Jolijn Santegoeds – Why forced psychiatric treatment must be prohibited

Why forced psychiatric treatment must be prohibited

Translation of Dutch article “Waarom gedwongen GGZ behandeling verboden moet worden”

Why forced psychiatric treatment must be prohibited
29 March 2016, by Jolijn Santegoeds, founder of Stichting Mind Rights[1], Co-chair of World Network of Users and Survivors of Psychiatry (WNUSP)[2], board member of European Network of (Ex-) Users and Survivors of Psychiatry (ENUSP)[3]

Click here to download the article:
Why forced psychiatric treatment must be prohibited_29 March 2016

 

For centuries there has been resistance against forced admission in institutions, confinement in isolation cells, tying persons up with fixation-straps, the forced administration of medication, forced electroshocks, and other forced psychiatric treatments.

Coercion is not care
Coercion is one of the most horrific things that people can do to each other, while good care is actually one of the best things that people can offer to each other. There is a fundamental difference between coercion and care.

Coercion works countereffective to wellbeing, and leads amongst others to despair, fear, anger and grief for the person concerned. During coercion the voice of the person is ignored, and their boundaries are not respected. Coercion does not lead to more safety, or recovery of mental health. On the contrary: By suffering, powerlessness, and a lack of support, the risks for increasing psychosocial problems and escalation increase. Coercion is the opposite of care.

Coercion means a lack of care
Forced psychiatric interventions are not a solution, but are a problem for mental health care. For a long time, the existence of forced treatments, which enables caregivers to turn their back to the crisissituation and leave the person behind without actual support, is undermining the real development of good care practices.

Good care is possible
Good care can prevent coercion. By a respectful attitude and good support, problems and escalation can be prevented successfully, which makes coercion obsolete[4]. Real care is possible.

Efforts are needed
Despite the fact that all stakeholders in Dutch mental health care want to ban coercion[5], the total number of the use of coercion (the number of  legal measures RM and IBS) is rising annually. There are however specific initiatives to reduce coercion at various locations, such as the development of HIC (High/Intensive Care psychiatry)[6], where they aim to prevent solitary confinement by enabling intensive support. On the other hand there is an enormous rise in outpatient coercion (conditional measures), as well as in incidents with “confused people”. It has been concluded a number of times, that the practices are “persistent”, and that the culture is “hard to change”.

Learning from history
Europe has a long history of xenophobia against persons with psychosocial problems. Ever since the 15th century there have been special prison-like “madhouses”, where persons were chained and locked up like beasts, and exorcisms were common. After the discoveries of Charles Darwin and the Renaissance (17th and 18th century), the medical sector started to arise, followed by the arrival of the first Dutch Lunacy-law in the 19thcentury, which arranged “admission and nursing of lunatics in mental hospitals”, with the goal to provide “more humane” care as compared to the madhouses. The young medical science comprised a diversity of perceptions, and in the 20th century a lot of experiments followed, such as hot and cold baths, lobotomy, electroshock and so on. The “special anthropology”[7] or racial-science and eugenics, focussed on the search for the perfect human being, and “racial hygiene” to “avoid deterioration of the race”, openly doubting the capacities of certain populations, which resulted in genocide which didn’t spare psychiatric patients (WOII).

After these dark pages in history, universal declarations of human rights were established, emphasizing the value of each human being, and gradually the community became more tolerant. However, psychiatry hardly changed and held on to the questionable and experimental foundation, with confinement, regulation regimes, and experimental treatment methods as the unchanged core of the treatment range. Currently, efforts are still made to force persons into behavioural changes with the argument that they are “incapable of will” themselves, and not able to express preferences. This is absolutely incorrect: Every person sends signals. The challenge is to deal with that in a good way. Real care notices the person behind the behaviour. Professional care is something totally different than primitive repression of symptoms.

It is time to draw a line. It is urgently needed to recognize that mental health care got on a wrong track by history. Harsh ‘correction’ of persons until they are found ‘good enough’ is not a righteous goal of mental health care. It should be about wellbeing. Coercion is a revealed mistake of mental health care. Innovation is needed.

Worldwide need for coercion-free care
All over the world forced treatment exists. Extremely atrocious images are known from poorer parts of the world, with chained people for example in Asia[8] and Africa[9], but also in our own country with Brandon[10] and Alex[11]. As long as the western world keeps claiming that coercion is the same as good care, these scenes will be harder to ban, especially since several countries have high expectation of the western approach. It is important to come up with good solutions in the world wide search for coercion-free care.

Call by the United Nations
Since 2006, the UN Convention on the Rights of Persons with Disabilities (CRPD)[12]exists, which illustrates that a worldwide change is needed towards persons with disabilities. Several UN mechanisms clarify that coercion in care is a violation of human rights[13][14][15][16], also when it comes to the Netherlands[17][18]. A change is needed.

What’s next?
This is an important question.
What do we want now? Are we finally going to make it really right?
Are we going to show ourselves from our best sides?

A real change of culture is needed. Mental health care needs to reinvent itself, and put an end to the confinement and the use of coercion. Good care is possible.

“Yes but it is not possible…”
Commonly heard reactions are “These are good ideals, but not realistic” or “There is no other way, because the system isn’t supportive” or “The community is totally not ready for this”. The implicit assumption that a culture change would be ”unrealistic”, indicates limited perspective, hope and ambition. The system is in our hands. We are the current generation. Change is possible. The world is changing constantly. Also mental health care can change[19][20], as can the public opinion. We are not powerless or insensitive. Efforts are needed to make the world better and nicer together. We can do that.

Change can feel scary. Without positive history or good practices elsewhere it may be a bit harder to imagine that everything can be different, but this cannot be a reason to just give up immediately. We do not question ourselves whether stopping all hunger in the world is realistic before we start with that. Every person counts. Real care is possible and needs to be realized, also in acute and complex crisis situations. Practices of abuse need to stop instantly. This is the task that has been given to our generation. It is worth to unite all our efforts to make the historical shift from exclusion to inclusion.

Also the remark “Yes but coercion is needed, as long as there are no alternatives”  needs to be refuted here. Coercion is not care, but it is abuse, and there is no valid excuse for abuse. Coercion is never needed. Good care is needed.

Making human rights a reality
The UN Convention on the Rights of Persons with Disabilities (CRPD) gives a momentum for change. If everyone cooperates now, throughout all layers of the system, then the intended change gets an unprecedented impulse. The articles of the UN-Convention offer a guidance, which enables worldwide coherent action. The UN Convention offers vast opportunities to change the world.

Together we can ban forced psychiatric treatments. When there’s will, there’s a way. In history, confinement was put central, and by now we know better. So we have to do better too. A largely unexplored world is ahead of us.

Key points
It is not easy to change the mental health care system, and the confidence in mental health care doesn’t restore without efforts. Several things are necessary to change the situation sustainably:

-Realise good care
The old fashioned psychiatry is not founded on human rights, diversity and inclusion, but on xenophobia and exclusion. Science has focussed so far on homogenising the community, and attempts to change the people (a bodice and check box mentality). Modern mental health care should focus on enabling a heterogeneous and  diverse community, by creating the right conditions in the community and to enable self-determination, liberty and inclusion, so that everyone can be happy and live a fulfilling life in our community. A fundamental reform is needed in mental health care.

Wellbeing – or mental health – is a very personal intrinsic value, which cannot be produced by coercion. Recovery from psychosocial problems is not an isolated process of the person concerned, but is closely intertwined with the social context of the person, such as chances in life, social acceptance and inclusion. The range of care needs to be reviewed fully, and adapted to the requirements of today.

Deprivation of liberty needs to be stopped immediately. The organization of care of good quality is necessary and urgent, and cannot be postponed any longer. The previous guidelines under the law BOPZ of 1994 to use coercion “as little as possible” and “as short as possible” have failed obviously, and the numbers on the use of coercion (legal measures RM and IBS) continuously keep on rising annually, and have more than doubled in the past 10 years. This trend is unacceptable, and therefore something really needs to change now. A need for support cannot be a reason for deprivation of liberty. Good care is possible.

Without good care, the mess will only transfer. It is absolutely necessary to make all possible efforts right now to provide care of good quality, including good care in crisis situations.

– Legislation: prohibit coercion, arrange care
The legislation on forced psychiatric treatments needs to be changed. The goal of mental health care is not: Treating vulnerable persons in a rough way, but the goal is to provide good care, also in crisis situations. A transition is needed.

The lunacy law dates from 1841, from a time when the medical profession was absolutely in it’s infancy. The law BOPZ of 1994, and also the law proposal on Mandatory Mental Health Care (recent) have a similar structure of legal measures RM and IBS, and resp. confinement and forced treatment form the core. This system is not founded upon awareness of human rights, and it is not about care of good quality, and it has to change.

Forced treatment is abuse. Legislation needs to protect all citizens from abuse. When the government participates in the abuse against certain groups, this is torture[21][22], which is absolutely prohibited. The laws on coercion, such as BOPZ and the law proposal on Mandatory Mental Health Care are therefore unacceptable.

Legislation is meant to offer a fair framework for the community. A prohibition of forced treatments is necessary because of human rights[23]. Additionally, certain legislation can speed up the provision of good care and organize innovation[24]. It is possible to create laws that are really useful to the community. Wouldn’t that be great?

– Compensation: Recognize the seriousness
For years and years, the government and countless caregivers have taken over the lives of psychiatric patients, and forcefully subjected them to “care”, such as horrible forced treatment, isolation cells, forced medication, restraint-belts, electroshocks, all motivated by so-called “good intentions”. The sincerity of those responsible can now prove itself by genuine recognition of the suffering that many had to endure. A compensation would be appropriate: When you break something you have to pay for it. We consider that very normal.

* Apologies are needed to recover the relation between (ex-) users and caregivers.
* Recognition of the trauma’s by coercion, and support in overcoming these if desired.
* Compensation to show that the change of attitude is genuine.

Now it’s time to show that the Netherlands is indeed a civilized country.

Take action
I would like to call on everyone to contribute to the change in culture. Let’s ensure together that human rights will be realized for every human being, and that old-fashioned psychiatry disappears, and that mental health care only comprises good care.

Please spread this message to raise awareness.

 

**

To reinforce the above plea, I have attached a description of my personal experiences with forced psychiatry, which can be found via this link:

“16 years old, depressed and tortured in psychiatry – A testimony on forced psychiatric interventions constituting torture and ill-treatment”

 

**

This publication is part of the ‘Absolute Prohibition Campaign’, see https://absoluteprohibition.wordpress.com

 

[1] Actiegroep Tekeer tegen de isoleer! / Stichting Mind Rights www.mindrights.nl

[2] WNUSP: World Network of Users and Survivors of Psychiatry www.wnusp.net

[3] ENUSP: European Network of (Ex-) Users and Survivors of Psychiatry www.enusp.org

[4] Report: Best practices rondom dwangreductie in de GGZ 2011

[5] Declaration on reduction of coercion:  Intentieverklaring GGZ: preventie van dwang in de GGZ 2011

[6] High Intensive Care HIC (HIC)

[7] Description of Racial-science e.a.: Winkler Prins Algemeene Encyclopaedie, vijfde druk, Elsevier, 1936

[8] Human Rights Watch “Living in hell – abuses against people with psychosocial disabilities in Indonesia”, 2016

[9] Robin Hammond, fotoserie “Condemned – Mental health in African countries in crisis”

[10] Brandon van Ingen, Jongen al 3 jaar vastgebonden in een zorginstelling

[11] Alex Oudman, Schokkende beelden uit isoleercel – Toen en nu

[12] UN Convention on the Rights of Persons with Disabilities (CRPD)

[13] CRPD General Comment no. 1 on CRPD article 12 Equal Recognition before the law

[14] CRPD Guidelines on CRPD article 14 Liberty and Security of Person

[15] Statement of 2 UN Special Rapporteurs “Dignity must prevail – an appeal to do away with non-consensual psychiatric treatments” World Mental Health Day, 10 October 2015

[16] A/HRC/22/53 Special Rapporteur on Torture, Juan E Mendez, Torture in health care settings (2013)

[17] Communication sent to the Kingdom of the Netherlands by the UN Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment and the UN Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health. AL Health (2002-7) G/SO 214 (53-24) NLD 2/2013, October 2013, https://spdb.ohchr.org/hrdb/24th/public_-_AL_Netherlands_08.10.13_(2.2013).pdf

[18] CAT/C/NLD/CO/5-6, CAT Concluding Observations on the Netherlands

[19] High Intensive Care HIC (HIC)

[20] Intensive Home Treatment (IHT)

[21] Torture, for full definitiion see article 1 CAT, Convention Against Torture.

[22] A/HRC/22/53 Special Rapporteur on Torture, Juan E Mendez, Torture in health care settings (2013)

[23] amongst others the right to liberty, freedom from torture / Civil and political rights and CRPD

[24] amongst others the right to health care and adequate standard of living / Social, economic and cultural rights and CRPD

 

ENUSP -Forced psychiatric interventions constitute a violation of rights and disable care

Human rights context

Since 2006, the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD) calls for a paradigm shift to break away from paternalistic laws and paternalistic attitudes towards persons with disabilities, and shift to respectful support of decision-making based on the person’s own will and preferences. The implicit call of the UN CRPD to put an end to forced psychiatric treatments has been made explicit by several publications of the CRPD Committee, and especially by the Guidelines to Article 14. The Guidelines make clear that the detention of persons with psychosocial disabilities under domestic legislation on the grounds of their actual or perceived impairment and supposed dangerousness to themselves and/or to others “is discriminatory in nature and amounts to arbitrary deprivation of liberty.”[1]

 

Nevertheless, two UN treaty bodies currently are in conflict with the standards set by the UN CRPD: the Human Rights Committee[2] and the Subcommittee on Prevention of Torture (SPT) in their document “Rights of persons institutionalized and medically treated without informed consent”. Yet the Human Rights Committee admits that forced measures are harmful: “The Committee emphasizes the harm inherent in any deprivation of liberty and also the particular harms that may result in situations of involuntary hospitalization.” [3] The Human Rights Committee even recommends States parties “to revise outdated laws and practices” and says that “States parties should make available adequate community-based or alternative social-care services for persons with psychosocial disabilities, in order to provide less restrictive alternatives to confinement.” However, despite this, the Human Rights Committee acknowledges the possibility of forced measures, provided they are applied “as a measure of last resort and for the shortest appropriate period of time, and must be accompanied by adequate procedural and substantive safeguards established by law.”[4]

Also the SPT allows forced commitment and forced treatment, but they go even further by saying that abolition would violate the “right to health” and the “right to be free from torture and other ill-treatment”. For instance, the SPT states “…placement in a psychiatric facility may be necessary to protect the detainee from discrimination, abuse and health risks stemming from illness”[5], “The measure [treatment without consent] must be a last resort to avoid irreparable damage to the life, integrity or health of the person concerned…”[6]. In addition, the SPT acknowledges restraints as a legitimate measure: “Restraints, physical or pharmacological … should be considered only as measures of last resort for safety reasons”[7], and further allows for “medical isolation”[8].

It is interesting to note that before the publication of these two documents mentioned above, the thematic report “Torture in Health Care Settings” by the UN Special Rapporteur on Torture and other cruel, inhuman or degrading treatment or punishment (A/HRC/22/53), urged an absolute ban on forced psychiatric interventions, in order to ensure that persons with psychosocial, intellectual and other disabilities be free from torture and ill-treatment. However his voice apparently was not heard, as well as other voices documenting numerous violations of human rights in psychiatric institutions. One of them is the report of FRA issued in 2012, which reveals the trauma and fear that people experience, and states that “the extremely substandard conditions, absence of health care and persistent abuse have resulted in deaths of residents in institutional care.”[9]

 

Therefore, it can be seen that the arguments in favour of the administration of forced measures are based on false grounds, because as has been proven by numerous sources, including CPT reports and the sources mentioned above, psychiatric institutions in no case can be considered a safe haven from discrimination, abuse, torture and ill treatment. With regard to medical considerations and care we put forward the following:

 

Forced psychiatric interventions are not care.

Care is supposed to result in improved well-being and recovery. Well-being – or mental health – is a very personal, intrinsic value, which cannot be produced by force. Caring for one another is one of the best things that people can offer to each other. On the contrary, forced psychiatric interventions are very traumatizing, and result in suffering and more psychosocial problems. It makes the situation worse, and is amongst the worst things that people can do to each other. There is a huge difference between forced interventions and care. They are the total opposite of each other.

 

Forced psychiatric interventions disable care.

Forced psychiatric interventions are counter-productive to mental health and care, and represent a “breach of contact”. This can be seen on the one hand, for example, with nurses who stop trying to communicate or provide support, and resort to forced interventions. It can also be seen on the other hand, in the feelings of misunderstanding and trauma of the person subjected to forced interventions, which disable meaningful contact. It is obvious that good contact and communication are necessary for good mental health care. The end of communication, as is induced by forced psychiatric interventions, is a very harmful practice, which makes meaningful contact, and therefore mental health care in itself, impossible.

 

Forced psychiatric interventions do not result in safety.

Due to suffering, increased psychosocial problems, and a lack of any support for recovery caused by forced psychiatric interventions, the risks of escalation increase, and can even result in an endless circle of struggle and escalation, as our experiences show. The common argument given “to protect from harm or injury to self or others”, is not based on factual evidence supporting this statement. Forced psychiatric interventions do not result in more safety, but lead to more crises, and subsequently to greater risk of escalation.

 

Forced psychiatric interventions indicate a deficiency in mental health care.

Forced psychiatric interventions are more of a mechanism for (attempted) social control embedded within an underdeveloped and structurally neglected (and politically abused) system of mental health care that is built on the horrible remnants of the past, rather than on skills to support mental health and well-being. Underdevelopment and insufficient funding of the mental health care system is in place because of the extremely low political priority given to mental health care, consequently explaining the extremely low level of funding. It is impossible to deliver quality care without proper funding and attention to quality standards. However, due to historical stigma, mental health care remains unpopular with society, i.e. voters, and therefore politicians. In case of dire shortage of funding, the best possible solution for the system is to keep things calm, by delivering lots of harmful and in many cases unwanted medication to isolated people and calling it medical care. However, real mental health care is possible when efforts are made and sufficient funding is provided.

 

A world of options between “last resort” and “no care”

Many persons, including many States, cannot see beyond a very narrow “black and white” approach regarding psychosocial crisis situations, with only two options: either forced treatments (torture), or doing nothing (neglect). This simply isn’t the full picture. Between these two extremities, there is a largely undiscovered world of options for real support and real mental health care in psychosocial crisis-situations, with aspects such as: non-violent de-escalation, prevention of crisis in the earliest stage possible, focussing on contact and openness instead of repression, building trust and providing real support in acute crisis-situations. (Ex-) users and survivors who have experienced this are the best positioned to be involved in this shift of paradigm.

 

Real development of mental health care is urgently needed.

Unfortunately for decades, the real development of good care practices has been undermined by the existence of forced treatments, which has enabled caregivers to turn their back to the crisis situation, and leave the person behind without actual care, repressed and stripped of their dignity. This should stop. Forced psychiatric interventions constitute a very serious human rights violation. They can never be called care and cannot be considered a safety and anti-discrimination measure, because they lead to exactly the opposite.

 

We believe in the creative potential of humanity and the possibility to solve complicated problems when appropriate efforts are made. But in order to allocate the appropriate resources and generate enough creative efforts, appropriate motivation is needed. The UN CRPD standards give us and should give policymakers such motivation to realize and state publicly that the status quo in psychiatry is totally unacceptable and must be changed to a humane system of real care.

 

The discrepancies in the recommendations referred to above, even among different entities of the same organization (United Nations) must be eliminated and the provisions of the CRPD must prevail.

 

This is a challenge, but by thinking and acting together, it is possible to make this a reality.

 

We must keep in mind just one thing as a basis for this objective:

 

 

Forced psychiatric interventions constitute torture and ill-treatment and

must be banned!

 

 

 

 

 

 

 

[1] CRPD Committee’s Guidelines on article 14 Liberty and security of person, III, para.6 (September 2015)

[2] General Comment No.35, para.19 (30 October 2014)

[3] Ibid.

[4] Ibid.

[5] SPT, Rights of persons institutionalized and medically treated without informed consent, para.8

[6] Id. para.15

[7] Id. para. 9

[8] Id. para.10

[9] European Fundamental Rights Agency: Involuntary placement and involuntary treatment of persons with mental health problems, 2012. Available at: http://fra.europa.eu/sites/default/files/involuntary-placement-and-involuntary-treatment-of-persons-with-mental-health-problems_en.pdf

Fiona Walsh – Convention on the Rights of Persons with Disabilities (CRPD): Civil Liberties, Equality and Upholding Human Rights

The 100th Anniversary of the 1916 Rising (Easter Rebellion) is currently being marked in Dublin City and Ireland. The Rising was launched by a small number of Irish Republicans at Easter time 1916 aiming to terminate British rule in Ireland and establish an independent Irish Republic. One of the principles of the Proclamation guaranteed:

‘religious and civil liberty, equal rights and equal opportunities to all its citizens’

In the context of those presenting in emotional distress today in Ireland in 2016 however there is still no guarantee that civil liberties will be respected and the reality of equal rights/opportunities for those perceived to be suffering from ‘mental disorders’ is not on the horizon just yet.   Diagnoses are based on subjective interpretation of ‘symptoms’ by Irish psychiatrists and other professionals who typically see individuals in terms of perceived deficits, brain disorders and inherited genetic defects. There are some more enlightened professionals who think in terms of ‘support’ and supporting decision making for those in distress as opposed to those who however compassionate and well meaning think in terms of ‘control’ ‘risk’ and substitute decision making. Many survivors of psychiatric abuse dread the paternalistic ‘best interests’ approach which typically has been used to deprive them of their basic human rights and to define what has contributed to their distress and what might support them to come through it.

 

Typically individuals in Ireland present in a voluntary capacity via their General Practitioner (GP), out of hours service or to the Accident & Emergency Unit of their local public hospital or to one of the private facilities. I am not aware of any psychiatric unit that does not use coercive practices of some sort.   Most who present in a voluntary capacity on the first occasion are not made aware on entering the facility they can be detained and forcibly treated, albeit on the 2nd opinion of another psychiatrist, which usually validates the first opinion. If you do not agree to Diagnosis and Treatment, then you may well be subjected to detention and forced drugging, seclusion, restraint, ECT etc. Under international human rights law this is could be regarded as Torture. The first thing that typically goes is the individuals clothes, access to fresh air etc, access to phonecalls/visitors , even your children until it is established that you will essentially play ball. Mothers can as I did receive threats such as ‘you know we have the option to contact child protection services’. True informed consent for any ‘Treatment’ including around serious side effects of medication must be sought yet typically is not and usually information not provided automatically either way so that the individual can make or be supported to make an informed decision. For those that know how the system operates and disagree with the medical model fear permeates and is increasingly stopping individuals in distress from reaching out to get the support they desperately crave in a given crisis. Reports of individuals taking their own life rather than submitting to coercion are sadly not uncommon and increasing in frequency in Ireland. Members of our Traveller Community have an increased incidence of suicide seven times higher than the rest of the population and fear often prevents travellers seeking professional support.

 

Ministers Frances Fitzgerald and Aodhan O Riordain published a ‘Road Map for Ratification of UN Convention on the Rights of Persons with Disabilities’ on 21st October 2015.   Introducing Capacity Legislation features on this road map. Accordingly on 30/12/2015 our President Michael D Higgins signed the Assisted Decision Making (Capacity) Bill 2013. Rather than respecting the principles of CRPD though our Departments of Justice and Health and Government bizarrely based the legislation around ‘Mental Capacity’ providing for a ‘Functional Capacity Test’. Prof Brendan Kelly, a prominent Irish Psychiatrist has had huge influence and uses the CRPD to even defend administering Electroshock against the expressed wishes of an individual (family/loved ones have no rights either in respect of those with involuntary status).  Minister Kathleen Lynch refused to listen to the voice of Civil Society Capacity Coalition, chaired by Eilionoir Flynn, Deputy Director, Centre for Disability Law & Policy NUI Galway and essentially deprived Irish Citizens of the Right to have Legal Capacity respected in law. In addition the legislation denies the right to make a legally binding Advance Healthcare Directive in the context of emotional health, even in respect of ECT. Although the word ‘unwilling’ was recently removed from our Mental Health Act 2001 , the word ‘unable’ still remains, essentially allowing forced detention and drugging to continue unabated. As a survivor of Psychiatry (my experience is relatively mild in many respects) I sat in the Public Gallery of our Houses of Parliament (Dail and Seanad) saddened by the refusal of our Minister and Government to uphold the principles contained in CRPD and respect Human Rights, despite being challenged by brillant Human Rights advocates including Jillian Van Turnhout and Katherine Zappone in our Seanad and Padraig Mac Lochlainn along with other elected representatives in our Dail Chamber. At a recent NGO Forum on Human Rights in Dublin Castle , ‘United Nations Council, ten years on’ (which UN Rapporteur Ms Catalina Devandas Aguilar was invited to speak and attended) Layla de Cogan Chin, Dept of Justice left attendees in no doubt with the Dept line that the Irish Government will essentially pick and choose what rights will be respected and that CRPD will be ratified with reservations/declarations.

 

Increasingly Irish survivors are looking to United Nations and the International Human Rights arena to expose the inability/indifference of the Irish Government and Psychiatry Profession to respectively legislate and usher in reform so that those who seek support can do so free of fear and terror of coercion. For some layer by layer of their human dignity is stripped away and they have to recover from the Diagnosis and ‘Treatment’ in addition to what brought them in contact with services in the first place.   In my own case presenting in a voluntary capacity agreeing to take all prescribed medication, still resulted in an attempt by treating Psychiatrist in 2011 to attempt sectioning on the basis of a second opinion of her choice not mine. My apparent ‘crime’ was that I did not agree with given diagnosis or that medication would be of therapeutic benefit.  A dear friend of mine, fellow human rights defender and member of Recovery Experts by Experience (REE) , at 77 years of age has to live daily with the fear of having ECT forced upon her despite having a power of attorney and Advance Directive made. Why should any Psychiatrist have the power to totally disregard her expressed wishes and disrespect her right to Legal Capacity should she ever become distressed in the future? Why should any human being live with the daily fear of having forced ECT again? As a member of Recovery Experts by Experience (REE) we made a submission to UN ICCPR in 2014. Tallaght Trialogue advocacy also submitted two reports under UN ICESCR in addition to contributing to joint parallel report from Civil Society, coordinated by Noeline Blackwell on behalf of FLAC. As a member of Tallaght Trialogue Advocacy I presented in person in June 2015 to UN ICESCR Committee in Geneva (speaking notes link below).

 

The UN CRPD reflects that each Human being has a right to be treated equally (Article 5) and have their will and preferences respected, that their legal capacity (Article 12) is inherent and above all that their human dignity must be respected. My hope is that the standards in the Convention that prohibit forced detention (Article 14) and treatment will propel Irish elected representatives to seek, resource and fund alternative approaches to coercion such as Open Dialogue, Hearing Voices Approach (see http://hearingvoicesnetworkireland.ie/ ) , Crisis Houses, Peer Support & Advocacy … Survivors of Psychiatry deserve to have their voices heard not silenced as is the case in Ireland where tick a box engagement is typical and ‘Experts speak to Experts’ time and time again without the voice of lived experience.

 

Thank you Tina Minkowitz and fellow advocates at CHRUSP, Eilionoir Flynn & past and present Colleagues, CDLP NUI Galway , Fiona Morrissey Lawyer & Researcher and to all who contributed to the CRPD and advocate to have the standards enshrined upheld. It is time the incoming Irish Government embraced the principles of Civil Liberties and Equality in the 1916 Proclamation and ratified the CRPD (signed 30th March 2007) and Optional Protocol without declarations/reservations. Why not embrace the opportunity without further delay to respect Legal Capacity (Article 12) and the will and preferences of individuals and treat every citizen equally regardless of physical disability, psycho-social disability or a perceived disability? A Democracy that silences the voice of Civil Society is not what the signatories of the 1916 Proclamation aspired to, nor is it appropriate for the survivors of psychiatric abuse past and present in 2016. It is time for Irish Legislators to be challenged by those charged nationally to uphold human rights to step up to the plate and respect and ratify the CRPD and Optional Protocol. Accordingly I unreservedly support the Campaign to Support CRPD Absolute Prohibition of Commitment and Forced Treatment.

 

Signed: Fiona Walsh, Human Rights Defender & Survivor of Irish Psychiatric Abuse

Dated: 28th March 2016

Member:

  1. Recovery Experts by Experience (REE)
  2. Tallaght Trialogue Advocacy (on facebook & twitter @TallaTrialogue)

 

Speaking notes ICESCR Review Ireland June 2015 , Fiona Walsh, Tallaght Trialogue Advocacy (pages 19/20 FLAC newsletter)

http://www.flac.ie/publications/flac-news-25-2-aprjun-2015/

http://hearingvoicesnetworkireland.ie/

 

Irish Examiner Newspaper Article 20/01/2016

http://www.irishexaminer.com/viewpoints/yourview/electroconvulsive-therapy-is-still-given-to-patients-who-dont-want-it-377065.html

 

Dr. Fiona Morrissey, Lawyer & Mental Health Researcher: Article in Irish Examiner dated 21/11/2015 and link to her research regarding Advance Directives

http://www.irishexaminer.com/viewpoints/analysis/assisted-decision-making-bill-why-changes-are-needed-to-current-laws-366167.html

 

Article in Irish Independent 15/11/2015

http://www.independent.ie/irish-news/health/mentally-ill-still-forced-to-endure-shock-treatment-34201655.html

Eilionoir Flynn CDLP NUI Galway – Blog Posts on www.humanrights.ie

http://humanrights.ie/author/eilionoirflynn/

Prof Brendan Kelly, Psychiatrist, letter to editor 22/11/2015

http://www.independent.ie/opinion/letters/dont-deny-them-this-treatment-34223005.html

Roadmap to ratification of CRPD issued by Irish Dept of Justice

http://www.justice.ie/en/JELR/Roadmap%20to%20Ratification%20of%20CRPD.pdf/Files/Roadmap%20to%20Ratification%20of%20CRPD.pdf

Linda Steele: Challenging Law’s ‘Monopoly on Violence’

Challenging Law’s ‘Monopoly on Violence’: Human Rights and Disability-Specific Lawful Violence

Dr Linda Steele, Lecturer, School of Law University of Wollongong, Australia

29 March 2016

The Convention on the Rights of Persons with Disabilities[i] (‘the CRPD’) provides a human rights basis for seeing non-consensual medical treatment, detention and chemical and physical restraint as forms of discriminatory violence against people with disability. United Nations human rights bodies must be consistent and persistent in urging states parties to reform criminal and civil laws to explicitly prohibit these practices and provide legal avenues for redress. Until this occurs, these practices will continue to be lawful forms of violence which are condoned and, indeed, made possible by the state and by law.

In my blog post I will briefly discuss the concept of ‘lawful violence’ and why non-consensual medical treatment, detention and physical and chemical restraint constitute ‘disability-specific lawful violence’. I will then explain how the CRPD provides a human rights basis to contest the lawfulness of this violence, and what needs to be done to urge states parties to follow the CRPD and ultimately prohibit and remedy disability-specific lawful violence.

Questioning Violence’s Legal Status

People with disability experience disproportionately high rates of violence when compared to people without disability[ii] (even taking into account the issues with data collection which result in an under-quantification of the rates of violence against people with disability[iii]). There are numerous approaches to categorizing violence against people with disability for the purposes of analysis and devising recommendations for law reform directed to reducing its incidence and enhancing justice for survivors. One approach which I adopt in this blog post is to categories violence in terms of its legal status under domestic law: whether violence is prohibited and legally actionable, or instead permitted and condoned by law. This approach is particularly fruitful for appreciating the significance of the interface of the CRPD and domestic law to states parties addressing all forms of violence against people with disability.

  • Unlawful violence

Some unwanted contact, detention and restraint against people with disability constitutes ‘unlawful violence’ – violence that is prohibited by domestic criminal laws (e.g. offences of assault or sexual assault) and/or constitutes a tortious wrong pursuant to civil law (e.g. torts of battery or false imprisonment). While people with disability experiencing ‘unlawful violence’ technically have available to them criminal and civil legal protection and remedies, at an individual level there are considerable issues with enforcing these laws vis-à-vis survivors with disability. These issues are due to such factors as discriminatory views about disability (and the intersection of disability with gender, sexuality, race, criminality and age) held by police, prosecutors and judges, and because of discriminatory evidential and procedural laws.

Despite the significant issues with ‘unlawful violence’ vis-à-vis people with disability, there are some forms of unwanted contact, detention and restraint of people with disability which do not even fit within this category of ‘unlawful violence’ such that there is not even the possibility of punishment and remedy. For present purposes, non-consensual medical treatment, detention and restraint of people with disability do not fall within the category of ‘unlawful violence’, as I will now turn to explain.

  • Lawful violence

Some unwanted contact, detention and restraint of people with disability – notably non-consensual medical treatment, detention and physical and chemical restraint – is not prohibited or actionable under domestic law and instead is legally permissible. As such, these practices fall outside of the category of ‘unlawful violence’ and sit in a different category of ‘lawful violence’ or, as I term it by reason of the significance of ‘disability’ to its lawfulness, a category of ‘disability-specific lawful violence’.[iv]

Disability-Specific Lawful Violence

Drawing on the work of Robert Cover[v] on ‘legal violence’ (i.e. violence permitted by law), Austin Sarat and Thomas Kearns[vi] argue that law has a ‘monopoly’ on violence, because law determines what is possible to do to another’s body without any legal accountability. Domestic law, and particularly criminal law and tort law, has singular control over violence because regardless of individual experiences of or social values towards unwanted contact detention and restraint (or, indeed, even international human rights perspectives on unwanted contact, detention and restraint) it is the domestic legal system that determines what will be punished or remedied and conversely what will be permitted and go without any punishment of the perpetrator or remedy for the survivor. Unwanted contact, detention and restraint becomes violence that is ‘lawful’ where it is permitted by law. This is not to suggest that legal permissibility means that lawful violence is completely at large. Generally, lawful violence is deeply embedded in legislative and common law frameworks and in judicial and administrative procedures (many of which purportedly ‘protect’ those subjected to lawful violence through ‘procedural’ oversight). Therefore, the state and law are significantly complicit in the operation of and legitimation of unwanted contact, detention and restraint where this is permitted by law.

  • Lawfulness

Turning then to non-consensual medical treatment, detention and physical and chemical restraint of people with disability, these practices are lawful violence in the sense discussed above because they are not prohibited by or actionable under law. In very general terms, criminal law defines assault and civil law defines battery in terms of non-consensual interpersonal physical contact or the non-consensual threat of such contact. The tort of false imprisonment and related criminal offences consider detention and restraint unlawful where it is the non-consensual deprivation of liberty in a delimited space. In the face of the general criminal and tortious prohibition of these acts, the entry point for the legality of such acts vis-à-vis people with disability is the legal exceptions to unlawful violence created by certain defences to criminal responsibility and tortious liability: consent, necessity and lawful authority. These are discussed here in very general terms (noting there will be differences between jurisdictions):

  1. Consent: Interpersonal physical contact does not constitute assault if consented to by the individual. However, where the individual does not have capacity to consent, the law permits a third party to consent on that person’s behalf. In the context of medical treatment of people with disability (such as sterilization) there are established legal processes for recognizing third party consent, e.g., involving determining lack of legal capacity on the basis of mental incapacity and then determining whether the medical decision is in the individual’s ‘best interests’ or a ‘step of last resort’.[vii]
  2. Necessity: Non-consensual medical treatment, detention and physical and chemical restraint of people with disability might also be considered to fall in the defence of medical necessity if the procedure is considered ‘necessary’ in order to protect the individual’s life, health or wellbeing and the act is reasonable and proportionate to the ‘harm’ to be addressed (regardless of whether this harm is in the context of an immediate and short term emergency or an ongoing state of affairs).[viii]
  3. Lawful authority: Non-consensual medical treatment, detention and physical and chemical restraint of people with disability are lawful when done pursuant to statutory or judicial authority.[ix] Such authority includes civil and forensic mental health legislation authoring detention and treatment, as well as legislation authorizing chemical and physical restraint.

These defences carve out an exception to ‘unlawful violence’ for non-consensual medical treatment, detention and physical and chemical restraint of people with disability, such that they become forms of ‘lawful violence’ regulated by law. This procedural protection on an individual basis of when and how such interventions take place elides questioning at a systemic level why these unwanted practices should ever be permitted and in turn elides categorically naming these practices as violence.

