Controversial views on psychiatric care practices

Whether voluntarily seeking mental stability or forcefully incarcerated, the patients in Dutch psychiatric care facilities face a very different daily life than those on the outside. But in one care centre, patients say conditions are unacceptable. JOEP DERKSEN investigates their claims only to discover institutionalised care is difficult for everyone involved.

Shadowy practices seem to be taking place at Spaarnepoort, the closed department psychiatric care centre GGZ inGeest (please define GGZ) in Hoofddorp. Patients complain that they are forced to take medication and that they are locked-up in a solitary cell for periods that can go longer than a week. Also, inhabitants use illegal drugs on a regular basis. The people who live in this closed department, are experiencing temporary confusion and looking to improve their mental health. Sometimes admission is forced upon them so that they can be guided into a better life in which they can independently function in the society. Until that time comes, liberties are severely restricted.

Upon admission, patients are often first placed in an isolation cell. Their time there can last anywhere from a few hours to stretches of up to eight days. As soon as patients are allowed to leave the isolation cell, they find that everyday life in this institution is no laughing matter. All of the centre's rooms look exactly the same and contain a bed, nightstand and closet. A table and office chair can be found in the one corner and, in many cases, patients are not allowed to watch television. The entire building has one recreation room and two dining rooms. A patient's stay in the care centre can vary between a few days to more than three years. During that time, liberties can be built up. These can include a few hours on the Internet or even outside access. Patients without these liberties can only admire the sun and clouds from the patio; an open space without a roof located in the centre of the institution.

Darker side

It sounds like the average psychiatric institution environment, but John and Simon* reveal a darker side to life at GGZ inGeest. “Fights happen on a regular basis and fellow-inhabitants abuse each other,”says John. He says he has informed supervisors that there is need for camera surveillance and that certain patients should be guided and watched more intense. But he says there is another reason for worry. Patients are sometimes forced to take medication; a severe breach of the physical privacy. “Without any clear explanation people are heavily sedated with Haldol and this often happens before a court case takes place. Because of the Haldol, patients are not able to make their point in front of a judge,” John says. Because patients can be forcefully placed in the institution, there is often the possibility to appeal that decision. In these cases, a judge visits the centre and a trial takes place on site.

However, Simon says that some patients are intentionally drugged by their psychiatrist beforehand. He or she is then further confused, and a judge inevitably extends their stay in the facility. “Some of us did not even know that the man in front of us was a judge,” says Simon. “This injecting of people is equal to practices in the Second World War. The medical staff can do whatever they want.”

A maximum of 18 patients resides at Spaarnepoort, among which are four drug addicts. These patients create extra problems, say John and Simon, because they use all options to obtain their shot of coke or drag of hashish. One of them has escaped for seven times already, Simon informs. “And no measurements are taken to stop this.” When the addict returns, he smuggles drugs into the institution, “in his wallet, pants or underpants.” Both John and Simon have had enough of these unacceptable conditions and call out to the media to let people know of these mishaps.

Claims

Indeed, these claims are largely confirmed by GGZ inGeest officials. Because of professional courtesy, communication adviser Gert de Jager cannot answer any questions regarding individual problems, but he does support claims that drugs are being smuggled inside the clinic. He also confirms that separation, or isolation, practices are is used when needed for example when a patient is unruly or refusing treatment. At least two times, patients have been put in isolation for eight days. De Jager says that no laws have been broken in doing this. “In applying separation, GGZ inGeest is following legal procedures. In an acute emergency situation, separation can be applied for a period of a maximum of seven days. When there is still danger, a longer period of separation is necessary.”

According to the Bijzondere Opnemingen in het Psychiatrisch Ziekenhuis (Bopz, Special Admissions in the Psychiatric Hospital) laws, there is no maximum term for isolation periods. After the seven day period, however, doctors and the centre's director judges whether separation should continue. This is the case when a patient poses a threat to the department which cannot be curtailed in any other way. “When all alternatives have been tried and failed, separation is the one and only way to protect the patient and his environment, the fellow patients and the employees,” says De Jager. Locking patients in an isolation cell occurs much less than it did a few years ago. This is largely due to a project called Compulsion and Pressure wherein separation rooms were shut down and employees were trained in de-escalation.

De Jager acknowledges that there may be some truth to John and Simon's claims that illegal drugs are used within the institution. “Within all clinics of GGZ inGeest, therefore also at Spaarnepoort, we have an active policy of keeping the departments free of drugs. Special house rules have been set up for this, which the patients have to read when being incarcerated. However, a psychiatric clinic is not a prison. We strive for a humane climate, without too much repression. When patients recover from their acute crisis, it is therefore common use to provide them with liberties outside the clinic. In these situations, drugs may enter the clinic, despite solid understandings and supervision.”

Tamper

However, De Jager denies the suggestion that medication such as Haldol is forced on patients. He further disagrees with the idea that this is intentionally done to tamper with court cases. “This is not true. According to the law and strict conditions forced medication, such as Haldol, can be used with patients who are being held against their will. This has nothing to do with the time period before a court case takes place.”

Haloperidol is a typical antipsychotic. It is in the butyrophenone class of antipsychotic medications and has pharmacological effects similar to the phenothiazines. Haloperidol is an older antipsychotic used in the treatment of schizophrenia and, more acutely, in the treatment of acute psychotic states and delirium. A long-acting decanoate ester is used as a long-acting injection given every 4 weeks to people with schizophrenia or related illnesses who have a poor compliance with medication and suffer frequent relapses of illness, or to overcome the drawbacks inherent to its orally administered counterpart that burst dosage increases risk or intensity of side effects. In some countries this can be involuntary under Community Treatment Orders.

Potent

Haloperidol is an antipsychotic butyrophenone. Due to its strong central antidopaminergic action, it is classified as a highly potent neuroleptic. It is approximately 50 times more potent than chlorpromazine (sold under the brand name Thorazine, among others) on a weight basis (50 mg chlorpromazine is equivalent to 1 mg haloperidol). Haloperidol possesses a strong activity against delusions and hallucinations, most likely due to an effective dopaminergic receptor blockage in the mesocortex and the limbic system of the brain. It blocks the dopaminergic action in the nigrostriatal pathways, which is the probable reason for the high frequency of extrapyramidal-motoric side effects
The drug is well and rapidly absorbed and has a high bioavailability. Plasma-levels reach their maximum within 20 minutes after injection. The decanoate injectable formulation is for intramuscular administration only and should never be used intravenously. The bioavailability is 100% and the very rapid onset of action is seen within seconds. The duration of action is 3 to 6 hours. If haloperidol is given as a slow IV infusion, the onset of action is slowed, and the duration prolonged.

De Jager says that one of the centre's patients has indeed escaped - seven times. He does this in any way possible, for example by lighting his coat on fire. In doing this, smoke detectors sound the alarm and all doors open automatically, thus giving him an opportunity to escape. A few hours later he returns, and is under the influence.

De Jager says that measures are taken to prevent this from happening and that security is on hand to keep unauthorised patients from leaving the facility. “Yet, the climate at the department and inside the buildings should not resemble a prison. Besides, according to the fire safety rules, all clinic doors should open immediately when a fire alarm sounds. Because of this, we cannot provide a 100% guarantee that patients will never leave on their own initiative,” he says.

Furthermore, special measures are taken to prevent the most disturbed patients from escaping. “Patients who are so confused that they are being held against their will are nursed on a closed department,” he explains. “The medical staff of that department is informed of the liberties of each patient and keeps track of who.”


* To protect the persons involved, their real names are only known by the writer