FOSTREN Country blog – Greece by C. Bora, A. Douzenis, C. Ioannou, and S. Stylianidis.
(for Greek version, please click on this link)
What is coercion and why does FOSTREN want to reduce it?
Coercion occurs in this context when a person receiving mental health care (i.e. a patient or service user) is compelled through physical force or threat to accept care or treatment against their will. It takes many forms in both community and hospital settings, comprising both legally constituted practices and informal strategies adopted by professionals, family and friends in crisis situations to manage violence, self-harm, suicide attempts, absconding and medication non-compliance. Its use varies widely across Europe . Many countries make extensive use of outpatient commitment, enforced medication and the option of compulsory admission to coercively manage patients in the community. Overt coercive measures within hospitals using physical force include enforced medication (‘rapid tranquillisation’), mechanical restraint and/or seclusion in a locked room.
For many reasons it is imperative at this time to galvanise efforts to reduce these coercive practices. The Council of Europe has recently (June 2019) unanimously adopted a resolution to “immediately start to transition to the abolition of coercive practices in mental health settings”. Coercion often meets the criteria for inhuman or degrading treatment which contravenes the European Convention for the prevention of such acts5. Article 15 of the UN Convention on the Rights of Persons with Disabilities upholds the human right to freedom from torture or cruel, inhuman or degrading treatment or punishment. In terms of international policy objectives, coercion in principle contravenes the objectives of the European Mental Health Action Plan 2013-20207 which stipulates in Objective 2 that people with mental health problems receiving services: “are citizens whose human rights (should be) fully valued, respected and promoted”; and in Objective 4 that they are “entitled to respectful, safe and effective treatment.” At the social level, coercion is financially costly to health services and wider society. At the individual level, coercion is dangerous and can severely damage the therapeutic relationship between staff and patients.
What is your country’s stand on coercion reduction?
Following the example of other European countries, Greece, too, is trying to reduce coercion in the health care system., although such a topic remains a subject of utmost concern since the country’s psychiatric reform remains incomplete (Douzenis et al. 2014).
In Greece, the decision to commit a patient is regulated by Law 2071/1992 Article 96 Section 5, a legislation that concurs according to European standards. It encompasses two different routes for involuntary admissions: the “normal” and the “emergency” one. The former is rarely used and requires two separate psychiatric assessments by ‘approved’ psychiatrists to be completed before admission (Douzenis et al, 2012). More specifically, in clinical practice the observed paths related to involuntary hospitalization are the following: i) The “normal” one, with a direct order for involuntary hospitalization, where two psychiatric evaluations are required before admission, and are then submitted to the Prosecutor and the latter issues an order to the Police to locate and accompany the patient to a competent psychiatric facility. ii) The “normal” one, with a written order for involuntary examination, where in cases of inability to submit the necessary psychiatric evaluations, the applicant informs the police with a written statement, which is submitted with the pre-investigation material to the Prosecutor. Then, the prosecutor issues a written order to the police, who are called within 3 days to locate and accompany the person to an on-duty psychiatric clinic for involuntary psychiatric examination, during which the need for treatment is determined. In this case, the police accompany the patient and hand him over to the psychiatrists on duty at a public psychiatric clinic / hospital. The third one is iii) the “emergency” one, following an oral order for involuntary examination: In exceptional and extremely urgent cases, the prosecutor may receive information from the police on the basis of testimonies they have collected from relatives. An immediate verbal order is given (avoiding the bureaucratic procedure) to transport the patient to an on-duty psychiatric clinic / hospital for evaluation and investigation of the need for hospitalization. Lastly, iv) in cases where there are no relatives, the procedure is initiated ex-officio where the police are again ordered by the Prosecutor to locate and transport the patient to an on-duty psychiatric unit for examination. The ex-officio procedure is usually activated by the Police themselves, the EKKA (National Centre for Social Solidarity) but also by third parties. Then, after being informed, the Prosecutor orders the police to carry out the preparatory part of the procedure. The order can be given in writing or orally for exceptional cases. It’s important to note that this process can lead to further traumatization and stigmatization, due to the fact that police in some cases treat mentally ill patients as criminals, due to lack of appropriate training (Chatzisimeonidis et al., 2021). The maximum duration of involuntary hospitalization comes to 6 months. The public prosecutor requests medical reports at 3 and 6 months of hospitalisation, the latter in the rare instance that the patient is not discharged earlier (Douzenis et al., 2014). On this occasion, in-patient treatment lasts on average 4–6 weeks and the hospital discharge can take place whenever the responsible medical doctor decides that the criteria for involuntary admission are no longer met (Douzenis & Lykouras, 2008).
