Tuesday, 11 November 2008

Coercion in the mental health system - A Norwegian documentary

On October 28th 2008 the Norwegian television station NRK 1 broadcasted the documentary "Tvang i psykiatrien" (Coercion in the mental health system) in the series "Brennpunkt" (Focus). The program can be watched here (in Norwegian language).

In the program two young women, Kristina and Hege, tell about their experience with commitment and coercion in the Norwegian mental health system. The thought that immediately came to my mind after watching the program was: 'Grotesque'. While I, at the same time and once again, hardly could believe my own luck.


Kristina S. Larsen's first experience with psychiatry occurs after she has been assaulted physically and, as a result of this, loses the child she at the time is pregnant with. She says, that what she herself felt she needed, was to be listened to, a calm and safe environment, and her feelings being acknowledged as real enough.

Around Christmas 2007 her mother notices that Kristina becomes more and more stressed, doesn't sleep well, and loses her appetite. Kristina is committed to a psychiatric hospital where she is assessed as being in need of "protection" - "protection" and "protected unit" are euphemisms for seclusion, while there officially is no such thing as seclusion in the Scandinavian mental health system - to "calm down", as her psychiatrist says.

Kristina describes the situation as extremely humiliating, especially being forcibly drugged, and not knowing when she'd be allowed to leave. She says, the only way to get a somewhat tolerable stay at the hospital was to not get angry,not criticize, not cry, not show any emotions, and to just please the staff. "These people act as if they are gods. They may define, they may judge, and no one can in any way re-examine what they say and do", she says.

After some time at the "protected unit", Kristina is moved, only to be sent back into "protection" shortly after again, because she, according to her psychiatrist, has a very "unfavourable influence" on the other patients at the unit, whom she makes refuse to take their drugs.

In March 2008, after two and a half months at the hospital, Kristina is discharged, but is now under outpatient commitment referred to the community mental health system. She asks for a female therapist, preferably with some experience in treating women who have experienced violence and the loss of a child due to spontaneous abortion. She is referred to a young male psychiatrist in training, who hasn't much understanding for her situation, and whom she often becomes angry with. In July 2008 the therapist assesses, that Kristina isn't angry with him, but "hypomanic". He contacts her psychiatrist at the hospital, and they decide that Kristina would have to go back to the hospital, since another "episode" seemed to be on its way.

Kristina's mother arranges for her to escape and hide at Store Torungen Lighthouse Station. The lighthouse keeper says, there were no problems with Kristina whatsoever during her stay. On the contrary, she was cooking, making coffee, and easily socializing with the people in the community.

Meanwhile, her psychiatrist chooses to see her escape as a "sign that her ability of decision making is rather poor. She could have come here, and proven that she was sane, and left again. But she chose not to show up. I experienced this as poor ability of decision making. And it is typical for these episodical diseases that the ability of decision making deteriorates."

Three weeks after her escape, Kristina's mother succeeds to arrange a meeting between her, Kristina and the psychiatrist. On neutral ground. Kristina, of course, refuses to go and talk to her psychiatrist at the hospital as long as the court order for her commitment is effective. "You never know what these people can imagine to do", she says, while she attentively watches the parking lot where her mother is waiting for the psychiatrist. He, nevertheless, arrives alone, and after a one and a half hour long meeting at a nearby hotel, he agrees to lift the commitment order for Kristina if she is willing to stay in touch with the community mental health system and see a therapist.


The other woman in the documentary is Hege J. Orefellen. In summer 2003 Hege has been in contact with Folloklinikken, a community mental health facility under Aker University Hospital, for a shorter period because of emotional problems. - Interestingly, at the top of the website the terms "openness", "community", "respect", and "involvement" appear in turns. Well, just a - somewhat funny - observation. - Hege, whose baby daughter suffers from a rare condition, and is very dependent on Hege breast feeding her, is not minded to take psychiatric drugs, and wants to end her regular talk sessions at Folloklinikken.

The 3rd of July 2003, while Hege is preparing to go to university to discuss her thesis with her supervisor, she receives a phone call from Folloklinikken and is told, that if she doesn't show up at the clinic within an hour, they'll send the police to come and pick her up. After consulting her GP about the matter, Hege, who feels clearly threatened by the phone call, and says, just as Kristina, that no one knows what these people might imagine to do, decides to go "voluntarily" to the clinic, still convinced, that she'll be able to leave as soon as she has made sure, that she isn't in any need of "treatment". What she doesn't know is that the psychiatrist at Folloklinikken assesses her to suffer from "major depression" and to be "a danger to herself", "acutely suicidal".

