ENUSP: Comment to: “Quality Assurance in Mental Health Care, Draft. Human Rights of People with Mental Disorders”, WHO 1997; publication of the comment in worked-over form: “Forum – The Declaration of Madrid and current psychiatric practice: users’ and advocates’ views”, in: Current Opinion in Psychiatry (1999)
“Quality Assurance in Mental Health Care, Draft. Human Rights of People with Mental Disorders”
To:
WHO
Dr. J.M. Bertolote
Mental Disorders Control
CH-1211 Geneve 27
April 24, 1997
Comment to: Quality Assurance in Mental Health Care, “Draft. Human Rights of People with Mental Disorders”, WHO 1997
All fat-printed words and sentences should be added resp. changed. This would optimize the quality assurance in the psychiatric/psychosocial field.
National Legislation
1. There is national legislation concerning the respect of human rights of people with mental disorders and their relatives. The national organizations of (ex-)users/survivors of psychiatry should be invited to hearings before laws are passed.
5. There is legal mechanism whereby any decision involving involuntary treatment of hospitalization is automatic and periodically reviewed by a competent body. No decision should be made without the consent of the national organizations of (ex-)users/survivors of psychiatry.
7. Every person with a mental disorder or who is said to have a mental disorder has the right to exercise all civil, political, economic, social and cultural rights recognized in the Universal Declaration of Human Rights and other UN documents.
Monitoring Bodies
8. There is an ombudsman/ombudswoman who should be an (ex-)user/survivor of psychiatry at the national level.
9. There is a body including (ex-)user/survivors of psychiatry specifically charged, at the national level, with monitoring the respect of human rights of people with mental disorders or who are said to have mental disorders. The task of this body should include the registration of new treatment measures and decisions of ethics’ comissions in research fields.
11. The national psychiatric association (college/board) has a section particularly dedicated to human rights. No decision should be made without the consent of the national organizations of (ex-)users/survivors of psychiatry.
12. The national association (college/board) of psychologists has a section particularly dedicated to human rights. No decision should be made without the consent of the national organizations of (ex-)users/survivors of psychiatry.
13. The national association (college/board) of nurses has a section particularly dedicated to human rights. No decision should be made without the consent of the national organizations of (ex-)users/survivors of psychiatry.
14. The national association (college/board) of social workers has a section particularly dedicated to human rights. No decision should be made without the consent of the national organizations of (ex-)users/survivors of psychiatry.
15. The national association (college/board) of occupational therapists has a section particularly dedicated to human rights. No decision should be made without the consent of the national organizations of (ex-)users/survivors of psychiatry.
15a. As a form of monitoring (ex-)users/survivors of psychiatry have to be involved in the education (including the boards of examiners) of psychiatrists, physicians, psychologists, nurses, social workers, occupational therapists on a well-payed level.
Equity and Access to Treatment
18. At least 20% of all psychiatric beds are located in general hospitals. For every psychiatric bed there should be one bed in an anti- or nonpsychiatric run-away-house. Each second psychiatric bed has to be placed in a Soteria-like institution.
21. Sterilization, abortion or any treatment that can be harmful for the patients’ (future) children are never carried out on people with mental disorders or who are said to have mental disorders against their will.
22. Psychosurgery and other intrusive and irreversible treatments such as psychiatric drugs, electro- and insulinshock for mental disorders are never carried out on an involuntary patient and without informed consent. To make declarations-in-advance safe they should be acknowledged explicitly. Treatment agreements should be possible too. Psychiatrists who treat without informed consent should lose their medical approbation.
23. Clinical trials and experimental treatments are never carried out on an involuntary patient without informed. The institutions and persons carrying out these measures are obliged to prove that possible damages are not due to these measures.
24. Essential psychiatric drugs are easily and quickly available to all those who want them.
26. There are written guidelines/norms on quality assurance of mental health care. These guidelines/norms require the consent of the national organizations of (ex-) users/survivors of psychiatry.
Specific Facilities
27. There are appropriate facilities for the treatment of criminal offenders with mental disorders or who are said to have mental disorders. Treatment should include nonpharmacological measures such as psychotherapy.
28. There are appropriate facilities/services for the treatment of children/adolescents with mental disorders or who are said to have mental disorders. Treatment should include nonpharmacological measures such as psychotherapy.
29. There are appropriate facilities for the treatment of the elderly with mental disorders or who are said to have mental disorders. Treatment should include nonpharmacological measures such as psychotherapy.