Theoretically, the law preserves human rights, but in practice a lack of resources renders the law’s application defective (Douzenis et al., 2014). The Greek mental health system remains fragmented, uncoordinated, and unstable. It is characterised by a shortage of community services and provides limited access and information to patients, parents and their carers about the existing interventions and services, as well as about their use (Chondros, 2015; Loukidou et al., 2013; Stylianidis et al., 2014). Additionally, the aforementioned defect in the law’s application and the prevalent use of restrained measures are maintained due to the limited continuation of care and coordination among mental healthcare services, especially in continuity of care between hospital-based and community-based services (Stylianidis et al., 2017). Other factors that may also explain the high rates of involuntary hospitalizations in Greece are relatives’ burden and limited knowledge on illness management and access to services (Chondros, 2015; Loukidou et al., 2013; Stylianidis et al., 2014). Also, unqualified mental health experts in the use of alternative measures, shortage of mental health professionals in hospitals, the maintenance of the dangerousness stereotype for people with severe mental illness, as well as an omnipresent paternalism in the conceptualisation and treatment of mental disorders in Greece (Ploumpidis, Garanis-Papadatos, & Economou, 2008), explain the high levels of involuntary admissions. Regrettably, the measure of involuntary hospitalization has ended up being a routine and the first-choice approach for those involved, a fact that reflects the wrong and inadequate application of the law.
In Greece there are no mandatory instructions, which are applied by all mental structures (Bilanakis et al, 2010). According to the Greek legislation, when restraining measures are necessary, they can be applied, although no explicit reference to the type of those measures is made in the relevant Article (Article 98, Law 2071/1992). In 2019, a public consultation took place for a reform of Involuntary Psychiatric Care (08-05-2019), proposing that restraining measures are not allowed, unless in exceptional cases when they are deemed necessary for the patient’s or others’ protection from impending or manifested self-destructive or heterocatastrophic behaviour and only the following can be enforced:
- Mechanical restraint;
- Physical restraint;
A significant lack of protocols and specific safety rules across psychiatric acute admission wards in Athens was revealed due to the minimum number of security features existing in the wards, such as intercom system, panic alarm in office, and an emergency response telephone extension. A variety of practices concerning banned items (including alcoholic drinks, medications, drugs, pens, knives, weapons, solvents, and flexes), as well as patient searches whether upon admission or upon return from leave (bag- pocket- body-strip search, check with fixed point or hand-held metal detector, patients’ bed space search, visitors search) (Koukia et al., 2010).
Other safety measures that are used in psychiatric wards in Greece are (Koukia et al., 2010):
- Bathrooms are kept locked when not in use;
- Taps/plugs are removed from bath;
- Plastic crockery, cutlery and glasses/tumblers are used instead or metal ones;
- The cleaning cupboard is locked;
- Patients do not have access to boiling water for making drinks;
- Cutlery is counted after use.