Yet, the ‘regulation’ by law of these practices is typically framed as ‘protective’ because law’s involvement provides administrative and judicial procedural oversight to when and how these non-consensual interventions occur. In fact, the greater ‘procedural justice’ afforded to people with disability in the past couple of decades is frequently characterized as a marker of a more enlightened and progressive approach by law and society to people with disability insofar as it is juxtaposed to earlier purportedly extra-legal, arbitrary and repressive practices towards people with disability. However, far from showing law’s role in the ‘salvation’ or ‘empowerment’ of people with disability, the legal processes through which non-consensual medical treatment, detention and physical and chemical restraint of people with disability are permitted in fact signal law’s complicity in this violence: the state’s regulation of a legal economy of violence against people with disability. The state and law contributes to the production of broader social and ethical norms about what is permissible to be done to people with disability and ultimately lowers the value of the bodies and lives of people with disability.

The status of some violence against people with disability as lawful has implications for the punishment of perpetrators and remedies for survivors – in short, there are none. For example, if an individual is detained in a mental health facility and given treatment pursuant to a court order made under civil mental health legislation, that individual cannot report this to police and have the doctor charged with assault (although if the doctor acts outside of the specifics of the order, this would then be unlawful). Similarly, if a girl with intellectual disability is sterilized pursuant to her parent’s consent, she cannot claim civil damages for battery where the doctor acted pursuant to her parents’ decision which was authorized by the court as being in her best interests. A further example is the detention in forensic mental health system of a non-convicted individual on basis of unfitness: this is lawful if is unfitness determined pursuant to the legal process specified by forensic mental health legislation and an individual cannot claim damages for years of imprisonment.

  • Disability-specificity

Above I have explained how non-consensual medical treatment, detention and physical and chemical restraint of people with disability become ‘lawful violence’. I refer to this as ‘disability-specific’ lawful violence because disability is central to the lawfulness of this violence specifically to (and sometimes exclusively to) people with disability:

  1. This violence occurs in institutional circumstances specific to the marginalization, segregation and regulation of people with disability, e.g., mental health facilities, forensic mental health system, sterilization.
  2. Circulating across all of the defences discussed above and the associated legal frameworks of substituted decision-making (in the context of the defence of consent) and authorizing legislation (in the context of the defence of lawful authority), are stereotypes about disability as exemplified by judicial interpretation of such value-laden legal concepts as ‘harm’, ‘necessity’, ‘reasonable’, ‘best interests’ in relation to people with disability.[x]
  3. These defences and the associated legal frameworks of substituted decision-making and authorizing legislation appear as socially and ethically acceptable because of ideas associated with people with disability as needing (and benefiting from) medical treatment, detention and restraint. Significant here are discourses of disability linked to medicine and defect (rationales of therapy), helplessness (rationales of care and protection) and danger (rationales of risk management).
  4. Running across all of the defences and the associated legal frameworks of substituted decision-making and authorizing legislation is the significance of ‘mental incapacity’: either as the basis for the removal of legal capacity (e.g. in defences of consent and necessity) and/or as a basis for indicating lack of self-control, danger or vulnerability (e.g. in defences of necessity and lawful authority). ‘Mental incapacity’, while typically thought of as a scientifically objective characteristic of individuals, is a problematic concept embodying norms of rationality, self-sufficiency and bodily impermeability that are premised on an able subject.[xi]

Therefore, categorizing violence against people with disability in terms of its legal status illuminates how some violence against people with disability is legally permitted and state sanctioned. Where law has a monopoly over ‘violence’ against people with disability, it is arguable that turning to law to address individual instances of this violence is futile. A criminal or civil action can never be successful even with the best lawyers and judges: we cannot turn to domestic law for punishment or remedy (nor can we turn to the state to condone this violence) because law says they are not ‘violence’ in the legal sense and as such are not wrongs or harms and do not constitute injustices.

CRPD and Disability-Specific Lawful Violence

The CRPD provides the possibility of seeing non-consensual medical treatment, detention and physical and chemical restraint of people with disability as violence, and provides a human rights basis for states parties to prohibit these practices as unlawful violence. The CRPD explicitly imposes obligations on states parties to protect people with disability from violence, including by taking legal measures (presumably to prohibit violence and provide appropriate remedies). Article 16 of the CRPD states in part that: ‘States Parties shall take all appropriate legislative, administrative, social, educational and other measures to protect persons with disabilities, both within and outside the home, from all forms of exploitation, violence and abuse, including their gender-based aspects.’

Yet, the obligation in Article 16 is not merely to protect individuals from currently unlawful violence, e.g., enhancing enforcement in relation to individual cases. Rather, when Article 16 is read in conjunction with other Articles of the CRPD, it becomes apparent that states parties’ obligations under the CRPD in relation to violence include protecting people with disability from forms of violence which are presently lawful and hence from ‘disability-specific lawful violence’:

  1. The right to equality and non-discrimination in Article 5 and the right to personal integrity in Article 17 of the CRPD mean that individuals must have recognized their self-determination and ability to make their own decisions to consent to or withhold consent to interventions in their bodies and in their lives to the same degree as people without disability. People with disability cannot be subjected to non-consensual physical contact, detention or restraint on the basis of their disability.
  2. The right to equality and non-discrimination in Article 5 in conjunction with the right to legal capacity in Article 12 of the CRPD means that individuals should have their legal capacity to make decisions recognized to the same extent as individuals without disability and should not be denied legal capacity on the basis of ‘mental incapacity’. The right to exercise autonomy in consenting or withholding consent should be available to all regardless of perceived ‘mental incapacity’. In turn, non-consensual physical contact, detention or restraint on the basis of a denial of legal capacity is discriminatory because it applies only to individuals with a disability-linked ‘mental incapacity’ (itself a discriminatory concept, as mentioned above).[xii] On a similar basis, non-consensual detention on the basis of disability constitutes arbitrary detention pursuant to Article 14.[xiii]
  3. The right to freedom from torture in Article 15 means that the purportedly protective judicial and administrative procedural frameworks surrounding non-consensual contact, detention or restraint could, perversely, render these interventions not merely violence but state-sanctioned discriminatory violence and hence torture.[xiv]
  4. The shift evident in the preamble to the CRPD in the meaning of disability from a medical model to disability as ‘an evolving concept and that disability results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others’ illuminates the significance of the social and political contingency of the meaning of disability to the realization of the human rights of people with disability including through domestic legal frameworks. In turn, this shift suggests that stereotypes about disability might presently circulate in legal frameworks that render lawful non-consensual contact, detention or restraint of people with disability.

The CRPD is quite radical in the new approach to violence against people with disability that it provides. This is because this approach contests foundational concepts of consent, capacity, state/judicial authority which order domestic legal systems (and to a certain extent international human rights law). This approach also contests old (but ever growing) institutions, disciplines and industries of incarceration and therapy through which non-consensual physical contact, detention or restraint are administered.

What needs to be done?

Despite these rather revolutionary ideas about disability and violence provided by the CRPD, disability-specific lawful violence continues. While the CRPD has prompted some states parties to ‘review’ (though perhaps not necessarily ‘reform’) capacity laws and mental health laws, ten years on from the coming into force the CRPD has not witnessed the prohibition of non-consensual physical contact, detention or restraint of people with disability.

Here I conclude by making a number of suggestions related to the significance of the interface of CRPD and domestic law to the prohibition and remedying of (presently lawful) violence against people with disability.

United Nations human rights committees must be consistent and persistent in urging states parties to reform criminal and civil laws to explicitly prohibit non-consensual physical contact, detention or restraint of people with disability including prohibit forced medical treatment, detention and chemical and physical restraint. United Nations human rights bodies should continue to encourage states parties to remove or withdraw interpretive declarations which interpret human rights to enable non-consensual medical treatment, detention and restraint (even when only as a ‘last resort’ or when in ‘best interests’). Unfortunately, these strategies might be impeded by the discrepancies which exist between United Nations human rights bodies in relation to the approach to disability and violence, with some human rights bodies failing to acknowledge disability-specific lawful violence and focusing on the ‘procedural’ protection approach to (regulating) violence. The discrepancies between United Nations human rights bodies might enable states parties to pick and choose how to interpret their obligations related to violence in such a way that ultimately focuses on addressing currently ‘unlawful’ violence and ignoring eliminating disability-specific lawful violence. United Nations human rights bodies might need to turn to consider the ideas of disability underpinning their approaches to violence against people with disability, some of which might precede the CRPD and its shift from a medical approach to disability.

A number of additional strategies which states parties should pursue (and which United Nations human rights bodies should encourage states parties to pursue) include:

  1. States parties should not limit their ‘review’ and ‘reform’ efforts to attaining a best practice in judicial and administrative oversight of disability-specific lawful violence (i.e. through procedural safeguards) to questioning whether some practices should ever be state sanctioned on anyone (including people with disability) regardless of the legal procedure through which this sanctioning occurs. Central to this is making apparent and naming the ideas about disability inherent in the law itself, rather than only addressing stereotypes about law that circulate in the application or enforcement of law at an individual level. This involves denaturalizing centuries-old legal concepts, legal procedures and jurisdictions – some of which are foundational to legal authority generally.
  2. States parties should consider the intersection of ideas about disability with other dimensions of identity, particularly being mindful of the identities of the individuals to whom these practices disproportionately apply: e.g. gender and forced mental health treatment and detention of women, age and chemical and physical restraint of older people with dementia in aged care facilities, Indigeneity and over-representation of Indigenous Australians in forensic mental health detention, gender and sterilization, ideas about criminality re people in forensic mental health detention.
  3. States parties should revisit the ideas of bodies and space envisaged by domestic laws related to violence, notably in relation to false imprisonment. In domestic law, detention and restraint focuses on external factors which restrict the individual’s movement – yet much of the interventions in the disability-specific context work from within the body – to restrain and regulate from within (e.g. chemical restraint[xv]).
  4. States parties should develop a strategy for ‘transitional justice’[xvi] that addresses prohibiting and making legally actionable future instances of non-consensual medical treatment, detention and restraint as well as developing a system to recognize, remedy and remember past instances of these practices when they were still lawful.[xvii] This might involve thinking beyond disability to how law (both international and domestic legal frameworks) have dealt with mass atrocities, historical injustices and state-sanctioned violence in relation to other marginalized groups. This system must not only focus on the individuals and institutions administering these practices, but also address how to make the state and law account for their complicity.
  5. States parties should address the role of ‘para-legal’ regulatory frameworks such as bioethics (e.g. research, clinical, professional) in legitimizing the administration of disability-specific lawful violence.[xviii]
  6. States parties should work with health, medical and disability services to challenge institutional, disciplinary and (importantly in an increasingly privatized and corporatized context) economic imperatives[xix] for the continuation of the administration of disability-specific lawful violence.
  7. States parties should encourage reforms to tertiary legal education which take a critical approach to disability and to disability-specific lawful violence in courses such as criminal law and tort law. Typically, law text books cover the operation of defences in relation to people with disability in a self-evident and non-critical manner which then naturalizes the legal treatment of people with disability and negates their subjection to violence and the law and state’s complicity in this violence.

Ultimately, the lower legal threshold of violence in relation to people with disability reflects a devaluing of bodies and lives of individuals with disability – until this is addressed the human rights of people with disability promised by the CRPD will be profoundly and disappointingly incomplete.

 

[i] Convention on the Rights of Persons with Disabilities, opened for signature 13 December 2006, 2515 UNTS 3 (entered into force 3 May 2008).

[ii] See, e.g., Karen Hughes, Mark A Bellis, Lisa Jones, Sara Wood, Geoff Bates, Lindsay Eckley, Ellie McCoy, Christopher Mikton, Tom Shakespeare and Alana Officer, ‘Prevalence and Risk of Violence against Adults with Disabilities: A Systematic Review and Meta-Analysis of Observational Studies’ (2012) 379(9826) Lancet 1621.

[iii] See, e.g., Jess Cadwallader, Anne Kavanagh and Sally Robinson, ‘We Count What Matters, and Violence Against People with Disability Matters’, The Conversation, 27 November 2015, http://theconversation.com/we-count-what-matters-and-violence-against-people-with-disability-matters-51320, accessed 6 January 2016.

[iv] On ‘disability-specific lawful violence’ generally see, e.g., Linda Steele, ‘Disability, Abnormality and Criminal Law: Sterilisation as Lawful and Good Violence’ (2014) 23(3) Griffith Law Review 467; Submission to the Senate Community Affairs References Committee, Inquiry into violence, abuse and neglect against people with disability in institutional and residential settings, including the gender and age related dimensions, and the particular situation of Aboriginal and Torres Strait Islander people with disability, and culturally and linguistically diverse people with disability (2015).

[v] Robert Cover, ‘Violence and the Word’ (1986) 95 Yale Law Journal 1601.

[vi] Austin Sarat and Thomas R Kearns, ‘Introduction’ in Austin Sarat and Thomas R Kearns (eds), Law’s Violence (University of Michigan Press, 1992) 1, 4.

[vii] In the Australian context see, e.g., Secretary, Department of Health and Community Services v JWB (1992) 175 CLR 218.

[viii] In the UK and Australian context see, e.g., Re F (Mental Patient Sterilisation) [1990] 2 AC 1.

[ix] In the Australian context see, e.g., Coco v R (1994) 179 CLR 427.

[x] On best interests see, e.g., Linda Steele, ‘Making Sense of the Family Court’s Decisions on the Non-Therapeutic Sterilisation of Girls with Intellectual Disability’ (2008) 22(1) Australian Journal of Family Law 1.

[xi] See, e.g., Linda Steele, ‘Disability, Abnormality and Criminal Law: Sterilisation as Lawful and Good Violence’ (2014) 23(3) Griffith Law Review 467.

[xii] Committee on the Rights of Persons with Disabilities, General Comment No 1 (2014): Article 12: Equal recognition before the law, 11th sess, UN Doc CRPD/C/GC/1 (19 May 2014).

[xiii] Committee on the Rights of Persons with Disabilities, General Comment No 1 (2014): Article 12: Equal recognition before the law, 11th sess, UN Doc CRPD/C/GC/1 (19 May 2014); see also Report of the Working Group on Arbitrary Detention: United Nations Basic Principles and Guidelines on Remedies and Procedures on the Right of Anyone Deprived of Their Liberty to Bring Proceedings Before a Court, 30th sess, UN Doc A/HRC/30/37 (6 July 2015), notably Principle 20 and Guideline 20.

[xiv] Committee on the Rights of Persons with Disabilities, General Comment No 1 (2014): Article 12: Equal recognition before the law, 11th sess, UN Doc CRPD/C/GC/1 (19 May 2014) 11[42]. On non-consensual medical treatment, detention and restraint of people with disability as torture, see Dinesh Wadiwel, ‘Black Sites: Disability and Torture’, paper presented at Critical Social Futures: Querying Systems of Disability Support, Symposium of The Australia Sociological Association, 19 June 2015.

[xv] Erick Fabris, Tranquil Prisons: Chemical Incarceration under Community Treatment Orders (University of Toronto Press, 2011).

[xvi] See, e.g., Carolyn Frohmader and Therese Sands, Australian Cross Disability Alliance (ACDA) Submission to the Senate Community Affairs References Committee Inquiry into Violence, Abuse and Neglect Against People with Disability in Institutional and Residential Settings, August 2015.

[xvii] See, eg, Hege Orefellen, ‘Hege Orefellen on Reparations’, Campaign to Support CRPD Absolute Prohibition of Commitment and Forced Treatment, https://absoluteprohibition.wordpress.com/2016/02/06/hege-orefellen-on-reparations/, accessed 27 March 2016.

[xviii] The significance of bioethics is apparent from the controversy around Ashley X: see, e.g., Eva Feder Kittay, ‘Forever Small: The Strange Case of Ashley X’ (2011) 26(3) Hypatia 610.

[xix] On the ‘therapeutic industrial complex’ see, e.g., Michelle Chen, ‘How Prison Reform Could Turn the Prison-Industrial Complex Into the Treatment-Industrial Complex’, The Nation (20 November 2015) http://www.thenation.com/article/how-prison-reform-could-turn-the-prison-industrial-complex-into-the-treatment-industrial-complex/, accessed 29 March 2016.

Documenta (México)

We at Documenta work to ensure the CRPD absolute prohibition of commitment and forced treatment for persons with psychosocial and intelectual disabilities in Mexico, particularly in connection with security measures.

The second video has English subtitles; others are in Spanish.  Please visit Documenta’s website http://www.documenta.org.mx and their YouTube channel https://www.youtube.com/channel/UC2mXb9uN_To_JrwND7HvGuw for more information.

[youtube https://www.youtube.com/watch?v=fPo2BfAVAFQ]

Published on Nov 10, 2015

Este año, Documenta presentó el caso de Arturo ante el Comité de la ONU sobre los Derechos de las Personas con Discapacidad. Su caso representa la terrible realidad de las personas con discapacidad cuando se enfrentan a un proceso penal en México.

[youtube https://www.youtube.com/watch?v=okUZBlI4s2w]

Published on Nov 27, 2015

Un corto documental sobre las dificultades de Víctor como persona con discapacidad psicosocial al enfrentarse al sistema de justicia penal de México. #CuestionemosLaInimputabilidad

[vimeo 136127114 w=500 h=281]

En la voz de… Eunice Leyva García 1 (Abogada del Área de Litigio Estratégico de Documenta A.C.), Primera intervención/Sobre Peritajes realizados.

La Prohibición Absoluta a los Internamientos Involuntarios y Tratamientos Forzados en Psiquiatría: Tensiones con los mecanismos de privación de libertad por motivos de salud mental en Chile – Francisca Figueroa

La-libertad-es-terapéutica-780x439

http://www.saludmentalycomunidad.cl/la-prohibicion-absoluta-a-los-internamientos-involuntarios-y-tratamientos-forzados-en-psiquiatria-tensiones-con-los-mecanismos-de-privacion-de-libertad-por-motivos-de-salud-mental-en-chile/

A continuación, presentamos el texto de la abogada chilena Francisca Figueroa que se suma a la campaña en Apoyo a la Prohibición Absoluta de la CDPD de los Tratamientos Forzosos y los Internamientos Involuntarios


Tensiones con los mecanismos de privación de libertad por motivos de salud mental en Chile

La campaña por la Prohibición Absoluta de los internamientos involuntarios y tratamientos psiquiátricos forzados se enmarca dentro del contexto de los art. 12, 14 y 15 de la Convención sobre los Derechos de las Personas con Discapacidad (en adelante, CDPD), adoptada por la Asamblea General de la Organización de las Naciones Unidas con fecha 13 de diciembre de 2006 en la ciudad de Nueva York; la cual fue ratificada y promulgada por Chile, entrando en vigencia en nuestro país el año 2008.

El contenido específico de las disposiciones que tal instrumento de derechos humanos refiere –el cual extiende su alcance a las personas en situación de discapacidad mental o psicosocial, e intelectual (Fernández, 2010: 10)-, se encuentra aún en proceso de delimitación por parte del Comité sobre los Derechos de las Personas con Discapacidad, el que recientemente se pronunció respecto al alcance del derecho contenido en el art. 14 de la CDPD, éste es, el derecho a la Libertad y Seguridad de la Persona.

Tal pronunciamiento impone un cambio de paradigma al prohibir de forma categórica y absoluta la privación de libertad de la persona por motivos de discapacidad –sea ésta,  real o aparente-, aun al considerarse que la persona se encuentra en situación de crisis o que puede constituir un peligro para sí mismo u otros (pr. 13, 14 y 15). En tal aspecto radica, el carácter absoluto de la prohibición.

Los fundamentos jurídicos de este posicionamiento radical por la no discriminación, dicen relación con el alcance del art. 12 de la CDPD, el cual impone a los Estados Partes el deber de reconocer la capacidad jurídica de las personas en situación de discapacidad en igualdad de condiciones y en todos los aspectos de su vida. Así, si bien el art. 14 impone como limitación al derecho a la libertad de la persona que ésta se ajuste a la legalidad, no es menos cierto que existen en el ordenamiento jurídico chileno, leyes que sistemáticamente niegan la capacidad jurídica de la persona en diversos ámbitos de desarrollo de su vida, lo cual se encuentra en evidente contradicción con la CDPD (Observatorio de Derechos Humanos de las Personas con Discapacidad mental, 2014), conforme se ha pronunciado el Comité sobre los Derechos de las Personas con Discapacidad y el Relator Especial sobre la Tortura y otros Tratos o Penas Crueles, Inhumanos o Degradantes.

Ejemplo de esto son los regímenes de interdicción, las declaraciones de inimputabilidad penal, las normas que regulan los internamientos involuntarios y los tratamientos invasivos e irreversibles -como son, las psicocirugías, las terapias de electroshock y esterilizaciones, entre otros- en los que operan mecanismos de sustitución de la voluntad de persona (Instituto Nacional de Derechos Humanos [INDH], 2014), vulnerando el Principio de Autonomía contenido en el art. 3 letra a) de la CDPD que contempla “El respeto de la dignidad inherente, la autonomía individual, incluida la libertad de tomar las propias decisiones, y la independencia de las personas” y el art. 12; sometiendo a la persona a un estatus de minoridad social propio de los paternalistas sistemas de tutela decimonónicos (Castel, 2009).

Para dar cuenta de este desolador panorama, pese a la entrada en vigencia de la CDPD en Chile el año 2008, es posible constatar la siguiente situación conforme datos oficiales del Ministerio de Salud (2014):

las medidas forzadas en relación con la hospitalización han aumentado entre los años 2004 y 2012. La proporción de ingresos de urgencia se han triplicado, llegando a 30,8% del total de ingresos. Los ingresos administrativos (hospitalizaciones involuntarias autorizadas por las SEREMI de Salud) se han cuadriplicado y durante el año 2012 representaron el 6,6% de los ingresos, mientras que los ingresos por orden judicial se duplicaron, con un 5,4% para el 2012. Además, también hubo un incremento en el uso de la contención y/o aislamiento, desde 17,8% del total personas hospitalizadas en el 2004 a 26,1% en el 2012 (ídem: 53).

Así, atendido al panorama anteriormente descrito y los actuales estándares de derechos humanos a los que se ha comprometido a dar cumplimiento el Estado de Chile, deben progresivamente abolirse los regímenes administrativos de internamientos involuntarios que no hacen sino reproducir el estigma que asocia “enfermedad mental” y peligrosidad, cuestión que se advierte claramente en las disposiciones del D.S. Nº 570 del Ministerio de Salud, que permite privar de libertad a una persona “aparentemente afectada por un trastorno mental” e internarle en un establecimiento psiquiátrico por cuanto su conducta “pone en riesgo su integridad y la de los demás, o bien, altera el orden o la tranquilidad en lugares de uso o acceso público”, operando los encierros psiquiátricos a modo de auténticas medidas de seguridad predelictuales (Dufraix, 2013: 272-274; Horwitz y López, 2004: 565) y por lo demás, sin cumplir con garantías mínimas de resguardo a los derechos humanos, al carecer de control judicial, de órgano autónomo de revisión y de un procedimiento de apelación contra la resolución administrativa-sanitaria que priva de libertad a la persona contra su voluntad (INDH, 2014: 120; Ministerio de Salud, 2014: 37).

Si bien se ha planteado como un avance en la materia la creación de la Comisión Nacional de Protección de las Personas afectadas por Enfermedad Mental y las Comisiones Regionales establecidas en virtud de la Ley 20.584, se hace indispensable advertir que éstas dependen tanto en su constitución como en su funcionamiento de la autoridad administrativa a quien debe controlar y observar, careciendo de facultades resolutivas vinculantes y por tanto, no siendo apta para garantizar un resguardo imparcial de los derechos humanos conforme el compromiso adoptado por Chile al ratificar la CDPD. Sobre este punto, el Comité sobre los Derechos de las Personas con Discapacidad ha sido explícito al referir que los Estados Partes deben establecer mecanismos independientes de vigilancia y garantizar la participación de la sociedad civil en las labores monitoreo (pr. 19).

Por otra parte, los alcances de la Prohibición Absoluta invitan a re-pensar a la luz de la CDPD, el régimen de inimputabilidad penal y la utilización de los internamientos psiquiátricos involuntarios y tratamientos forzados en instituciones de salud mental a modo de medidas de seguridad, conforme se contempla en el art. 457 del Código Procesal Penal. Éstas, fundadas en la declaración de peligrosidad de la persona en ausencia de culpabilidad, no sólo privan del ejercicio de derechos fundamentales careciendo de regulación constitucional (Falcone, 2007: 248), sino también, vulneran los actuales estándares de derechos humanos que comprometen a los Estados Partes a reconocer la capacidad jurídica de las personas en situación de discapacidad en todos los ámbitos de la vida. Al respecto, el Comité ha recomendado la eliminación de las medidas de seguridad, incluyendo las de tratamiento médico obligatorio en instituciones psiquiátricas (pr. 16, 20).

La objeción a este posicionamiento es evidente. ¿Qué sucede si la persona se encuentra “descompensada” y creemos que puede llevar a cabo comportamientos que afecten los derechos de los otros?. Es en ese punto donde el Comité ancla su posicionamiento en la no discriminación, al recordarnos que tanto las personas en situación de discapacidad como las que no, tenemos el deber de no causar daños a los demás (pr. 14), así como contamos con la libertad para disponer de nuestra integridad e incluso nuestra vida, cuestión que hace que las autolesiones y la tentativa de suicidio no sean punibles en el Código Penal. Por tanto, ¿Qué justifica el privar de libertad a una persona en situación de discapacidad en base a un pronóstico de peligrosidad –y en el caso de los internamientos administrativos, no habiendo cometido la persona hecho constitutivo de delito alguno-, siendo que todas las personas contamos con el mismo deber respecto a los derechos de demás e idéntica libertad de disposición respecto a los derechos propios?. La respuesta es que tal privación de libertad no se ancla sino en una evidente manifestación de discriminación por motivos de discapacidad, prohibida explícitamente por el art. 14 de la CDPD.

La campaña por la Prohibición Absoluta es en una invitación a enterarnos de los nuevos estándares de derechos humanos que rigen en materia de privación de libertad y tratamientos forzados por motivos de salud mental, los que han hecho propias las voces de críticos y sobrevivientes de la psiquiatría que han padecido la violencia del modelo psiquiátrico, justificado por la ideología terapéutica que específicamente se analiza por el Relator Especial sobre la Tortura y otros Tratos o Penas Crueles, Inhumanos o Degradantes en sus Informes A/63/175 y A/HRC/22/53, extendiendo a estas prácticas no consentidas las categorías de tortura y malos tratos, dando aplicación al art. 15 de la CDPD que contempla tal prohibición.

De esta manera, hacemos una invitación a cuestionar las racionalidades que justifican la vigencia de un estatuto legal paralelo respecto a las personas etiquetadas con diagnósticos psiquiátricos, el cual permite privarlas de libertad en base a criterios que se imponen a modo de pensamiento único a través de la hegemonía del modelo médico-psiquiátrico en salud mental, negando la autonomía de la persona y controlando sus diferencias en el plano psíquico a través del uso de la violencia.

Francisca Figueroa San Martín, Abogada. 

Bibliografía

Castel, R. (2009). El orden psiquiátrico. Edad de oro del alienismo. Buenos Aires: Nueva Visión.

Committee on the Rights of Persons with Disabilities (2015). Guidelines on article 14 of 

the Convention on the Rights of Persons with Disabilities. The right lo liberty and security of persons with disabilities. [en línea] Ginebra, Suiza. Disponible en: http://www.ohchr.org/EN/HRBodies/CRPD/Pages/CRPDIndex.aspx

Dufraix, R. (2013). Las medidas de seguridad aplicables al inimputable por condición mental en el Derecho Penal Chileno. Tesis Doctoral. Universidad del País Vasco.

Falcone, D. (2004). Una mirada crítica a la regulación de las medidas de seguridad en Chile. Revista de Derecho de la Pontificia Universidad Católica de Valparaíso. XXIX, pp. 235-256.

Fernández, M. (2010). La discapacidad mental o psicosocial y la convención sobre los Derechos      de las Personas con Discapacidad. Revista de derechos humanos – dfensor. (11), pp. 10-17

Horwitz, M. y López, J. (2004). Derecho procesal penal chileno, Tomo II. Santiago: Editorial Jurídica de Chile.

Instituto Nacional de Derechos Humanos [INDH], (2014). Situación de los Derechos Humanos en Chile. Informe Anual 2014. [en línea] Santiago. Disponible en: http://www.indh.cl/informe-anual-situacion-de-los-derechos-humanos-en-chile-2014 [Último acceso 15 Marzo 2016].

Ministerio de Salud, (2014). “Evaluación Sistemas de Salud Mental de Chile”. Segundo Informe, 2014. Informe sobre la base del Instrumento de evaluación del sistema de salud mental de OMS (OMS IESM/ WHO AIMS). [en línea] Santiago de Chile. Disponible en: http://www.who.int/mental_health/who_aims_country_reports/who_aims_report_chile.pdf [Último acceso 12 Febrero 2016].

Observatorio de Derechos Humanos de las personas con Discapacidad mental (2014). Derechos humanos de las personas con Discapacidad mental: Diagnóstico de la situación en Chile.  [en línea] Santiago de Chile.  Disponible en: http://www.observatoriodiscapacidadmental.cl/wp-content/uploads/2014/05/informe-ODDHHPDM-final.pdf[Último acceso 13  Marzo 2016].

Organización de Naciones Unidas [ONU], (2006). Convención sobre los Derechos de las Personas con Discapacidad y Protocolo Facultativo. [en línea] Nueva York. Disponible en: http://www.un.org/disabilities/documents/convention/convoptprot-s.pdf [Último acceso 15  Marzo 2016].

Pink Belette: La psiquiatrie en France/ Psychiatry in France

La psychiatrie en France, zone de non-droit (par Pink Belette)

Une patiente française sous contrainte fait son « audit » dans le cadre de la campagne pour soutenir l’Abolition totale des soins et de l’hospitalisation sans consentement en application de la CDPH de l’ONU

http://depsychiatriser.blogspot.no/2016/03/la-psychiatrie-en-france-zone-de-non.html

 

Pourquoi je suis contre les « soins sous contrainte » :

On pourrait croire que, au pays de la liberté, on a encore droit à son intégrité morale et physique.

Rien n’est plus faux. Par experience, impossible pour quiconque d’échapper à un soin sous contrainte (SPDT, « soin à la demande d’un tiers » ou « péril imminent »).

Il suffit que : une personne la demande (que ce soit la famille, un voisin…), qu’on soit « pas bien », déstabilisé, agité, « instable », en colère, dépressif, sur la défensive, « en opposition », « délirant », amaigri, boulimique, fumeur de shit, drogué…

Il suffit aussi qu’on refuse l’hospitalisation ou un traitement pour que les médecins se relaient pour demander un soin sous contrainte. Une fois hospitalisé, « on » vous fait comprendre que vous perdez vos droits à la personne, l’argument étant : « maintenant on est responsable de vous pour TOUT »… Par contre, vis-à-vis de vous, « on » n’est responsable de rien…

 

Depuis la loi Bachelot du 5 Juillet 2011, en particulier si on a le malheur de contester le diagnostic ou le traitement, c’est alors après la sortie d’hospitalisation qu’on ne peut plus se débarrasser de la contrainte, et c’est là que c’est le plus pervers : injections forcées, consultations obligatoires avec un praticien hospitalier non choisi (à la rigueur, on a le choix entre deux médecins).

Le pire : si on refuse de se rendre au centre médico-psychologique du secteur assigné, la police vient gentiment vous cueillir chez vous pour vous hospitaliser en soins obligatoires à un degré encore plus coercitif (SPDRE, « sur la demande de l’Etat ») et sur un temps plus long et sans contact autorisé avec l’extérieur (!) jusqu’à ce qu’il aient réussi à réduire votre volonté à néant. Ainsi, il arrive que les personnes concernées doivent abandonner leur logement pour « vivre » en psychiatrie (parfois pendant des dizaines d’années, voir le cas de Dimitri Fargette)…

 

Je suis témoin : en France, il y a réellement du souci à se faire…

  1. Il n’y a aucune alternative à la psychiatrie institutionnelle (lobbying des psychiatres ET de l’industrie pharmaceutique contre d’autres formes de thérapies) ;
  2. Aucune littérature ou culture antipsychiatrique (des « survivants », il n’y en a pas…)
  3. L’Ordre des Medecins Psychiatres qui suspend : tout psychiatre « en décalage » avec le système consensuel (d’après le Dr. O.G, psychiatre libéral et ex-chef de clinique) ;
  4. L’Ordre des Medecins Psychiatres qui suspend : un psychiatre responsable de la mort d’une patiente… seulement pour 2 semaines (voir l’affaire Florence Edaine)
  5. La « Mafia des tutelles » : tout patient faisant des séjours répétés est automatiquement placé sous curatelle ou tutelle (sans consentement, c’est renforcé)…
  6. Des mères se voient enlever leurs enfants immédiatement après la pose d’un diagnostic de maladie mentale ; jamais de scandale médiatique…
  7. On fait comprendre aux femmes en âge de procréer qu’il faut surtout adopter la contraception, en sous-entendant qu’on leur enlèverait leur enfant de toute façon. Ce qu’on ne leur dit pas, c’est que tous les neuroleptiques passent la barrière placentaire, c’est pourquoi j’ai entendu parler d’autant de cas d’avortements spontanés chez les femmes sous traitement. Dixit une infirmière, on donne de l’Haldol aux femmes enceintes, ce qui « prouverait » soi-disant « le peu de nocivité de l’Haldol » (!). Jamais d’étude là-dessus ni de scandale médiatique…
  8. Des services fermés qui regorgent de dépressifs qui ne sont pas en « péril imminent » et qui se sentent surtout mal de recevoir par exemple 4(!) antidépresseurs à la fois…
  9. Une cellule d’isolement toujours occupée (appelée « chambre de soins intensifs »!), ce qui participe du « folklore »…
  10. « Abonné une fois, abonné toujours » : les traitements qu’on ne peut plus JAMAIS arrêter ;
  11. Aucune étude à long-terme sur les effets des psychotropes…
  12. Aucun recours en cas d’abus psychiatriques (système interne de « médiation » caduc : mal vous en prend d’écrire une lettre au directeur de l’établissement…)

 

Pourquoi je suis contre ce nouveau système de « Juge des Libertés et Détentions » (relatif à la loi du 27 septembre 2013) :

On vous fait croire que c’est une voie de recours. Rien n’est plus faux, à part en cas de vice de forme (ce qui n’arrive quasiment jamais, puisque les psychiatres ont intérêt à ce que la procédure se passe en bonne et dûe forme). Au contraire, c’est un enfermement de plus…

  1. Le juge n’est pas psychiatre, il se garderait bien de remettre en question le jugement des médecins sur le fond. Par contre, on lui a expliqué que tout patient qui conteste le traitement est en « opposition », ce qui constitue déjà une preuve de « déni de maladie ».
  2. Les médecins y trouvent donc une voie bien pratique pour se décharger de leurs responsabilités, puisque « c’est le juge qui décide ». Et alors on voit défiler les patients dans le bureau du juge, accompagnés d’un soignant : « on vous amène Mme X »…
  3. On vous octroie un avocat commis d’office une semaine avant, mais qu’on ne peut pas contacter avant. Le jour de l’audience, c’est 15 minutes pour faire connaissance et se préparer, et ceci « dans les cases »…
  4. Ce qui est très alarmant, c’est qu’on ne trouve pas d’avocat en libéral, à part peut-être à Paris, et seulement pour un recours aux assises.
  5. Le juge prétexte qu’il ne peut lever le soin sous contrainte si c’est à la demande du directeur de l’établissement. Or, toutes les demandes de mise en soins sous contrainte passent par l’approbation du directeur. Tout le monde se donne bonne conscience, donc ;
  6. Une fois l’audience terminée (10 minutes), où l’on se voit déstabilisé, accusé et mis en doute, le juge « ordonne » le maintien en hospitalisation complète et de la mesure de contrainte, ce qui confère force de loi aux médecins (et donc une impunité totale) et SURTOUT donne encore plus de poids à la mesure.
  7. Inutile de préciser que si on était encore crédible avant, on ne l’est plus du tout et c’est définitif. Si on refuse de signer la feuille ou de comparaître, c’est pire, et on s’attire les foudres des médecins et du personnel soignant, qui vous mettent la pression, vous humilient et vous maltraitent. On ne peut pas non plus refuser que l’audience ait lieu.
  8. Le juge sait pertinemment qu’il s’agit d’une volonté potitique de faire taire les « récalcitrants » par voie chimique et coercitive. Il y adhère donc pleinement.

