Written by Juš Škraban
What is your country’s stand on coercion reduction?
In Slovenia, institutional capacities in the field of mental health are divided into health and social care sector. According to the Mental Health Act (1) in Slovenia there are two types of units which are locked, namely locked acute psychiatric units and secure units in social care institutions. The first is designed for acute treatment and the second is aimed at providing care for users who do not need acute psychiatric but continuous social care treatment. Admission to the acute and secure unit can be voluntary or not, but regardless of it the door remains locked for all. Involuntary placement to both types of locked units can be done only when justified in the process before the court. In both types of units “special protective measures” can be applied. These include the use of seclusion room and mechanical restraint.
Slovenia does not have a strategy, or a programme aimed at reducing coercion. Quite on contrary, there have been some steps to enable further use of coercion. Namely, a new locked forensic psychiatric unit was opened in 2011; a new locked adolescent psychiatric unit was built in 2019; there have been some infrastructural investments in secure units in 2020 etc. The recent proposal of amendment of the Mental Health Act aims to increase the number of beds in secure units since existent secure units are overcrowded.
In 2018, Guidelines for the use of special protective measures in psychiatry were issued (2). Although the documents states that seclusion and mechanical restraint are “last resort”, it does not contain any guidelines of reduction of coercion.
Currently, there are two social care institutions in a project of deinstitutionalization. One of them has a secure unit and the plan of transformation to community-based services encompasses the whole institution, including the secure unit. Additionally, a national strategy of deinstitutionalization is being written. It will encompass social care (not psychiatric) institutions and will possibly also include transformation of secure units into community-based services which would reduce coercion for some people in long-term care.
What kind of research is happening in your country on this topic?
Possibly the first article about the topic is authored by two Italian psychiatrists, Bruno Norcio and Lorenzo Toresini, and entitled “Epidemiology of involuntary psychiatric admission in the Alpe-Adria region” (3). They presented some differences in national legislation related to forced hospitalization and undertook a survey in three locations (in Italy, Slovenia, and Austria). The first part of survey was related to sociodemographic information; the second was related to diagnosis, reasons for admission, who accompanied patients for admission etc.; and the third was related to the type of ward one was admitted to, duration and kind of treatment and continuation of treatment after discharge.
Another research article analyses involuntary admissions in male unit of Begunje psychiatric hospital in the year of 1993 (4). The author first shows the percentage of unvoluntary admissions related to all admissions (4,34%) and different categories of involuntary admission. He analyses the data also regarding prior history of admissions, reasons for involuntary admission, diagnosis upon admission, type of applied psychiatric medication, patient’s state when discharged, patient’s collaboration in outpatient care etc. The author, finally, expresses his concerns that newcoming legislation should not overemphasise human rights to detriment the right to healthcare.
Another, more recent article analyzes involuntary admissions in Vojnik psychiatric hospital in the year of 2006 (5). The authors find that 9,5 % of all admissions were involuntary. They analyse if admission was a posteriori justified by court or not, if patients were taking medication prior to admission, what was their diagnosis, the rate of aggression and under the effects of psychoactive substances etc. As authors are both medical and legal experts, they conclude that courts’ decisions about unjustifiable involuntary admission usually leads to a higher rate of re-hospitalization and poorer clinical outcome.
The next study is, possibly, the largest study of the kind to date (6). The authors review records for a 5-year period regarding involuntary admissions to Department of Psychiatry of the Maribor University Clinical Centre. They find that 2% of all admissions were involuntary. They furthermore analyse the number of involuntary admitted patients by gender and diagnosis per year etc. They conclude that there is the need to reduce involuntary admissions and that to achieve the objective, strong community services are needed.
There has been also a naturalistic observational study conducted at the University Psychiatric Hospital in Ljubljana (7). The authors evaluate the differences between patients managed with net-beds and patients managed with bed-belts, since the use of net-beds were substituted with the use of bed-belts in 1999. They find out that the use of bed-belts was reduced in comparison to the use of net-beds, and they suppose that it was so due to changes in the availability of coercive measures.