Especially, during the period of Covid 19 pandemic, the need for a reform in the mental health care system is vital. According to Stylianidis (2021), an inspiring initiative comes from the Italian mental health community, as presented in a relevant declaration entitled “Mental health care as recognition of the value of the individual and defence of democracy”. Similarly, other countries, such as Italy, Sweden, the United Kingdom, France, Australia and Canada, offer alternatives to compulsory hospitalisation which are less restrictive and allow for the patient to be treated outside hospitals (Chatzisimeonidis et al., 2021). Such alternatives are aligned with the legislation of each country, which authorises compulsory treatment in the community, instead of the hospital. Necessary is the shift of focus from the biomedical and pharmacological model and the sterile application of therapeutic protocols, which ignore the subjective suffering and the humanistic dimension, towards the protection of fundamental human rights of mentally ill fellow citizens. We are in the middle of an upcoming mental health pandemic, as an outcome of the population’s collective trauma (Stylianidis, 2021). The pandemic gives us an opportunity to change not only the public health system, but also the essence of psychiatric and psychological care, to humanize a barbaric and inefficient system. As stated in the article (Stylianidis, 2021), “Opportunities are always conquered, never given away”.
What kind of research is happening in your country on this topic?
In order to investigate the involuntary admissions in Greece, two large research programmes were launched. The frequency of involuntary hospitalizations in Greece is measured by Studies of Involuntary Hospitalisations in Attica region (M.A.N.A, 2011 – 2017) and in Greece in general (M.A.N.E., 2017 – 2020). These studies reveal that in the past decade, roughly 60% of hospitalized patients in the Psychiatric Hospital of Attica were admitted involuntarily (M.A.N.A.) (Stylianidis et al., 2017), while this percentage remains approximately the same for Greece generally (M.A.N.E.), where 57% of patients’ hospitalizations are made involuntarily by prosecutor’s order and in many cases with the use of restraining measures. According to M.A.N.A 69,8% of admissions were requested by relatives and 30,2% were requested by the police or directly by the district attorney. Furthermore, 55% of involuntary hospitalisations were attributed to reported aggression and 34,2% to discontinuation of pharmaceutical treatment (Stylianidis et al., 2017). These causes do not necessarily refer to psychopathological manifestations of the patients themselves, but they can often be attributed to the views held by the immediate family and social environment, as well as gaps in hospital care and the lack of continued care within the community (Chondros, 2015; Loukidou et al., 2013; Stylianidis et al., 2014).. Remarkable is the rapid rise in involuntary hospitalization rates reported after 2012. Specifically, the rates changed from 56,6% in 2012, to 63,5% in 2013, to 74,5% in 2014 (Stylianidis et al., 2020). Recent findings indicate that currently 97.2% of admissions are involuntary and done through the emergency route, where patients are brought at the hospital by police patrols and only 2.4% by National Emergency Aid Centre (Chatzisimeonidis et al., 2021). Critically, it appears that there are age group differences, so that younger individuals are more likely to be admitted involuntarily than older ones, and more likely to be hospitalized by the emergency procedure (Chatzisimeonidis et al., 2021).
Moreover, the ΜΑΝΑ study (Stylianidis et al., 2017) revealed that the diagnosis of unipolar depression was found to exert a protective effect against compulsory admission, whereas patients with psychotic spectrum disorders, organic mental disorders and bipolar disorder displayed similar odds of being involuntarily hospitalized. This finding reflects the Greek system’s incapacity to deal with severe and enduring mental illnesses, rendering compulsory hospitalisation as the only way forward. This is particularly alarming, that the quota of involuntary hospitalizations in Greece is particularly high, rendering the direct restrictions on patients’ human rights inherent in involuntary hospitalization. The aforementioned figures may not derive from institutional bodies, but offer an insight into the national data regarding involuntary admissions. Due to the pivotal position of the Psychiatric Hospital of Attica in the Greek mental health care system, those data are indicative of the process and underpinnings of compulsory admissions in Greece and are, thus, of high relevance at a national level. It’s worth noting that during the Covid 19 pandemic and particularly from April 2020 to March 2021 the quota of the use of compulsory psychiatric treatment has risen to 66,62%, despite the voluntary ones which comes to 33,38% .