 

Pourquoi je suis contre les traitements forcés :

J’insiste sur le fait que les psychiatres hospitaliers ont les pleins pouvoirs sur le choix et le dosage des traitements, il ne s’agit JAMAIS d’un consentement éclairé. La « balance bénéfice-risque » est toujours de leur côté, même en cas de surdosage, même si la personne prend déjà 17 médicaments et pèse 200kg (ce qui est le cas d’une amie à qui on a donné Zyprexa ET Xeroquel suite à quoi elle a fait un accident vasculaire cérébral). Ils ne sont jamais responsables des effets secondaires non plus et vous orientent « gentiment » vers votre généraliste…

De plus, c’est toujours les médecins qui « décident » à votre place si vous allez bien ou non, et ce, même s’ils ne vous connaissent pas ou vous on vu seulement 5 minutes…

L’effet pervers de la chose, c’est que c’est tellement insupportable d’être enfermé et camisolé chimiquement qu’au bout d’un mois, on fait semblant d’aller mieux, on renie ses opinions et on arrête de se plaindre des effets secondaires pour pouvoir sortir, sous peine de se voir diagnostiquer en plus des « troubles du comportement » et un « déni de la maladie»…

 

J’AI ETE TORTUREE : au Zyprexa (surdosage), au Solian, au Tercian, au Risperdal (8 mg pour un poids de 50 kg), à l’Haldol (90 gouttes par jour) et « shootée » au Valium (40mg!)…

Le médecin et le personnel infirmier refusaient de prendre en compte : les troubles de l’élocution, tremblements, convulsions, dyskinésies, impatiences insupportables, angoisses mortelles, envie de mourir et tortures psychiques (« enfer » mental) qui ont apparu immédiatement et ont même empiré avec le temps. Je me suis battue en vain en plaidant que les neuroleptiques anesthésient la conscience, font perdre la mémoire, rendent docile et influençable, rendent dépressif et encore plus anxieux, affectent les capacités intellectuelles et détruisent l’âme.

J’ai également été mise plusieurs fois en isolement avec violences de la part du personnel ET des employés de la sécurité, alors que je n’ai JAMAIS été agressive. J’ai été mise sous contention, j’ai été déshabillée de force, j’ai été déshydratée, humiliée, bafouée, maltraitée…

Aujourd’hui, même si j’ai droit à un traitement moins inhumain, l’Abilify en injectable (après une 4ème tentative de suicide), je reste « accro » au Valium, traumatisée et toujours en alerte, dans l’angoisse de manquer à mes « obligations » ou de faire mauvaise impression, sans parler de l’absence totale de perspectives, de motivation et de joie dans ma vie, sans parler de ma vie affective qui est une misère (mort spirituelle, isolation, dépression, anxiété…).

Ma carrière artistique, qui avait débuté avec succès, a été définitivement brisée pendant mes meilleures années (la trentaine) et je suis aujourd’hui dans l’incapacité de créer alors qu’avant je foisonnais d’idées et me donnais les moyens pour les mettre en œuvre. Il est également trop tard et trop compliqué pour moi maintenant pour devenir mère.

Je vis dans la précarité à la charge de l’Etat.

 

Pourquoi j’ai toujours été opposée à leurs « diagnostics » pathologisants :

Je suis une personne ayant vécu les pires traumatismes dans la petite enfance (viols et abus, harcèlement), dont la plupart des souvenirs sont remontés plus de trente ans après, ce qui a grandement affecté mon équilibre psychique. J’ai malheureusement dû constater que, d’après les psychiatres (pour autant qu’ils m’aient crue…), il n’y aurait aucune relation de cause à effet entre ce que j’ai subi et mes troubles (!), ce qui est tellement énorme et risible qu’on aurait plutôt envie d’en pleurer…

J’ai pu constater, à l’instar de la Dre Muriel Salmona, seule psychiatre en France à ma connaissance qui aborde la souffrance psychique sous l’angle du trauma, qu’en France, aucune prise en charge spécifique n’est prévue ou proposée, et après 8 ans de psychiatrie, aucun médecin à ce jour ne m’a diagnostiqué un syndrôme de stress post-traumatique avec dissociation, ce qui pourtant devrait être le cas après des viols dans la grande majorité des cas selon la Dre muriel Salmona ( Association Mémoire Traumatique et Victimologie ). Je n’ai quasiment jamais pu faire de travail thérapeutique avec un psychiatre.

Quant à leur diagnostic de schizophrénie, il n’a jamais été étayé, expliqué ou argumenté, et mon dossier a été établi sur des « observations » des médecins et de simples « impressions » du personnel soignant… J’ai constaté également que parler de spiritualité conduisait immanquablement à un diagnostic de « délire mystique », donc, selon eux, de schizophrénie.

J’en conclus que l’enfermement et leurs mauvais soins n’ont fait qu’en rajouter à mes traumatismes, je ne crois pas un seul instant que leurs maladies imaginaires résultent d’un déséquilibre chimique dans mon cerveau ou d’une quelconque « maladie » biologique, je sais que les effets des neuroleptiques sont catastrophiques à long-terme et je suis totalement en accord avec de nombreux anti-psychiatres à l’international, dont le Dr. Peter Breggin, Joanna Moncrieff, David Healy, Robert Whitaker, Thomas Szazs, Peter Goetzsche et autres… (cf. le site madinamerica.com).

 

CONFORMEMENT À LA CONVENTION DES NATIONS UNIES SUR LES DROITS DES PERSONNES HANDICAPÉES, ARTICLES 12, 14 ET 15, TEL QU’INTERPRÉTÉ DANS L’OBSERVATION GÉNÉRALE NO. 1 ET LES LIGNES DIRECTRICES SUR L’ARTICLE 14, ET AUX PRINCIPES DE BASE ET LIGNES DIRECTRICES PUBLIEES PAR LE GROUPE DE TRAVAIL SUR LA DETENTION ARBITRAIRE DE L’ONU, PRINCIPE 20 ET LIGNE DIRECTRICE 20, JE PLAIDE POUR L’ABOLITION TOTALE DE LA PSYCHIATRIE COERCITIVE ET DES TRAITEMENTS FORCES.

JE REVENDIQUE TOUS MES DROITS A LA PERSONNE EN TANT QUE FEMME MAJEURE PROTEGEE, PERSONNE HANDICAPEE, EN PARTICULIER LE DROIT INALIENABLE DE DISPOSER PLEINEMENT DE MON CORPS ET DE MON ESPRIT SANS CHIMIE IATROGENE, DE MA LIBERTE INCONDITIONNELLE.

JE CONSIDERE LA PSYCHIATRIE INSTITUTIONNELLE ET SES PRATIQUES COERCITIVES COMME UN CRIME CONTRE L’HUMANITE, UNE ATTEINTE A LA DIGNITE ET A LA LIBERTE DE PENSEE 

Pink Belette, Mars 2016

 

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Psychiatry in France, NO-RIGHTS-ZONE (By Pink Belette)

A french patient under forced commitment makes her « audit assignment » as part of the campaign to support CRPD absolute prohibition of commitment and forced treatment

 

Why I am against commitment and forced treatment :

One could believe that, in the land of liberty, one is still entitled to his or her physical and moral integrity.

Experience proves it wrong. It is impossible for anyone to escape forced commitment (so-called « care on demand of a third party » or « imminent danger »).

It’s already a done deal if : one person asks for it (family, neighbour…), one is « not well », unsettled, agitated, « not stable », gets angry, is depressed, on the defensive, « in opposition », exuberant, emaciated, bulimic, shit smoker, drugged…

It is sufficient if one refuses hospitalization or a treatment for the doctors to relieve each other in order to enforce commitment. Once hospitalized, it is been made perfectly clear that one looses his or her personal rights, only argument is : « now we are responsible of you for EVERYTHING »… Thus, towards the « patient », nobody is responsible of anything…

 

Since the « Bachelot law » of July 5th 2011, particularly if one has something to object, be it diagnose or treatment, it is then after being out of hospital that one cannot get rid of commitment, which is most perverse : forced injections, mandatory appointments with an non-chosen clinical psychiatrist (or, best case, with a choice between two doctors).

And, worst of all : if one refuses to go to the assigned medical center of one’s district, the police comes to pick one up at home and rehospitalization is mandatory with an increased commitment that is even more coercive (« on demand of the State »), on a longer lapse of time and with no authorization to communicate with the outside (!) until they succeed to break one’s will and reduce one to nothingness… It so happens that people loose their home and « live » in psychiatry (sometimes for decades, see Dimitri Fargette’s case)…

 

I witness : in France, there is really matter to worry about… 

  1. There is no alternative to institutional psychiatry (lobbying of psychiatrists AND pharmaceutical industry against other forms of therapies) ;
  2. No antipsychiatric litterature nor culture (no « survivors »…)
  3. The « College of Psychiatrists » who suspends : every psychiatrist « not aligned » with this consensual system (according to Dr. O.G, liberal psychiatrist and former head of clinic);
  4. The « College of psychiatrists » suspending : a psychiatrist responsible for the death of a patient… only for two weeks (see the case of young patient Florence Edaine)
  5. The « Guardianship mafia » : every patient who is repeatedly hospitalized is automatically placed under guardianship under a certain degree (without consent, it is being reinforced…)
  6. Single mothers get their children robbed and placed immediately after a diagnosis of mental illness is established, never one scandal about this…
  7. Women in age to bear a child are being strongly recommended a contraception, with a wink that their child would be taken away from them anyway. What they are not being told is that all neuroleptics pass the placenta barrier, that’s why i have heard of so many miscarriages from women under treatment. A quote from a nurse : « pregnant women are given Haldol, which proves it’s little nocivity » (!). Never one study about that nor mediatic scandal.
  8. Closed wards full of depressive people who are not in « immediate danger » and are feeling bad mainly because they are being given for example 4 (!) antidepressants at a time…
  9. An always occupied isolation chamber (so-called « intensive care chamber »!), which participates to the « folklore »…
  10. « Once subscriber, always subscriber » : treatments one can NEVER withdraw from ;
  11. No long-term study on psychotropic medication… (All so-called studies are biased)
  12. No recourse in case of even flagrant psychiatric abuse (internal system of « mediation » obsolete : it’s a very bad idea to write a letter to the director of the institution…)

 

Why I am against this new system of « Judge of Liberties and Detentions » (related to the law of september 27th 2013) :

They are making believe it is a recourse. I was proved wrong, except for instance on a technicality (which almost never happens, because it’s in the psychiatrists’ interest that the procedure goes well and in due form). On the contrary, it’s in the sense of more legal coercion…

  1. The judge is no psychiatrist, he would never ever put into question the judgment of the physicians concerning the core. Thus, he has been briefed about the « fact » that any patient who opposes treatment is « in opposition », which establishes already a proof of « illness denial » (and as a proof of illness itself).
  2. Therein it has been found a very practical way for doctors to be discharged of their responsibilities, as « it’s the judge who decides ». And now, bunches of patients are being spotted filing up before the judges’ office, escorted by a nurse : « we bring you Ms. X »…
  3. Patients get a mandated advocate one week before the audience, but who cannot be contacted in advance. At audience day, it’s 15 minutes to meet and prepare, and, of course, in a « formated » way.
  4. Very alarming is the fact that no liberal advocate is to be found for psychiatric abuse pleas, except maybe in Paris, and mostly for a recourse before the Court of Assize.
  5. The judge pretends he cannot lift the forced commitment because it’s asked for by the hospital director. Yet, all demands for forced commitment have to be validated by the director. Hence everyone gives him- or herself a good conscience there ;
  6. Once the audience done (10 minutes), where one gets destabilized, accused and doubted of, the judge « orders » the maintaining of the person in complete hospitalization and of the measure, which confers force of law on the doctors (hence, total impunity).
  7. Not to mention the fact that if one still had credibility before, it’s no longer the case and irreversible. If one refuses to sign the convocation or to attend the audience, it’s worse, and one is being bullied by staff members and doctors alike, who put one under pressure, humiliates one… One also cannot refuse the audience being held despite of one’s absence.
  8. The judge knows pretty well that it’s a political will to make silent the « opponents » of the system, chemically and coercively. He therefore fully concurs with it.

 

Why I am against forced treatment :

I insist on the fact that hospital psychiatrists are almighty regarding the choice and dosage of treatments, it’s never about an « informed consent ». The « benefit- risk balance » is always on their side, even in case of overdosage, even if the person already takes 17 meds and weighs 400 pounds (which is the case of a friend to whom was administered Zyprexa AND Seroquel after which she had a cerebral attack with impairment). They are also never responsible for side effects and, in case of complaint, derefer to one’s generalist physician…

Thus, it is always them who « decide » on one’s behalf if one is well or not and this, even if they don’t know the person or have seen him or her only five minutes…

Perverse effect of the thing : it’s so unbearable being locked up and silenced chemically, that, after a month, one pretends to feel better, disavow his or her opinions and stops complaining about side effects in order to get out, knowing that otherwise one will be diagnosed behavioural troubles and « illness deny »…

 

I WAS TORTURED : with Zyprexa (overdosis), Amisulpride, Cyamemazine, Risperdal (8 mg for a weight of 100 pounds), Haldol (90 drops a day) and « shooted » with Valium (40mg!)…

The doctors and staff refused to take into account : speaking troubles, heavy trembling, convulsions, dyskinesia, unbearable akathisia, heavy existential fear, wish to be dead and psychical tortures (mental « hell ») which appeared immediately and even worsened as time went by. I fought in vain, pleading that neuroleptics anesthetize consciousness, occasion memory loss, make one docile and influentiable, make depressive and even more anxious, impair one cognitively and destroy the soul.

I was also put into solitary confinement several times with violences from the staff AND security agents, despite the fact I have NEVER been even agressive. I was put under contention, was violently undressed, dehydrated, humiliated, spoliated, mistreated…

Today, even if I get a « less inhumane » treatment – Abilify retard injection – (after a 4th suicide attempt), I remain addicted to Valium, traumatized and always on alert, fearing to miss my « obligations » or to make bad impression, without mentioning total absence of perspectives, motivation or joy in life, without mentioning my affective life that is a misery (spiritual death, isolation, depression, anxiety…).

My artistic career, which finally started with success has been definitively broken during my best years (in my 30′) and today I am totally unable to create despite the fact that before, I had thousands of ideas and was giving a great deal to put them into meaningful use. It is also too late and too complicated for me now to become a mother.

I live in precarity at the charge of the State.

 

Why I was always opposed to their pathologizing « diagnoses » :

I’m a person who endured the worst traumas in early childhood (rape and abuse, mobbing…), while most memories came up again more than 30 years afterwards, which greatly affected my emotional balance. I had unfortunately to experience that, according to psychiatrists (if they even believed me), there would be no cause-to-effect relationship between what I had to bear and my troubles (!), which I find so enormous and stupid that one would rather cry…

I had to notice, alike Dr. Muriel Salmona – only psychiatrist in France knowingly approaching psychical suffering under the perspective of trauma – that in France, no specific caretaking is being proposed nor planned, and after 8 years of psychiatry, not one physician has diagnosed me a post-traumatic stress disorder with dissociation which, according to Dr. Muriel Salmona (« Association Mémoire Traumatique et Victimologie ») is the case after rape and abuse.

I could almost never do a therapeutic work with a psychiatrist.

Regarding their diagnosis of schizophrenia, it has never been illustrated, explained or argumented, and my medical records have been established on mere « observations » from the doctors and sheer « impressions » from the staff…

I also came to the conclusion that to actually speak about spirituality would eventually always end in them diagnosing a « mystical delirium » and, as such, schizophrenia.

My conclusion is that their imprisoning and bad treatments have done none but to aggravate my traumas and personal issues, I don’t believe a second that their imaginary « diseases » result in a chemical imbalance in my brain or an unknown « biological » illness, I know that neuroleptics and affiliated meds are catastrophic in the long-term (causing brain damage) and I totally agree with numerous anti-psychiatrists internationally, such as the Drs. Peter Breggin, Joanna Moncrieff, David Healy, Robert Whitaker, Thomas Szazs, Peter Goetzsche and others… (see on madinamerica.com).

 

IN ACCORDANCE WITH THE UNITED NATIONS CONVENTION ON THE RIGHTS OF PERSONS WITH DISABILITIES, ARTICLES 12, 14 AND 15, AS INTERPRETED IN GENERAL COMMENT NO. 1 AND THE GUIDELINES ON ARTICLE 14, AND WITH THE BASIC PRINCIPLES AND GUIDELINES OF THE UN WORKING GROUP ON ARBITRARY DETENTION PUBLISHED IN 2015, PRINCIPLE 20 AND GUIDELINE 20, I SPEAK IN FAVOUR OF ABSOLUTE PROHIBITION OF COERCIVE PSYCHIATRY AND FORCED TREATMENT.

I RECLAIM ALL MY RIGHTS TO PERSONHOOD AS A DISABLED ADULT WOMAN UNDER PROTECTION, IN PARTICULAR THE INALIENABLE RIGHT TO DISPOSE ENTIRELY OF MY BODY, MIND AND SOUL WITHOUT IATROGENIC CHEMICALS AND MY UNCONDITIONAL LIBERTY.

I CONSIDER INSTITUTIONAL PSYCHIATRY AND ITS COERCIVE PRACTICES A CRIME AGAINST HUMANITY, A SEVERE HARM TO DIGNITY AND TO FREEDOM OF THINKING.

 

Pink Belette, March 2016

 

 

Eveline Zenith – Freedom From Religion

Freedom From Religion: Campaign to Support CRPD

http://muddledtranslation.blogspot.no

Freedom of Religion, Freedom from Religion: A Psychotherapy Survivor’s Account of Unravelling the Colossal Irony

By Eveline Zenith

Our freedom to believe and practice as we choose is correlated with the core values of liberty and autonomy. The Canadian Charter of Rights and Freedoms protects our rights by stating that everyone has freedom of conscience and religion; also, religious belief cannot be preferred to non-belief. In the United States, freedom of religion is constitutionally protected in the First Amendment, and is associated with the separation between church and state.

Freudian psychoanalysis is a religious ideology that has absolutely no relevance in my life. I can only say that now I have researched it in depth, and this has been no simple task. Finding information about this clandestine methodology required: hours of detective work; a small fortune of books; under-cover attendance at a psychoanalytic seminar; six months of email correspondence with a psychoanalyst; intensive abuse recovery; jumping through every possible hoop in the system… and it remains today irredeemable. I did all this in order to regain sanity after therapy; my mind became so scrambled I had to abruptly discharge myself from the transaction. I am staggeringly aware of how lucky I am.

I had a nervous breakdown and began constantly re-living the bizarre statements my analyst had said to me. They were all vague and stated in a slow hypnotic tone, by a man who had been presenting as a “blank slate”. I had absolutely no familiarity or understanding of him: his intentions, beliefs, or personality. With sheer terror I would wake at 3am… trembling, eyes watering, remembering his intense staring, cutting words, sadistic glee, and condescending manner. There were other times when I felt bonded with him, that he cared, that he was a spiritual guide. The cognitive dissonance alone was torture enough to drive me insane!

Once I went “no contact” all my illusions disintegrated; I became appallingly aware of the prospect that he had deliberately abused me. He has the power, the education, and the techniques at his disposal to really screw me just for kicks. The research I have done on emotional abuse is a succinct match to the so-called techniques; I was vulnerable and had no idea what I was consenting to. He would simply shift the goalposts whenever I grew wise; he’d divert to blaming my hyper-vigilance and trust issues.

I never imagined I would have to defend my human dignity to an institution that is supposed to protect me, or that they would dismiss my testimony and actually try to silence me. The greatest, deepest betrayal was that it was an endeavour to heal from childhood abuse. That therapist held the keys to my most defenseless wounds and senselessly battered them. There is still no accountability on behalf of the profession: either this is considered permissible, or this practitioner needs to be corrected.

I have learned that Freudian psychoanalysis – perhaps psychotherapy on the whole – holds the absolute belief that the pathological relationship will inevitably re-enact. What this means is that if you were abused before, you will re-experience it in therapy and be re-traumatized. I have not yet found anyone in the field who will explain in plain language how this works; it makes no rational sense. This is an accessibility issue. Not only is it illogical, it is downright heinous without mandatory informed consent. Currently, the authorities assume on good faith that the practitioner will inform the client. If you have any knowledge of the world of predators, abuse, and exploitation, you will know this is a loophole for corruption. Also, if you don’t understand this is the process, you will only experience your therapist as your abuser and hopefully get out of it like I did!

There is no therapeutic value in having your spiritual guide manifest as your worst nightmare unless there is a therapeutic alliance; this can only be forged through informed consent every step of the way. Sex, boxing, and psychotherapy are similar: if one person isn’t participating it’s a crime. Psychoanalysis believes practitioners can subject us to treatment because they feel we need it; they have a plan for us, but they don’t reveal it. There are plenty of ethics seminars where theories are discussed about what’s good or bad for clients, but no actual observance of human rights is mandated. The entire “treatment” goes on in complete privacy, with biased accounts of clients’ “transferences” scratched on notepads for billing purposes. I never consented to any transference; I assumed everything was in the here and now. All of this religious interpretation was done behind my back so there was no way I could refute it, question it, challenge it, or even benefit from it. I have searched far and wide in a vast wilderness of possibilities, finally concluding that my practitioner is delusional, sadistic-aggressive, lacks empathy, and has no substantive reasoning for any of it besides money and control. This conclusion is the reason I am alive and well today.

The imperative reason I advocate for the absolute prohibition of coercive treatments is because this harm is done to the previously harmed, vulnerable, and voiceless members of our society. These are people who have had cruel, devastating, and heinous things done to us; large parts of our bodies and souls have been murdered. Even with all the agency I possess, I can’t get through to anyone on the other side of the door. The lack of education and total absence of conversation about abuse in the mental health profession is criminal negligence, considering that is the number one reason people use these services. Although the Code of Ethics for Psychiatry explicitly states informed consent, I am told by the authorities I consented simply by being there.

In terms of CRPD principles, although many sections address aspects of this problem I focus on sections 14 through 16:

Article 14: Liberty and security of the person 

  1. States Parties shall ensure that persons with disabilities, on an equal basis with others:

(a) Enjoy the right to liberty and security of person;

(b) Are not deprived of their liberty unlawfully or arbitrarily, and that any deprivation of liberty is in conformity with the law, and that the existence of a disability shall in no case justify a deprivation of liberty.

  1. States Parties shall ensure that if persons with disabilities are deprived of their liberty through any process, they are, on an equal basis with others, entitled to guarantees in accordance with international human rights law and shall be treated in compliance with the objectives and principles of this Convention, including by provision of reasonable accommodation.

Article 15: Freedom from torture or cruel, inhuman or degrading treatment or punishment 

  1. No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his or her free consent to medical or scientific experimentation.
  2. States Parties shall take all effective legislative, administrative, judicial or other measures to prevent persons with disabilities, on an equal basis with others, from being subjected to torture or cruel, inhuman or degrading treatment or punishment.

Article 16: Freedom from exploitation, violence and abuse 

  1. States Parties shall take all appropriate legislative, administrative, social, educational and other measures to protect persons with disabilities, both within and outside the home, from all forms of exploitation, violence and abuse, including their gender-based aspects.
  2. States Parties shall also take all appropriate measures to prevent all forms of exploitation, violence and abuse by ensuring, inter alia, appropriate forms of gender- and age-sensitive assistance and support for persons with disabilities and their families and caregivers, including through the provision of information and education on how to avoid, recognize and report instances of exploitation, violence and abuse. States Parties shall ensure that protection services are age-, gender- and disability-sensitive.
  3. In order to prevent the occurrence of all forms of exploitation, violence and abuse, States Parties shall ensure that all facilities and programmes designed to serve persons with disabilities are effectively monitored by independent authorities.
  4. States Parties shall take all appropriate measures to promote the physical, cognitive and psychological recovery, rehabilitation and social reintegration of persons with disabilities who become victims of any form of exploitation, violence or abuse, including through the provision of protection services. Such recovery and reintegration shall take place in an environment that fosters the health, welfare, self-respect, dignity and autonomy of the person and takes into account gender- and age-specific needs. 
  5. States Parties shall put in place effective legislation and policies, including women- and child-focused legislation and policies, to ensure that instances of exploitation, violence and abuse against persons with disabilities are identified, investigated and, where appropriate, prosecuted. 

Unravel edit

The contested freedom of the ‘scary’ – Karlijn Roex

The contested freedom of the ‘scary’: the use of coercion in psychiatry violates basic human rights

Detention, solitary confinement, forced drugging; throughout history, societies have had the tendency to aggressively constrain people with psycho-social disabilities and preferred an security-obsessed instrumentalism above universal human rights. But recently, the use of coercion in psychiatry is a highly debated practice in human rights circles; witness the latest report of Human Rights Watch[1] on shackling. This increased interest has gotten a great impulse by the recent release of the UN Convention on the Rights of Persons with Disabilities. Drawing upon scientific work, ‘user’ narratives and moral principles, I support the call made by the Committee on the Rights of Persons with Disabilities (CRPD) to abandon the use of coercion in psychiatry.

According to authoritative documents of the Convention[2], the use of coercion in psychiatry is a form of discrimination of people with psycho-social disabilities, and violates the right of these people to enjoy autonomy and personal integrity. These principles are to be respected, regardless of any instrumental benefits that may result from applying coercive psychiatric interventions. But the perceived instrumental benefits are exactly why the use of coercion in psychiatry has long gone uncontested. And these benefits have moral significance too. People have the right to be protected against themselves, or against dangerous fellow-humans. In fact, many proponents of coercion in psychiatry follow this ethical ‘lesser evil’ reasoning. According to them, it is allowed to introduce an evil when a greater evil is prevented by this. Thus, such a lesser evil argument justifies the abandonment of some key fundamental human rights. This is dangerous, because human rights are typically abandoned during the times in which they are most needed[3]. In fact, these human rights are meant to protect our scapegoated minorities from being oppressed during times of public fear. In times of public fear, some human rights become a privilege of the non-scary, or if one prefers, of the ‘respectable section of society’[4]. In the context here, the lucky ones are the people without psycho-social disabilities. The scary, by contrast, have to deal with a contested freedom.

Coercive psychiatric interventions are decisions or actions imposed on the individual, without his/ her informed consent, based on psycho-social disability. In this regard, the CRPD has also come out against the use of this danger standard, or any other criteria, as a way of legitimizing psychiatric detention[5]. To be clear, the coercive interventions that are discussed here are not taken because of a criminal suspicion or criminal conviction. Today, most countries allow coercive psychiatric interventions only when an individual is considered dangerous to him-/herself or to others. However, the initial assessment of dangerousness is taken by psychiatrists only. A court is not yet involved in this initial decision to psychiatrically detain an individual. This is highly problematic, because the psychiatric perspective and security-obsessed instrumentalism are clearly dominating the process of key decision making, at the cost of the human rights perspective. At the moment where the psychiatrists’ initial decision is critically reviewed, marks of shame have already been added to the affected individual. Not only has this mark of shame been added through the unfavourable initial psychiatric guess, which gains much epistemological authority in our societies, but also because of the very stigmatizing practice of the detention itself[6]. It is then much harder for the affected individual to win credibility.

We therefore see that the conditions for coercive psychiatric interventions have become stricter over time, but that they fail to seriously challenge the practice of arbitrary detention. This may explain why the ‘stricter’ danger standard has not led to a decrease in the number of psychiatric detentions[7]. Probably, the innovation has rather served to silence any critical voices from the human rights corner. This silencing has been achieved by incorporating insignificant parts of the critical demands into the existing policy, without meaningfully changing any inherently oppressive and discriminatory principles[8]. Apparently, there is a high demand in society to confine people with psycho-social disabilities, and one of the main drivers behind this demand is a perceived danger.

Protecting people against themselves: the right not to be a false positive[9]

But what is wrong with this dangerous-criterion? Is it, for instance, not our moral duty to protect people from themselves when needed? Obviously, it is! But we should become reflect one more moment about our ability to assess mental states: when is someone to be considered a danger to him-/ herself? Let me take suicide as an example. As a researcher in this topic, the literature clearly shows me that assessing the risk of suicide in individuals is a very difficult task. Most people that disclosure suicidal thoughts do not commit suicide, especially women[10]. Secondly, psychiatric risk assessments are proven to be really unreliable[11], leading to many ‘false positives’: people who are considered a danger while they are actually not. The statement whether someone is a danger, is in fact a hypothesis about mental states and future behaviours. These are unobservable things that are hard to measure. Even when an individual has committed self-harming acts in the past, this does not necessarily make him dangerous for the present, or the future. Test results are likely to be biased and steered by common prejudices about people with psycho-social disabilities[12], ethnic minorities, and the poor[13]. Worse, the dangerousness claim is strictly not falsifiable, at least at a short term: how can one prove today that one will not kill himself soon? As a consequence of this, many individuals are subjected to coercive interventions because they were wrongly labelled as ‘dangerous’ and cannot easily escape this label. Escaping the dangerousness-label is made even more difficult by general mistrusting attitudes of hospital staff towards mental patients[14], and the fact that people tend to start behaving conform the stigma over time, due to its adverse effects on them[15]. The accumulation of humiliating interactions, which would frustrate every normal person, can lead to responses that can be termed as ‘aggressive’. How would you respond if you learn that you were wrongly informed about your legal status[16] concerning something as important as your freedom?

These ‘false positives’ are vulnerable people, just like people who are a real danger to themselves. But is it actually a wise strategy to expose such people to some of the very traumatic coercive psychiatric interventions? There are numerous accounts of patients or ‘ex-users’ of psychiatry that indicate how stressful and traumatic these interventions were to them. Indeed, some human rights advocates define some of these interventions as torture. There are even indications that exposure to such interventions can lead to post-traumatic stress symptoms and suicide[17]. There are user narratives that indicate that individuals without any previous suicidal tendencies became suicidal after being exposed to coercive interventions, such as solitary confinement. User narratives indicate how humiliating these experiences can be, with people losing their personal integrity, humanity and dignity. Affected individuals often carry along these feelings until long after the incidents.

Protecting people against their dangerous fellow-citizens: contesting the freedom of the ‘Other’

But what if a person is not a danger to him-/ herself, but to others? When we want to be protected against our dangerous fellow-citizens, then what is morally wrong with that? Well, nothing, but of course we have to come with reasonable grounds and evidence of this supposed danger. The mere existence of a psycho-social disorder, cannot point towards a certain danger. When an individual tells me that he is going to harm me, he can be prosecuted for threats. Most countries have also criminalized several public order disturbances. We can already prosecute anybody who has visibly undertaken preparations for committing a criminal offense, or who has clearly tried to commit a certain crime. Therefore: we already have a great law that protects us against dangerous fellow-citizens: the Criminal Law! Even greater, this law protects the citizen against the state and an over-feared community. We cannot just convict an individual because of a mere suspicion; instead, conviction requires that we have some tangible evidence against this individual.

With this great law in mind, why would we create another law especially for people with psycho-social disabilities? Because we are afraid of people with psycho-social disabilities. A mere suspicion of dangerousness in a person with mental illness is already terrifying enough, isn’t it? Why then bother about visible evidence for a criminal conviction? Mental health laws are the dubious innovation of a frightened society. These laws enable communities to incarcerate individuals with psycho-social disabilities when we suspect that they are dangerous. This suspicion is backed with test results from, again, very unreliable and biased psychiatric risk-assessments. As a consequence, we have created two types of citizenship: the ‘normal’ citizens and the scary semi-citizens. The latter group has found his freedom contested: it can be denied at any time, as soon as a suspicion of dangerousness arises. Whereas the majority of us can feel safe and count on the basic human rights principles that respect our freedom and integrity, there is a group in our society whose members can simply be detained without the regular battery of legal requirements.

This is an inconvenient leak in our modern democracies, and should concern every citizen. No citizen can find himself guaranteed at the ‘right’ side of the divide, because the boundaries between mental illness and normality are time-dependent and not nature-given. In the past, we have seen the ‘psychiatrization’ of homosexuality, political dissent, and poverty. This teaches us that mental health laws are a convenient way to subtly discipline certain categories of people; much more smoothly and subtly than explicitly prosecuting these deviants through criminal courts[18]. And although our societies are now to be considered ‘free-minded’, or ‘post-modern’, we should always be aware of the disciplinary potential of mental health laws. This disciplinary potential can be toxic in combination with the timeless fact that we are never aware of the oppressive ideas of our own time.

In all, let’s give it a shot and abandon the use of coercion in psychiatry towards history. Fear makes that we immediately grab towards the so-called ‘last resort’ of a coercive intervention, whereas there are instances in which a simple conversation would already help. Such a conversation would also help us, learning about the specific and different logics behind madness, and therefore render it a little bit less unpredictable and scary.

Karlijn Roex is a PhD-candidate in Sociology and human rights activist. She lives in Germany.

[1] Human Rights Watch (2016, March 20). Indonesia: Treating Mental Health With Shackles. Human Rights Watch. Retrieved 21 March 2016, from: https://www.hrw.org/news/2016/03/20/indonesia-treating-mental-health-shackles

[2] See for instance: CRPD. (2015). Guidelines on Article 14 of the Convention on the Rights of Persons with Disabilities – The right to liberty and security of persons with disabilities. New York: United Nations; CRPD. (2014). General Comment No. 1 (2014). Article 12: Equal Recognition Before the Law. New York: United Nations; United Nations Human Rights Committee (2015, October 10). Dignity must prevail – An appeal to do away with non-consensual psychiatric treatment World Mental Health Day. United Nations. Retrieved 10 March 2016, from: http://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=16583&LangID=E

[3] Hudson, B. (2009). Justice in a Time of Terror. British journal of Criminology, Delinquency and Deviant Social Behaviour, 5(49), 702-717; Roex, K.L. A. & Riezen, Van. B. (2012). Counter-Terrorism in the Netherlands and the United Kingdom: A Comparative Literature Review Study. Social Cosmos, 3(1), 97-110.

[4] Berger, P.L. (1992). Sociology as a Form of Consciousness. In H. Robboy & C. Clark (edit.), Social Interaction. Readings in Sociology (pp. 6-22). Richmond: Worth Publishers.

[5] See for example CRPD. (2015). Guidelines on Article 14 of the Convention on the Rights of Persons with Disabilities – The right to liberty and security of persons with disabilities. New York: United Nations.

[6] Goffman, E. (1961). Asylums. Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books; Becker, H. S. (1963). Outsiders. New York: The Free Press.

[7] At least in Europe. See: Salize, H. J., Dressing, H. & Peitz, M. (2002). Compulsory Admission and Involuntary Treatment of Mentally Ill Patients – Legislation and Practice in EU-Member States. Brussels: European Commission.

[8] This strategy to silence critics is widely analysed by the Foucaultian sociologist Mathiesen: Mathiesen, T. (2004). Silently Silenced. Essays on the Creation of Acquiescence in Modern Society. Winchester: Waterside Press. See also on this specific topic: Harding ,T.W. (2000): Human Rights Law in the Field of Mental Health: a Critical Review. Acta Psychiatrica Scandinavica, 101: 24-30

[9] Borrowed from Steadman, H. J. (1980). The Right Not to be A False Positive: Problems in the Application of the Dangerousness Standard. Psychiatric Quarterly, 2, 84-99.

[10] Cannetto, S. S. & Sakinosky, I. (1998). The Gender Paradox in Suicide. Suicide & Life Threatening Behavior, 28(1), 1-23 and Möller-Leimkühler, A. M. (2003). The Gender Gap in Suicide and Premature Death or: Why Are Men So Vulnerable? Eur Arch Psychiatry Clin Neurosc, 253: 1-8.

[11] Steadman, H. J. (1980). The Right Not to be A False Positive: Problems in the Application of the Dangerousness Standard. Psychiatric Quarterly, 2, 84-99; Madsen T, Agerbo E, Mortensen PB, Nordentoft M (2012) Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry 73:144–151; Steeg S, Kapur N, Webb R, Applegate E, Stewart SL, Hawton K, Bergen H, Waters K, Cooper J (2012) The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT self-harm rule. Psychol Med 42:2383–2394; Ryan C, Nielssen O, Paton M, Large M (2010) Clinical decisions in psychiatry should not be based on risk assessment. Australas Psychiatry 18:398–403.

[12] Link et al., (1999).Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance. American Journal of Public Health, 89(9), 1328-1333; Perscosolido, et al. (2013). The ‘Backbone’ of Stigma: Identifying the Global Core of Public Prejudice Associated With Mental Illness. American Journal of Public Health, 103(5), 853-860.

[13] The population of involuntarily hospitalized psychiatric patients contains an overrepresentation of low-income indiivduals, black people, and people of an ethnic minority. See for example: Salize, H. J., Dressing, H. & Peitz, M. (2002). Compulsory Admission and Involuntary Treatment of Mentally Ill Patients – Legislation and Practice in EU-Member States. Brussels: European Commission.