Hege says about the conversation: "I realize then, that my words don't count anymore. No matter what I may say, it is of no importance." She is denied permission to call her partner or her GP, and is referred to Blakstad hospital, where another psychiatrist is to assess her within 24 hours, and confirm that she is acutely suicidal in order to keep the commitment order effective. At Blakstad hospital Hege, who according to the psychiatrist at Folloklinikken is acutly suicidal, is asked to wait in a kind of workroom, with scissors, glue, paint, and lots of other stuff that easily could be (ab-)used to commit suicide...

At night, Hege writes a complaint to the control commission at Blakstad hospital: "I write this complaint, hoping that someone might see what a commitment can do to an individual. My story is long, but the way here to Blakstad is terrifyingly short. I admit, that I was in need of help and support, but instead I got a traumatizing commitment."

The next day, the psychiatrist at Blakstad assesses Hege as not suicidal, and she is discharged. Since she hadn't been under commitment for more than 24 hours, her stay at the hospital is registered as "voluntary".

Hege decides to sue Aker hospital for violation of human rights, illegal loss of liberty, and violation of family and private life, in regard to the threatening information she was given in the initial phone call from Folloklinikken, and wins in court.

The commitment procedure has left Hege with a deep feeling of insecurity towards both the health system, telephone calls, and the police, and a couple of months after she is discharged from Blakstad, while passing by a police station on her way to her GP, there's a turn-out that provokes an anxiety-attack in Hege. Her GP gives her a couple of valiums and a prescription for more. Hege isn't quite happy to take the valiums, as she isn't happy to take psychotropic drugs at all, since she has experienced adverse drug reactions before, but agrees to take them anyway. The valium causes an adverse reaction. Hege doesn't recall anything from the time period after she left her GP's office until next day, when she recovers her senses at Moss hospital. She learns, that she has been to a pharmacy and bought the prescribed valium, which she then took altogether.

Moss hospital has Hege assessed by a psychologist while she still is under the influence of the valium - she doesn't recall the conversation with the psychologist either - and the psychologist evaluates that she should be sent to Blakstad psychiatric hospital. At Blakstad hospital, Hege is asked to give up her cell phone which she denies as it is her "last lifeline to the outside world", as she says. The alarm goes, and Hege is violently thrown to the ground by four staff members, her arm twisted around onto her back, and the phone pulled out of her hand, with her fingers getting sprained. The whole incident only takes a few seconds, and Hege says, she didn't even get what was happening to her, and only felt extremely trampled on.

"The first three days at Blakstad were a downward spiral for me, psychologically seen", Hege says. "I can't stand further commitments, I can't stand further assaults. I won't be able to cope if they do implement involuntary drugging, I won't be able to cope if they do implement electroshock, I won't be able to cope with further interventions against me now. I reached a point where ending my life was the only solution. But it wasn't a solution anyway, because I could never have done that to my child."

Also this time, Hege complains to the control commission. At a meeting with the commission on the sixth day of her hospital stay, the commission evaluates her as neither depressed nor suicidal at all, and she is discharged.

Hege, who holds a doctorate in chemistry, went to law school after her experiences with human rights violations in the mental health system, and specialized in human and patient rights. She is active in the user/ex-user/survivor movement, and a member of MindFreedom International.

Accidentally, I came across Sørlandet hospital's reaction to a statement by Hege from 2005, quoted in a Norwegian newspaper, that says that one of the main reasons for people to commit suicide are the mental health system's "own suicide-triggering mechanisms". A statement, clearly based on her own dehumanizing and humiliating experience. Of course, the staff at Sørlandet hospital "believe[s] that Hege Orefellen is wrong to theorize" this. I believe - also from my own (even though only hypothetical) experience - she is right on. My plans in case of a possible commitment were quite clear to me.

Some thoughts about the documentary

There are several things, I found noteworthy about this documentary. First of all the striking difference between Kristina's experience of herself, her situation, and her needs, on the one hand, and the "expert's" perception of her and her needs on the other. While Kristina says, that what she felt she needed most was someone to ask her what had happened to her, that made her react the way she did, and while she, additionally, expresses that she didn't feel any whatsoever need for "protection" (isolation), or to be "medicated" into a consciousness erasing, mental fog, the "expert" states, that he couldn't "expose" Kristina to the "strain" a dialoge with her at the time of acute crisis in his opinion would have been. "Kristina was asking for dialogue. That's right. But during the acute phase, I don't work with dialogue but with treatment to stabilize", the "expert" says. "And when an individual is stable, then the intention is, that dialogue, accordingly to what Kristina is asking for, treatment of her psychological traumas, becomes relevant. Because this in itself, being treated for psychological traumas, is a strain. I can't put strain on someone in an acute phase."

I wonder how it is, that this "expert" doesn't seem to realize how much more straining it can be for an individual in acute crisis to be denied his/her most vital need, the need to come to an understanding of him-/herself through dialogue, to be met, than a dialogue in itself ever could be. And I wonder, if we also here have projection being at work, to be understood in the way that a dialogue with Kristina first of all would have been straining for the "expert", and not for Kristina.