Other researches (Douzenis et. al, 2010, Drakonakis et al., 2021) support the previous findings, suggesting that despite the new legislation, patients’ rights are still being violated, with a large percentage not only being persecuted against their will (87.5%), but also the police being present during their examination (58.1%). This finding is critical, if we take into consideration that the vast majority of patients did not offer resistance (82.3%). Only the 3,7% show serious resistance, behavior which leads to handcuffing or use of physical force (Douzenis et. al, 2010). Such policies may thrive not only due to the underdeveloped primary psychiatric care in Greece (Bowers et al., 2005; Karastergiou et al., 2005), but also due to the high rates of stigmatization of patients with serious mental illness (Economou et al., 2009) and their family’s reluctance to refer them to psychiatric services before the situation deteriorates (Douzenis et. al, 2010). Another cohort study (Drakonakis et al., 2021), investigating the relationship between the patients’ legal status (involuntary vs voluntary) and the outcome of their hospitalization 2 years after discharge. The findings indicated that 64.7% of patients were admitted involuntarily. Nevertheless, independently of their legal status, there was a statistically significant improvement in global functioning and symptomatology levels from admission to discharge for all treated patients. For involuntary patients the quota of readmission was higher than in voluntary patients (Drakonakis et al., 2021).
Recent national data collected by the Ministry of Health, follow the above trend, revealing that the total number of hospitalizations in hospitals that belong to the Hellenic National Health System, is estimated around 23.000 to 25.000 annually. In 2018 the involuntary admissions in Greece came to 8,366, in 2019 to 9,861 and during the first five months of 2021 to 3,728 (Hellenic Ministry of Health, 2021).
Why are you in the network? What would you like to achieve with it?
We, as a Greek team, joined the FOSTREN network for several reasons. A first objective was to acquire evidence-based experience and knowledge regarding the implementation of coercion measures in other member countries. Critically, a central aim of our participation is to explore best practices and sustainable strategies that facilitate the effective promotion of coercion reduction. The interaction with other Member States and the exchange of expertise, data, good practices and overall knowledge on the topic will allow the better and more holistic targeting of such a reduction in the imposed coercive measures. Greece, in particular, has a lot of challenging work to do in this regard and long-lasting changes in the mental health care system are of utmost importance. Therefore, we hope that we will sufficiently contribute to reaching these changes, raising awareness and to be confronted on the challenges brought by involuntary hospitalization and coercive measures in general. We strongly believe that FOSTREN constitutes an innovative network connecting specialized researchers and practitioners from various backgrounds across Europe and provides a unique opportunity of a multidisciplinary exchange of knowledge.
Is there anything else that you want to share with us?
The voice of individuals, who have experienced the application of restrictive and/or restraining measures during hospitalisation, is a critical aspect in understanding coercion and its implications on the individual. Patients’ narrations about the aforementioned experiences constitute a rich source of information that can be used in promoting such an understanding. A qualitative research exploring patients’ views about the rightfulness of compulsory admission, their experience of hospitalization and potential interventions for reducing its consequences in Athens, shows that raising awareness initiatives, adequate training of all involved parties, the integration of psychotherapy in the treatment plan, the creation of a therapeutic milieu and less coercive alternatives to acute psychiatric care were the course of action suggested by patients (Stylianidis et al., 2018).
The active participation of patients and their family in decision making could also contribute, as could the early intervention in critical cases and the promotion of community psychosocial healthcare, as ascertaining the continuity of care in the community after discharge from hospital is vital. Community mental health practices applied in Greece were developed as part of the process of psychiatric reform. The following are some examples that provide a supplement and/or alternative to classic treatment and can contribute to the reduction of coercion:
- Home intervention or Assertive Community Treatment (ACT) which is implemented at the EPAPSY Day Centre “Franco Basaglia”, at the Fifth Mental Healthcare District of Athens, is an intensive intervention programme in the community for people with serious mental conditions (usually schizophrenia or psychotic disorders (Krokidas et al., 2016). The programme may prove to be particularly effective in preventing repeated hospitalisations, by reducing not only costs but also the mental and emotional effect of hospitalisations, particularly after a court order for involuntary psychiatric assessment. Contrary to inpatient therapeutic practices which focus on a clinical model, ACT is more assertive and patient-oriented, trying to encourage patients to keep up with their therapy, in order a stability in the treatment effort and a continuity in the provision of services to be achieved (Stanhope and Matejkowski 2010 ; Phillips et al. 2001).