The most recent article from Slovene psychiatrists related to coercion (8) differs from the others in at least two ways. First, it does not contain their own research, but it provides a short review of the topic. Second, it also contains some information about initiatives aimed at reduction of coercion and concludes that it would be sound to introduce interventions to reduce coercion in psychiatric practice in Slovenia.
In the field of mental health, seclusion and restraint can be used also in special social care institutions. However, there is almost no data regarding the use of coercion in these institutions. One of the few studies is written by social worker Breznik (9) who was employed in the biggest special social care institution in Slovenia, Hrastovec. The institution decided to close one location (a castle Cmurek) in 2004 and resettled around 200 residents into community. Breznik research was accompanying the transition from medical to social model of care, especially related to crisis resolution. She compared, among other things, the rates of the use of seclusion room before and after the transition and found out that after the social model was applied, the reduction of seclusion episodes was 82%.
From social care sector, the research on reducing coercion is scarce and more narratively oriented. In one article (10), abolishment of the use of seclusion room in a special social care institution Dutovlje is presented.
It can be observed that most of the research papers were issued before the Mental Health Act was approved in 2008. Most of the research is based on data from one institution (most of the research regards psychiatric hospitals). It must be pointed out that most of papers also lack a critical stance towards coercion and contain neither any information about the need of reducing it or information about initiatives aimed at doing so.
Why are you in the network? What would you like to achieve with it?
While working on reducing coercion in Slovenia, I feel the need to obtain an insight of similar attempts abroad. I am convinced that these attempts can be successful only if achieved in strong coalition and teamwork.
- Zakon o duševnem zdravju: http://www.pisrs.si/Pis.web/pregledPredpisa?id=ZAKO2157
- Novak Grubič, V., Bon, J., & Novak Šarotar, B. (2018). Priporočila in smernice za uporabo posebnih varovalnih ukrepov v psihiatriji: http://www.zpsih.si/media/documents/PVU2018.pdf.
- Norcio, B., & Toresini, L. (1994). Italijanski zakon na področju psihiatrije: primerjalna analiza z zakoni na območju Alpe-Jadran. Socialno delo, 33(3), 185–188.
- Žmitek, A. (1995) Pregled neprostovljnih hospitalizacij Na moškem oddelku Psihiatrične bolnšnice Begunje v letu 1993. In: Janez Romih & Andrej Žmitek (eds.), Dileme ob neprostovoljni hospitalizaciji. Begunje: Psihiatrična bolnica Begunje. Pp. 66–74.
- Korošec Jagodič, H., Korošec, B., Lajlar, D., Winkler, V., Novak, V., Jagodič, K., & Pintarič, L. (2008). Hospitalizacija brez bolnikove privolitve. Zdravniški vestnik, 77(4), IV-45-IV-49.
- Turčin, A., & Kores Plesničar, B. (2008). Sprejem in zdravljenje brez privolitve na oddelku za psihiatrijo UKC Maribor. Zdravstveno varstvo, 47(3), 137–142.
- Tavčar, R., Dernovšek, M. Z., & Novak Grubič, V. (2005). Use of Coercive Measures in a Psychiatric Intensive Care Unit in Slovenia. Psychiatric Services, 56(44), 491–492.
- Kokalj, A., Rus Prelog, P., & Kores Plesničar, B. (2017). Sprejem brez privolitve in uporaba posebnih varovalnih ukrepov v psihiatriji. ViceVersa, 63, 30–34.
- Breznik, I. (2005). Obravnava kriznih stanj v Zavodu Hrastovec – Trate nekoč in danes. (Specialistična naloga). Fakulteta za socialno delo, Ljubljana.
Flego, M., Sorta, H., & Orel, K. (2012). Proces dezinstitucionalizacije in odprava prisile v posebnih socialnih zavodih: Primer Socialno varstvenega zavoda Dutovlje. Iz-hod iz totalnih ustanov med ljudi, Časopis za kritiko znanosti, domišljijo in novo antro