As far as I myself am concerned, the need for dialogue, for being listened to, became overwhelming at periods of crisis. And that I certainly not am an isolated case, this experience can serve as a good example for. In principle, I guess, everyone has at some point in their lives had the opportunity to observe that the more overwhelming an experience is, the greater the need to come to terms with it - through expressing one's feelings about it in words, terms, through a dialogue with another human being - becomes.

It sometimes seems to me like there's a short circuit happening in the thinking of people, especially in that of the "experts": On the one hand it is acknowledged, that people who've had an overwhelming experience need to talk it through, and crisis intervention is offered. But as soon as the overwhelming experience, on the other hand, isn't immediately understandable for one's surroundings, the reaction to it is defined as "sick", the reacting individual as having a brain disease and thus in need of medical "treatment": "protection" (isolation) and the administration of chemical substances, that blunt consciousness, and render clear thought and speech a city in China. Instead of being recognized as in need of a dialogue. If at all, a dialogue is only offered after the individual has been "treated" enough, to make an open dialogue with the potential for coming to terms more or less impossible. Backwards world.

Thus, of course, the "expert" in the program also questions Kristina's ability of decision making. By definition, an individual's ability of decision making is put out of the running - by an alleged brain disease - if the individual is in crisis, and the cause of the crisis isn't immediately recognizable for the individual's surroundings - so that the cause can't but must be the alleged brain disease. Very simple.

Unfortunately - for the "experts" - the outcome of Kristina's story shows, that her ability of decision making obviously, and in stark contrast to the "expert's" allegations, was at its peak. Intuitively, she did what was best for her in her situation. While she mentions, that her immediate reaction to hospitalization and "treatment" - as being the opposite of what she herself felt, she was in need of - was anger.

Kristina's story clearly shows, what people in crisis really need, instead of "treatment": self-determination, personal freedom, and security - for, even if she is on the run for three weeks, this situation feels more secure to her than a commitment, with the inextricably linked to it loss of personal freedom and self-determination, ever could have felt. Security does not equal to be exposed to others' "care", for better or for worse. Security equals to being respected unconditionally.

The worst that can happen to an individual who has had an overwhelming experience, is feeling an additional loss of control over the situation. For instance by being controlled by others, by being told what to do and what not to do, by being "protected" (isolated), by being "medicated" with substances, that make the individual concerned lose control over their own thinking, intuition and body sensation, by being told by others what and how to think, and feel, and how to define oneself, etc. Such interventions in an individual's privacy will already under "normal" circumstances be perceived as a violation of one's limits. It becomes unbearable, if an individual beforehand is in a very vulnerable state because of an acute crisis. Nevertheless, the only logic reactions to the intrusions - in the shape of fear and anger - are regarded a worsening of the "symptoms", of the "illness", thus needing further "treatment", i.e. further intrusions. A vicious circle, or spiral, that unfortunately all too often ends with the individual in crisis going down, breaking. Mentally - or physically.

Quite interesting I also find the system's definition of "voluntary", in the program illustrated by Hege's story. "If you don't show up within an hour, you'll be picked up by the police", and the defence lawyer underlines how much effort is put into making people to show up voluntarily, although they also need to be informed about what will happen, if they - completely voluntarily - decide not to show up. A somewhat strange definition of "voluntary" the system makes use of. Kafka* comes to my mind. Just as I think 'Kafka', as I hear Hege tell about her conversation with the psychiatrist at Folloklinikken: "I realize then, that my words don't count anymore. No matter what I may say, it is of no importance."

I wonder, when the system eventually will start to respect and treat its clientele as human beings. And if the system ever will be capable at all of the humility, this would require. That the outlook, so far, is rather sinister, also this documentary again shows.

Which distinguishes this program from most other programs on the matter I've seen, is that not only Hege but also Kristina is given the opportunity to present herself as a fully accountable human being, fully aware her own situation and absolutely capable of making reasonable decisions about it, that she is given the opportunity to speak for herself, while, even though the "expert" involved in her case also is given the opportunity to tell his view of the situation, there is no attempt made to devalue Kristina's self-presentation as being that of a "mentally ill" person, and thus not trustworthy. On the contrary, the program actually proves the in the psychiatric establishment widespread idea that "patients" with "serious mental illnesses" have poor insight and thus are incapable of decision making, that is explicitly stated by Kristina's psychiatrist in the program, wrong.

Kristina chooses not to name her diagnosis directly in the program. But that it isn't in the category of some sort of "anxiety disorder" or the like, stands pretty clear. Her mother tells that the therapist saw Kristina's anger toward him to be "hypomania", so, figure it out. While, if at all I had to label anything in regard to Kristina, in regard to my own experience, and/or in regard to everything else, that gets labelled as "mental illness", I'd say there is only one "mental illness": PTSD.