[14] Goffman, E. (1961). Asylums. Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books.

[15] Becker, H. S. (1963). Outsiders. New York: The Free Press.

[16] Something that appears to happen quite often in EU countries: see Salize et al. (2002)

[17] For instance: Large, M. M. & Ryan, C. (2014). Disturbing Findings about the Risk of Suicide and Psychiatric Hospitals. Soc Psychiatr Epidemiol, 49, 1353-1355.

[18] See also the different works of Michèl Foucault on this

Aporte de Lucila López, Usuaria y sobreviviente de la psiquiatría en Argentina

CAMPAÑA DE APOYO A LA CDPD COMPROMISO CON LA PROHIBICIÓN ABSOLUTA DE LA PRIVACIÓN DE LA LIBERTAD Y EL TRATAMIENTO FORZADO DE LAS PERSONAS CON DISCAPACIDAD PSICOSOCIAL

 

Señores del Comité sobre los Derechos de las Personas con Discapacidad:

Solicito tengan a bien dar la merecida atención a todas las voces que elevamos los actores socio-políticos que pedimos la prohibición absoluta de la privación de la libertad por motivos de discapacidad psicosocial.

Lucila López

Usuaria y sobreviviente de la psiquiatría en Argentina.

(también se puede leer en https://sodisperu.org/2016/03/22/aporte-a-la-campana-prohibicionabsoluta-por-lucila-lopez-usuaria-y-sobreviviente-de-la-psiquiatria-en-argentina/)

CAMPAÑA DE APOYO A LA CDPD ART. 14 LL-MARZO14 2016 (doc)

Intentaré exponer los motivos sobre la importancia de obtener el apoyo necesario para que la Campaign to Support CRPD Absolute Prohibition of Commitment and Forced Treatment  – Campaña de apoyo CDPD COMPROMISO CON LA ABSOLUTA PROHIBICIÓN DE LA INTERNACIÓN Y EL TRATAMIENTO FORZADO iniciada por la Dra. Tina Mikowitz resulte como positivo fortalecimiento al momento de las Observaciones Generales a favor del irrestricto cumplimiento del artículo 14 inc. y todos los artículos vinculantes.

Artículo 14

Libertad y seguridad de la persona

  1. Los Estados Partes asegurarán que las personas con discapacidad, en igualdad de condiciones con las demás:

a) Disfruten del derecho a la libertad y seguridad de la persona;

b) No se vean privadas de su libertad ilegal o arbitrariamente y que cualquier privación de libertad sea de conformidad con la ley, y que la existencia de una discapacidad no justifique en ningún caso una privación de la libertad.

2. Los Estados Partes asegurarán que las personas con discapacidad que se vean privadas de su libertad en razón de un proceso tengan, en igualdad de condiciones con las demás, derecho a garantías de conformidad con el derecho internacional de los derechos humanos y a ser tratadas de conformidad con los objetivos y principios de la presente Convención, incluida la realización de ajustes razonables.

“El Comité sobre los Derechos de las Personas con Discapacidad reafirma que la libertad y la seguridad de la persona es uno de los derechos más preciosos a que tiene derecho. En particular, para las personas con discapacidad, y en especial las personas con discapacidad intelectual y discapacidad psicosocial tienen derecho a la libertad en conformidad con el artículo 14 de la Convención. En él se especifica el alcance del derecho a la libertad y a la seguridad de la persona en relación con las personas con discapacidad, prohíbe toda discriminación basada en la discapacidad. De este modo, el artículo 14 se relaciona directamente con el propósito de la Convención, que es garantizar el disfrute pleno e igual de todos los derechos humanos y las libertades fundamentales a todas las personas con discapacidad y promover el respeto de su dignidad inherente.”[i]

__________________

Nada se puede pensar por fuera de un contexto. El tema propuesto es un tema ineludible en términos de un pensamiento con eje en los Derechos Humanos.

Escribir en Argentina sobre la necesidad de garantizar la prohibición absoluta de privar de la libertad a las personas con discapacidad en nombre de tratamientos impuestos, forzados, en contra de la propia voluntad, es escribir en un contexto en el que el respeto a los DD.HH. es ostensiblemente violado provocando actualmente una seria preocupación para el CIDH, específicamente por una presa política. En relación al tema, es significativo que Estela de Carlotto[ii] haya preguntado -¿Cómo se puede decir que está muy bien una mujer presa? Y calificó esa afirmación de la más alta autoridad del país como “una barrabasada”. El texto completo es el siguiente:

“La barrabasada[iii]que dijeron es que la habían visitado en la cárcel y que estaba muy bien. Fue violento. ¿Cómo se puede decir que está muy bien una mujer presa?

Me permito hacer un parangón y preguntar:   ¿Cómo se puede decir que está bien una persona privada de la libertad (presa) por su discapacidad?

Estoy a favor de la prohibición absoluta de la privación de la libertad involuntaria y tratamientos forzados de las personas con discapacidad psicosocial y el compromiso para con todos comienza en el ejercicio para mi propia vida de ese derecho y el Art. 14 de la CDPD me autoriza a exigir el cumplimiento de la norma jurídica.

Mis argumentos son en nombre propio a partir de mis experiencias y la observación de la experiencia de otros, articulando mi condición de usuaria y sobreviviente de la psiquiatría, mi visión como profesional dedicada a la prevención en Salud Mental y Derechos Humanos y como familiar, en tanto soy madre de un hombre que siendo niño y hasta entrada su adultez, necesitó de la protección de sus derechos incluido el derecho a la salud y el derecho a la salud mental.

Estuve privada de la libertad y en contra de mi voluntad por última vez entre el 5 de julio de 2014 y el 12 de enero de 2015. La cuarta vez en mi vida y la más extensa en tiempo.

Esa misma barrabasada “que me encontraban muy bien” la escuché de familiares y amigo/as y me mantuve en un total mutismo.

Desde el año 2011, la crisis anterior con internación contraria a mi voluntad, comencé a guardar mutismo absoluto delante de los que apoyaron esa medida y están dispuestos a apoyarla de nuevo.

¿Por qué guardar mutismo?

Por lo intolerable que resulta la alianza entre los profesionales de la salud mental y familiares y/o amigos:

  • Ignoran la CDPD.
  • No tienen en cuenta el respeto a la persona como un igual.
  • Prevalezcan sobre mi cuerpo y sobre mi psiquismo[iv] decisiones ajenas violatorias de todos
  • Los siguientes derechos enumerados en la CDPD (Ley 26.378) que es parte del cuerpo jurídico de la Constitución Nacional de Argentina.

Artículo 5º

Igualdad y no discriminación

Artículo 12

Igual reconocimiento como persona ante la ley[v]       

Artículo 14

Libertad y seguridad de la persona

Artículo 15

Protección contra la tortura y otros tratos o penas crueles, inhumanos o degradantes

Artículo 17

Protección de la integridad personal

Artículo 18

Libertad de desplazamiento y nacionalidad

Artículo 19

Derecho a vivir de forma independiente y a ser incluido en la comunidad

Artículo 22

Respeto de la privacidad

Artículo 23

Respeto del hogar y de la familia

1.C) Las personas con discapacidad, incluidos los niños y las niñas, mantengan su fertilidad, en igualdad de condiciones con las demás.

Artículo 24

Educación

Artículo 25

Salud

Artículo 27

Trabajo y empleo

Artículo 28

Nivel de vida adecuado y protección social

Enumerados todos los derechos vinculantes que se violan a partir de la falta de respeto al art. 14, argumentaré los motivos por los que pido la PROHIBICIÓN ABSOLUTA DE LA PRIVACIÓN DE LA LIBERTAD INVOLUNTARIA.

En Argentina, exigir la prohibición absoluta de la libertad involuntaria por motivos de discapacidad psicosocial encuentra un horizonte de futuro posible con la prohibición establecida por la LNSM –Ley 26.657 – de la creación de nuevos manicomios públicos y privados en todo el territorio de la Nación y el cierre definitivo de todos para el año 2020.

La privación forzada de la libertad, -o internación involuntaria- o no por motivos de discapacidad psicosocial es claramente una acción discriminatoria, de acuerdo a la legislación argentina y el marco jurídico internacional:

“La discriminación es el acto de agrupar a los seres humanos según algún criterio que lleva a una forma de relacionarse socialmente. Concretamente, suele ser usado para hacer diferenciaciones que atentan contra la igualdad, ya que implica un posicionamiento jerarquizado entre grupos sociales 1, es decir, cuando se erige un grupo con más legitimidad o poder que el resto.

En el año 1988, se sancionó la Ley Nº 23.592 sobre Actos Discriminatorios que en su Artículo 1º reconoce como discriminación cualquier impedimento o restricción del pleno ejercicio “sobre bases igualitarias de los derechos y garantías fundamentales reconocidos en la Constitución Nacional […] por motivos tales como raza, religión, nacionalidad, ideología, opinión política o gremial, sexo, posición económica, condición social o caracteres físicos”. Asimismo, el documento titulado “Hacia un Plan Nacional contra la Discriminación”, aprobado por Decreto Nº 1086/2005.Instituto Nacional contra la Discriminación, la Xenofobia y el Racismo. (INADI ¿Qué es la discriminación?).-

 

La privación de la libertad involuntaria a partir de la  CDPD se constituye en un acto de violación de DD.HH.y el Estado se debe responsabilizar de ello[vi] pues  aún cuando en Argentina ha ratificado la CDPD y le ha dado status constitucional:

La Ley Nacional de Salud Mental Ley 26.657- que es considerada una Ley de Salud Mental modelo por todos los avances dirigidos hacia el nuevo paradigma social y del respeto de los DD.HH. de las personas con discapacidad, incurre en la violación del artículo 14 considerando que:

La LNSM En el Capítulo VII, Art. 20) contempla de la internación involuntaria:Ley 26.657 ARTICULO 20. — La internación involuntaria de una persona debe concebirse como recurso terapéutico excepcional en caso de que no sean posibles los abordajes ambulatorios, y sólo podrá realizarse cuando a criterio del equipo de salud mediare situación de riesgo cierto e inminente para sí o para terceros. Para que proceda la internación involuntaria, además de los requisitos comunes a toda internación, debe hacerse constar… “

Acá encontramos un argumento a favor de la internación involuntaria contraria a la letra de la CDPD y su art. 14.-

La idea que prevalece en este artículo de la LNSM es la del paradigma del MMH., encuentra gran receptividad tanto en los profesionales de la salud como así también de familiares. Desde la implementación de la LNSM no se cumple con el art. 14 de la CDPD pero tampoco se cumple con lo que estipula la LNSM en el Art. 20, pues la concepción de recurso terapéutico excepcional se convierte en letra muerta de la ley y es una mera formulación administrativa o de buenas intenciones si se pueden llamar así a los argumentos esgrimidos para privar de la libertad en forma involuntaria.

Este acto discriminatorio y violatorio de DD.HH. goza de un consenso intelectual que supone el encierro de las PcD como “un corte, una instancia de reordenamiento subjetivo”.

El “corte subjetivo” se produce en la PcD en el momento que se denomina crisis y no necesita de ser privada de la libertad. Se puede “volver a la vida plena” en la vida plena de poder padecer un “corte” de “conexión con la realidad” si se brindan todos los apoyos y ajustes necesarios para tornar viable la vida en la comunidad.

No podemos ser discriminados por ser personas con discapacidad psicosocial y considerar terapéutico el encierro y el aislamiento que es una práctica iatrogénica al igual que la medicación forzada.

Vuelvo sobre la necesidad de contextuar el texto.

En Argentina hay una gran resistencia de parte de los profesionales de la salud mental a mencionar el tema discapacidad ligado al tema de las problemáticas de la salud mental.

En este presente inmediato, hablar de Derechos Humanos en Argentina articulados con la Salud Mental o con cualquier otro aspecto de la vida de las personas en general es un tema que pone en cierto peligro a quien se anima a denunciar.

Mi opinión al respecto después de muchos años de indagar el tema es que los profesionales de la salud mental junto a una gran parte de la población no aceptan que las PcD psicosocial somos personas con el reconocimiento de la dignidad y el valor inherentes y de los derechos iguales e inalienables de todos los miembros de la familia humana.

No aceptan la condición de sujeto de derecho en igualdad de condiciones que invoca la CDPD y esto es especialmente notorio al observar que en Argentina, la LNSM Nro. 26.657, es despreciada e incumplida por la corporación médico-psiquiátrica quienes consideran que debe ser derogada porque entre algunos de sus acertados artículos se promueve la interdisciplinariedad, el cierre de la totalidad de los manicomios públicos y privados en todo el territorio nacional y también promueve las internaciones en hospitales generales (considerando el respeto a quien desee ser internado de forma voluntaria).-

El primer obstáculo para hacer notar que el art. 20 de la LNSM 26.657 viola el Art. 14 de la CDPD es que los profesionales de la salud y de la salud mental, los trabajadores sociales y un amplio espectro de la justicia y una enorme masa de la población en general no están dispuestos a respetar los DD.HH. de las PcD psicosocial y que las lógicas manicomiales prevalecen en el imaginario social sobre los avances y cambios que en la materia se vienen discutiendo a nivel mundial.

La mayoría de las internaciones que se realizan son involuntarias y en general no se cumplen los pasos que la LNSM dispone para estos casos. Una ingeniería perversa de mecanismos burocráticos actúa evitando que la información llegue a la justicia en tiempo y forma, haciendo permanecer a una persona hasta por cuatro meses internada sin haber ejercido ni el consentimiento informando sobre el tratamiento que le administran arbitrariamente ni tuvo acceso a un abogado defensor como lo estipula la LNSM.

Es de mi particular interés las internaciones involuntarias de niños/as-adolescentes y jóvenes por motivos vinculados al consumo problemático de sustancias psicotrópicas en instituciones aberrantes con la anuencia de sus familias y también, en el otro extremo del arco, a las personas mayores y la naturalización de su institucionalización en lugares llamados geriátricos, residencias u hogares que también, con un proceder perverso, ocultan las problemáticas de discapacidad mental más propias de la ancianidad, del deterioro cognitivo que puede aparecer con el avance de la edad y otras formas de discapacidad mental que no son atendidas en su particular singularidad y sí son privadas de la libertad casi siempre sin su propio consentimiento.

Entonces sufren internaciones involuntarias y así se violan los DD.HH. de:

Niñas, niños, adolescentes mujeres y hombres, jóvenes, adulta/os y ancianas/os declarados o no personas con discapacidad mental por razones vinculadas a problemáticas de la salud mental.

En todos estos casos prevalece el concepto discriminatorio que no tenemos igual reconocimiento como persona ante la ley.

Partiendo de esta premisa comenzaré a exponer de qué manera la internación, la privación de la libertad involuntaria es una verdadera violación de DD.HH. que comete el Estado atropellando derechos y aumentando la discapacidad y propiciando el empobrecimiento de las personas afectadas en sus intereses económicos, sociales y culturales.

La internación involuntaria es iatrogénica:

  • en lugar de un resultado positivo para la salud, la privación de la libertad junto a tratamientos con drogas psiquiátricas forzados generan enfermedades, atenta contra la salud psíquica y física de la persona y la despoja del ejercicio de un sinfín de derechos aún cuando no se haya restringido su capacidad jurídica y esto también en internaciones –involuntarias o no- a corto plazo.

La realidad de una gran mayoría es que su capacidad jurídica está restringida.

En Argentina actualmente hay más de 20.000 personas privadas de la libertad en manicomios públicos y privados, según datos poco fidedignos, en su mayoría hombres entre 20 y 40 años que en su mayoría llevan un promedio de 15 a 20 años de privación de la libertad. De esa mayoría un número elevado entró en el circuito de las internaciones por consumo problemático de sustancias psicotrópicas siendo el alcohol la que encabeza el listado de ellas, que no es una droga ilegal.

Es muy llamativo que los datos oficiales oculten las cifras que puedan informar la cantidad de niñas y mujeres privadas de la libertad de manera involuntaria que hay en el país y me animo a decir que debe ser significativamente superior a la cantidad de hombres privados de la libertad.

En todos o en casi todos esos casos, ya sea en el ámbito público como en el privado la violación al art. 14 de la CDPD conlleva la violación de todos los otros artículos de la CDPD enumerados anteriormente.

La libertad y la seguridad de la persona son avasalladas y entonces su integridad en el más amplio concepto de la palabra también.

Hay una gran parte de la población privada de la libertad por motivos de discapacidad psicosocial que desconocen su verdadera identidad. Están desprovistas de documentos de identidad. No tienen contacto con familiares desde hace años y han sido separados de su comunidad.

Muchos, con estudios iniciados, han perdido el derecho a continuarlos, otros directamente no acceden porque comienzan el derrotero de las internaciones psiquiátricas durante la infancia. Conocí en el manicomio a un hombre mayor de cincuenta años que estaba internado desde los cinco años, desde su primera infancia… y allí murió.

Las instituciones psiquiátricas tienden a incurrir en una doble violación al Derecho a la Salud, en tanto:

  1. La privación de la libertad involuntaria o no, es iatrogénica.
  2. La PcD psicosocial internada en instituciones psiquiátricas suele carecer de verdadera atención médica en otros aspectos que su salud requiera: la aparición de síntomas de un quebrantamiento de la salud física suele ser ignorado, “interpretado” como síntoma o manipulación de la PcD desde el discurso médico-psiquiátrico y también, se le niega el acceso a profesionales de otras especialidades. Ejemplo: la asistencia de un otorrinolaringólogo… “porque es incómodo el traslado a un servicio especializado” y la persona debe aceptar y tolerar no ser atendida. Esta triste realidad trae aparejado resultados muy graves: muertes por enfermedades tratables tanto en la población femenina como en la masculina. También se les niega el acceso a los tratamientos indicados por médicos especialistas en el caso que tengan acceso a una consulta.

Todo esto está reñido con el principio básico del ser en igualdad de condiciones.

La vida privada de la libertad “no es vida”.

La privación de la libertad acompañada por el tratamiento forzada con drogas psiquiátricas provoca una especie de muerte psíquica.

Los acontecimientos de la vida cotidiana bajo los efectos de la medicación psiquiátrica –forzada o no, dentro y fuera de la internación- se perciben como si se mirara a través de un vidrio esmerilado, la voz de los otros llega a uno con un efecto retardado, y nuestros pensamientos también resultan lentos bajo los efectos de las drogas psiquiátricas. El contacto con el otro, con el afuera, está “mediado” por una cortina invisible que ralentiza los movimientos por el cuerpo rigidizado y los sentidos aletargados.

Así, el otro, cualquiera que sea, nos percibe “raros” “distintos” y los médicos aseveran que es el “devenir propio de la enfermedad diagnosticada” negando de cuajo que ese estado es el efecto de la privación de la libertad y del tratamiento químico forzado.

Con la privación de la libertad involuntaria, suele aparecer un estado de apatía profundo, un gran desinterés por todo… en mi experiencia esta apatía y el desinterés –incluso de hablar y permanecer en un mutismo absoluto- lo produce la imposibilidad de comprender que para el círculo de personas de mi afecto, esa situación fuera considerada buena, que dijeran que me “encontraban mejor”… si realmente esa es la mirada que tienen mis afectos cercanos, sean familiares o amigos, debo decir que no tienen registro alguno de las vivencias ciertas de humillación y maltrato que se viven en una internación.

Hay personas que estando internadas involuntariamente, hacen abandono de su aspecto físico y de su higiene. También eso es leído como un aspecto de “su enfermedad”… no se lee como un efecto iatrogénico de la privación de la libertad.

Los cambios a los que el cuerpo se ve sometido, desde el notorio aumento de peso con la pérdida de las formas propias del cuerpo y además, la falta de agilidad que provoca la medicación que rigidiza los músculos y el estado de “desconexión” que las mismas producen – y se aumenta notablemente con la privación de la libertad-, son otros aspectos que la persona padece, que pueden resultar motivo de vergüenza o mayor disminución de la estima.

La persona privada de la libertad, en un manicomio, tiene que poder evaluar estrategias de supervivencia y muchas veces, las elecciones son “el mal menor” y no lo que corresponde ni es justo ni a lo que se tiene derecho aún cuando se sea plenamente consciente de que se tiene derecho.

Cabe aclarar que una gran mayoría de la población internada desconoce todos sus derechos y además, cree que no los tiene. En las PcD psicosocial institucionalizadas durante muchos años en forma permanente o intermitente, se notan conductas propias de las personas sometidas a gran sometimiento y la faceta que muestran con claridad es la idea de “no tener derechos”

Así es muy poco probable que ellos luchen por una forma de vida independiente, el derecho a ser incluid en la comunidad en igualdad de condiciones porque se perciben así mismos como “personas enfermas”

Es común escuchar a adolescentes afectados a tratamientos -involuntarios o no- por consumo excesivo de drogas psicotrópicas, y en especial alcohol, decir “no tengo derecho a nada porque he consumido drogas y ese discurso es avalado por los responsables de su rehabilitación y tratamiento y en cierta medida y en muchas oportunidades también ese concepto es sostenido por familiares, se suma a esto que los profesionales de la salud mental encuentran dificultades para aceptar que los problemas derivados del consumo excesivo de drogas legales o ilegales es un tema que debe ser abordado dentro del ámbito de la salud… y son enviados a lugares de encierro con un régimen propio y diría “sin ley” donde prevalece la ley del más fuerte que suele ser en general “un adicto recuperado” que impone tratos degradantes.

Así, son salvajemente humillados y denigrados, abusados sexualmente y de otras formas niñas/niños y adolescentes sometidos a trabajo solamente comparables a la tortura y la esclavitud en el marco de internaciones forzadas o no.

En relación a esta problemática de la salud mental el entramado es de una gran complejidad y la violación de DD.HH. es indescriptible.

Nadie que está privado de la libertad tiene la posibilidad de decidir un lugar de residencia por fuera del manicomio que le ha tocado en desgracia y en virtud de su status social o el de su familia…

La mayor cantidad de personas privadas de la libertad de modo involuntario lo son por problemas sociales y al mismo tiempo:

La mayor parte de las problemáticas llamadas “enfermedades mentales” provienen de problemas sociales no atendidos debidamente por el Estado y afectan de manera altamente significativa a la población de menos recursos.

Poblaciones importantes en las que, de generación en generación, han transcurrido sus vidas en situaciones de extrema pobreza sin conocimiento de los Derechos Humanos que los asisten si tienen la desgracia de “caer en el manicomio, no tienen salida”. Se patologiza la pobreza!!! Hay un perverso discurso que “dice que la persona no ha sido capaz de tener ingresos adecuados para su sustento y/o el de su familia y garantizar vivienda, educación y salud”.

Esa supuesta enfermedad de una persona: ¿cómo se llama cuándo el sistema de salud mental con la privación de la libertad –involuntaria o no- des-ancla a la persona de su vida, de sus bienes, de sus ingresos económicos, de su universidad o de su escuela de estudios primarios y así, la deja en un vacío de derechos y sobre eso la re-diagnostica?

No hay mayor factor discapacitante que la pobreza, el hambre, la falta de techo y de educación. Y eso puede ser un punto de partida o de llegada para una persona con discapacidad social.

También muchas personas que caen abruptamente en la pobreza como consecuencia de las crisis económicas que se conocen como “respuestas al humor de los mercados”, es decir: las crisis económicas resultado de propuestas políticas neoliberales y del salvaje capitalismo, arrojan a la “locura” y al intento de suicidio –cuando no a la muerte misma- a muchas personas que mantuvieron durante gran parte de su vida un status de vida acorde a los derechos propios de una persona trabajadora con derecho al trabajo, la salud y la vivienda como derechos básicos inalienables y esas personas, recalan en los manicomios con un diagnóstico de enfermos psiquiátricos pero en sus Historias Clínicas no constan las condiciones de existencia al momento de la internación ni sus antecedentes culturales, laborales, familiares y sociales, ni nada, absolutamente nada de su vida antes de haber sido calificado como enfermo/a psiquiátrico/a.

Con horror observo que la familia reproduce el sistema de pensamiento manicomial.

La misma familia termina violando el derecho al hogar y la familia.

Poco a poco se aleja hasta dejar en el abandono a la persona.

Se la priva de la familia, de los hijos y de los nietos.

La familia se aleja porque es estigmatizada y además no recibe psico-educación alguna para albergar al familiar que sufre y contribuir a su inserción en la comunidad. Todo lo contrario, siempre se acentúa el hecho que la persona está enferma, que su enfermedad es incurable y que con el tiempo estará cada vez peor.

Eso es verdad cuando a una persona la privan de la libertad, en forma involuntaria o no, porque todo lo que le va pasando no es consecuencia de su padecimiento espiritual, emocional o psíquico… es consecuencia del asilamiento tras los muros agudizado por la “droga- dependencia- inducida” y por la soledad impuesta, que llega a sus grados de tortura más elevado en las celdas de aislamiento o con la sujeción mecánica en los casos que la persona presente algún tipo de excitación motriz que bien pudo ser ocasionada por un ”medicamento” o por falta de una caricia… por un miedo extremo o por una profunda angustia que nadie parece dispuesto a aliviar con un acompañar en un cuerpo a cuerpo hasta que el terror disminuya.

¿Dónde están escritas las bases del encierro involuntario como forma de cura?

En la decisión de privar de la libertad a una persona con discapacidad psicosocial de manera forzada hay un pensamiento, hay una lógica “a priori” que dispone que esa persona “no tiene cura en su enfermedad” y es una persona gravosa para la comunidad a la que se atribuyen todo tipos de males para sí mismo y o para terceros y que merecen la condena del encierro. Esto subyace en el pensamiento de quienes ejercen autoridad sobre la PcD psicosocial y le restringen la vida y la sumen en una vida en su mínima expresión, carente de sueños y anhelos, de amor y de libertad.

En Argentina los manicomios en su mayoría cuentan con “dispositivos de inserción laboral” a los cuales las personas privadas de la libertad son “invitados” a participar. Esa invitación y la aceptación o no, lleva a aumentar la cantidad de etiquetas que una persona puede ir sumando en el encierro de acuerdo a lo que se llama la falta o no de “adherencia al tratamiento”. Si la persona acepta trabajar en un emprendimiento de inserción laboral intra-hospitalario, recibirá un peculio[vii]… una míseros centavos por su trabajo y si no acepta, se le calificará como a una persona “institucionalizada que no tiene voluntad ni interés en el trabajo” y con pocas posibilidades de su inserción en la comunidad.

Las personas que estando internadas nos preocupamos por nuestra situación laboral somos desmotivadas y se nos promueve un pensamiento basado en la imposibilidad de continuar con tareas “normales” y el “beneficio” de acceder a “pensiones por discapacidad”.

Sostener delante de un psiquiatra la firme decisión de continuar trabajando en el mercado de trabajo como un ciudadano más, es descalificado en sus palabras, se es tratado como una persona que niega su “incapacidad” y lo usual es que el médico psiquiatra desconozca absolutamente todo lo referido a esa persona: sus estudios, su historia laboral y su estándar de vida si se trata de un manicomio púbico y en uno privado, si la persona en situación de encierro tiene un estar en el mundo alivianado de preocupaciones económicas porque posee dinero suficiente… no es menos descalificado… solo que esa persona puede llegar a tener más posibilidades de una vida autónoma si es que los familiares no lo inhabilitan restringiendo su capacidad jurídica para hacer ellos, usufructo de los bienes económicos de la persona con discapacidad.

Ninguna persona que tenga como único sustento en Argentina una pensión por discapacidad puede acceder a una canasta básica de alimentos, ni a la vivienda ni a la salud, no puede tener una vida independiente y autónoma ni puede vivir con libertad en la comunidad porque sus ingresos económicos, que son considerados “un beneficio” social, no le permiten tener ninguna autonomía económica.

No existe un nivel de vida adecuado ni protección social verdadera.

Vuelvo sobre el rechazo en Argentina de parte de los profesionales de la salud por la noción de discapacidad de la “persona con padecimiento mental” en cualquiera de sus manifestaciones.

La discapacidad es una concepción que pone en cuestión a la tan preciada, tanto como despreciada “enfermedad mental” corriendo el eje de la enfermedad individual al eje de las barreras sociales que obstaculizan la libertad individual, lo que se da en llamar el cambio de paradigma.

Los aún hoy promotores de las lógicas manicomiales encuentran en la concepción de la discapacidad una herramienta que otorga derecho a quienes ellos le quieren negar -ya no los derechos- si no la vida misma condenándoles al encierro y al estado de ser muertos vivientes, verdaderos zombis que deambulan entre los muros sin más pregunta que si la inmunda comida llegó a la mesa o no… si alguien se acordó de su existencia y llegó de visita o no…

A las mujeres privadas de la libertad se les puede llegar a producir la esterilidad quirúrgica…de modo involuntario… como se las puede prostituir… o abusar sexualmente de ellas y provocarle embarazos no deseados y hasta obligarlas a abortos o someterlas al robo de sus hijos…

Ingresar al manicomio es ingresar a la mismísima anomia[viii]: no se tuvo vida, la vida comienza y termina en los muros del manicomio.

La falta de ley a la que la palabra anomia refiere es lo que hace del manicomio un territorio que es tierra de nadie… y feudo de unos cuántos a la vez… en ese feudo la crueldad es ejercida con menos sutileza a medida que el ejecutor se aleja de la jerarquía del psiquiatra… y llega al personal de limpieza…

La degradación del concepto de ser humano y ser humano en igualdad de condiciones se traduce en el concepto de enfermo mental que es legislado por una concepción que se rige por un supuesto científico que designa la normalidad de las personas…

¿Quién puede decir yo soy normal, usted es normal y usted no sin sonrojarse?

Solamente alguien enceguecido de soberbia, solamente un ser que tanto teme a la locura, es capaz de pensar que es posible encerrarla tras los muros sin cometer violación de DD.HH.

La anomia en este caso es el estado provocado por un conjunto de personas que han degradado del juramento hipocrático y de otras que ejercen la violación de Derechos Humanos.

Para los que imponen esa legislación –paradójicamente carente de ley- para los que degradan con sus conceptos la condición humana al extremo de la privación involuntaria de la libertad, de tratamientos forzados, de humillaciones, torturas y tratos degradantes… para ellos la concepción de la diversidad funcional no existe y sin embargo, los involucra en tanto seres humanos- lo peor que les puede pasar es probar su propia medicina.

Puedo escribir miles de palabras más para tratar de transmitir la tortura que significa ser privada de la libertad – forma involuntaria o no- y de las graves consecuencias en mi salud y la observada en la salud de otros, como yo, obligados a la ingesta de drogas psiquiátricas en contra de nuestra voluntad.

Sin embargo, los profesionales de la salud mental con compendios de siglas alfanuméricas que definen conductas como los son los DSM y el CIE viven tan pagados de sus saberes y tan pagados por la industria farmacéutica y por los circuitos económicos que se destinan al sistema de salud,

  • son incapaces de recapacitar sobre sus prácticas, sobre su negación del paradigma de la discapacidad y ni pensar que puedan asomar su inteligencia al mundo de la diversidad funcional,
  • ni pueden comprender un mundo en evolución a velocidades nunca vividas en direcciones impensables hace menos de un cuarto de siglo, que desborda de nuevas problemáticas sociales donde todo parece desquiciado[ix] y estallado -y no necesariamente enfermo- sino nuevo y desconocido.

Como nuevo y desconocido hasta hace poco en Argentina es que nosotros, las PcD psicosocial, tenemos derechos y somos sujetos de derechos, pedimos trato en pie de igualdad y nos negamos a la internación involuntaria y al tratamiento forzado.

Hay una palabra en psicología muy interesante: constructo.

No voy a definir con exactitud el término, voy a explicar que constructo viene a designar esos aspectos que se saben que existen pero son difíciles de probar, de definir o controvertidos al momento de querer hacerlos “objetivables”.

Son constructos la inteligencia, la personalidad y la creatividad.

Me pregunto en qué lugar del cerebro está el recuerdo del olor dulce de mi abuela paterna… y de la voz de mi madre… dónde se guardan las canciones de cuna con las que he mecido el sueño de mis niños… dónde en el cerebro está el registro del primer diente, de la primera risa, de la primera travesura de mis hijos…en qué célula está el clima que rodeaba la escena que recuerdo de mi padre lustrando mis zapatos para ir a la escuela… dónde viven en mí los cuentos de hadas y brujas, el encanto del otoño teñido con el recuerdo del primer beso… donde se localizan los recuerdos de los compañeros desaparecidos, cómo perduran sus voces a pesar de los años… dónde se almacena todo lo aprendido y dónde permanece lo desaprendido, donde se produce y se reproduce la capacidad de amar cuando se ha sido vejada… cómo y donde están objetivados en mi cerebro lo que me permite pensar en colores para pintar, danzar, reír y llorar… olvidar y recordar…

Me pregunto de qué otra manera se puede privar de la libertad en forma involuntaria si no es a la fuerza y si no es desconociendo los derechos que nos atañen.

Esa fuerza tan bien descrita por Antonin Artaud en su CARTA A LOS DIRECTORES DE LOS ASILOS DE LOS LOCOS. “……………………………………………………….No nos sorprende ver hasta qué punto ustedes están por debajo de una tarea para la que sólo hay muy pocos predestinados. Pero nos rebelamos contra el derecho concedido a ciertos hombres – incapacitados o no – de dar por terminadas sus investigaciones en el campo del espíritu con un veredicto de encarcelamiento perpetuo……………………………………………………………………………………………………………………………………………………………….. ¡Y qué encarcelamiento! Se sabe – nunca se sabrá lo suficiente – que los asilos, lejos de ser “asilos”, son cárceles horrendas donde los recluidos proveen mano de obra gratuita y cómoda, y donde la brutalidad es norma. Y ustedes toleran todo esto. El hospicio de alienados, bajo el amparo de la ciencia y de la justicia, es comparable a los cuarteles, a las cárceles, a los penales…………………………………………………………………………………………………………………………………………………………………………….Esperamos que mañana por la mañana, a la hora de la visita médica, recuerden esto, cuando traten de conversar sin léxico con esos hombres sobre los cuales – reconózcanlo – sólo tienen la superioridad que da la fuerza.[x]

Lucila López

Usuaria y Sobreviviente de la Psiquiatría                                                                                           Psicóloga Social                                                                                                                                                                                            Psicodramatista                                                                                                                                       Analista Institucional                                                                                                                             Agente Comunitaria en Prevención de adicciones.

Miembro de WNUSP

Miembro de INWWD 

 

C.A.B.A

ARGENTINA

______________________________________________

Escrito por Lucila López en apoyo a la CAMPAÑA POR LA PROHIBICIÓN ABSOLUTA DE LA PRIVACIÓN DE LA LIBERTAD Y EL TRATAMIENTO FORZADO DE LAS PERSONAS CON DISCAPACIDAD PSICOSOCIAL, POR EL CUMPLIMIENTO IRRESTRICTO DEL ART. 14.- Buenos Aires, Argentina, Marzo 14, 2016

logo_wnusp

 

[i] Committee on the Rights of Persons with Disabilities /Guidelines on article 14 of the Convention on the Rights of Persons with DisabilitiesThe right to liberty and security of persons with disabilities/

Adopted during the Committee’s 14th session, held in September 2015

[ii] Estela de Carlotto, Presidenta a Abuelas de Plaza de Mayo uno de los organismos más importantes de Derechos Humanos de la Argentina.

[iii] *) Barrabasada: 2. Hecho equivocado que origina un gran destrozo o perjuicio. (evil thing) RAE

[iv] Y la de todos los privados de la libertad por motivos de discapacidad psicosocial.

[v] Ley NSM viola el art. 12 al decir: “Se presume la capacidad jurídica”… En la CDPD el art. 12 especifica “igual reconocimiento ante la ley”…

 

[vi] Se hace indispensable el resarcimiento económico.

[vii] *) Para el libre ejercicio del artículo 19, el respeto absoluto del art. 27 – Trabajo y empleo es una condición inalienable y elemental.

Me voy a detener a explicar en el significado de peculio porque es gravísimo que haya muchas PcD psicosocial y con otras discapacidades también, que trabajen con carácter obligatorio y sean pagadas con un peculio porque eso es rayano a un sistema de esclavitud.  El Derecho al Trabajo y al Empleo se viola de manera flagrante y es una vergüenza.

Peculio.- Significado – etimología- definiciones. Del lat. peculium.

  1. m. Dinero y bienes propios de una persona.
  2. m. Hacienda o caudal que el padre o señor permitía al hijo o siervo para su uso y comercio.