30. At any given facililty, the space (treat & recr) is sufficient for the number of inmates/patients admitted. There should be phones-boxes for inmates/patients in each psychiatric ward. There should be easily visible coin-operated telephones at the entrance halls of each psychiatric institution. In each psychiatric ward should be an easily visible notice, that inmates/patients can get writing-paper, envelopes and stamps if wanted. There are notice-boards in every ward, on which local, regional and national organisations of (ex-)users and survivors of psychiatry can put up uncensored information. For each inmate/patient there should be the offer to have a daily walk in the open air for at least one hour. On each ward should be a kitchen where inmates/patients can prepare food and drinks around the clock. The nonsmokers’ right to have good air to breathe is guaranteed. The smokers’ right to smoke as long as they want is guaranteed too.
32. Meals served to inmates/patients meet recommended minimum nutritional requirements. The needs of people who want special diets have to be met.
33. Staff speak frequently to inmates/patients and always in a friendly, positive and courteous manner. On request staff should remain silent and leave inmates/patients alone.
34. Written records are appropriately maintained for all inmates/patients, who are entitled to access their own records at any time and without justification. Copies of records should be available. Inmates/patients should have the right to revise records or to add commentaries.
38. Help and support are made available by staff to family members who want them.
For the European Network of (ex-)Users and Survivors of Psychiatry
Peter Lehmann
Commentary to: WHO Quality Assurance in Mental Health Care: “Draft. Human rights of people with mental disorders” (1997)
We list here some remarks and points that should be added, in our opinion, to the Declaration of Madrid.
Psychiatrists have to reflect that their measures can only suppress ›symptoms‹ with medical methods because treated persons regularly suffer from emotional problems of social nature and not from bodily diseases. To call all subjects ›infirm‹ is libellous.
To base ethical behaviour on the psychiatrist’s individual sense of responsibility allows him or her to act arbitrarily. Ethical psychiatric behaviour should be based primarily on the treated person’s individual ethic, on the Universal Declaration of Human Rights and other United Nations documents, especially the right of freedom from bodily harm, and on the civil and criminal law.
At any given facility, there should be sufficient space for the number of inmates or patients admitted. There should be phone boxes for inmates or patients in every psychiatric ward. There should be easily visible coin- operated telephones at the entrance hall of each psychiatric institution. In each psychiatric ward there should be an easily visible notice stating that inmates or patients can get writing paper, envelopes and stamps if wanted. There should be notice boards in every ward on which local, regional and national organisations of (ex-) users and survivors of psychiatry can put uncensored information. For each inmate or patient there should be the offer to have a daily walk in the open air for at least 1 h. On each ward there should be a kitchen where inmates or patients can prepare food and drinks around the clock. The nonsmokers’ right to have good air to breathe should be guaranteed. The smokers’ right to smoke as long as they want should also be guaranteed. Meals served to inmates or patients should meet recommended minimum nutritional requirements. The needs of people who want special diets should be met.
Psychiatrists should provide not only relevant information to empower individuals to make a rational decision; they should give all information about the risks of treatment which are possible and not to be excluded.
It should be acknowledged by psychiatric associations and/or by reforms of the law that advance directives (made during non-doubted states of normality) about wanted and unwanted treatments have to be respected.
Psychiatrists who treat without informed consent should lose their medical approbation. The national psychiatric associations should have a section particularly dedicated to human rights. No decision should be made without the consent of national organisations of (ex-) users and survivors of psychiatry.
(Ex-) users and survivors of psychiatry should be involved in the education (including the boards of examiners) of psychiatrists meaningfully and on a well paid level. Organisations of (ex-) users and survivors of psychiatry should be acknowledged as organisations of individuals with a high level of expertise. There should be ombudsmen and ombudswomen who are (ex-) users and survivors of psychiatry at national levels.
There should be bodies including (ex-) users and survivors of psychiatry specifically charged, at national levels, with monitoring the respect of human rights of people with mental disorders or who are said to have mental disorders. The task of these bodies should include the registration of new treatment measures and decisions of ethics’ commissions in research fields. Help and support should be made available by staff to family members, friends and persons of trust.
Treatment, if ethical, should be primarily based on nonpharmacological measures such as psychotherapy. Psychosurgery and other intrusive treatments which may possibly cause irreversible damage, such as psychiatric drugs, electro- and insulin shock treatments, should never be carried out on an involuntary inmate or patient without informed consent. Sterilisation, abortion or any treatment that can be harmful for the inmate’s or patient’s (future) children should never be carried out on people with mental disorders or who are said to have mental disorders.
Clinical trials and experimental treatments should never be carried out on an involuntary inmate or patient without informed consent. The institutions and persons carrying out these trials should be obliged to prove that resultant damage is not a result of these measures.
Information obtained in the treatment relationship should principally be kept in confidence. Written records should be appropriately maintained for all inmates and patients, who should be entitled to access their own records at any time and without justification. Copies of records should be available. Inmates and patients should have the right to revise records or to add commentaries.
Peter Lehmann, Chair, European Network of (ex-) Users and Survivors of Psychiatry