No matter how critical of psychiatric practices otherwise, all Danish programs dealing with the matter of psychiatric "treatment", choose to only interview individuals who, in contrast to Kristina, display "insight" and furthermore, and also in stark contrast to Kristina, are compliant with psychiatric "treatment", i.e. drugs. The Danish media still has it coming to them to give people labelled with "serious mental illnesses" who are not "insightful" and "treatment compliant" a fair chance to speak out.

Until today, this group of "patients" is only reported about. Preferably in context with incidents that are meant to prove the insanity and lack of accountability of the individuals in question on the one hand, and to emphasize the alleged necessity of getting these individuals into psychiatric "treatment" as fast and extensively as possible to prevent further damage and deterioration, on the other. Proving psychiatric "treatment" - i.e. drugging and electroshock - to be both life-saving "treatment" measures, and the only reasonable, "evidence-based", "treatment" options for "severe mental illness", and thus being completely in line with the mainstream doctrine.

Individuals labelled with "severe mental illness" who successfully chose to do without the "help" of the system, have not yet been given a chance to present themselves and their reasons to do without the system's "help" in the Danish media. Hat off to the Norwegian NRK 1 for having the courage to do this groundbreaking documentary!

You can read more about the documentary, Kristina and Hege at MindFreedom's website.

* or Orwell


David said...

Thanks, a fascinating read.

Marian said...

It's a fascinating, although also terrifying, documentary. I heard, that the Norwegian television (NRK) plans an English-subtitled version, so that it can be shown at international festivals.

David said...

thanks marian - email me if it comes out - I'd like to see it - (my norwegian is non-existent) D

Marian said...

What?! You don't speak Norwegian?? I thought, everyone did. :D
I'll let you know, when it comes out. I guess, I'll also post a note here on the blog.

Monica Cassani said...

this is an awesome review of the movie...thank you so much...

I saw this on my feed and imagined you were just telling people about it in order to watch it...and I couldn't watch it because it was in Norway (I'd heard of it in other corners of the net) so I never stopped by to read it!!

So glad I finally did...I was sitting here thinking, gee I miss Marian's writing, she's just been writing for her Dutch blog...anyway...glad I came by and you did a beautiful job...

stuff like what happened in the documentary happens here all the time too! it's very dismaying.

hope you are happy and healthy!

Marian said...

Thanks Gianna. I thought, I'd do this quite detailed summary of the film, now that its mentioning on the list had made people somewhat curious, and since I found it really thought-provoking and revolutionizing - the perspective, the questions it raises in regard to the mh system - and absolutely worth a post. And, of course, I needed to do a summary if I wanted to comment on it, since it isn't yet available in English.

Actually, one thing I didn't comment further on, but which nevertheless is totally mind-boggling to me, is the idea, that people in crisis would have to get isolated - or "protected"... - so that they can calm down. Now I know, that isolation can come in far worse shapes than it does for Kristina in Norway: four white walls, a chair, a desk, and a bed, all exquisite, Scandinavian institution-design (yuk!). But I can assure you, even now, while I'm certainly not in any acute crisis, when I saw that room in the film, and imagined having to stay at it for just a day, this mere thought was anything else but calming me down... What the heck are these people thinking of? What's wrong with them?? "As little stimuli as possible", the "expert" says. Square, cold, and indeed hostile, I'd say. Generating, stimulating, fear, anger and despair. Nice. Makes me think of E's comment at FS: "Psychiatric services may not always live up to the ideal but I don’t know of any Psychiatrist, Nurse, or Therapists who doesn’t at least try to offer a service that is both humane and effective, whether it is perceived as such is another matter." I'd so like to believe that they "at least try". But each time I hear about or see things like this doc, it only confirms my quite different perception (!) that they either don't give a damn, and/or that something is profoundly wrong with them. - Certainly my perception, something's wrong with...

Apart from the usual disillusionment (and anger), I'm ok, yes. Trying hard to turn the disillusionment (and anger) into compassion... Brilliant post, btw, the one on psychosis.

Hope, you're ok too!


djbarney said...

Hello, I saw this linked off the MindFreedom list. The contradictory nature of their definition of "voluntary", as well as ignoring the patient are all deliberate methods. They are not "strange". The people who use these methods are criminals and psychopaths, but just like many of those types they are deliberate and calculating. Psychiatry has many skeletons in it's cupboard. One of them being Eugenics. They regard themselves as social engineers "guiding" society. They are really henchmen for consumerism and the state. Their methods are taken from military interrogation techniques and the methods used by advertising and marketing people to coerce and confuse. There may be something wrong with them but their brutalisations and infuriating injustices are not random. They are intended to erase the personality of the individual and install a new "better" and "healthy" personality. I strongly believe that revealing these deliberate methods can demystify and unmask these monsters.