La palabra peculio proviene en su etimología del latín “peculium” que a su vez deriva de “pecus” que significa ganado, ya que esa era la medida que se aplicaba para valorar los bienes, cuando no existía la moneda. Los peculios eran porciones pequeñas de bie

nes, que se separaban en el antiguo Derecho Romano, del patrimonio familiar, que pertenecía en su integridad y en propiedad al pater, jefe de la unidad político religiosa en qué consistía la familia, y varón de mayor edad dentro de ella. Destina una pequeña porción a hijo y esclavos. También relacionado con el ámbito carcelario.

Hasta hace pocos días el peculio era de $150.- mensuales, equivalentes a  u$s 0,34 diarios.

Actualmente el peculio es $300.- mensuales equivalente a u$s 20,34 = u$s 0,68 diarios.

Los talleres protegidos para personas con discapacidad están naturalizados y solamente en la Provincia de Buenos Aires, hay 4.500 personas con discapacidad que trabajan en más 173 talleres protegidos.  En la Ciudad Autónoma de Buenos Aires un importante taller protegido, las personas con discapacidad psicosocial  hacen  los muebles para la administración pública y hospitales de la ciudad.

El actual valor del peculio en la Provincia de Buenos Aires fue anunciado hace pocos días por el Ministro de Desarrollos Social quien dijo: “van a recibir 300 pesos por mes como parte del peculio, en lugar de los 150 que cobran actualmente, que van a servir no solo para ayudar a ellos sino también a sus familias”. Asimismo informó que los operarios recibirán una tarjeta para la compra de productos alimenticios por un monto de 100 pesos mensuales. (equivalente a u$s 0,21 diarios ¡para alimentos! ¿Y consideran que deben ayudar a la familia!

Al día 14 de enero de 2016 se les adeudaba el pago desde septiembre de 2015.

[viii] Anomia: del gr. ἀνομία anomía.1. f. Ausencia de ley. 2. f. Psicol. y Sociol. Conjunto de situaciones que derivan de la carencia de normas sociales o de su degradación RAE

[ix] Desquiciar

  1. tr. Desencajar o sacar de quicio algo. Desquiciar una puerta, una ventana.U. t. c. prnl. U. t. en sent. fig.
  2. tr. Descomponer algo quitándole la firmeza con que se mantenía. U. t. c. prnl.
  3. tr. Trastornar, descomponer o exasperar a alguien. U. t. c. prnl.
  4. tr. p. us. Hacer perder a alguien la privanza, o la amistad o valimiento con otrapersona. RAE

[x] http://lalibertaddeotrodecir.blogspot.com.ar/2016/03/carta-los-directores-de-los-asilos-de.html

 

 

 

 

 

Workfare coercion in UK – Anne-Laure Donskoy

Workfare coercion in the UK: an assault on persons with disabilities and their human rights

Anne-Laure Donskoy_Survivor researcher, UK

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While there is a lot of focus on coercion organised and implemented in psychiatry, less attention is being paid to state engineered welfare measures based on libertarian paternalism1, which have coercive practices at their core. Among them are policies that strongly support behavioural change using positive psychology and cognitive behavioural therapy. Freidli and Stearn (2015)2 call this “psychocompulsion”. These policies and measures are increasingly used to ambush and coerce persons with disabilities and the long term sick into adopting new ways of being and living conditions under the constant threat of sanctions and which have driven many to attempt to their lives. This paper builds on the work of Friedli and Stearn3 as an attempt to highlight current coercive welfare policies, including forcing ‘therapy’ on individuals, as human rights violation of the CRPD.

 

Background: Psychocompulsion as state sponsored human rights violations

Psychocompulsion, the use of psychological strategies to “nudge” individuals to make “life changes” that fit a political ideology or programme, is not entirely new to the UK. Already in the 1970s, some long term job claimants would be sent for a medical examination, on the premise that if people were not physically ill then they should be able to find and take up work, any work. This had all the flavours of Victorian paternalism written all over it. The ‘mentally disordered’ and the ‘mentally handicapped’ experienced a particular brand of paternalism, hidden away from society and from consciousness in specialist homes and services, often suffering physical and mental abuse or used in rehabilitation work with little or no protection.

Today, psychocompulsion in the UK has been promoted by the Behavioural Insights Team (nicknamed the “Nudge Unit”), now in private hands as a social purpose company but still working closely with the Cabinet Office4, thereby guaranteeing prime influence on policy making. It is clear that psychocompulsion is being used to lock individuals, including the long term unemployed, the sick and persons with disabilities, into back-to-work schemes as a conditionality of welfare. In recent months and weeks, voices of dissent have arisen mostly from social movements, denouncing the use of coercion which put people’s lives at risk5.

As Friedli and Stearn’s paper show, this finger wagging attitude has taken on a far more sinister slant.

First, it turns on its head the idea that unemployment is the product of a failing economy by strongly suggesting that it is a state of mind, worse still a ‘mental illness’ that can be corrected by changing the psychology of claimants, thus placing the onus of responsibility for success, for betterment, for choice etc. on the individuals themselves. This totally ignores issues of social (in-)justice.

Second, it widens the scope by netting in the most vulnerable people in society, specifically the long term sick and those with disabilities, including psychosocial disabilities. This strategy narrowly avoids attracting full-on accusations of discrimination by putting these individuals on par with the long term unemployed and by stressing ad nauseam that the policy is about helping people which should be achieved through (any type of paid) employment. Paid employment becomes the embodiment and the “pinnacle of human experience”.6

Third, the underlying premise that ‘work is good for you’ ignores those dissenting voices which argue that without strong provisos (taking into account the complexity of individual circumstances, choice, timeliness, appropriateness as much as the quality of support and work on offer) the argument is both unhelpful and counterproductive7, and can have devastating consequences for those concerned.

Finally, the stance of the policy totally fits within the libertarian paternalism agenda which moves away from collective to total individual (libertarian) responsibility, slowly realising Ayn Rand’s vision for a permanently productive (and permanently disposable/replaceable) workforce serving an elite. In this scheme, all coercive strategies acquire a legitimacy that the psychiatric survivor movement rejects.

 

Being ill or disabled, and on welfare benefits: state coercion and the CRPD

The Welfare Reform Act 2012 introduced a wide range of reforms to the benefits and tax credits system. The stated aim was to reduce the financial burden of the cost of welfare. This is being achieved by introducing ever drastic and punitive policies under the guises of a responsibilisation agenda, underpinned with an intense authoritarian ideology not seen or experienced since Victorian times. The Tory manifesto of the 2015 general elections claimed it aimed to help people with mental health issues back in to work. The reality is very different and people with mental health issues clearly face discriminations which other groups do not.

 

Article 4: The rights and freedoms of persons with disabilities are violated under the social security scrutiny regime:

When people with mental health issues are on welfare benefits, they find themselves the object of intense, intrusive and inappropriate scrutiny by the system, notably through the Work Capability Assessment (WCA) which has consistently failed these claimants as it is totally unsuited to their singular predicaments and experiences. As a result, more and more people are placed on the Work Related Activity Group of the Employment and Support Allowance which comes with strict conditionalities. Also affected are those under the new Universal Credit (UC) system which is being rolled out for all benefits claimants which places yet another layer of scrutiny on individuals, possibly more so those in work.

 

Article 1-5: Discrimination

A judicial review in 2013 found that the WCA process actively discriminates against people with mental health issues. Since then very little has been done to change the process and the status quo remains.

The Centre for Welfare reform, in its recent report A Fair Society?, also shows that persons with disabilities are targeted the most despite the fact that they have the greatest and often most complex needs.

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Article 10: Right to life: “States Parties reaffirm that every human being has the inherent right to life and shall take all necessary measures to ensure its effective enjoyment by persons with disabilities on an equal basis with others”.

A poll of over 1,000 GPs commissioned by Rethink Mental Illness in 2015, found that over 20% have patients who have felt suicidal due to the WCA8.

In a report sent to the Department for Work and Pensions (DWP), the senior coroner for inner north London, Mary Hassell, said “the trigger” for the suicide was the man being found fit for work by the department”9.

[A Freedom of Information request has] revealed that the Department for Work and Pensions (DWP) has investigated decisions, via peer reviews, about the welfare payments of 60 claimants following their deaths. A peer review, according to the DWP guidance for employees, must be undertaken when suicide is associated with DWP activity to ensure that any DWP action or involvement with the person was appropriate and procedurally correct.10

 

Article 13: Access to justice: 13.1: “States Parties shall ensure effective access to justice for persons with disabilities on an equal basis with others, including through the provision of procedural and age-appropriate accommodations, in order to facilitate their effective role as direct and indirect participants, including as witnesses, in all legal proceedings, including at investigative and other preliminary stages.”

Benefit claimants who wish to appeal a decision need access to justice. This represents an expense they can ill afford (if at all) therefore need access to legal aid. However, the Ministry of Justice has removed welfare benefits matters from the scope of legal aid funding, thereby denying access to justice and discriminating against the most vulnerable and poorest, among whom people with mental health issues:

In order to challenge a decision of a First-tier Tribunal (FtT) the appellant needs to identify an error of law in the FtT’s decision and then request permission to appeal to the Upper Tribunal (UT). The process of appealing on a point of law to the UT has two stages, but, for the reasons set out below, the legal aid contract only covers the second stage … The absence of any legal aid at Stage One of an appeal to a UT on a point of law represents a major flaw in the current scheme as it is simply unrealistic to expect an appellant to draft an appeal on a point of law without any assistance.11

In the future, social security claimants who find themselves faced with an incorrect Upper Tribunal decision, or who win their case at the Upper Tribunal but find themselves on the receiving end of an appeal by the DWP12, HMRC13 or a local authority, could be facing the courts and the costs risks attached on their own or not at all.14

In practice, benefit claimants who wish to appeal decisions have to resort to charitable organisations to support them through the process. However these are seeing their funding cut, or they are not coping with increasing number of calls for help.15 There has also been some criticism from within the legal system with regard to persons with intellectual disabilities on matters of legal representation regarding privation of liberty; the same issues also apply to persons with psychosocial disabilities:

The Law Society, which represents solicitors throughout England and Wales, intervened [in a particular case]. Its president, Jonathan Smithers, said: “When a vulnerable person doesn’t have friends or family to represent them during a decision to restrict their liberty, it is vital that person is able to participate in the decision-making process . . . If this is not possible then they must have a legal representative to protect their rights as well as their health and general welfare. Those who are least able to defend themselves should not be sacrificed on the altar of austerity.” 16

 

Actively changing the narrative of workfare and welfare benefits

The narrative of welfare is changing drastically. As Friedi says, we are moving from a “what people have to do [to find work] to what they have to be [demonstrating the right attitude to be employable]17. This is exemplified through the new ‘Work and Health Programme’ planned to be rolled out in England and Wales.

This programme has many strands, including:

−   Embedding psychological services within Job Centres

−   Placing ‘job coaches’ within GP surgeries for people with certain conditions (specifically people with mental health issues): the ‘Working Better’ pilot scheme is funded by the Department for Work and Pensions and the coaches will be provided by welfare to work agency, Remploy (a welfare-to-work subsidiary of the Maximus).

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This programme blurs the boundary between health and welfare, health and work domains, in a way that has not happened before. This is a coordinated move to effectively bring in the benefits system within NHS care: joblessness, being unemployed becomes an illness, specifically a mental illness which needs to and care be cured through psychological therapies.

It will not only extend benefit conditionality into the NHS but also compromise clinical independence and clinical ethics. In practice, people who display the wrong attitude to work, to work placements or who have been unemployed for a long time will be referred to psychologists and given forced Cognitive Behavioural Therapy, and be sent many motivational emails and text messages throughout the week; or they will be prescribed referrals to an in-house ‘job coach’. Failure to comply with these forced prescriptions will trigger an immediate sanction regime. This will inevitably threaten if not destroy that first quality that patients place in their doctor, trust. People may become reluctant to say anything whether it is about their situation or their health for fear of being forced into the schemes.

 

CRPD violations:

Articles 1-5: (equality, choice, autonomy, capacity)

Persons with disabilities are specifically targeted by the new measures

 

Article 25 (Right to health):

Currently both schemes are in the early stages of being rolled out (pilot stage) and the official line claims that they are voluntary. However, as the Tory manifesto stated “We will help you back into work if you have a long-term yet treatable condition”, this is set to become compulsory: “People who might benefit from treatment should get the medical help they need so they can return to work. If they refuse a recommended treatment, we will review whether their benefits should be reduced.”(p. 28). However, being forced to receive “therapy” for a “treatable condition” is not the same thing as being offered support, which would imply that the individual is free to choose to take it up or not. Most observers agree that what is currently taking place on a voluntary basis as part of the pilot projects will become compulsory, which would only follow the UK Government’s own stance of applying any means to get people “back to work”18.

This means that people with mental health problems will no longer be able to freely choose to consent, or withhold their consent, to ‘treatment’. There is also a high risk that people will feel intimidated into consenting to undergo these ‘therapies’. This is very similar to what happens in psychiatry whereby the right to health is invoked to forcibly treat people for their own good, “in their best interest” … but as their only option. To decline a recommended treatment or to fail to comply to the letter with the injunctions and expectations of the system will result in benefits sanctions.

Cognitive behavioural therapy (CBT), the approach chosen by the Government is highly controversial and does not suit everybody. Therefore a one-fits-all approach, whether it is applied forcibly or not, will be counterproductive as it may make some people feel worse (counter to their right to health) and shows the total lack of understanding of the often complex and singular situations of persons with disabilities.

 

Art 10: (Right to life)

Any Government that uses coercion and sanctions as a means to a political end must take full responsibility for the consequences of its actions. As with the Work Capability Assessment, people being coerced into receiving behavioural or any therapy they did not fully consent to, may experience adverse effects (making people even more unwell by making them even poorer and forcing them to live in a constant state of anxiety, making them suicidal).

It also denies the person as an autonomous individual able to make their own choices (Art 12, Equal recognition before the law; Art 16, Freedom from exploitation, violence and abuse and threatens their integrity (Art 17)).

It also contradicts the Government’s own claims that it is doing everything to make UK domestic law compliant with the CRPD:

The Convention is not legally binding in domestic law in the UK but is given effect through the comprehensive range of existing and developing legislation, policies and programmes that are collectively delivering the Government’s vision of equality.19

 

Article 17 (Protecting the integrity of the person): The issue of coercion goes beyond “designating work as a cure for unemployment and poverty”20 as Friedli puts it; this is also about changing people’s societal status and identity. In the new narrative, there are productive and unproductive individuals, therefore there is no such thing as a long-term sick or disabled person (all disabilities included). These notions pretty much disappear in the name of inclusiveness and fairness (in relation to so-called “hard working people”21 who are deserving of help and will do their utmost not to rely on the state for their individual needs).

Language is indeed important in this context, and language is shifting. As many have observed, ‘sick notes’ have become ‘fit notes’, the term ‘disability’ too is being erased as ‘Disability Living Allowance’ becomes ‘Personal Individual Payment’. This speaks to a simplistic but powerful narrative of ‘can-do-no-matter-what’ supported by having a compulsory ‘right attitude, which is where psychocompulsion comes in. Nudging then forcing people into having the ‘right attitude’.

 

Forcing people back to work by reducing their welfare benefits

Persons with disabilities are clearly targeted over and above other categories of individuals (Art 1-5 equality, discrimination, choice, autonomy). Indeed, another form of coercion has emerged through a recent drastic to the ESA in weekly support from £103 to £73, contained in the Welfare Reform and Work Bill. It will apply to new ESA claimants in the work-related activity group. This vote, pushed through Parliament on 7 March 201622, is meant to “incentivise disabled people to find work quicker”. This (purely ideological) decision will not only strip them of financial security but also reinforce the idea, by bringing the rate into line with Jobseeker’s Allowance, that disability no longer exists, that anyone can and should work, that there are only productive (deserving) and unproductive (undeserving) people.

 

An unethical social experiment

It has come to light that these new programmes are also the subject of ‘research’. The new Work and Health Programme is currently at a research and trialing stage23. As Kitty Jones writes,

Part of the experimental nudge element of this research entails enlisting GPs to “prescribe” job coaches, and to participate in constructing “a health and work passport to collate employment and health information.24

However, this ‘research’ (if one can call it so), has been heavily criticised because it is not sanctioned according to the usual robust ethical guidelines. Research that adheres to robust ethical guidelines would absolutely seek not to cause harm to its participants, and would seek their informed consent beforehand25. This is not the case here where claimants are the participants are the involuntary and ‘unconsented’ participants of an experiment they know nothing about.

There are a wide range of legal and Human Rights implications connected with experimentation and research trials conducted on social groups and human subjects.26

A spokesperson for Disabled People Against Cuts (DPAC), talked of the UN CRPD Committee’s visit to the UK and described the situation thus:

It means the UN will examine the vicious and punitive attacks on disabled people’s independent living as well as the cuts which have seen so many placed in inhuman circumstances and has led to unnecessary deaths.27

 

Articles 1-5: discrimination against persons with disabilities who are targeted through this programme.

Article 9: right to communication: The existence of this experiment and the format of its conduct has not been communicated with the claimants (the participants).

 

Article 10 (Right to Life): when coercion brings people to the brink of suicide or they succeed in killing themselves (one court case at least has pronounced on the clear link between benefits sanctions and reasons for suicide):

Research from the Black Triangle campaign group found more than 80 cases of suicide directly linked to billions of pounds in benefit cuts. John McArdle, co-founder of Black Triangle, said: “The Dept of Work and Pensions refuses to reveal the findings of their own peer reviews of suicides linked to the sanctions so we will never know the truth in those cases. . . He said the Work Capability Assessment regime applied to all sick and disabled people, without adequate risk assessment ‘built into the system’28

Mortality rates bring their own tales of woe:

[The government] published or, rather, was forced to after several Freedom of Information requests – that show more than 80 people a month are dying after being declared “fit for work”. These are complex figures but early analysis points to two notable facts. First that

2,380 people died between December 2011 and February 2014 shortly after being judged “fit for work” and rejected for the sickness and disability benefit, Employment and Support Allowance (ESA). We also now know that 7,200 claimants died after being awarded ESA and being placed in the work-related activity group – by definition, people whom the government had judged were able to “prepare” to get back to work.29

 

Articles 12, 17, 19: Coercive measures embedded in all aspects of the Work and Health Programme and its various tools and strategies run counter to the premise that the person is free and able to make choices for themselves, and considerably threatens their right to independent living when they are forced into poverty.

Nothing seems to shift the current UK Government’s assault on people with disabilities or long term sickness, and on their human rights. Not the many Freedom of Information requests which have revealed that the DWP did look into the death of 60 benefits claimants but sat on the findings; nor a Commons Select Committee inquiry into benefits sanctions in April 2015, nor the visit by the UN CRPD committee at the request of a disability group (DPAC) in the late autumn of 2015, nor a coroner’s report clearly linking a claimant’s suicide to the stress caused by the Work Capability Assessment. The UK is effectively engineering and encouraging coercive and punitive policies that specifically target people with disabilities and the long term sick, putting their lives and their future at high risk. Many have observed that ‘austerity’ was only ever an excuse to establish and implement ideological policies. This is not about saving money in hard times; this is about the willful annihilation of the disabled, either through language or deeds.

 

Anne-Laure Donskoy

March 2016

 

Notes:

1https://kittysjones.wordpress.com/2015/11/28/the-goverments-reductive-positivistic-approach-to-social-research- is-a-nudge-back-to-the-nineteenth-century/– The idea that it is both possible and legitimate for governments, public and private institutions to affect and change the behaviours of citizens whilst also [controversially] “respecting freedom of choice.”

2 Friedli L, et al. Med Humanit 2015;41:40–47. doi:10.1136/medhum-2014-010622

3 See also this short film: https://vimeo.com/157125824

4 http://www.behaviouralinsights.co.uk/

5 http://www.disabilitynewsservice.com/coroners-ground-breaking-verdict-suicide-was-triggered-by-fit-for-work-test/

6Cole M. Sociology contra government? The contest for the meaning of unemployment in UK policy debates. Work Employment Soc 2008;22(1):27–43.

7 Even the Department of Work and Pensions (DWP) who are driving these policies, acknowledged in a 2006 study have put forth provisos that “account must be taken of the nature and quality of work and its social context” and that, for sick and disabled people, “there is little direct reference or linkage to scientific evidence on the physical or mental health benefits of (early) (return to) work for sick or disabled people.” 8https://www.gov.uk/government/publications/is-work-good-for-your-health-and-well-being

https://www.rethink.org/media-centre/2012/09/new-gp-survey-shows-government-welfare-test-is-pushing- vulnerable-people-to-the-brink

9 See note 3

10 https://www.wsws.org/en/articles/2015/02/05/welf-f05.html

11 https://gclaw.wordpress.com/2014/05/30/what-legal-aid-is-still-available-for-work-undertaken-on-welfare-benefits-post-laspo/

12 Department of Works and Pensions

13 Her Majesty’s Revenue and Customs

14 http://www.cpag.org.uk/content/legal-aid-reform-or-termination

15 http://www.theguardian.com/society/2014/feb/25/benefit-cuts-welfare-linked-mental-health

16 http://www.theguardian.com/society/2016/mar/10/judge-challenges-government-over-legal-representation-for-

vulnerable-people?CMP=share_btn_tw

17 https://www.youtube.com/watch?v=Dt-V0e0-ipY

18 A side point has been made by Friedli and others about the questionable ethics of those clinical psychologists who accept to take part in such initiatives and about the rapid expansion of the back-to-work industry.

19 Office for Disability Issues, UK Initial Report On the UN Convention on the Rights of Persons with Disabilities, May 2011,

www.odi.gov.uk/un-report

20 https://www.youtube.com/watch?v=Dt-V0e0-ipY

21 An expression used as a constant leitmotiv by the UK government.

22 Ministers claimed “financial privilege” to assert the Commons’ right to have the final say on budgetary measures

23 http://php.york.ac.uk/inst/spru/research/summs/esa.php

24 https://kittysjones.wordpress.com/2015/12/14/the-department-for-work-and-pensions-dont-know-what-their-ethical-and- safeguarding-guidelines-are-but-still-claim-they-have-some/

25 https://en.wikipedia.org/wiki/Ethical_research_in_social_science

26 See note 15

27 http://www.disabilitynewsservice.com/confirmed-un-is-investigating-uks-grave-violations-of-disabled-peoples-rights/

28http://www.mirror.co.uk/news/uk-news/more-80-suicide-cases-directly-5634404

29 http://www.theguardian.com/commentisfree/2015/aug/27/death-britains-benefits-system-fit-for-work-safety-net

 

 

Nachgefragt – die Reform der Zwangsbehandlung mit Neuroleptika in der Praxis der Betreuungsgerichte

http://www.ilcappellaiomatto.org/2016/03/campagna-no-tso-nachgefragt-die-reform.html

Nachgefragt – die Reform der Zwangsbehandlung mit Neuroleptika in der Praxis der Betreuungsgerichte

http://psychiatrierecht.de/nachgefragt.htm 

http://www.die-bpe.de/


Von RA Thomas Saschenbrecker

 und em. Prof. Wolf-Dieter Narr

Abhandlung als Broschüre: hier bestellen oder selber ausdrucken

Abhandlung als Broschüre: hier bestellen oder selber ausdrucken

Hinweis: um eine Fußnote zu lesen, bitte den Cursor direkt daraufhalten oder am Ende des Textes lesen
Die Diskussion über die Zulässigkeit einer ärztlichen Zwangsbehandlung mit Neuroleptika gegen den Willen eines Patienten im Rahmen einer Unterbringung nach § 1906 BGB hat auch nach den richtungsweisenden Entscheidungen des Bundesverfassungsgerichtes nach 20111 schon wegen der hohen Bedeutung des Grundrechts aus Art. 2, Abs. 2, Satz 1 GG nichts an Aktualität verloren.

Mit Vorlagebeschluss vom 01. Juli 2015 – XII ZB 89/15 hat jüngst der BGH dem Bundesverfassungsgericht die Frage zur Entscheidung vorgelegt, ob § 1906 Abs. 3 BGB n.F. mit dem Gleichheitsgrundsatz aus Art. 3 Abs. 1 GG vereinbar sei. Motiv des 12. Senates des BGH war allerdings eher eine vermutete Schlechterstellung von betroffenen Patienten, die sich einer Zwangsbehandlung räumlich nicht entziehen wollen oder hierzu körperlich nicht in der Lage sind, gegenüber nach § 1906 BGB untergebrachten Betroffenen. Der BGH geht dabei von seiner eigenen engen Definition der mit Freiheitsentziehung verbundenen Unterbringung aus2, die nur solche Maßnahmen umfasst, welche die “persönliche Bewegungsfreiheit des Betroffenen nicht nur kurzfristig auf einen bestimmten räumlichen Lebensbereich” begrenzt.

Die aufgrund ihrer persönlichen Disposition nicht von Freiheitsentzug betroffenen Personen wähnt der BGH deshalb benachteiligt, weil entsprechende Zwangsmaßnahmen nur im Rahmen einer Unterbringung nach § 1906 Abs. 1 BGB erfolgen könnten. Soweit eine solche nicht in Betracht käme, gäbe es auch keine Grundlage der Zwangsbehandlung.

Auch wenn der BGH mit seinem Vorlagebeschluss mehr oder minder ersichtlich die Einführung einer rechtlich in hohem Maße bedenklichen ambulanten Zwangsbehandlung favorisiert, ist zumindest zweifelhaft, ob das Bundesverfassungsgericht diesem Drängen in Sinne einer allumfassenden Vernunfthoheit im Gesundheitswesen nachkommen wird3, um den Gesetzgeber in Konsequenz hieraus zur Schaffung von Rechtsgrundlagen für die ambulante Zwangsbehandlung zu veranlassen. Wesentlich naheliegender und mit weitreichenderen Folgen dürfte daher sein, dass eine Entscheidung der Verfassungshüter zum Vorlagebeschluss in letzter Konsequenz zu einer Ablehnung der Grundlagen der Zwangsbehandlung insgesamt führen könnte. Der Gesetzgeber wäre mit seiner Novelle zur Zwangsbehandlung gescheitert.

Vor dem Hintergrund der Rechtsprechung des Bundesverfassungsgerichts4 und des Bundesgerichtshofs5 zum 26. Februar 2013 in Kraft getretenen Neuregelungen der § 1906 Abs. 3 und 3a BGB sowie der §§ 312, 323, 329 und 333 FamFG wollte der Gesetzgeber materielle und formelle Eingriffsvoraussetzungen für die Veranlassung einer ärztlichen Zwangsmaßnahme unter geschlossenen stationären Bedingungen durch den Betreuer neu schaffen6. Die Frage, ob dieses Vorhaben der Rechtspraxis gerecht geworden ist oder aber die Bedeutung und die Tragweite des Grundrechts aus Art. 2, Abs. 2, Satz 1 GG weiterhin verkannt wird, ist der Anlass, die Genehmigung der Einwilligung in eine ärztliche Zwangsmaßnahme nach § 312 Satz 1 Nr. 1 FamFG in Verbindung mit § 1906 Abs. 1 bis 3a BGB nach zwei Jahren der Reform in der Praxis der Betreuungsgerichte in einer Totalerhebung zu erfragen. Das Bundesverfassungsgericht muss nach wie vor Verletzungen der Bedeutung und Tragweite des Grundrechts aus Art. 2 Abs. 2 Satz 1 GG rügen7.

Grundproblematik:

Nach einem Moratorium, das auf die Rechtsprechung des Verfassungsgerichtes 2 BvR 882/09 vom 23.03.2011 und 2 BvR 633/11 vom 12.10.2011 gründete und den Bundesgerichtshof veranlasste, in zwei Beschlüssen vom 20.06.20128 zu § 1906 BGB a.F.9 die Zwangsbehandlung mit Neuroleptika für unzulässig zu erklären und seine bisherige Rechtsprechung zur medikamentösen Zwangsbehandlung im Rahmen des § 1906 BGB a.F. aufzugeben, soll die Zwangsbehandlung von nicht einwilligungsfähigen psychisch Kranken nach § 1906 BGB auf Bundesebene im Betreuungsrecht seit dem 26.02.2013 wieder möglich sein. Der Bundestag billigte am 17.01.2013 einen entsprechenden Gesetzentwurf von Union und FDP, wonach Ärzten grundsätzlich als `ultima ratio´ erlaubt wird, psychisch kranke oder geistig behinderte Menschen, die als nicht einwilligungsfähig gelten und bei denen keine wirksame Willensbekundung durch eine Patientenverfügung entsprechend § 1901a BGB vorliegt, auch gegen ihren Willen zu behandeln.

Der Gesetzgeber hat durch das Gesetz zur Regelung der betreuungsrechtlichen Einwilligung in eine ärztliche Zwangsmaßnahme vom 18. Februar 201310 mit Wirkung vom 26. Februar 2013 in die Vorschrift des § 1906 BGB die neuen Absätze 3 und 3a eingefügt. So wurden die Voraussetzungen der Einwilligung des Betreuers in eine ärztliche Zwangsmaßnahme, sowie das gerichtliche Genehmigungserfordernis geregelt.

Die medizinische Behandlung gegen den natürlichen Willen (Zwangsbehandlung) einer betroffenen Person greift in deren Grundrecht aus Art. 2 Abs. 2 Satz 1 GG ein, das die körperliche Integrität der Grundrechtsträgerin und damit auch das diesbezügliche Selbstbestimmungsrecht schützt. Zwangsbehandlung ist rechtlich damit zunächst von Verfassungs wegen verboten. Zwangsbehandlung könnte damit wenn überhaupt, wie jeder andere Grundrechtseingriff, nur auf der Grundlage eines Gesetzes zulässig werden, das die Voraussetzungen für die Zulässigkeit des Eingriffs bestimmte11.
Der Grundsatz des Vorbehaltes des Gesetzes für die materiellen und für die formellen Eingriffsvoraussetzungen hat den Sinn, die primäre Zuständigkeit für die Bewertung von Grundrechtsbeschränkungen als begründet oder ungerechtfertigt zu bestimmen. Nur so ist gewährleistet, dass die Grenzen zwischen zulässigem und unzulässigem Grundrechtsgebrauch und zwischen zulässiger und unzulässiger Grundrechtseinschränkung nicht fallweise nach eigener Einschätzung von beliebigen Behörden oder Gerichten, sondern primär – in der Form eines allgemeinen Gesetzes – durch den Gesetzgeber gezogen werden12. Zudem wird durch einen Gesetzesvorbehalt regelmäßig eine richterliche Kontrolle der Maßnahme ermöglicht.

Die Voraussetzungen für die Zulässigkeit des Eingriffs müssen hinreichend klar und bestimmt geregelt sein. Die zur Normanwendung berufenen Entscheidungsträger der Unterbringungseinrichtungen benötigen auch im eigenen Interesse eine “klare, Rechtssicherheit vermittelnde Eingriffsgrundlage”13. Die wesentlichen Voraussetzungen für eine Zwangsbehandlung müssen aus dem Gesetz selbst in materieller, als auch in verfahrensrechtlicher Hinsicht erkennbar sein. Das bedeutete eine “über abstrakte Verhältnismäßigkeitsanforderungen hinausgehende Konkretisierung dieser Voraussetzungen”14.

Auch die weiteren Voraussetzungen für die Zulässigkeit einer Zwangsbehandlung, einschließlich der Anforderungen, denen die gesetzliche Grundlage für eine solche Behandlung genügen müsste, hat das Bundesverfassungsgericht zunächst in seinen beiden genannten Beschlüssen BvR 882/09 und 2 BvR 633/11 geklärt15, um folgende Voraussetzungen für eine Zwangsbehandlung, die dem erforderlichen Gesetzesvorbehalt auch materiell-rechtlich genügt, aufzustellen:

1.  Zwangsbehandlungen eines Einwilligungsfähigen sind generell unzulässig. Dem Einwilligungsfähigen gleichgestellt sind Betroffene, die ihren freien Willen im Rahmen einer Patientenverfügung, § 1901a BGB, vorab hinsichtlich einer künftigen Zwangsbehandlung bzw. Nichtbehandlung verbindlich festgelegt haben.
Eine vorab formulierte Patientenverfügung ist in jedem Fall bindend, wenn diese die Zwangsbehandlung und eine vorausgehende Untersuchung untersagt: Eine Patientenverfügung manifestiert den früher geäußerten freien Willen eines Patienten selbst dann, wenn dieser im Zuge einer akuten Erkrankung als nicht einwilligungsfähig gälte. Der in der Verfügung geäußerte Wille ist maßgeblich. Es handelt sich um Entscheidungen des Betroffenen über die Einwilligung oder Nichteinwilligung in bestimmte Untersuchungen des Gesundheitszustands, Heilbehandlungen oder ärztliche Eingriffe, die auf die darauffolgend konkret eingetretene Lebens- und Behandlungssituation zutreffen. Diese Entscheidung ist für Ärzte, Gerichte und auch andere Beteiligte bindend.

2. Zwangsbehandlungen müssen den angezielten “Erfolg” erreichen

3. Zwangsbehandlung ist nur als “ultima ratio” denkbar.

4. Jeder Zwangsbehandlung muss unabhängig von der Einwilligungsfähigkeit eines Patienten “der ernsthafte, mit dem nötigen Zeitaufwand und ohne Ausübung unzulässigen Drucks unternommene Versuch vorausgegangen sein, die Zustimmung des Untergebrachten zu erreichen”16.

5. Eine Zwangsbehandlung ist so rechtzeitig anzukündigen, dass der Betroffene vorher rechtzeitig vor den Gerichten Rechtsschutz suchen kann.

6. Anordnung und Überwachung der Zwangsbehandlung dürften nur durch die Ärzte erfolgen, die in der Dokumentation zur Aufklärung und zur Behandlung namentlich genannt werden. Die Zwangsbehandlung selber, aber auch das vorangegangene Gespräch, müssen widerspruchsfrei von jenen Ärzten schriftlich dokumentiert werden.

7. Die Zwangsmedikation muss vorab in jedem Schritt hinsichtlich der Behandlung, ihrer Art, ihrer Dauer und der Dosierung der Medikation konkretisiert werden. In dem Genehmigungsbeschluss muss “die von dem Betreuten zu duldende Behandlung präzise an(ge)geben” werden. Dazu gehören die Angabe des Medikaments, seine Dosierung, Verabreichungshäufigkeit und ein Ersatzmedikament, falls das genehmigte Medikament nicht vertragen wird17.

8. Die Notwendigkeit einer länger andauernden Zwangsbehandlung muss von einem einrichtungsexternen Gutachtergremium geprüft werden.

9. Wenn eine gesetzliche Regelung fehlt, kann sie nicht mehr im Wege einer verfassungskonformen Auslegung ergänzt werden18.
Kein Patient kann im Zuge einer Duldungspflicht genötigt werden, einen medizinischen Eingriff oder eine medizinische Behandlung und damit eine Maßnahme zu dulden, “die den Straftatbestand der Körperverletzung erfüllt”. Jeder Eingriff in die körperliche Unversehrtheit ist “nur mit der Einwilligung des Betroffenen zulässig”19.

Während es selbstverständlich ist, dass ein Patient auch unter den Bedingungen von freiheitsentziehenden Maßnahmen im Zuge seines Selbstbestimmungsrechtes jedwede ärztliche oder therapeutische Behandlung ablehnen darf, auch wenn gesundheitliche Gefahr droht20, soll dies bei einem psychisch kranken Menschen im Zuge einer speziellen Gesetzgebung für psychisch Kranke zumindest dann nicht gelten, wenn ein Facharzt für Psychiatrie bei dem Betroffenen von beabsichtigten Zwangsmaßnahmen “Einwilligungsunfähigkeit” konstatiert hat.

Zwangsbehandlung wurde bis 2011 auf verschiedene Rechtsgrundlagen gestützt, betreuungsrechtlich auf die §§ 1904 und 1906 a.F. BGB, öffentlich-rechtlich auf landesrechtliche Vorschriften zur Unterbring psychisch Kranker (PsychKG).

Anlässlich einer Entscheidung zum Unterbringungsgesetz des Landes Baden-Württemberg hat das Bundesverfassungsgericht 1981 auf die mögliche Gefahr einer “Vernunfthoheit des Arztes über den Patienten” und einer “umfassende staatliche Gesundheitsvormundschaft” hingewiesen. Dieser sei auf dem Rechtsweg im Zuge effektiver richterlicher Kontrolle auch im Sinne eines “Rechtes auf Krankheit” zu begegnen21. Die Richter des BVerfG zogen dabei nicht die naheliegende Konsequenz, die Legitimation von Zwangseingriffen generell in Frage zu stellen. Vielmehr wurde in dieser Entscheidung aus 1981 zwischen leichteren Formen psychischer Erkrankungen, bei denen eben dieses “Recht auf Krankheit” gelten solle, und schwereren Verlaufsformen, bei denen die “psychisch Kranken vor sich selbst in Schutz zu nehmen” seien, unterschieden. Nur für die leichteren Verlaufsformen und “Abweichungen vom Durchschnittsverhalten”22 anerkannten die Richter ein Selbstbestimmungsrecht jenseits staatlicher Fürsorge.

