of us are struggling when it comes to involuntary treatment of patients.

In this year’s action plan we want to illuminate the present status of education in that specific topic of psychiatric training and to provide information using the EFPT network to colleagues from different European countries to raise awareness and ethical reflections on involuntary treatment.

Dr. Katharina Schönegger
Chair of the Involuntary treatment WG