- Mental Health Mobile Units (MHMU): The main aim of these units is the logging of patients’ needs and the provision of timely diagnosis and interventions. MHMU not only offer psychological support, counselling and psychotherapy to adults, children and youths, but also schedules home interventions (Stylianidis et al., 2016). This action forwards the training of volunteers and the cooperation with the local authorities. Key principles are the deinstitutionalization, the conveyance of hospitals’ psychiatric care to communities and the defence of human rights. In Greece there are a number of Mental Health Mobile Units operating at several cities on the mainland and offering mental health services at islands of the Aegean and Ionian seas.
- Application of the Open Dialogue approach in community mental health services (Council of Europe, 2021) offers another opportunity to provide primarily outpatient care services. This practise is useful as an alternative to hospital because treatment takes place at a place familiar to the patient (usually their home), with the participation of the person’s network and at least two therapists. The dialogue takes place only in the presence of the network where all voices are equal and heard with respect. The application of Open Dialogue allows for a decrease in hospitalisations and a reduction in care costs as well as a substantial improvement in recovery rates, through effective coordination of existing services, promotion and dissemination of the availability and frequency of the use of services, and mobilisation of community resources. A pilot application of Open Dialogue is taking place since 2018, by an interdisciplinary team of mental health professionals, at the EPAPSY Day Centre “Franco Basaglia” (Skourteli et al, 2019; Skourteli et al., 2021; Stylianidis, 2019).
- Other actions that can enhance community mental health services are the creation of 24-hour crisis centers and early psychosis intervention units, which can strengthen the local community resources, aiming to minimize symptom relapse and involuntary hospitalizations (Sashidharan & Saraceno, 2017).
Some other suggested policies that can be promoted in order to reduce coercion are:
- A better operation of psychiatric emergency units and application of the rule for 48-hour hospitalization for monitoring, in order for the initial suggestion for involuntary admission to be reevaluated.
- Urgent need for the education of mental health professionals in de-escalation techniques in case of self-destructive behaviors by patients. They should also get informed of the medical complications following the coercion measures and ensuring the safety and dignity of patients (Alevizopoulos et al., 2017).
- Creation of 2-3 pilot-sectors with full-scale operation of services with continuous external evaluation, education of professionals, and scientific validation of practices, on a 3-year trial period.
- An updated and more accurate application of thenew legal framework for involuntary hospitalizations.
- Police, which is the first responder for the prosecutor’s order, should be appropriately trained from mental health practitioners (Chatzisimeonidis et al., 2021).
- The need for patients to be transferred by ambulance, instead of patrol cars is imperative, in order to shift the centre of gravity from repression to care and promotion of patients’ rights.
- Above all, the Greek mental health care system should be amended to include more humanistic and patient-centered approaches, which are inclusive, and community based.
FOSTREN’s first steps in Greece
- All Primary Care Mental Health and Psychiatric Units of Greece have been informed about the project, its objectives and the ways in which they can contribute to the enhancement of the network and to the dissemination of relevant material.
- The creation of the Greek FOSTREN Blog, which is available in both English and Greek: https://fostren.eu/blogs/
- The creation and use of social media for raising general public awareness regarding involuntary hospitalizations and the use of coercive measures in general and for dissemination of the goals and actions of the FOSTREN network in Greece, specifically. You can stay informed about FOSTREN’s actions and contact us through:
a. E-mail: firstname.lastname@example.org
b. Facebook: Fostren-Greece: Fostering and Strengthening Approaches
c. Twitter: @fostren