Seit 2011 fand in der höchstrichterlichen Rechtsprechung kontinuierlich bis heute ein tiefgreifender Wandel statt. Dass Zwangsbehandlung rechtfertigende Eingriffe besondere Grundrechtsintensität aufweisen, wurde in mehreren Leitsatzentscheidungen erstmals in dieser Deutlichkeit anerkannt. Bei Einwilligungsfähigkeit eines Patienten kommen sie generell nicht in Betracht.
Für den Maßregelvollzug wurde die Zwangsbehandlung mit Neuroleptika mangels hinreichender Rechtsgrundlage erstmals mit Beschluss des Bundesverfassungsgerichtes vom 23.3.201123 in Rheinland-Pfalz für unzulässig beschieden (vorausgegangene Eilentscheidung 2009). Die dortige bislang herangezogene Eingriffsgrundlage, § 6 Absatz 1 Satz 2 MVollzG des Bundeslandes Rheinland-Pfalz, wurde für nichtig erklärt. Es folgten weitere Nichtigkeitsentscheidungen des Bundesverfassungsgerichtes vom 12.10.2011 zu § 8 UBG BW des Bundeslandes Baden-Württemberg24 und am 10. Februar 2013 zu den landesgesetzlichen Regelungen der §§ 22, 23 SächsPsychKG25. Im November 2013 erfolgte eine weitere Entscheidung des Bundesverfassungsgerichtes zum Erfordernis einer grundrechtlich nirgends hinzunehmenden Rechtfertigung einer Zwangsbehandlung26 bezüglich einer hinreichenden Sachaufklärung, ebenso in 201527. Auch Verletzungen des Verhältnismäßigkeitsgrundsatzes waren Gegenstand der verfassungsgerichtlichen Rechtsprechung28.

Gerade wegen der Potenzierung der Rechtsgutverletzungen des § 1906 BGB (dem Patienten wird durch Unterbringung auf einer geschlossenen Station seine Freiheit vollständig entzogen; er wird zwangsweise durch massive Eingriffe in die körperliche Unversehrtheit veranlasst, Psychopharmaka mit wesensveränderndem Einfluss und starken Nebenwirkungen einzunehmen) kann es zur denkbar schwersten Eingriffsintensität beim Betroffenen kommen. Er unterliegt schutzlos nicht nur dem Freiheitsentzug, sondern kumulativ hierzu der Zwangsbehandlung. Sie geht oft einher mit Fixierungen und anderen freiheitsbeschränkenden Maßnahmen des § 1906 Abs. 4 BGB.

Eine Zwangsbehandlung eines einsichtsfähigen und einwilligungsfähigen Patienten muss nach den verfassungsrechtlichen Vorgaben zum Selbstbestimmungsrecht des Patienten aus den Entscheidungen von 2011 und 2012 generell ohne Ausnahme künftig ausscheiden.
Nur wenn ein Patient krankheitsbedingt nicht einwilligungsfähig sei, sei eine Zwangsbehandlung bei hinreichenden gesetzlichen Vorgaben denkbar. Denn nur in diesem Falle könne der Betroffene überhaupt gehindert sein, “seine grundrechtlichen Belange wahrzunehmen”. Das könne ebenfalls “zu einer Verletzung der Menschenwürde führen”.

Das Bundesverfassungsgericht hatte damit eine verfassungsrechtliche Rechtfertigung in sehr engen Grenzen zugelassen. Der BGH hat darauf verwiesen, “dass das Fehlen von Zwangsbefugnissen zur Durchsetzung notwendiger medizinischer Maßnahmen dazu führen könne, dass ein Betroffener ohne eine solche Behandlung einen erheblichen Schaden nehme”29. Ebenso hält der 12. Zivilsenat des BGH ärztliche Zwangsmaßnahmen außerhalb einer Unterbringung nach § 1906 Absatz 1 BGB für wünschenswert30. Dies obgleich der BGH noch 2000 in einer anstaltsexternen Zwangsbehandlung eine andere, aber ebenso schwerwiegende Eingriffsqualität im Sinne einer “Belastung für den Betroffenen” gesehen hatte, weil der Betroffene sich nur mit Zwang, unter Einschaltung der Polizei oder durch entsprechende Drohung, in das Psychiatrische Krankenhaus zu einer Zwangsbehandlung verbracht sähe, auch “wenn er die Behandlung dort ohne Gegenwehr über sich ergehen lasse”. Zudem erkennt der BGH in seiner Entscheidung aus 2000, dass die “Art der Vorführung nach außen hin diskriminierende Wirkung” hat.31
Die verfassungsgerichtlich aufgezeigte Option, dass es dem Gesetzgeber nach wie vor frei steht, Zwangsbehandlung “durch Schweigen zu verbieten”32 wird bislang nicht bzw. noch nicht vom BGH als tatsächliche Alternative zur derzeitigen Situation der gesetzlich normierten Zwangsbehandlung gesehen.

Die Forderungen nach einem “Schweigen” des Gesetzgebers zu jeglicher Form der Zwangsbehandlung mit Neuroleptika im psychiatrischen Bereich wurde indes schon durch den am 1. Februar 2013 veröffentlichten Bericht über den Missbrauch von Gesundheitseinrichtungen erhoben. Der UN-Sonderberichterstatter über Folter und andere grausame, unmenschliche oder erniedrigende Behandlung oder Strafe, Juan E. Méndez, sprach sich für ein absolutes Verbot von jeglichen Zwangsmaßnahmen aus und empfiehlt den Staaten dem damals schon beschlossenen Gesetz gegenläufige gesetzliche Änderungen33. “Die Darstellung des Sonderberichterstatters” sei, so das Institut für Menschenrechte, “wegen der strengen menschenrechtlichen Anforderungen an die psychiatrische Versorgung in Einrichtungen für die aktuelle Diskussion in Deutschland zu Psychiatrie und Maßregelvollzug von großer Bedeutung und hoher Aktualität.” Seine Position unterstreiche “das Erfordernis, die psychiatrische Versorgung in Deutschland konsequent am Ziel der Freiwilligkeit auszurichten und eine darauf verpflichtete Psychiatriereform voranzutreiben.”34

Auch der UN-Fachausschuss für die Behindertenrechtskonvention (BRK) hat im September 2015 seine Richtlinien zur Interpretation und dem Umgang mit dem Artikel 14 der BRK, Freiheit und Sicherheit der Person, dahingehend verabschiedet, dass explizit die Möglichkeiten untersagt werden, die das Grundgesetz zur Aufhebung der Grundrechte durch ein Gesetz offen gelassen hat, wenn diese gesetzlichen Sonderregelungen eine “Behinderung” zum Kriterium haben35. Hierzu zählt auch die Zwangsbehandlung psychisch Kranker36. Eine solche Behandlung gegen den Willen wäre bei einem gesunden Menschen ausgeschlossen.

Das Deutsche Institut für Menschenrechte hatte sich schon 2013 in mehreren Stellungnahmen u.a. für den Deutschen Bundestag für eine “gewaltfreie Psychiatrie” ausgesprochen und ausgeführt, “Es bestehen nach wie vor große Zweifel, ob der Entwurf im Einklang mit der UN-Behindertenrechtskonvention steht”37. Menschenrechtlich und ethisch sei es “fragwürdig, ob eine psychiatrische Behandlung ohne freie Zustimmung der betroffenen Person vorgenommen werden dürfe”. Vor dem Hintergrund der aktuellen menschenrechtlichen Diskussion und der Entwicklung des internationalen Rechts gebe es “schwerwiegende Bedenken gegen eine solche Regelung”38. Schon mit Verabschiedung der Gesetzesvorlage zur Zwangsbehandlung im Rahmen des § 1906 BGB habe Deutschland “eine historische Chance verpasst, aus den Erfahrungen einer Psychiatrie ohne Zwang zu lernen und das System der psychiatrischen Versorgung weiterzuentwickeln.” Es werde mit einem falschen und unverhältnismäßigen Ansatz über eine gesetzliche Neuregelung der Zwangsbehandlung nachgedacht, ohne eine unabdingbare, umfassende Überprüfung der Psychiatrie und strukturelle Verbesserungen der psychiatrischen Versorgung auf der Basis der Menschenrechte erfolgen zu lassen39.

Eine wesentliche Kritik des Bundesverfassungsgerichtes40 an einer Zwangsbehandlung mit Psychopharmaka besteht darin, dass in Deutschland, nachdem von der Deutschen Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN) in den neunziger Jahren initiierte Versuche zur Etablierung medizinischer “Standards” für Zwangsbehandlungen zu keinem Ergebnis geführt haben41, “nach wie vor keine medizinischen Standards für psychiatrische Zwangsbehandlungen existieren. Aus denen müsste mit der notwendigen Deutlichkeit hervorgehen, dass Zwangsbehandlungen mit dem Ziel, den Untergebrachten entlassungsfähig zu machen, ausschließlich im Fall krankheitsbedingter Einsichtsunfähigkeit zulässig sind”42. Eine entsprechende Einsichtsfähigkeit sei verbindlich zu definieren.

Distincte et clare gilt:

Ebenso praktikable wie eindeutige Standards sind nicht denkbar.

Bis heute gibt es keine verbindlichen Standards zur Beantwortung, auf welcher Grundlage Psychiater zur Einschätzung gelangen wollen, dass bei einem Patienten Einwilligungsunfähigkeit gegeben sei. Es gibt keine Standards für die Behandlung zur Wiederherstellung einer solchen Einwilligungsfähigkeit. Diese Wiederherstellung der Einwilligungsfähigkeit muss nach gesetzgeberischem Willen im Zuge der Gesetzesinitiativen erklärtermaßen das Ziel einer Zwangsbehandlung sein.

Psychiatrische Diagnosen wie die Feststellung einer psychiatrischen Erkrankung als Anlass einer Zwangsbehandlung unterliegen dem zeitlichen, ethischen und auch kulturellen Wandel. Der neu erschienene Diagnosekatalog DSM-5, der auch Grundlage für den neuen ICD-11 als Standardverzeichnis psychischer Erkrankungen werden wird, legt die Grenzen einer psychischen Erkrankung und einer zugrundeliegenden Diagnose derart weit auseinander, dass “viele Gesunde über Nacht zu psychisch Kranken”43 gemacht werden. Erwartet wird ein signifikanter Zuwachs vermeintlicher, oder auch erfundener psychiatrischer Krankheiten bei Kindern und bei Erwachsenen, die nicht zuletzt auch die Grundlage von Zwangsbehandlungen und Zwangsmedikationen sein können. Der Psychiater Allen Frances spricht in seinem Buch “NORMAL” von einer regelrechten “Inflation psychiatrischer Diagnosen” durch das neue Manual “DSM-V”.
Künftig wird die Grenze, die bisher mit jeder neuen Ausgabe bzw. Neuauflage des DSM zu Lasten des Bereichs des Normalen verschoben wurde, noch weiter gezogen werden (Eine banale Schüchternheit wird zu einer psychiatrisch behandlungspflichtigen “sozialen Phobie”, “kindliches Trotzen” wird zur psychiatrisch-behandlungspflichtigen “Wutkrankheit” und selbst starke prämenstruelle Beschwerden gelten künftig ebenso als psychische Krankheit, wie das “Binge-Eating”, also Essattacken)44. Einer Studie zufolge erfüllten schon mehr als achtzig Prozent (!) der jungen Erwachsenen die Kriterien für eine psychische Störung45.

Sich hieraus ergebende Gefahren für den vom Bundesverfassungsgericht geforderten Grundrechtschutz46 sind evident. Alleine die Diagnose einer psychischen Krankheit soll bei Annahme einer vorübergehenden Einwilligungsunfähigkeit Grundlage einer Zwangsbehandlung sein. Gerade aber der bislang bei allen Gesetzesinitiativen unbeantworteten vom Bundesverfassungsgericht47 gesehenen Frage, wie der Problematik der Ermangelung jedweder medizinischer Standards für Zwangsbehandlungen und das Kriterium der Einwilligungsunfähigkeit einer Lösung zugeführt wird, kommt bei sämtlichen geplanten Novellierungen zur Zwangsbehandlung signifikante Bedeutung zu. Bezeichnenderweise hat auch der Direktor des National Institut für Mental Health (NIHM), Thomas Insel, am 29.4.2013 in einer NIMH-Veröffentlichung ausgeführt, dass sämtliche psychiatrische Diagnosen bisher keine hinreichende Validität hatten. Er spricht von einem “lack of validity”48.

In Kumulation mit dem Umstand, dass es im Zuge einer Zwangsbehandlung keine freie Arztwahl, geschweige denn eine Option zur Auswahl der Therapie gäbe, sowie kein Recht, bei Zweifeln an der vorgeschlagenen Therapie einen anderen Arzt aufzusuchen, um sich eine zweite Meinung einzuholen49, das seitens vieler gesetzlichen Krankenkassen für ihre Versicherten eingeräumt wird, dürfte elementarer Grundrechtschutz vor dem Hintergrund immer weiter ausufernder, invalider, psychiatrischer Diagnosestellungen auf dem Spiel stehen.

Die Umfrage

In einer Totalerhebung wurden 676 Amtsgerichte in ganz Deutschland per Fax angeschrieben. Vor dem Hintergrund der Reform wurden sie gebeten, Fragen in 4 Komplexen zu beantworten50. Es gingen 181 Antworten ein, von 5 Gerichten mehrere Antworten verschiedener Richter, also 176 antwortende Amtsgerichte. Das sind rund 26 %.
Zu berücksichtigen ist dabei, dass die Justizministerien der Länder Bayern, Nordrhein-Westfalen und Schleswig-Holstein eine Erinnerung an die Umfrage für unerwünscht erklärten, hingegen die Justizministerien der Länder Baden-Württemberg und Niedersachsen die Umfrage unterstützten. Dies schränkte den weiteren Rücklauf von Gerichten aus den drei Bundesländern, die daraufhin nicht mehr erinnert wurden, deutlich ein. Aus den anderen Ländern erreichte uns ca. 50% des Rücklaufs erst nach Erinnerung.

Die Fragen und Antworthäufigkeiten für die Komplexe A bis D lauteten wie folgt:

Komplex A)

A1. Werden an Ihrem Betreuungsgericht psychiatrische Zwangsbehandlungen richterlich genehmigt?

▢ Ja
▢ Seitens unseres AGs wird auf diese Maßnahmen verzichtet

Vom gesamten Rücklauf waren:

Zwangsbehandlung genehmigende Antworten
128
abzüglich 5 mehrfache Antworten derselben Gerichte, also 123 70 %
auf Zwang verzichtend 14 ——–8 %
keine Anträge eingegangen  11 6 %
gar keine Antwort gegeben bzw. verweigert 28  16 %

Das AG Stolzenau autorisierte, dass dessen Verzicht auf Zwangsbehandlung öffentlich benannt wird.

Komplex B)

B1. Haben die Entscheidungen des BGH und des Bundesverfassungsgerichtes zur Unzulässigkeit der Zwangsbehandlung und die darauf folgende Reform des § 1906 BGB Einfluss auf die Anzahl der betreuungsgerichtlichen Unterbringungen?

▢ Nein
▢ Ja

Wenn ja, welchen?

B2. Bitte nennen Sie uns die Anzahl der Verfahren, bei denen es in Ihrem Gericht seit dem 1.3.2013 zu Genehmigungen einer Zwangsbehandlung gekommen ist.

Bezug wird in allen folgenden % Angaben nur auf die 176 – 28 = 148 Gerichte genommen, die Antworten gegeben bzw. nicht verweigert haben:

Kein Einfluss auf die Anzahl der Unterbringungen   103 70%
Ja, hatte Einfluss auf die Anzahl der Unterbringungen      38 25%
Keine Antwort     7 ——-5 %
Angaben zwischen 0 und 167 Genehmigungen machten 120 Gerichte
(-2 mehrfache Antworten derselben Gerichte)   118  80%

Komplex C)

C1. Haben Sie in entsprechenden Beschlüssen

▢ genaue Angabe über das Arzneimittel oder den Wirkstoff,
▢ dessen (Höchst-) Dosierung,
▢ die Verabreichungshäufigkeit gemacht?
▢ die Ernsthaftigkeit eines Überzeugungsversuchs nachprüfbar ermittelt?
▢ nachprüfbar ermittelt, dass keine unzulässige Druckausübung beim Überzeugungsversuch ausgeübt wurde?

genaue Angabe über das Arzneimittel oder den Wirkstoff 110
(-3 mehrfache Antworten derselben Gerichte)
107  72 %
dessen (Höchst-) Dosierung 100
(-3 mehrfache Antworten derselben Gerichte)
97 65,5 %
die Verabreichungshäufigkeit 96
(-2 mehrfache Antworten derselben Gerichte)
94 63,5,%
die Ernsthaftigkeit eines Überzeugungsversuchs nachprüfbar
ermittelt 104 (-3)
101 ——-68 %
nachprüfbar ermittelt, dass keine unzulässige Druckausübung
beim Überzeugungsversuch ausgeübt wurde
47  32 %
alle 5 gefragten Kriterien entsprechend den höchstrichterlichen
Beschlüssen erfüllt  35 23,5 %

Auffällig: Bei den vier Gerichten mit mehrfachen Antworten, sind die Antworten der Richter uneinheitlich.

Komplex D)

•Wie beeinflusst eine Patientenverfügung, in der psychiatrische Diagnostik und Behandlung mit Neuroleptika ausgeschlossen wird, den Ausgang eines Verfahrens auf Genehmigung einer Zwangsbehandlung?
•Haben Sie nachprüfbare konkrete Anhaltspunkte ermittelt, um den mutmaßlichen Willen zu bestimmen, zwangsbehandelt werden zu wollen, wenn bei einem einwilligungsunfähigen psychisch Kranken keine Patientenverfügung vorhanden war?
▢ Nein
▢ Ja
Wenn ja welche?

Wie beeinflusst eine Patientenverfügung den Ausgang eines
Verfahrens auf Genehmigung einer Zwangsbehandlung?
Antworten unterschiedlich (-5)
119 80%
Werden nachprüfbare konkrete Anhaltspunkte ermittelt, um
den mutmaßlichen Willen zu bestimmen, zwangsbehandelt
werden zu wollen? Nein (-2)
69  ——-47%
Ja (-2)       49  33%

Die Umfragebögen und die Antworten der Gerichte sind im Internet abrufbar: http://userpage.fu-berlin.de/narrwd/legende.htm

Die Rechtsprechung reagiert im Ergebnis dieser Befragung verhalten auf die Novellierungen des Gesetzgebers zur Zwangsbehandlung. Die Anzahl der Unterbringungsverfahren sei rückläufig, so die Tendenz mancher Betreuungsgerichte in Hinblick auf die Rechtsprechung des Bundesverfassungsgerichtes.

Die strengen Voraussetzungen, die überhaupt noch zur Unterbringung führen dürfen, sehen die Gerichte allerdings teilweise als wenig praktikabel an. Die jeweiligen Entscheidungen der Betreuungsgerichte werden dem Charakter einer Zwangsbehandlung als “ultima Ratio” nicht gerecht. Besonders zeigt sich dies daran, dass nur 23,5 % der Zwangsbehandlung genehmigenden Gerichte alle 5 gefragten Kriterien entsprechenden den höchstrichterlichen Beschlüssen erfüllten.
Die Anwendung der einschränkenden Bedingungen für “ultima Ratio” führen dazu, dass die Freiheitsgrundrechte eines Betroffenen immer wieder unzureichend beachtet werden, so dass die Thematik noch häufig vor dem Bundesverfassungsgericht mündet.
Erst jüngst hat das Bundesverfassungsgericht in zwei aktuellen Entscheidungen51 nochmals moniert, dass die Gerichte trotz eindeutiger Vorgaben des Gesetzgebers “bei der Auslegung und Anwendung des einfachen Rechts die Bedeutung und Tragweite des Freiheitsgrundrechts verkannt” hätten.
Es hat die Fachgerichte nochmals angemahnt, die Eingriffsqualität einer Zwangsbehandlung zu beachten. Inhalt und Tragweite der Freiheitsgrundrechte sei durch hinreichende Sachverhaltsprüfung Rechnung zu tragen. Die medizinische Behandlung gegen den natürlichen Willen bzw. Zwangsbehandlung einer Betroffenen könne und dürfe entgegen der früher geübten Praxis wegen des intensiven Eingriffs in die körperliche Integrität der Betroffenen als Grundrechtsträgerin nicht erfolgen, wenn nicht alle strengen Voraussetzungen hierfür erfüllt seien.

Die befragten Gerichte haben sich in der weit überwiegenden Anzahl für den Vorrang einer Patientenverfügung und für die Beachtung der Vorsorgevollmacht ausgesprochen und diese als Hindernis der Überwindung eines entgegenstehenden Willens bei der Zwangsbehandlung anerkannt. Bedenklich ist gleichwohl, dass rd. 20% der Gerichte nach wie vor Schwierigkeiten haben, die eindeutigen Prämissen des Gesetzgebers umzusetzen, um generell gegen eine Zwangsbehandlung zu entscheiden, wenn eine Patientenverfügung vorliegt, die Zwangsbehandlung untersagt. Hier sind die Betreuungsgerichte künftig gehalten, neue auf dem individuellen Willen basierende Lebensmodelle jenseits des psychiatrischen Zwangs zuzulassen, denn auch die Mitgliedschaft “in einem sich gegen den Einsatz von Psychopharmaka engagierenden Verein” muss einem Betreuungsgericht Anlass sein, zu ermitteln, ob sich der Betroffene nicht schon “im Zustand freier Willensbildung zur Absetzung der Neuroleptika entschieden hat” und ein beachtlicher, der Zwangsbehandlung entgegenstehender, Wille kundgetan wurde52.

Die Last der Prüfungsdichte, die die Betreuungsgerichte als kaum praktikabel beklagen, wiegt in Hinblick auf diese aktuellen Entscheidungen des Verfassungsgerichtes noch schwerer. Auch bei psychiatrischer Behandlung wird es den selbstbestimmten Patienten geben. Die bisherige Praxis der Behandlung eines Betroffenen gegen seinen Willen mit Neuroleptika wird zum Auslaufmodell.

Ausblick

Auch wenn in der Umfrage keine Fragen gestellt wurden, die auf die seit dem 1.1.2009 zum einfachen Gesetz gewordene BRK eingehen, ist auch für die Gerichte der seit dem 17.5.2015 vorliegende Staatenbericht des zuständigen UN-Fachausschusses über Deutschland bedeutsam. In ihm wird im Hinblick auf die Psychiatrie scharfe Kritik geübt, siehe insbesondere Artikel 11., 12., 25., 26., 29., 30., 33., 34. 38. Z.B. wird Zwangsbehandlung als Folter bezeichnet53.

Die Regelung zur Zwangsbehandlung zielt nach den Feststellungen des Deutschen Institutes für Menschenrechte darauf ab, sich über das Kriterium der Einwilligungsunfähigkeit “über den natürlichen Willen der betroffenen Person hinwegsetzen zu können und an die Stelle der persönlichen Entscheidung die Entscheidung Dritter zu setzen – eine so genannte, durch die BRK untersagte, ersetzende Entscheidungsfindung (“substituted decision-making”).”

Ergänzend wird dort ausgeführt: “Im Lichte der aktuellen menschenrechtlichen Diskussion, wie sie auch in Studien des UN-Hochkommissariats für Menschenrechte (UN Doc. A/HRC/10/48 vom 26. Januar 2009) und in der Auslegungspraxis des UN-Fachausschusses für die Rechte von Menschen mit Behinderungen im Zusammenhang der gesundheitlichen Versorgung von Menschen mit Behinderungen Ausdruck findet, ist der Ansatz, wonach eine psychiatrische Behandlung ohne freie und informierte Zustimmung der betroffenen Person, allein legitimiert über die Entscheidung Dritter vorgenommen werden soll, menschenrechtlich in Frage gestellt.”54

Die gesetzlichen Regelungen des § 1906 BGB haben eine “Behinderung” zum Kriterium, die gemessen an den Grundsätzen des Artikel 14 der Behindertenrechtskonvention, Freiheit und Sicherheit der Person, als Sondergesetzgebung gegen geltendes Konventionsrecht verstoßen. So der UN-Fachausschuss für die BRK und dessen in der 14. Sitzung aufgestellten Richtlinien zur Interpretation und dem Umgang mit dem Artikel 14 BRK55.

Das Bundesverfassungsgericht hatte zur Frage der Einwilligungsfähigkeit schon 2011 ausgeführt:

“In Deutschland existieren, nachdem von der Deutschen Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN) in den neunziger Jahren initiierte Versuche zur Etablierung medizinischer Standards für Zwangsbehandlungen nicht zu einem Ergebnis geführt haben (vgl. Steinert, in: Ketelsen/Schulz/Zechert, Seelische Krise und Aggressivität, 2004, S. 44 <47>), keine medizinischen Standards für psychiatrische Zwangsbehandlungen, aus denen mit der notwendigen Deutlichkeit hervorginge, dass Zwangsbehandlungen mit dem Ziel, den Untergebrachten entlassungsfähig zu machen, ausschließlich im Fall krankheitsbedingter Einsichtsunfähigkeit zulässig sind. Dass dementsprechend ein Bewusstsein hierfür in den medizinischen und juristischen Fachkreisen noch nicht allgemein verbreitet und eine gesetzliche Regelung, wie im Beschluss des Senats vom 23. März 2011 festgestellt, unverzichtbar ist, illustriert nicht zuletzt der vorliegende Fall, in dem weder die Klinik noch die Fachgerichte sich mit der Frage, ob beim Beschwerdeführer eine krankheitsbedingte Unfähigkeit zur Einsicht in die Notwendigkeit der Behandlung bestehe, auch nur ansatzweise auseinandergesetzt haben. Die bloße Feststellung einer Persönlichkeitsstörung beantwortet diese Frage nicht.”56
Der Begriff der Einwilligungsunfähigkeit ist schon deshalb problematisch, weil der Begriff in Ermangelung von Standards, als unbestimmter und damit ausfüllbarer und sich wandelnden subjektiven Definitionen zugänglicher Rechtsbegriff gelten muss. Als solcher wird er wegen der Eingriffsintensität den Anforderungen des Bundesverfassungsgerichtes ebenso wenig genügen, wie in den Vorentscheidungen der Begriff der “Regeln der ärztlichen Kunst”57.

In einer Entscheidung vom Februar 2013 hat das Bundesverfassungsgericht zu § 22 SächsPsychKG in einem weiteren Nichtigkeitsbeschluss zu entsprechenden Regelungswerken der Länder ausgeführt:

“… dass § 22 Abs. 1 Satz 1 SächsPsychKG auf die Regeln der ärztlichen Kunst verweist, ändert daran nichts. Unabhängig von der Frage, ob dieser Verweis überhaupt hinreichend deutlich eine umfassende Bindung an die Regeln der ärztlichen Kunst statuiert, liegt in einer solchen Bindung keine hinreichend deutliche gesetzliche Begrenzung der Möglichkeit der Zwangsbehandlung auf Fälle der fehlenden Einsichtsfähigkeit.”58
Ohne die Schaffung von Grundvoraussetzungen und Standards besteht jedenfalls die konkrete Gefahr einer Subjektivierung des Begriffes der Einwilligungsunfähigkeit je nach Gutdünken des jeweiligen Arztes oder Gutachters.

Eine Kritik, der sich auch die DGPPN nicht verschließen kann, wenn und soweit kritisch ausgeführt wird: “Als wenig praxisgerecht erscheint dagegen die Forderung, dass unbeteiligte Sachverständige, die nicht in die Behandlung einbezogen und nicht in der behandelnden Klinik tätig sind, in dem rechtlichen Verfahren gutachterlich tätig werden sollen. (….) Erschwerend kommt der Mangel an kompetenten, externen Gutachtern dazu59.”

Damit wird von höchster fachpsychiatrischer Ebene die Gutachterkompetenz bei der Einschätzung einer Einwilligungsunfähigkeit, die immerhin über das “ob und wie” eines erheblichen Grundrechtseingriffes entscheidet, in Frage gestellt und eingeräumt, dass je nach subjektiver Gedankenwelt und Vorstel-lungen des Sachverständigen Ergebnisse bei gleichem Probanden variieren und letztlich ein schlichtes Bauchgefühl über Freiheit oder Unterbringung und Zwangsmedikation entscheidet. Bei einem psychologischen Sachverstän-digengutachten muss es sich hingegen um eine wissenschaftliche Leistung handeln.

Die Einschätzung einer Nichteinsichtsfähigkeit in eine Behandlung ist fachlich hochgradig instabil bzw. subjektiv, weil bislang keine handhabbaren Kriterien existieren, zwischen Einsichtsfähigkeit und Nichteinsichtsfähigkeit zu unterscheiden. Hierauf einen Eingriff in Grundrechte zu stützen, ist verfassungsrechtlich jedenfalls unhaltbar.

Regelung zur Patientenverfügung – Fehlende Regelungen zur Vorsorgevollmacht

Die Regelungen zur Patientenverfügung des Gesetzesvorhabens trägt dem Selbstbestimmungsrecht Rechnung. Diesem Willen wird aber nach wie vor nicht von allen Betreuungsgerichten für eine Untersuchung wie auch für eine Behandlung Rechnung getragen. Jeder Mensch hat das Recht, sich in freier Entscheidung gegen eine Unterbringung zu seinem eigenen Schutz zu entscheiden und stattdessen mit den Risiken seiner Krankheit in Freiheit leben zu wollen. Diese Entscheidung kann auch in einer Patientenverfügung für den Fall eines späteren Verlusts der Einsichtsfähigkeit niedergelegt werden60.

Die Regelungen erfolgen in Beachtung des aus § 1901a Abs. 1 Satz 1 BGB resultierenden Selbstbestimmungsrechtes eines Patienten bei Errichtung einer Patientenverfügung. Das Recht auf Selbstbestimmung und die personale Würde des Patienten (Art. 2 Abs. 2 S. 2 GG) gebieten es, jedem Patienten gegenüber einem Arzt und Krankenhaus grundsätzlich Anspruch auf Ablehnung von Diagnosestellungen und ärztlichen Behandlungen einzuräumen. Der Vorrang wird unbedingt gewährt. Es entspricht den Vorgaben des Verfassungsgerichtes zu einem generellen Zwangsbehandlungsverbot bei Einwilligungsfähigkeit bzw. antizipierter Willensbekundung im Zustand der Einwilligungsfähigkeit.

Zusammenfassung

Inzwischen hat sich in der Rechtsprechung durchgesetzt, dass die Entscheidungen des Bundesverfassungsgerichtes vom 23.03.2011 (NJW 2011, 2113ff.) sowie vom 12.10.2011 (NJW 2011, 3571ff) für alle gesetzlichen Regelungen über Zwangsbehandlungen Bedeutung haben und Zwangsbehandlungsgesetze generell den vom Bundesverfassungsgericht aufgestellten Anforderungen genügen müssten61.

Die Entscheidungen des Bundesverfassungsgerichtes sind auch in der Rechtsprechung und weiten Teilen der Literatur allgemein als verbindlich für alle Regelwerke betreffend Zwangsmaßnahmen bei der Gabe von Neuroleptika angenommen worden.

Die Monitoring-Stelle zur UN-Behindertenrechtskonvention, die in Berlin am Deutschen Institut für Menschenrechte angesiedelt ist, sieht die Wiedereinführung von Regelungen zur Zwangsbehandlung als nicht zulässig.

In einer Stellungnahme der Monitoring-Stelle zur öffentlichen Sitzung des Rechtsausschusses des Bundestages vom Dezember 2012 wird hervorgehoben, dass das Konzept der “krankheitsbedingten Nichteinsichtsfähigkeit” im Wortlaut der UN-Behindertenrechtskonventionen selbst keinen Halt finde.
Weder der Wortlaut des Artikels 12 UN-BRK über die gleiche rechtliche Handlungsfähigkeit noch die Auslegungspraxis des UN-BRK-Ausschusses ließen derzeit den Schluss zu, dass die rechtliche Handlungsfähigkeit auf Grund einer Behinderung eingeschränkt werden dürfe. Im Rahmen der internationalen Verhandlungen zur Schaffung der UN-BRK habe man sich bewusst dagegen entschieden, ein entsprechendes Kriterium zur Einschränkung beziehungsweise zur Bestimmung der Einschränkbarkeit aufzunehmen.

Die UN-BRK gehe davon aus, dass alle Menschen mit Behinderungen “Rechts- und Handlungsfähigkeit” genießen (Artikel 12 Absatz 2 UN-BRK). In Verbindung mit dem Recht auf Gesundheit (Artikel 25 UN-BRK) bedeutet dies das Recht, in Fragen individueller gesundheitlicher Angelegenheiten in allen Fällen eine “freie und informierte Entscheidung” über die eigenen gesundheitlichen Belange treffen zu dürfen, insbesondere darüber, ob und wenn ja, welche Therapie angewendet wird.
Die im deutschen Verfassungsrecht anerkannte Figur der “Freiheit zur Krankheit” sei genau in diesem Kontext zu verorten. Die menschenrechtlichen Regelungen gehen darüber hinaus.
In Anbetracht der Interpretation des UN-BRK-Ausschusses sind die Anwendung von Zwang im Zusammenhang mit der Behandlung von Menschen mit Behinderungen nicht legitim.

Die zwangsweise Unterbringung und zwangsweise Behandlung von Menschen mit Behinderungen stelle eine Reihe von menschenrechtlich verbrieften Rechtsgewährleistungen in Frage.
Insbesondere wenn Menschen auf Grund ihrer Behinderung oder in der Kombination mit einem behinderungsrelevanten Merkmal eine stärkere Einschränkung ihrer Rechte zugemutet werde als Nichtbehinderten, lasse dies eine Ungleichbehandlung erkennen, die nach Maßgabe des Diskriminierungsverbots (Artikel 5 UN-BRK) nicht zu rechtfertigen sei.

Darüber hinaus sei die Einschätzung einer Nichtzustimmungsfähigkeit in eine Behandlung fachlich hochgradig instabil, weil handhabbare Kriterien bislang nicht zu finden sind, zwischen Einsichtsfähigkeit und Nichteinsichtsfähigkeit zu unterscheiden.
Nach Artikel 12 UN-BRK bestehe aber die Verpflichtung, die Unterstützung (“support”) für Menschen mit Behinderungen so zu gewährleisten, dass sie autonom entscheiden – die unterstützende Entscheidungsfindung (“supported decision-making”). Diese anspruchsvolle Form der Unterstützung im Sinne von Assistenz dürfe weder über die gesetzliche Vertretung, noch durch eine zwangsweise durchgesetzte Entscheidung, die Dritte für eine betroffene Person getroffen haben, ersetzt werden62.

Der Sonderberichterstatter über Folter des UN-Hochkommissariats für Menschenrechte, Juan E Méndez, erklärte in der 22. Sitzung des “Human Rights Council” am 4. März 2013 Zwangsbehandlung in der Psychiatrie zu Folter bzw. zu grausamer, unmenschlicher oder erniedrigender Behandlung. Er forderte, dass alle Staaten ein Verbot aller nicht einvernehmlichen medizinischen bzw. Zwangsbehandlungen verhängen sollten, einschließlich nicht-einvernehmlicher Psychochirurgie, Elektroschocks und Verabreichung bewusstseinsverändernder Drogen, sowohl in lang- wie kurzfristiger Anwendung. Die Verpflichtung, erzwungene psychiatrische Behandlung zu beenden, sei sofort zu verwirklichen und auch knappe finanzielle Ressourcen können keinen Aufschub der Umsetzung rechtfertigen63.

Auch der frühere Bundesrichter Wolfgang Neškovic kritisierte das Zwangsbehandlungsgesetz. Die Kriterien seien “bevormundend und paternalistisch”. Sie “ignorierten das Selbstbestimmungsrecht”, sie “entwürdigten den Patienten zum Objekt”. Genau das habe das Patientenverfügungsgesetz verhindern wollen. Das sollte nicht nur für Komapatienten und Demenzkranke, sondern für die gesamte Gruppe der “Einsichtsunfähigen” gelten. Wenn der Patient seinen Willen aktuell aber nicht klar äußern könne, müsse “auf dessen ausdrückliche Verfügung oder seinen mutmaßlichen Willen anhand konkreter Anhaltspunkte zurückgegriffen” werden64.

Die Kritik an Zwangsbehandlung stützt sich auf Verfassungsrecht. Es muss auch für den Einwilligungsunfähigen gelten. Das Bundesverfassungsgericht habe Art. 2 Abs. 2 Satz 1 GG menschenrechtlich zutreffend als Aktivrecht jeder Person ausgelegt: “Jeder hat das Recht auf Leben und körperliche Unversehrtheit.” Art. 2 Abs. 2 Satz 2 GG laute konsequent: “Die Freiheit der Person ist unverletzlich.” Das bedeute, jeder erfahre sich als Person, indem er über sich, das eigene Leben und die eigene Unversehrtheit zu allererst ihres/seines Körpers selbst entscheidet. Darum habe das Verfassungsgericht zutreffend formuliert, es sei unzulässig, stellvertretend, und sei es als Psychiater aus gesundheitlichen oder anderen Gründen der Rehabilitation, eine Person zwangsweise zu behandeln. Die Selbstbestimmung des Menschen schließe alle kranken oder gesunden Befindlichkeiten ein.

Indem das Bundesverfassungsgericht über die historisch herkömmliche Begrenzung des Kerns der Menschenrechte als Abwehrrechte hinausgehe, folge es der BRK der Vereinten Nationen von 2006. Sie sei auf Vorschlag der Bundesregierung im Dezember 2008 vom Deutschen Bundestag als Gesetz übernommen worden. Die Behindertenrechtskonvention gehe folgerichtig im Sinne der Wirklichkeit des Menschen und seiner sozialen Bedingungen darüber hinaus. Sie verlange, die sozialen, technischen und wissenschaftlichen Bedingungen zu schaffen um Behinderungen zu überwinden. Die Behinderten würden ansonsten um ihre Grund- und Menschenrechte gebracht, obwohl sie nominell gelten65. Die “Freiheit zur Krankheit”, als Ausfluss des allgemeinen Persönlichkeitsrechts und der allgemeinen Handlungsfreiheit werde durch die Entscheidungen der Gerichte bekräftigt.

Der Staat müsse es von jeher hinnehmen, schreibt Rinke 1988 in der Neuen Zeitschrift für Strafrecht, wenn der Bürger fürsorgerische Leistungen eigenverantwortlich ablehne66.

Zwei Jahre nach in Kraft treten des BGB-Gesetzes zur Zwangsbehandlung kann nur dessen Scheitern festgestellt werden: es hat das Ziel einer “Ultima Ratio” Regelung verfehlt, stattdessen Rechtsunsicherheit geschaffen. Der Versuch körperlich Kranke und psychisch Kranken ungleich zu behandeln und letztere rechtlich mit einem Sondergesetz zu diskriminieren, wenn sie einwilligungsunfähig diagnostiziert werden sollten, ist ein Verstoß gegen den Gleichbehandlungsgrundsatz von Art. 3 GG und gegen den Kern der BRK. Es darf kein staatliches Monopol gesundheitlicher Bevormundung mit Zwang geben. Freie Willensentscheidung mit körperverletzendem Zwang erreichen zu wollen, ist in sich paradox.

Entweder Grundrechte oder Behandlung um jeden Preis.

——————————————————————————–

1.BVerfG FamRZ 2011, 1128 und FamRZ 2011, 1927
2.BGH FamRZ 2015, 567 Rn. 12; FamRZ 2013, 1646 Rn. 12; FamRZ 2008, 866 Rn. 19 und FamRZ 2001, 149 f (BGH, Vorlagebeschluss vom 01. Juli 2015 – XII ZB 89/15 -, Rn. 17, juris)
3.ablehnend schon BVerfGE 58, 208 (226)
4.BVerfG FamRZ 2011, 1128 und FamRZ 2011, 1927
5.BGH, Beschlüsse vom 20. Juni 2012 – XII ZB 130/12 und XII ZB 99/12
6.BTDrucks 17/11513 und 17/12086
7.BVerfG, Beschluss vom 14. Juli 2015 – 2 BvR 1549/14, 2 BvR 1550/14 -, Rn. 27, juris
8.BGH XII ZB 99/12 und BGH XII ZB 130/12 Beschlüsse vom 20.06.2012
9.Inzwischen novelliert durch das am 26.02.2013 in Kraft getretene “Gesetz zur Regelung der betreuungsrechtlichen Einwilligung in eine ärztliche Zwangsmaßnahme” vom 18.02.2013, Bundesgesetzbl. 2013 Teil I Nr. 9
10.BGBl. I S. 266
11.BVerfG, BVerfGE 128, 282-322 S. 317 (Beschluss vom 23. März 2011 – 2 BvR 882/09)
12.BVerfGE 116, 69 S. 80
13.BVerfG, 2 BvR 228/12 Beschluss vom 20.2.2013
14.BVerfGE 128, 282 S. 318 ff. (Beschluss vom 23. März 2011 – 2 BvR 882/09)
15.BVerfGE a.a.O. (Beschluss vom 23. März 2011 – 2 BvR 882/09)
16.BverfGE a.a.O.
17.BGH, Beschl. v. 01.02.2006 – XII ZB 236/05 – Heitmann, jurisPR-FamR 9/2006 Anm. 1
18.Heitmann, Zwangsbehandlung und Verfassungsrecht jurisPR-FamR 13/2012, S. 18
19.OLG Zweibrücken, 1 Ws 90/11 Beschluss vom 01.08.2011 (juris)
20.BVerfG 2 BvR 1194/80 Beschluss vom 7. Oktober 1981 (BVerfG 58, 208 ff.)
21.BVerfG 2 BvR 1194/80; BVerfG 58, 208 (S. 227)
22.BVerfG a.a.O. S. 224 f.
23.BVerfG 2 BvR 882/09
24.BVerfG 2 BvR 633/11
25.BVerfG 2 BvR 228/12; zuvor schon BVerfG 2 BvR 2362/11 Beschluss vom 15.12.2011
26.BVerfG, Beschluss vom 28. November 2013 – 2 BvR 2784/12 -, juris Regelung
27.BVerfG, Beschluss vom 14. Juli 2015 – 2 BvR 1549/14, 2 BvR 1550/14
28.BVerfG, Nichtannahmebeschluss vom 07. Juli 2015 – 2 BvR 1180/15 -, juris
29.BGH XII ZB 99/12 Beschluss vom 20.06.2012
30.BGH, Vorlagebeschluss vom 01. Juli 2015 – XII ZB 89/15 -, Rn. 22, juris
31.BGH, Beschluss vom 11. Oktober 2000 – XII ZB 69/00 -, BGHZ 145, 297-310, Rn. 21
32.BVerfG Beschluss vom 23.03.2011 – 2 BvR 882/09
33.Institut für Menschenrechte, News vom 25.06.2013, “UN-Sonderberichterstatter: Absolutes Verbot von jeglichen Zwangsbehandlungen im Zusammenhang der psychiatrischen Versorgung”
34.Institut für Menschenrechte a.a.O.
35.http://www.ohchr.org/Documents/HRBodies/CRPD/14thsession/GuidelinesOnArticle14.doc
36.vgl. TAZ vom 26.2.2008 auf Seite 21
37.Pressemitteilung des Deutschen Instituts für Menschenrechte vom 13.01.2013, ” Monitoring-Stelle fordert Enquete-Kommission zu Psychiatrie-Reform” unter Bezugnahme auf Valentin Aichele, Leiter derMonitoring-Stelle zur UN-Behindertenrechtskonvention
38.Institut für Menschenrechte a.a.O.
39.Stellungnahme der Monitoring-Stelle zur UN-Behindertenrechtskonvention anlässlich der Öffentlichen Anhörung am 10. Dezember 2012 im Rahmen der 105. Sitzung des Rechtsausschusses des Deutschen Bundestages
40.BVerfG, 2 BvR 633/11 vom 12.10.2011
41.Steinert, in: Ketelsen/Schulz/Zechert, Seelische Krise und Aggressivität, 2004, 44 , S. 47
42.BVerfG, 2 BvR 633/11 vom 12.10.2011
43.Der Stern vom 31. Mai 2013, Neues Standardwerk der Psychiatrie DSM-5 -Psychisch krank über Nacht
44.Der Stern a.a.O.
45.Blech, J. in Spiegel online vom 12.04.2013 – “Normal von Allen Frances: Beichte eines Psychiater-Papstes”
46.BVerfGE 2 BvR 882/09 Beschluss vom 23.03.2011 und 2 BvR 633/11 Beschluss vom 12.10.2011
47.instruktiv BVerfG, 2 BvR 633/11 vom 12.10.2011
48.http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
49.statt vieler: Techniker Krankenkasse vom 05.01.2010: “Recht auf  Zweitmeinung”,
https://www.tk.de/tk/behandlungen/zweitmeinung/recht-auf-zweitmeinung/213558
50.Den jeweiligen Fragen der Umfrage sind einer Sammlung an Gesetzestexten und höchstrichterlichen Urteilen zugeordnet
51.BVerfG, Beschluss vom 07. Juli 2015 – 2 BvR 1180/15 und Beschluss vom 14. Juli 2015 – 2 BvR 1549/14
52.BVerfG Beschluss vom 14. Juli 2015 – 2 BvR 1549/14
53. http://www.institut-fuer-menschenrechte.de/fileadmin/user_upload/PDF-Dateien/UN-Dokumente/CRPD_Abschliessende_Bemerkungen_ueber_den_ersten_Staatenbericht_Deutschlands_ENTWURF.pdf
Abschliessende_Bemerkungen_ueber_den_ersten_Staatenbericht_Deutschlands_ENTWURF.pdf
54.Aichele, Valentin, Stellungnahme der Monitoring-Stelle zur UN-Behindertenrechtskonvention anlässlich der Öffentlichen Anhörung vom 10. Dezember 2012, im Rahmen der 105. Sitzung des Rechtsausschusses des Deutschen Bundestages
55.http://www.ohchr.org/Documents/HRBodies/CRPD/14thsession/GuidelinesOnArticle14.doc
56.BVerfG, 2 BvR 633/11 vom 12.10.2011
57.BVerfG, 2 BvR 633/11 vom 12.10.2011: “In Deutschland existieren, nachdem von der Deutschen Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN) in den neunziger Jahren initiierte Versuche zur Etablierung medizinischer Standards für Zwangsbehandlungen nicht zu einem Ergebnis geführt haben (vgl. Steinert, in: Ketelsen/Schulz/Zechert, Seelische Krise und Aggressivität, 2004, S. 44 <47>), keine medizinischen Standards für psychiatrische Zwangsbehandlungen, aus denen mit der notwendigen Deutlichkeit hervorginge, dass Zwangsbehandlungen mit dem Ziel, den Untergebrachten entlassungsfähig zu machen, ausschließlich im Fall krankheitsbedingter Einsichtsunfähigkeit zulässig sind.”
58.BVerfG, Beschluss vom 20. Februar 2013 – 2 BvR 228/12 -, juris (Rn 60)
59.Falkai, Zwangsmaßnahmen: Verfahren transparent gestalten Presse-Information Nr. 47 /19.11.2012 der DGPPN
60.Drucksage 18-0606 S. 10
61.Sachs, Grundrechte: Körperliche Unversehrtheit und Selbstbestimmung JuS 2011, 1047
62.Stellungnahme der Monitoring-Stelle zur UN-Behindertenrechtskonvention anlässlich der Öffentlichen Anhörung vom 10. Dezember 2012, im Rahmen der 105. Sitzung des Rechtsausschusses des Deutschen Bundestages
63.Statement by Mr. Juan E Méndez, SPECIAL RAPPORTEUR ON TORTURE AND OTHER CRUEL, INHUMAN OR DEGRADING TREATMENT OR PUNISHMENT, 22 nd session of the Human Rights Council, Agenda Item 3, 4 March 2013, Geneva
64.Neškovic, Der Wille des Patienten geht vor – Der Tagesspiegel, 29.11.2012
65.Narr et al. Behinderung, Menschenrechte und Zwang 2011
66.Rinke NStZ 1988, 10 S. 13

Contribution to the Campaign to Support the CRPD Absolute Prohibition of Commitment and Forced Treatment: María Teresa Fernández Vázquez (Mexico)

an English summary of the Spanish original posted at https://absoluteprohibition.wordpress.com/2016/03/18/aporte-a-la-campana-por-la-prohibicion-absoluta-en-la-cdpd-de-los-tratamientos-forzosos-y-los-internamientos-involuntarios-maria-teresa-fernandez-mexico/ and at https://sodisperu.org/2016/03/14/aporte-a-la-campana-por-la-prohibicion-absoluta-en-la-cdpd-de-los-tratamientos-forzosos-y-los-internamientos-involuntarios/

In this text I try to argue my support for the Campaign from three different approaches. First, from a humanistic and social perspective that sees the human person as a unique and irreducible being, whose “inexhaustible potential of existence” [1] unfolds and may unfold in infinite ways and expressions, all of which are equally valuable and precious. For centuries, however, persons with disabilities in general, and persons with psychosocial disabilities in particular, have been put down and aside, and their expressions rarely acknowledged or approved by the vast majority. Either through ignorance, fear, negligence, lust for power and control, etc., both governments and societies have been ready to repress human conducts that do not fit the socially construed parameters already embedded in unquestioned norms, habits, symbols and cultural stereotypes. So that the status quo is maintained. We should consider any attempt at repression of human expression as a form of social and political oppression that should not be tolerated. Instead, societies should open themselves to human diversity, and build with all those who are different a permanent dialogue; create – hand in hand with them – new forms of social interaction and coexistence that enrich us all. To this I bet.

Secondly, I talk from my personal experience as the sister of a man who in his adolescence was diagnosed with epilepsy and later in his life became an alcoholic. My brother was confined to health centers, “farms” and psychiatric hospitals on the recommendation of his treating physicians. I can testify the increasing deterioration suffered by my brother after each placement, which culminated with his painful and early death. His commitments were absolutely intolerable and ominous: for him, for us as his family, and for us all. I deeply regret that we did not have access to the information, advice, proper support or the services that would have allowed my brother to live his life differently, according to his needs and potential; humanly, in short. The worst of it all is that today – forty years later – things have not changed much. There is still the same lack of such: information, advice, proper support and services. People with psychosocial disabilities keep on being ill-treated and committed, even against their will; even if there is proved evidence that such treatments do not work, but, on the contrary, they do profound and irreversible harm. Both: governments (through laws, policies and lack of political will), health professionals and society as a whole continue to condemn persons with psychosocial disabilities to oblivion and to death, and do it with absolute impunity. This too is unacceptable and has to be changed. The UN Convention on the rights of persons with disabilities tells us how.

The third perspective I support the Campaign from is that of the UN Convention on the Rights of Persons with Disabilities, being myself a person with a physical disability and thus actively involved in its process. Complying with the Convention means respecting the dignity and individual autonomy of all persons with disabilities, as well as respecting their right to equality and non discrimination, to personal liberty and security. As the CRPD Committee declares: “forced treatment by psychiatric and other health and medical professionals is a violation of the right to equal recognition before the law (art. 5) and an infringement of the rights to personal integrity (art. 17); freedom from torture (art. 15); and freedom from violence, exploitation and abuse (art. 16). This practice denies the legal capacity of a person to choose medical treatment and is therefore a violation of article 12 of the Convention” (Par. 42).[2] The Committee also states that the segregation of persons with disabilities in institutions violates a number of the rights guaranteed under the Convention (Par. 46).

It is absolutely unacceptable, under the Convention, not to respect the dignity of persons with psychosocial disabilities, or to subject them to scrutiny and rude, authoritative assessments. Nor is admissible for anyone to attribute himself the faculty to decide in his opinion what best suits them, or to hold them in places where they loose everything: their autonomy, their freedom, and even their dignity. Places where they remain – subjected and powerless – under the absolute control of other persons’ will – never their own – and their integrity is lacerated. As the CRPD Committee clearly declares, such practices are in frank violation of the UN Convention on the rights of persons with disabilities and must be eradicated.

Instead, States Parties to the Convention – as well as the whole of societies – should fulfill their moral and legal obligation to eradicate all existing barriers and take all the necessary measures to guarantee that people with psychosocial disabilities enjoy each and every of their fundamental rights and are included as active and irreplaceable parts of society on an equal basis with others.

 

[1] Boff, Leonardo. Tiempo de la trascendencia, el ser humano como un proyecto infinito, Santander, Sal Terrae, Brasil, 2000.

[2] Committee on the Rights of Persons with Disabilities, General Comment No. 1 on Article 12 (2014).

Aporte a la Campaña por la “Prohibición Absoluta en la CDPD de los Tratamientos Forzosos y los Internamientos Involuntarios”: María Teresa Fernández (México)

https://sodisperu.org/2016/03/14/aporte-a-la-campana-por-la-prohibicion-absoluta-en-la-cdpd-de-los-tratamientos-forzosos-y-los-internamientos-involuntarios/

La institucionalización de personas con discapacidad es una declaración de incompetencia de las autoridades gubernamentales y de las sociedades frente al fenómeno que representa la existencia humana. Una declaración de soberbia supina y de falta de voluntad; también, de indolencia, y también, de impunidad. Nos atribuimos la facultad de decidir si una a una de estas personas debe vivir, y cómo; o debe morir – y literalmente – encerrada entre muros estrechos e indiferentes, atada a una cama, un catre, un poste; sometida a un medicamento o a un cierto trato, el que nos venga a bien dispensarle; reducida y frustrada en sus posibilidades y sueños, sin más compañía que su propia intimidad diferente y asustada. Y nos creemos juiciosos, protectores, responsables – éticos. Nos decimos humanos y nos damos baños de pureza. Mejor sería hacerlo en el Ganges.

Mi hermano fue diagnosticado con epilepsia cuando entró en la adolescencia. Se hizo alcohólico después. Me llevaba 18 años. Fue internado varias veces en distintos centros, hospitales y “granjas”. Cada vez que salía – de más en más aminorado – había perdido algo nuevo: el brillo de sus ojos, su sonrisa franca y espontánea, alguna más de sus ganas de vivir.

Y sin embargo seguimos. Seguimos sin prestar atención a lo que filósofos, teólogos, humanistas, han venido repitiendo a lo largo de la historia: el ser humano – como sus expresiones y manifestaciones – es único e irreductible, como inagotable es su potencial de existencia. Nuestra pequeñez y cortedad de miras – aunadas a nuestras ansias de “normalidad”, de resultados y de eficacia; de absurdos absurdos, pues – no alcanza, siquiera, a preguntarse lo que esas cualidades de “único” y de “irreductible”, en relación con la persona humana, puedan significar.

Si no, ¿por qué, a pesar de los tantos “avances”:  científicos, tecnológicos, garantistas de derechos, seguimos sin ser capaces de aceptar que el ser humano tiene una existencia “condenada a abrir caminos siempre nuevos y siempre sorprendentes”[1]?, ¿por qué no nos permitimos el diálogo posible – y promisorio – con las diversas percepciones y expresiones humanas de la realidad?

Cuando un niño es inquieto, o “de más” ; o un adolescente, desinteresado, o su respuesta es glacial; cuando una mujer rompe en llanto, o monta en cólera, ante – decimos – “la menor provocación”, no tardamos en enjuiciar su conducta, y diagnosticarla, y patologizarla; no sólo su conducta, su ser por entero. Son pocos y cortos los pasos para transitar del juicio al diagnóstico y de ahí a la etiqueta – que lo será, ya para siempre, incuestionable e inamovible; y luego, a la medicalización, y al mismo tiempo, o poco después, al encierro. Y en este apresurado camino nos hemos olvidado:  de él, de ella, de la persona humana que ahí vivía.  Ya hemos llegado – y con plena conciencia – al umbral. Es la muerte. Una muerte que  – pareciera que confiamos – todo lo resolverá; o por lo menos, hemos logrado que así pensando y haciendo todo se resuelva, al menos, para nosotros. La impunidad.

Cada vez que mi hermano salía de uno de esos encierros nos decía que no quería más: que se lo llevaran, que lo encerraran, que lo amarraran, que lo durmieran, que le aplicaran electro shocks. Que lo mal trataran, que lo desnudaran, que lo despojaran, hasta de su dignidad. Era intolerable. Era ominoso. Yo era muy joven. Hoy tengo 64 años. Hace 40 que mi hermano murió en uno cualquiera de esos hospitales. Sigue vivo en mí.

Estos años me han servido para aprender que a quien le importa lo humano, se propone indagar lo que hay ahí adentro de ese otro, también humano. Descubrir su razón, su interés, su necesidad, su intención, su propuesta, su expresión – diferentes. Y vestir su piel. Y estar dispuesto a moverse y a tender puentes – y cruzar esos puentes.

Por eso me pareció extraordinario que el proceso de negociación de lo que llegaría a ser la Convención de Naciones Unidas sobre los derechos de las personas con discapacidad (CDPD, 2006),[2] hubiera asumido ese reto:  abrir sus puertas – y poner oídos atentos – a lo que las propias personas con discapacidad psicosocial tenían que decir sobre ellas mismas: que son seres humanos, iguales, íntegros e integrales, redondos; formados e  informados; presentes, pensantes, sintientes, activos y comprometidos; con las mismas necesidades y búsquedas de cualquier otro ser humano – y con los mismos derechos y obligaciones; y aún así, cada una y cada uno, con maneras y expresiones distintas, únicas, propias, privadas: las suyas. Como usted, apreciable lector; como yo también, y como todas y todos. Y tan así, que la intervención de estas personas con discapacidad en las negociaciones para la Convención conmocionó – impactó –, y fue capaz de crear posibilidades nunca antes vislumbradas, para ellas, para las y los demás: Un camino al diálogo real con la diversidad.  El inicio de un movimiento franco hacia la aprehensión – y la inclusión – de formas variadas de ser y estar en el mundo. Para desde ahí, aprender. Y desde ahí, convivir. Desde ahí, transformarse y transformar.

Hasta entonces, no había pasado todavía que alguien defendiera públicamente, y con tanta fuerza y claridad, que no es posible vivir ignorando o aniquilando a seres humanos, y por el simple hecho de no ser capaces – nosotros – de inteligir sus maneras; o porque molesta que griten fuerte y disonante cuando el mundo les duele; o porque amenazan los referentes de los útiles y cómodos statu quo.

Las personas con discapacidad psicosocial desmantelaron  – en y con la Convención – uno a uno de los mitos que nos hemos fabricado sobre ellas: su indefensión, su fragilidad, su “peligrosidad”; su incapacidad: de tomar decisiones, de asumir obligaciones y responsabilidades; de vivir en este mundo y atreverse a cuestionarlo; de aportar, de enriquecer-nos.  No es gratuito, entonces, que – en y desde la Convención –, no quepa más hacer distingos sobre ellas. O no, si para atentar en contra de su dignidad, o para propiciar que se vulneren sus derechos; tampoco para someterlas a escrutinios y valoraciones groseras, autoritarias y sin fundamento, o al menos, moral. O para que alguien pueda atribuirse la facultad de poder decidir a su juicio lo que mejor les conviene, o de recluirlas en instancias en las que todo lo pierdan, incluso su autonomía y su libertad; incluso su dignidad.  Lugares donde queden – sometidas e impotentes – bajo el control absoluto de otra u otras voluntades – nunca la suya – y se lacere su integridad. ¿Qué razón – y qué derecho – le asiste: al Estado, a los profesionales de la salud, a las familias, a la sociedad en general, para permitirse un acto semejante?, me pregunto y se lo pregunto, sí, a usted, apreciable lector o lectora.

Todas las personas con discapacidad han sido reconocidas por la Convención con la misma dignidad y derechos que el resto de las personas.  Derechos de las personas con discapacidad – “incluidas aquellas que necesitan un apoyo más intenso” (Preámbulo CDPD, inciso j)) – son que se respete su dignidad y su valor; que se respete y aprecie su diferencia, tanto como su autonomía, su independencia y su libertad para tomar sus propias decisiones  – incluso, cuando estas decisiones puedan no coincidir con las nuestras, o nuestras opiniones y creencias – o nuestra voluntad; o nuestros intereses. Es también un derecho de todas las personas con discapacidad –reconocido por la Convención– que se les proporcionen los apoyos que ellas estimen necesitar para tomar sus propias decisiones (Artículo 12.3 CDPD), incluida la de dónde y con quién vivir, y sin que se vean obligadas a vivir con arreglo a un sistema de vida específico (Artículo 19. a)CDPD). También es derecho de ellas disponer de los servicios de apoyo que faciliten su existencia y su inclusión en la comunidad y eviten que se les separe o aísle de ésta (artículo 19. b) CDPD).

El Comité de Naciones Unidas sobre los Derechos de las Personas con Discapacidad (CRPD), en su Observación General No.1,[3] ha abundado sobre el alcance del derecho de las personas con discapacidad a tomar sus propias decisiones y que éstas sean respetadas: “en todo momento, incluso en situaciones de crisis, deben respetarse la autonomía individual y la capacidad de las personas con discapacidad de adoptar decisiones,” (O.G.No.1 CRPD, Párr.18). También ha afirmado que entre estas decisiones se incluyen aquellas “decisiones fundamentales con respecto a su salud” (O.G.No.1 CRPD, Párr. 8); y más específicamente, el Comité ha reconocido el derecho de las personas con discapacidad a no ser internadas contra su voluntad en una institución de salud mental y a no ser obligadas a someterse a un tratamiento de salud mental (Artículo 14 CDPD) (O.G.No.1 CRPD, Párr. 31). También el Comité CRPD ha dejado en claro que todas las formas de apoyo en la toma de decisiones que las personas con discapacidad opten por recibir, “incluidas las formas más intensas, deben estar basadas en la voluntad y las preferencias de la persona, no en lo que se suponga que es su interés superior objetivo.” (O.G.No.1 CRPD, Párr. 29, Inciso b)).

Lamento profundamente que nada de esto fuera del dominio público cuando yo era niña. Cuando mi madre, al no disponer de los recursos necesarios: información, asesoramiento, apoyos y servicios – porque no existían, o eran inaccesibles – no encontró mejor opción para él, para ella y para mí, que poner a mi hermano a disposición de los médicos. Ella creyendo que sabían lo que era debido hacer; ellos alegando saberlo, a pesar de que un número incontable de historias – entre las que después se contaría también la de mi hermano – testimoniaban fehacientemente lo contrario.

Gracias a mi involucramiento con los procesos sobre la Convención de Naciones Unidas sobre los Derechos de las Personas con Discapacidad, he aprendido que es éticamente insostenible pretender – usted, yo, los gobiernos y las sociedades – seguir ignorando las incuestionables e infinitas realidades y posibilidades humanas. Que es inadmisible seguir apelando a maneras arcaicas y lugares comunes para enmascarar nuestra incapacidad de derribar barreras, estigmas y prejuicios, o nuestra falta – evidente – de voluntad. Como la que reconoce el valor de otras existencias y mantiene con ellas interacciones fecundas; la que incursiona en nuevas formas de acercamiento a las situaciones y de brindar atención y cuidados.

Hace 40 años no existían los servicios y los apoyos que habrían llevado la historia de mi hermano por otros caminos, hoy lo sabemos, menos crueles y fatales; que habrían permitido que él – con la debida asistencia – encontrara sus propias respuestas.  Al día de hoy, esos servicios y esos apoyos siguen sin estar disponibles, o aquí, en mi país. A saber a cuántas más vidas les han hecho falta también para crearse y recrearse a sí mismas; a cuántas personas más su inexistencia las sigue condenando al olvido – o a la muerte. De las grandes claves para el cambio, y algo tan sencillo y a la vez tan crucial para producirlo, hoy sigue sin ser habitado; sin siquiera ser explorado; o aquí, en mi país. Esto también es inaceptable.

Es por todo eso que yo me pronuncio – y decididamente – por la “Prohibición Absoluta en la CDPD de los Tratamientos Forzosos y los Internamientos Involuntarios”. 

Porque, en resumen, considero que estas prácticas:

  • Son reductivas de la persona humana y de la situación existencial que experimenta;
  • Van contra la dignidad, la autonomía y la libertad de las personas con discapacidad (Art. 3 CDPD);
  • “Medicalizan” problemas que son de índole social, en los que intervienen otros elementos contextuales: familiares, sociales, e incluso políticos, que entonces son ignorados, desatendidos y perpetuados; incluso, profundizados;
  • Son invasivas, autoritarias y jerárquicas, al aplicarse a las personas aún en contra de su voluntad;
  • Son cuestionables en sus fines, en sus efectos y consecuencias – muchas irreversibles y fatales –, y en su efectividad.
  • Refuerzan los estigmas y prejuicios sociales sobre las personas con discapacidad psicosocial, al utilizar categorías diagnósticas que – además de cuestionables – encasillan arbitraria y vitaliciamente a las personas, haciéndolas vulnerables a la exclusión, a la discriminación y a la muerte – la social, la biológica;
  • Son violatorias de derechos inalienables de las personas con discapacidad como, entre otros, el derecho a no ser privadas de su libertad por motivo de discapacidad (Art. 14 CDPD); el derecho a otorgar su consentimiento libre e informado sobre los tratamientos médicos que se le propongan (Art. 25. Inciso d)); el derecho a la integridad física y moral (Art. 16); el derecho a vivir de manera autónoma e independiente en la comunidad y a ser incluida como parte activa y necesaria de ella (Art.19 CDPD).

Con mi pronunciamiento en apoyo a la “Prohibición Absoluta” quiero honrar la memoria de mi hermano, sí; pero también porque yo misma soy persona con discapacidad, en mi caso motriz, y sé lo que es y significa ser discriminada y excluida por tener una discapacidad. Pero, además, porque si bien he logrado evitar ser diagnosticada o etiquetada como persona con discapacidad psicosocial, yo también encuentro muy difícil lidiar con los tantos absurdos de nuestro mundo, y acomodarme, y cada vez, en alguna de sus escasas y limitadas formas permitidas de ser y de estar en él.

Y porque sueño.  Sueño con una humanidad polifónica y multiforme; lo suficientemente abierta, crítica y dialogante para permitirse tender hacia la otredad, en lugar de ignorarla, repudiarla o temerle; una humanidad que sabe vivir junto al otro y crear –con él–  realidades e intercambios nuevos, permeables, interdependientes, nutricios. Sueño mujeres y hombres convencidos de que toda y cualquier expresión humana – por ajena o chocante que nos resulte o parezca – no puede, al final, sino complementarnos, fortalecernos, enriquecernos.

Y porque sé que tarde o temprano así se habrá demostrado.


[1] Boff, Leonardo. Tiempo de la trascendencia, el ser humano como un proyecto infinito, Santander, Sal Terrae, Brasil, 2000.
[2] ONU, Convención sobre los Derechos de las Personas con Discapacidad, Resolución A/RES/61/106, Sexagésimo primer período de sesiones, Asamblea General, Naciones Unidas, del 13 de diciembre de 2006. Entró en vigor el 3 de mayo de 2008. Disponible en: http://www.un.org/disabilities/documents/convention/convoptprot-s.pdf
[3] ONU, Observación General No.1 (2014) sobre el Artículo 12: Igual reconocimiento como persona ante la ley, Comité sobre los Derechos de las Personas con Discapacidad, 11º período de sesiones. ONU Doc. CRPD/C/GC/1, del 19 de mayo de 2014.

Pueden leer más de la Campaña #ProhibiciónAbsolutaen: https://absoluteprohibition.wordpress.com/ 

Paula Caplan – Myths are Used to Justify Depriving People Diagnosed as Mentally Ill of Their Human Rights

http://www.madinamerica.com/2016/03/myths-are-used-to-justify-depriving-people-diagnosed-as-mentally-ill-of-their-human-rights/

Who in this world ought to have the right to make decisions about their lives, and who is required to lose that right and have the medical community and the courts take over?

Despite the fact that no one in history, not even the omnipotent American Psychiatric Association — which produces and profits mightily from the “Bible” of mental disorders — has come up with a halfway good definition of “mental illness,” and despite the fact that the process of creating and applying the labels of mental illness is unscientific, any of those labels can be used to deprive the person so labeled of their human rights. This is terrifying. It ought to terrify those who are so labeled and those who are not, because deprivation of human rights on totally arbitrary grounds is inhumane and immoral.

The combination of the specter of terrorism and highly publicized incidents of gun violence have led rapidly to politicians, therapists, and the general public blaming “the mentally ill” for these dangers, and that is used to justify depriving not just terrorists and other killers but anyone with a label of mental disorder of their rights. They can be locked up against their will, they can be ordered to comply with just about anything that a professional calls “treatment of the mentally ill,” no matter how these actions can harm the person and in the absence of scientific evidence that the “treatments” of people who have been psychiatrically labeled will prevent violence. In other words, the huge leap is often made from “This person has a psychiatric label” to “This person is therefore dangerous to themselves and others,” even in the absence of any history or current indication of such dangerousness, and that leap is then used to lock people up and/or otherwise “treat” them against their will.

Now the United Nations human rights treaty called the Convention on the Rights of Persons with Disabilities includes the absolute prohibition of forced commitment and forced treatment, and the brilliant and tireless advocate Tina Minkowitz is leading a campaign to show that there is a wide base of support for these prohibitions. This is especially important in the United States, because 162 nations have ratified the CRPD, but the U.S. has not.

Minkowitz worked on drafting and negotiations for the treaty from 2002-2006 and helped ensure the incorporation in the CRPD of Article 12, which says that “states,” countries and national governments bound by international law recognize that people with disabilities have the right to make their own decisions in all aspects of life and to do so free from coercion. Note that “people with disabilities” applies to anyone who has received a diagnosis of any mental disorder (in addition to other disabilities). It is important to note the CRPD’s Article14, which specifies according to the text and the authoritative interpretation by the Committee on the Rights of Persons with Disabilities that the existence of disability or perceived disability cannot be used to justify deprivation of liberty, and Article 25 requires that healthcare be provided on the basis of free and informed consent. The word “perceived” is crucial, in light of the fact that the ballooning numbers of categories listed as mental disorders in the two primary handbooks used to classify people as mentally ill have made it possible, even likely, that anyone entering a therapist’s or other professional’s office in other than a calm and happy state will be diagnosed as psychiatrically disordered, moving just about anyone into the “perceived as disabled” category. So one crucial myth that is relevant to the CRPD is that psychiatric diagnoses are scientific and usually appropriately applied.

If no harm came from being classified as mentally ill, there would be less cause for alarm. But it is easy, even likely, for laypeople, therapists and other healthcare professionals, and judges to assume wrongly that having a disability (even a perceived disability) means that one’s judgment is impaired and that one should not be allowed to make choices about their lives, their bodies, and the treatments to which they will be subjected. Frequently, the criterion of “dangerous to oneself and/or others” is used to justify forced commitment or forced treatment, and this is done despite the proven fact that people diagnosed as mentally ill are actually less likely than others to commit acts of violence and more likely to be victims of violence. The evidence for this pattern is all the more remarkable, given that for a number of reasons (e.g., defense attorneys trying to get psychiatric labels for their clients in order to obtain reduced sentences or diversion from prison to the mental health system; the skyhigh frequency of prisoners being diagnosed as mentally ill so that they can be heavily medicated and thus reduce the need for prison staff), statistics in the near future are likely to show an increasingly high correlation between psychiatric labels and violence. Thus, two other crucial myths that are relevant to the CRPD are that people who have received psychiatric labels are likely to be incompetent to make choices about their lives and that they are more likely than other people to be violent.

A fourth crucial myth is that forced commitment and forced treatment are beneficial (and, by implication, not harmful). That this is a myth is reflected in the high rates of suicide that follow inpatient treatment and the increased rates of suicide caused by many psychiatric drugs, as well as the plummeting rates of recovery and increased rates of longterm disability that have followed the introduction of various psychiatric drugs into the market and the use of electroshock.

Another myth is this: The important word “orthogonal” applies to the question of whether people diagnosed as mentally ill are able to make their own choices and whether they have good judgment. We all know people who have no psychiatric labels but who make terrible choices and poor judgment, yet those limitations are not used to deprive the of their human rights. These capacities are orthogonal to whether or not one has been diagnosed as mentally ill, meaning that knowing whether or not a person has a diagnosis is simply not a predictor of their judgment and ability to make good choices for themselves. A related myth is that if someone is diagnosed as mentally ill, all of their decision making power must be wrenched away from them, when — as with many people who are not so diagnosed — sometimes what the person needs is a little support of various kinds, including assistance with filling out forms or practical help with cooking or shopping or getting a service animal during times when they are struggling.

The CRPD standard is for people who have or are perceived to have disabilities must be provided the opportunity to give free and informed consent. That is very far from what happens with the vast majority of people treated by psychotherapists, not to mention those who are deprived of their human rights. Consider this: Psychiatric diagnosis is the bedrock, the first cause of everything bad that happens to people in and through the mental health system. If they do not diagnose you, they cannot treat (or “treat”) you, whether or not the treatments are helpful to you. But almost no one who enters a therapist’s office is ever fully informed and thus almost no one is put in a position where they even might give informed consent. Why? There are three reasons:

  1. They are almost never told, “In order for your insurance to pay my bills, I will have to give you a psychiatric diagnosis, but you have the right to know that psychiatric diagnoses are unscientific, that getting one does not help alleviate suffering, and that getting one carries a wide array of risks of harm, from plummeting self-confidence to loss of employment and of child custody and of security clearance…even to death from treatments that are justified on the basis of your label.”
  2. They are almost never told, “I am recommending Treatment X, but I am going to tell you everything about the potential benefits and potential kinds of harm that can result.” The reason they are almost never told this is that these days, the vast majority of treatments are with psychiatric drugs, and lawsuits have repeatedly revealed that the drug companies purposefully conceal much of the harm, so there is no way for conscientious therapists to get that information and thus no way for them to convey it to their patients. Something similar happens with electroshock and with expensive but intensively marketed programs called things like “neurobiofeedback” that have not been shown to be helpful but that are often very costly.
  3. They are almost never told, “I am recommending Treatment X, but I am also going to describe for you the huge array of approaches that have been helpful to people who are going through what you are going through … and that often carry little or no risks of harm.”

Alarmed about the lack of disclosure, which puts suffering people who seek help in the mental health system at huge risk of harm with no way even to know what questions to ask and what recommendations to challenge, I organized the filing of nine complaints to the Ethics Department of the American Psychiatric Association, because that APA publishes and hugely profits from the Diagnostic and Statistical Manual of Mental Disorders (DSM), whose categories had been used against the complaints with tragic effects. We said that if the APA had honestly disclosed the unscientific nature of its categories and the risks of harm, as well as that getting a label would be helpful largely or only in order to get insurance coverage for treatment, the complainants would not have blindly accepted their labels and the treatments that were justified to them on the basis of the labels (“You have Disorder Y, so you should accept Treatment Z, because that is what is used for people with Y”). The APA dismissed the complaints on spurious grounds and with not one iota of attention to their merits.

Five of those complainants then filed complaints with the U.S. Department of Health and Human Services’s Office of Civil Rights (OCR). The complaints were filed pursuant to the Americans with Disabilities Act, according to which people can be discriminated against by being treated as though they are disabled (mentally ill in these cases) when in fact they are not. All of the complainants had been experiencing upsetting life situations but should by no means have been diagnosed as mentally ill. Yet according to the (falsely-marketed as scientific) DSM, they were mentally ill, and the treatments that were justified on the basis of their labels had had devastating consequences for them. The OCR dismissed the complaints on spurious grounds and with no attention to their merits.

The outcomes of these complaints provide a solid paper trail revealing that in the United States, the enterprise of psychiatric diagnosis is entirely unregulated. This makes it even less regulated than the major financial institutions whose unregulated actions seriously damaged the economy. The paper trail shows that both the lobby group called the APA, which earned more than $100 million from the last edition of the DSM and spent not one cent to reveal the truth about its manual or to warn of the harms they knew about, and the government entity (OCR of HHS) that by all rights ought to provide oversight and regulation, have chosen to do nothing. This makes it all the more compelling for all of us to press for the United States government to ratify the CRPD. The loss of human rights of just one of us through fraudulent advertising, cover-ups, and perpetuation of dangerous myths is the loss of human rights of us all.

As a U.S. citizen, I am embarrassed and appalled that as this country discusses whether or not to ratify the CRPD, it wants to add what are called “RUDs,” reservations, understandings, and declarations created by the current federal administration and the Senate Foreign Relations Committee. According to Minkowitz, these include the claim that U.S law already fulfills or exceeds the obligations our country would have under the CRPD treaty. The above described complaints that we filed — and the rejection of those complaints by the U.S. Department of Health and Human Services’s Office of Civil Rights gives the lie to that claim, since there is simply no governmental regulation of psychiatric diagnosis, and diagnosis is the sine qua non of forced commitment and forced treatment.

* * * * *

Originally posted on paulajcaplan.net

This blog is a contribution to the Campaign to Support the CRPD Absolute Prohibition of Commitment and Forced Treatment. To see all of the Mad in America blogs for this campaign click here.

Paula J. Caplan, PhDPaula J. Caplan, PhD, is a clinical and research psychologist, activist, Associate at the DuBois Institute, Harvard University, and the author of 11 books, including one that won three national awards for nonfiction and two about psychiatric diagnosis. Her books include They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal and the edited Bias in Psychiatric Diagnosis.

-We are not violating the human rights. -Yes, you are! by Anne Grethe Teien

http://agteien.blogspot.no/2016/03/we-are-not-violating-human-rights-yes_74.html

Introduction

Psychiatric human rights violations are often  denied and trivialized, even distortedly re-defined as “human rights” and “right to necessary health help”. The UN convention for the rights of persons with disabilities, CRPD,  is changing that. CRPD demands an absolute prohibition of forced psychiatric treatment and involuntary commitment. These are important requirements in giving people with psychosocial disabilities equal human rights. In this text, I will look at different aspects of the CRPD related to that demand. I will illustrate with some references to Norway, the country where I live, showing ways in which the Norwegian Mental Health Act does not comply with the convention. I will also share some further reflections. Towards the end I have written a short version of my own experiences from forced psychiatry.  Mental health laws may vary between countries, but some elements are prevalent: the laws are typically directed specifically towards people with psychosocial disabilities and involve forced treatment and involuntary commitment . This text is written for the Campaign to Support CRPD Absolute Prohibition of Forced Treatment and Involuntary Commitment (17). Procrastinations must stop – CRPD-based law reforms must begin!

Norway and the CRPD 

Norway ratified the CRPD June 3rd 2013, but came up with some interpretative declarations of article 12, 14 and 25 that undermine central parts of the convention (1).  Norway uses these declarations to try to defend the Mental Health Act and forced psychiatric treatment. In February 2015, the president of the Norwegian Psychological Association, Tor Levin Hofgaard, wrote an article asking for a clarification from the government whether health personnel violate the human rights when they follow the coercion regulations in the Mental Health Act (2). He referred to a report sent to the authorities in December 2013 by the then Equality and Anti-Discrimination Ombud –  LDO, Sunniva Ørstavik (3). The report said that the Mental Health Act is discriminatory and does not comply with the CRPD. LDO also urged Norway to quickly withdraw its interpretative declarations. In public, the LDO report was met with a noisy silence by the authorities.  So, as time had went on, Hofgaard asked for the mentioned clarification.  Anne Grethe Erlandsen, State Secretary in the Ministry of Health and Care Services, answered on behalf of the Norwegian authorities: “Vi bryter ikke menneskerettighetene” / – We are not violating the human rights (4). That answer is absolutely not right.

Norway uses much coercion in psychiatry. In spite of reduction strategies, the use of coercion stays at stably high levels (3: p.6-8; 5: p.20-23). Also, reduction strategies instead of CRPD-based abolishment strategies do not go to the core of the issue. Norway is used to see itself as a human rights protective nation and often does not hesitate to criticize other countries for their human rights violations. So it is maybe hard for the authorities to take in that the state of Norway  is actually accepting torture and other severe human rights abuses in its own mental health system, via the Mental Health Act.  Point 42 of the CRPD General Comments No 1 says as follows:

As has been stated by the Committee in several concluding observations, forced treatment by psychiatric and other health and medical professionals is a violation of the right to equal recognition before the law and an infringement of the rights to personal integrity (art. 17); freedom from torture (art. 15); and freedom from violence, exploitation and abuse (art. 16). This practice denies the legal capacity of a person to choose medical treatment and is therefore a violation of article 12 of the Convention. States parties must, instead, respect the legal capacity of persons with disabilities to make decisions at all times, including in crisis situations; must ensure that accurate and accessible information is provided about service options and that non-medical approaches are made available; and must provide access to independent support. States parties have an obligation to provide access to support for decisions regarding psychiatric and other medical treatment. Forced treatment is a particular problem for persons with psychosocial, intellectual and other cognitive disabilities. States parties must abolish policies and legislative provisions that allow or perpetrate forced treatment, as it is an ongoing violation found in mental health laws across the globe, despite empirical evidence indicating its lack of effectiveness and the views of people using mental health systems who have experienced deep pain and trauma as a result of forced treatment. The Committee recommends that States parties ensure that decisions relating to a person’s physical or mental integrity can only be taken with the free and informed consent of the person concerned.“ (6: #42)

Neglected harms and traumas – and the need for reparations

Long-term studies have shown higher recovery rates for people who were not on neuroleptics and on very low doses (14, 15). The list of potential harmful effects from neuroleptic drugs is long, including tardive dyskinesia, brain damage, cognitive decline, neuroleptic-induced supersensitivity psychosis, Parkinsonism, sexual dysfunction, weight gain, diabetes, demotivation, anxiety, aggression, suicide, akathisia [ an extreme form of restlessness which in itself can lead to suicide], neuroleptic malignant syndrome — a potentially lethal complication of treatment etc (14, 18). In a research summary on possible harms from forced psychiatry done by nurse and researcher Reidun Norvoll, she listed the following main categories:  1) violation of autonomy and of psychological and physical integrity. Deprivation of freedom of movement (deprivation of freedom). 2) Physical harm and death. 3) Violence and abuse. 4) Trauma, retraumatisation and posttraumatic stress syndrome. 5) Offences/violations, loss of dignity and experiences of punishment. 6) Psychological agony in the forms of shame, anxiety, feeling unsafe, anger, powerlessness, depression and loss of self esteem. 7) Social problems  and loss of social identity. 8) Loss of access to own coping skills and of possibilities to self development. 9) Loss of access to voluntary treatment. 10) Harmed therapeutic relationships, resentment against- and distrust in mental health services. (7: p. 16; 8: #5.3).

It can be hard to process traumas that are not acknowledged and understood as such by society in general. When mental health services represents the abuser and as it is officially seen as the mental health helper, one can be left in a very lonely situation trying to handle psychiatry-induced traumas.  I think, as part of the implementation of CRPD, there should be provided access to help and support to those who struggle with traumas and other harms from forced psychiatry.  I imagine a reality where it is possible for everyone to ask for help when they feel they need it, knowing that they have the CRPD on their side; that the state can not expose them to torture and other terrible human rights violations for being in mental pain (!).

When the necessary abolishment of discriminatory mental health laws and the prohibition of forced psychiatric treatment and commitment has become reality, I think that representatives from politics and psychiatry should publicly perform statements about- and apologies for -the severe human rights abuses that have been going on for so long towards people with psychosocial disabilities. After all the societal acceptance, silence and denial of these kinds of abuses, I think such an acknowledgement and apology is of significant importance for starting reparation work. Compensations  is also a relevant part of this.  At the same time, there should be no pressure towards victims of forced psychiatry to forgive and get over.  I strongly recommend survivor and lawyer Hege Orefellen’s appeal on the urgent need for effective remedies, redress and guarantees of non-repetition regarding torture and other ill-treatment in psychiatry (9). Her appeal was held during a CRPD side-event about article 15 and its potential to end impunity for torture in psychiatry (10). Also, in Guidelines on article 14 of the CRPD, point 24 (a-f) one can read about “access to justice, reparation and redress to persons with disabilities deprived of their liberty in infringement of article 14 taken alone, and taken in conjunction with article 12 and/or article 15 of the Convention” (11).

Danger- and treatment criteria 

The Norwegian Mental Health Act has, in addition to its danger criteria, a criterion called the treatment criterion, which does not require danger to oneself or others. The treatment criterion allows for psychiatric coercion if the person is claimed to have a severe mental disorder,  and application of forced psychiatry is seen as necessary to prevent the person from having his/her prospects for recovery or significant improvement seriously reduced; alternatively that it’s seen as very possible that the person’s condition in the very near future will significantly deteriorate without coercion (12: Section 3 – 3. 3 a). A very wishy-washy criterion indeed, which is much in use. In 2014 the treatment criterion alone was used in 72% of the cases among people commited (16: p.37).

Both the treatment criterion and the criteria regarding danger to oneself or others discriminate against people with psychosocial disabilities in that disability, or ‘serious mental disorder’,  is a premise for psychiatric coercion to apply. In other words, this discrimination is a violation of CRPD article 14 which says that the existence of a disability shall in no case justify a deprivation of liberty (13). Secondly, as the Mental Health Act allows for forced psychiatric treatment, it violates the right to personal integrity (art. 17); freedom from torture (art. 15); and freedom from violence, exploitation and abuse (art. 16). (6:#42).

Points 13-15 in the Guidelines on article 14 are also relevant in this context:

VII. Deprivation of liberty on the basis of perceived dangerousness of persons with disabilities, alleged need for care or treatment, or any other reasons. 

  1. Throughout all the reviews of State party reports, the Committee has established that it is contrary to article 14 to allow for the detention of persons with disabilities based on the perceived danger of persons to themselves or to others. The involuntary detention of persons with disabilities based on risk or dangerousness, alleged need of care or treatment or other reasons tied to impairment or health diagnosis is contrary to the right to liberty, and amounts to arbitrary deprivation of liberty.
  1. Persons with intellectual or psychosocial impairments are frequently considered dangerous to themselves and others when they do not consent to and/or resist medical or therapeutic treatment. All persons, including those with disabilities, have a duty to do no harm. Legal systems based on the rule of law have criminal and other laws in place to deal with the breach of this obligation. Persons with disabilities are frequently denied equal protection under these laws by being diverted to a separate track of law, including through mental health laws. These laws and procedures commonly have a lower standard when it comes to human rights protection, particularly the right to due process and fair trial, and are incompatible with article 13 in conjunction with article 14 of the Convention. 
  1. The freedom to make one’s own choices established as a principle in article 3(a) of the Convention includes the freedom to take risks and make mistakes on an equal basis with others. In its General Comment No. 1, the Committee stated that decisions about medical and psychiatric treatment must be based on the free and informed consent of the person concerned and respect the person’s autonomy, will and preferences.  Deprivation of liberty on the basis of actual or perceived impairment or health conditions in mental health institutions which deprives persons with disabilities of their legal capacity also amounts to a violation of article 12 of the Convention.” (11: #13-15)

The laws that apply to people in the rest of society regarding acute situations and in the criminal justice system, must apply to people with disabilities too in non-discriminatory ways. The CRPD’s demand for absolute prohibition of forced treatment and involuntary commitment means that it applies both in criminal justice- and civil contexts. (11: #14, 16, 20-21, also 10-12). For people with psychosocial disabilities who come in contact with the criminal justice system, necessary support must be provided to ensure the right to legal capacity, equal recognition before the law and a fair trial. Forced psychiatric treatment and involuntary commitment can not be applied as sanctions for criminal acts and/or for the prevention of such.

Replacing substituted decision-making with supported decision-making

Substituted decision making must be replaced by supported decision making systems. Giving access to supported decision-making for some but still maintaining substitute decision-making regimes, is not sufficient to comply with article 12 of the CRPD (6: #28). From General Comment No 1:

A supported decision-making regime comprises various support options which give primacy to a person’s will and preferences and respect human rights norms. It should provide protection for all rights, including those related to autonomy (right to legal capacity, right to equal recognition before the law, right to choose where to live, etc.) and rights related to freedom from abuse and ill-treatment (…).” (6: #29)

Some who agree with the CRPD in that diagnostic criteria for coercion should be abolished, still seem fine with the idea that ‘mental incapacity’ can be used as criteria for psychiatric coercion. This is not in line with the CRPD, which neither accepts disability criteria for the deprivation of freedom nor psychiatric coercion. Here is a relevant point to note, from General Comments No1:  “The provision of support to exercise legal capacity should not hinge on mental capacity assessments; new, non-discriminatory indicators of support needs are required in the provision of support to exercise legal capacity.” (6:#29 i)

A summary of my own experiences from forced psychiatry 

I was not suicidal when psychiatry put me under the Mental Health Act and decided I should get forced neuroleptic “treatment”. I had never been suicidal. The former mentioned treatment criterion is the criterion that was used on me.  Forced psychiatry, with its locking me up, restraining me, drugging me, and keeping me on CTO when discharged from hospital, certainly did not make my life better  in any way– everything became indescribably much worse. I experienced forced psychiatry as one long punishment for having mental problems. After having been on neuroleptics for a while, my cognition, my intellectual abilities, were severely affected and reduced – and so was my language: from usually having a rich vocabulary I could just utter short, simple sentences. My body became rigid and lost its fine motor skills so I couldn’t dance anymore. A period I also had akathisia, a terrible restlessness which made me walk endlessly back and forth, back and forth. I’m trained a professional dancer and having my dance abilities medicated away was a big loss in itself. The medication took away my vitality, my sensitivity. My emotions were numbed. My personality faded away.  Then a severe depression set in – just a complete state of hopelessness – and for the first time in my life I became suicidal. Again and again I said to the staff, psychologists, doctors: – I can not be on meds. I tried to have them understand that the neuroleptics were destroying me and my life.  They communicated to me that they thought I was being fussy. They were a big wall that just would not listen to me. Respectlessly enough, some even told me –yes, told me -that I was doing better. The doctors said I would need to be on meds for the rest of my life. That was a message which just manifested the complete hopeless situation. From entering psychiatry, indeed having mental problems, but being a vital, thoughtful, and expressive person who was dancing several times a week, psychiatry  had coercively medicated me away from myself and iatrogenically made me severely depressed and suicidal . In effect a slow form of forced euthanasia . One day, while on CTO, shortly after a new forced injection in the buttocks with those horrible meds, I did a dramatic suicide attempt. I was put back into the hospital. I am very glad that I survived. Because unbelievably, a couple of months later, I was told that someone had made a bureaucratic mistake: the coercion documents had not been renewed in time, so there was nothing they could do to hold me back. Of course they would recommend me to stick to the treatment (Ha!) and not leave the hospital too fast (Ha!). I left the hospital the same day. It took me about half a year to become myself again, to be able to think and speak freely, to get my sensitivity, my emotions back, to dance, to feel human again, to feel life. I have never been in a mental hospital since then. I have never had another dose of neuroleptics. And I have never been suicidal again.  More than a decade later, I am still traumatized by my experiences from forced psychiatry.

Conclusion

I am very thankful to the CRPD committee for their important work. The CRPD represents a paradigm shift, and there is clearly a resistance out there to accept the full width and depth of the convention. That human rights and non-discrimination applies equally to people with disabilities should not be seen as a radical message in 2016, but sadly, it still is. Societies with their leaders need to realize that systematic, legalized discrimination and abuse of people with disabilities is based on tradition and habitual ways of thinking –not on human rights. That something has been brutally wrong for a long time does not make it more right. Forced psychiatric treatment and involuntary commitment need to be absolutely prohibited.

Thank you for your attention.

References:

1) MDAC:  Legal Opinion on Norway’s Declaration/Reservation to the UN Convention on the Rights of Persons with Disabilities http://mdac.org/sites/mdac.org/files/norway_declaration_-_legal_opinion.pdf

2)

Tor Levin Hofgaard:  Bryter vi menneskerettighetene?

http://www.dagensmedisin.no/blogger/tor-levin-hofgaard/2015/02/19/avklaring-etterlyses-bryter-vi-menneskerettighetene/

3)

In Norwegian: Equality and anti-discrimination ombud (LDO): CRPD report to Norwegian authorities 2013 – summary http://www.ldo.no/globalassets/brosjyrer-handboker-rapporter/rapporter_analyser/crpd–2013/crpd_report_sammendrag_pdf_ok.pdf

4)

Anne Grethe Erlandsen: Vi bryter ikke menneskerettighetene http://www.dagensmedisin.no/artikler/2015/02/27/vi-bryter-ikke-menneskerettighetene/

5)

In Norwegian: LDO’s report to the CRPD committee 2015 – a supplement to Norway’s 1st periodic report http://www.ldo.no/globalassets/03_nyheter-og-fag/publikasjoner/crpd2015rapport.pdf

6)

Link to download of CRPD General Comment No 1:  http://www.ohchr.org/EN/HRBodies/CRPD/Pages/GC.aspx

7)

In Norwegian: Equality and anti-discrimination ombud (LDO): CRPD report to Norwegian authorities 2013- full version  http://www.ldo.no/globalassets/brosjyrer-handboker-rapporter/rapporter_analyser/crpd–2013/rapportcrpd_psykiskhelsevern_pdf.pdf

8)

NOU 2011: 9. Økt selvbestemmelse og rettssikkerhet — Balansegangen mellom selvbestemmelsesrett og omsorgsansvar i psykisk helsevern. 5. Kunnskapsstatus med hensyn til skadevirkninger av tvang i det psykiske helsevernet. Utredning for Paulsrud-utvalget https://www.regjeringen.no/no/dokumenter/nou-2011-9/id647625/?q=&ch=12

9)

Hege Orefellen: Torture and other ill-treatment in psychiatry – urgent need for effective remedies, redress and guarantees of non-repetition https://absoluteprohibition.wordpress.com/2016/02/06/hege-orefellen-on-reparations/

10)

CRPD 13: WNUSP side event on Article 15: Its Potential to End Impunity for Torture in Psychiatry  http://www.treatybodywebcast.org/crpd-13-wnusp-side-event-on-article-15-english-audio/

11)

Link to guidelines on article 14 of the CRPD under “Recent Events and Developments” http://www.ohchr.org/EN/HRBodies/CRPD/Pages/CRPDIndex.aspx

12)

Norwegian Mental Health Act translated to English http://app.uio.no/ub/ujur/oversatte-lover/data/lov-19990702-062-eng.pdf

13)

CRPD Convention http://www.ohchr.org/EN/HRBodies/CRPD/Pages/ConventionRightsPersonsWithDisabilities.aspx#14

14)

Via Mad in America / ‘Anatomy of an Epidemic’ (Robert Whitaker):  List of long-term outcomes literature for antipsychotics http://www.madinamerica.com/mia-manual/antipsychoticsschizophrenia/

15)

Lex Wunderink et al: Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy. Long-term Follow-up of a 2-Year Randomized Clinical Trial http://archpsyc.jamanetwork.com/article.aspx?articleid=1707650

16)

Bruk av tvang i psykisk helsevern for voksne i 2014 (report on the use of coercion in psychiatry in Norway 2014) https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/1161/Rapport%20om%20tvang%20IS-2452.pdf

17)

Campaign to Support CRPD Absolute Prohibition of Forced Treatment and Involuntary Commitment https://absoluteprohibition.wordpress.com/

18)

RxISK Guide: Antipsychotics for Prescribers: What are the risks? http://rxisk.org/antipsychotics-for-prescribers/#How_likely_are_the_listed_side_effects_of_antipsychotics_to_happen

Other:

Status of Ratification Interactive Dashboard – Convention on the Rights of Persons with Disabilities http://indicators.ohchr.org/

CAPA video and petition to Canadian Govt

CAPA has joined the call to action urging the Canadian government to follow the guidelines of the UN Declaration for the Rights of Persons with Disabilities (CRPD). Although Canada signed this convention, they added a reservation which undermines one of the convention’s most important protections!

Allowing substitute decision making means that people with disabilities, including those in the psychiatric system, are often given “treatment” they do not want because somebody else decided it was best for them.

Check out our video below, sign the petition and go to chrusp.org for more information.
[youtube https://www.youtube.com/watch?v=zp2Y5YxwIdU]

Peter Gøtzsche – FORCED ADMISSION AND FORCED TREATMENT IN PSYCHIATRY CAUSES MORE HARM THAN GOOD

http://www.deadlymedicines.dk/forced-admission-and-forced-treatment-in-psychiatry-causes-more-harm-than-good/

By Peter C. Gøtzsche, Professor, MD, DrMedSci, MSc

8 March 2016

Forced treatment in psychiatry as we currently know it cannot be defended, neither on ethical, legal or scientific grounds. Ethically, the patients’ values and preferences are not being respected, although the fundamental human right to equal recognition before the law applies to everyone, also to people with mental disorders.1,2 This is clear from the United Nations Convention on the Rights of Persons with Disabilities,2 which virtually all countries have ratified. However, we ignore the convention and continue to discriminate against people with mental problems.

Please consider this. Doctors cannot give patients insulin without their permission, not even if the lack of insulin might kill them, and they cannot give adult Jehova’s witnesses blood transfusions without their permission, even if the lack of blood might kill them. The only drugs that can be given without permission are also some of the most dangerous ones. Psychiatric drugs are the third major killer after heart disease and cancer, with an estimated 539,000 deaths in the United States and European Union combined.1,3 Only soldiers at war and psychiatric patients are forced to run risks against their will that might kill or cripple them. But there is an important, ethically relevant difference: soldiers have chosen to become soldiers; psychiatric patients have not chosen to become psychiatric patients.

In many countries, a person considered insane, or in a similar condition, can be admitted to a psychiatric ward on an involuntary basis if the prospect of cure or substantial and significant improvement of the condition would otherwise be significantly impaired. After having studied the science carefully over many years, I have come to doubt that this is ever the case.1

Forced treatment most commonly involves the use of antipsychotics, but they are very poor drugs. The placebo controlled trials are seriously flawed because they have not been adequately blinded.1 Antipsychotics have many and conspicuous side effects, so most doctors and patients can guess whether an active drug or a placebo is given, which exaggerates the measured effect markedly.1 Furthermore, almost all patients in these trials were already in treatment with an antipsychotic drug before they were randomised after a short wash-out period. This cold turkey design means that abstinence symptoms – which may include psychosis – are being inflicted on patients who get placebo. Even helped by these formidable biases in the trials, the outcome is poor. The minimal improvement on the Clinical Global Impressions Ratings corresponds to about 15 points on the Positive and Negative Syndrome Scale,4 but what was obtained in recent placebo controlled trials in submissions to the FDA for newer antipsychotics was only 6 points,5 although it is easy for scores to improve quite a bit if people are knocked down by a tranquilliser and express their abnormal ideas less frequently. Thus, the FDA has approved newer antipsychotic drugs whose effect is far below what is clinically relevant. Old drugs are similarly ineffective.1

Whereas the benefits of antipsychotics are doubtful, the harms are certain, and the cold turkey design is lethal. One in every 145 patients who entered the trials for risperidone, olanzapine, quetiapine and sertindole died, but none of these deaths were mentioned in the scientific literature.6 Therefore, if we want to find out how lethal these drugs are, we should look at trials in dementia, as such patients are not so likely to have received antipsychotics before randomisation. Randomised trials in dementia shows that for every 100 patients treated for a few weeks, one is killed by an antipsychotic, compared to those treated with placebo.7 It could even be worse than this because deaths are seriously underreported in published trials. For example, a review found that only 19 of 50 deaths and 1 of 9 suicides on olanzapine described in trial summaries on websites also appeared in journal articles.8

There is no evidence that mechanical restraint in belts or seclusion has any benefits, but these treatments can also be lethal. Violence breeds violence and when psychotic patients become violent, it is very often because of the inhumane treatment they receive. It may also be because they get abstinence symptoms when they drop a few doses of an antipsychotic because they are very unpleasant to take, which can include akathisia – an extreme form of restlessness that predisposes to both suicide and homicide.1

Electroshock is also forced on people although it doesn’t seem to work for schizophrenia and although the effect on depression is temporary, which often results in a series of shocks.1 About half of the patients get memory loss1 and the more treatments they get, the more severe is the memory loss.9 Some psychiatrists claim that electroshock can be lifesaving but this has never been documented whereas we know that electroshock may kill people: about 1 in 1000 patients die.10

Another reason for using force is if patients present an obvious and substantial danger to themselves or others, in which case they can be involuntarily admitted. However, this is not necessary. The National Italian Mental Health Law specifies that a reason for involuntary treatment cannot be that the patient is dangerous. This is a matter for the police, as it also is in Iceland, and patients in Italy can decide that they want treatment elsewhere.1

Forced treatment does more harm than good and it kills many people, not only because of the direct harms of the drugs but also because of suicide. A register study of 2,429 suicides showed that the closer the contact with psychiatric staff – which often involves forced treatment – the worse the outcome.11 Compared to people who had not received any psychiatric treatment in the preceding year, the adjusted rate ratio for suicide was 44 (95% confidence interval 36 to 54) for people who had been admitted to a psychiatric hospital. These patients would be expected to be at greater risk of suicide than other patients (confounding by indication), but most of the potential biases in the study favoured the null hypothesis of there being no relationship. An accompanying editorial noted that some of the people who commit suicide during or after an admission to hospital do so because of conditions inherent in that hospitalisation.12

I fully admit that some patients are very difficult to treat optimally without using force. But it seems that, with adequate leadership and training of staff in de-escalation techniques, it is possible to practice psychiatry without using force.1,13,14 In Iceland, belts have not been used since 1932, and there are psychiatrists all over the world who have dealt with deeply disturbed patients for their entire career without ever having used antipsychotics, ECT or force.1

I believe we have to abolish laws of forced admission and treatment, in accordance with the United Nations Convention on the Rights of Persons with Disabilities.2 Abandoning using force will be harmful to some patients but it will benefit vastly many more. We will need to work out how we may best deal with those patients who would have benefited from forced treatment in a future where force is no longer allowed.

Peter C Gøtzsche graduated as a Master of Science in biology and chemistry in 1974 and as a physician 1984. He is a specialist in internal medicine. Co-founded the Cochrane Collaboration in 1993 and established The Nordic Cochrane Centre the same year. He became professor of Clinical Research Design and Analysis in 2010 at the University of Copenhagen.

References

1 Gøtzsche PC. Deadly psychiatry and organised denial. Copenhagen: People’s Press; 2015.

2 United Nations Convention on the Rights of Persons with Disabilities. General comment No. 1 2014 May 19. http://daccess-dds-ny.un.org/doc/UNDOC/GEN/G14/031/20/PDF/G1403120.pdf?OpenElement (accessed 1 April 2015).

3 Gøtzsche PC. Does long term use of psychiatric drugs cause more harm than good? BMJ 2015;350:h2435.

4 Leucht S, Kane JM, Etschel E, et al. Linking the PANSS, BPRS, and CGI: clinical implications. Neuropsychopharmacology 2006;31:2318-25.

5 Khin NA, Chen YF, Yang Y, et al. Exploratory analyses of efficacy data from schizophrenia trials in support of new drug applications submitted to the US Food and Drug Administration. J Clin Psychiatry 2012;73:856–64.

6 Whitaker R. Mad in America. Cambridge: Perseus Books Group; 2002.
7 Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-

analysis of randomized placebo-controlled trials. JAMA 2005;294:1934–43.

8 Hughes S, Cohen D, Jaggi R. Differences in reporting serious adverse events in industry sponsored clinical trial registries and journal articles on antidepressant and antipsychotic drugs: a cross-sectional study. BMJ Open 2014;4:e005535.

9 Sackeim HA, Prudic J, Fuller R, et al. The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology 2007;32:244-54.

10 Read J, Bentall R. The effectiveness of electroconvulsive therapy: a literature review. Epidemiol Psichiatr Soc 2010 Oct-Dec;19:333-47.

11 Hjorthøj CR, Madsen T, Agerbo E, et al. Risk of suicide according to level of psychiatric treatment: a nationwide nested case-control study. Soc Psychiatry Psychiatr Epidemiol 2014;49:1357–65.

12 Large MM, Ryan CJ. Disturbing findings about the risk of suicide and psychiatric hospitals. Soc Psychiatry Psychiatr Epidemiol 2014;49:1353–5.

13 Fiorillo A, De Rosa C, Del Vecchio V, et al. How to improve clinical practice on involuntary hospital admissions of psychiatric patients: Suggestions from the EUNOMIA study. Eur Psychiat 2011;26:201-7.

14 Scanlan JN. Interventions to reduce the use of seclusion and restraint in inpatient psychiatric settings: what we know so far, a review of the literature. Int J Soc Psychiat 2010;56:412–23.

Una campaña en contra de los internamientos involuntarios y las intervenciones psiquiátricas forzadas, por Ana María Sánchez

http://congresovisible.org/agora/post/una-campana-en-contra-de-los-internamientos-involuntarios-y-las-intervenciones-psiquiatricas-forzadas-por-ana-maria-sanchez/8152/

Escribo en apoyo a la campaña contra la prohibición absoluta de los internamientos involuntarios y las intervenciones psiquiátricas forzadas. Me piden argumentar con base a la Convención de los Derechos de las personas con Discapacidad y lo haré, aunque el argumento que expongo es el de la salvaguarda de la dignidad de todas las personas con respeto absoluto a sus derechos.

Me motiva escribir esta invitación a sumarnos en la insistente y motivada convocatoria que hace CHRUSP, Center for the Human Rights of Users and Survivors of Psychiatry, pero también ante la posibilidad de generar los cambios profundos que den un vuelco a paradigmas que estigmatizan y discriminan. Me sumo contra los internamientos involuntarios y las intervenciones psiquiátricas forzadas porque:

1. Reducen a la persona a un objeto al quien se le busca controlar, aniquilan la voluntad y la creatividad, acabando con su libertad.

2. Atemorizan, estigmatizan y desinforman sobre la discapacidad psicosocial.

3. No resuelven la parte estructural de una sociedad que actúa desde el paradigma de la “normalidad” encerrando a todos los que no se adaptan a los convencionalismos sociales.

4. Es una respuesta política cómoda e insuficiente que no responde a las necesidades específicas de las personas con discapacidad psicosocial y de sus familias.

5. Descarta y abandona a las personas con discapacidad psicosocial, las confina a vivir en aislamiento, privadas de su libertad y sometidas a tratos crueles e inhumanos.

6. Promueve el olvido social y la negligencia política ante los abusos y violaciones de los derechos de las personas con discapacidad psicosocial.

 

Me sumo hoy a esta causa, convencida desde mi propia lucha a favor del reconocimiento de los derechos de las personas con discapacidad. Desde las experiencias de personas que se han visto coartadas y obligadas a vivir aletargadas, forzadas a un tratamiento y confinamiento, separadas de una sociedad que busca normalizar, homogeneizar y catalogar a quienes somos diferentes. A partir de los testimonios de personas con discapacidad psicosocial y sus familiares que sufren rechazo y discriminación, padecen la falta de servicios adecuados y el abandono en reclusión o en calle, entre otros. No nos olvidemos por ejemplo, de la violencia contra mujeres con discapacidad psicosocial, sus derechos son negados y olvidados y por lo general no se retoma la lucha desde los movimientos a favor de los derechos de las mujeres.

La Convención de los derechos de las personas con discapacidad y otros instrumentos internacionales nos hacen la invitación a pensar y actuar para que los derechos de todos y todas se promuevan y respeten. No es suficiente estar en contra de los internamientos y tratamientos forzados, se requiere pensar creativamente para hacer del modelo de derechos humanos una realidad y exigir al estado las políticas públicas que promuevan y garanticen la realización de los derechos de las personas con discapacidad psicosocial.

Para más información sobre esta campaña: https://absoluteprohibition.wordpress.com/page/2/

 

 

Post on psychiatric torture by Initially NO

Initially NO has brought together art, graphics, narrative, essay, and articles of the CRPD containing rights that were denied to her, in a beautiful and moving composition asserting a claim for justice.  Since the art and graphics are integral to her work and I cannot reproduce the layout here, I am sharing her introduction and a few samples of the art work and urge you to visit the original for the full effect.

of our human rights

Rights denied me, again and again over a 14 year period (1998-2012) brings back such feelings that make me not wish to attempt to talk about this again. It hurts so much, it was so painful, it upsets me to remember, but it upsets me even more knowing that over 5700 people are subjected to such horror, every year in the state of Victoria, Australia, people who actively say no I don’t want this, very clearly and are then put on Community Treatment Orders, and tortured with forced injections, electricity, and verbally abusive appointments, that must be met, or they’ll be put into arbitrary detention again. It hurts me that the people who say no they do not wish to take psychiatric prescriptions are then subjected to the system longer.

When you refuse to be injected they do this. One ambulance man said to me he was just a small cog in a big wheel. That’s the symbolism here and the bombs in the body profiteering, Otherwise, that many hands on a small young lady, as I was, as strip her and stick her.

This is what happens when you’re given threats of worse treatments such as electro-shock and detention if you do not turn up to a fornightly ‘depo’ injection. I had to pretend to be happy with this senario to a point. (I’ve cut out the true-feeling related swear words here to fit with #UN CRPD Absolute prohibition.)

Article 15 – Freedom from torture or cruel, inhuman or degrading treatment or punishment

1. No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his or her free consent to medical or scientific experimentation.