“We are not saying ‘no hospitals’, but hospitals should be for a short period of time.” Mark Brown reports from Brussels on the new review of institutional care across Europe published by Mental Health Europe.
'The institution' looms large over the history of mental health. In the evocative 1961 words of then Conservative health minister, and later racist pin-up, Enoch Powell: “There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside - the asylums which our forefathers built with such immense solidity.”
- See also: In Our Right Mind
Mapping and Understanding Exclusion in Europe, a study of the state of mental health services across Europe, has just been by Mental Health Europe and the University of Kent Tizard Centre. The report confirms that, far from being consigned to the dustbin of history, large scale, long-term, institutional care that deprives people of fundamental rights remains a fact of European life rather than a distant memory.
"The vast majority of people can be supported to live an ordinary life in the community. Recovery doesn't mean cure. It doesn’t mean necessarily getting better. But it means living a good life in spite of your mental health problem.”
Mental Health Europe estimate that tens of thousands of people with mental health problems are living in psychiatric and other institutions in Europe today. At least 264,000 people live under full guardianship, without legal decision-making rights and isolated from society. Funded by the Open Society Foundation and an operating grant from the European Union Rights, Equality and Citizenship programme, the report looks at issues including coercion; forced medication; loss of rights and reliance on involuntary hospitalisation as treatment.
At the launch, author of the report’s introduction Prof. Dr. Dainius Puras, United Nations Special Rapporteur on the right to physical and mental health, told the press: “Europe remains dependent on outdated practices such as institutionalisation and over-excessive medicalisation. Institutionalisation is a violation of human rights itself, but can also lead to other abuses such as violence, exploitation and even torture. The public often remains mystified about what is happening with psychiatric institutions so coercion has remained in the shadows so far.”
- Editor's note: The 'right to liberty' is undermined by the fact that it is not consistently expressed in international agreements. The Convention on the Rights of Persons with Disabilities (CRPD) states 'the existence of a disability shall in no case justify a deprivation of liberty', however the Human Rights Convention (HRC) permits the ‘lawful detention’ of ‘persons of unsound mind’. As the CRPD is more recent, it should arguably hold more weight, in the UK and other countries that have signed up to it, than the HRC.
Slow progress in Western Europe
The picture painted by MHE’s report is of a Europe where there is no strong consensus on how best to provide the best care and support for people with mental health difficulties, despite the commitment of the EU to community-based treatmentment support and the commitment of funds to deinstitutionalisation. The continuation of huge, rights-depriving institutions has often been regarded as a central and eastern European problem, but the MHE report states it is a problem of western European countries including France, Belgium, Ireland, the Netherlands, Portugal, and Germany, across which “tens of thousands of people with mental health problems” are still living in institutions and “where little is being done about this situation.”
“In most countries the majority of beds for people with mental health problems are in general hospitals," said the Tizard Centre's Julie-Beadle Brown of the findings. "There are some countries where the primary provider of care in this situation were psychiatric hospitals. Some of these are very big, up to a thousand people. Such settings were the main form of such support provided in Eastern European countries [but] social care institutions are prevalent across Europe. These were generally large congregate settings, often very isolated from society. People generally live in these places indefinitely. They're not a short stay place. They go in because there's nowhere else."
Nigel Henderson, President of Mental Health Europe, claims hundreds of thousands of people are denied their rights - such as those set out in the United Nations Convention on the Rights of Persons with Disability. "Sometimes they don’t have the right to vote or to marry or to raise their children, even to have a bank account or to be able to go shopping.”
Other rights breaches
Henderson acknowledged that it was difficult to get a full picture of the situation across Europe as levels of data collection and recording differed from state to state. “We're not saying 'no hospitals', but those hospitals should be for a short period of time. The vast majority of people can be supported to live an ordinary life in the community. Recovery doesn't mean cure; it doesn’t mean necessarily getting better but it means living a good life in spite of your mental health problem.”
The report points to a number of reasons for this continuing incarceration and deprivation of rights across Europe including:
- poor cooperation between social and health authorities;
- lack of human rights compliant community-based services;
- trans-institutionalisation - where people move from one institution to another
Often the needs and rights of those who experience mental health difficulties are pushed to the back of the queue by other concerns. “Traditionally institutions have been placed out of town or in villages and they are often a major employer,” said Henderson. “So its 'we can’t close this place, because this place is dependent on the institution for its local economy'. We need to be listening to their legitimate concerns and need to actually say you are not going to be redundant. Professions are very clear about ‘this is our job and no one else can do it’. We need to melt some of those boundaries to try to help people to understand what the purpose [of deinstitutionalisation] is and what the goal is.”
EU has funded institutions
Marie-Anne Paraskevas, Senior Policy officer at the European Commission confirmed that EU structural funds had been used in some cases to build newer, bigger institutions. She expressed hope that specific obligations to deinstitutionalise would force countries to account for how EU funds were spent. “We're not for deinstitutionalisation for the sake of deinstitutionalisation,” she said, “we need to give people the right to be able to live in dignity and independently as possible.”
MHE suggest that where the voice of people with mental health difficulties is stronger, the pressure for change is harder for policy makers and governments to avoid, The report features testimony from Sabrina Palumbo, who has lived experience. Answering questions at the launch, Dr Puras - from Lithuania himself - said: “In Eastern Europe sometimes all good reforms are considered to be imposed by outside, so ‘why should we do this? We resisted Moscow, now we will resist Brussels’.”
Since the beginning of austerity in 2010, the public conversation in the UK has focused most on access to hospital beds, not avoiding them all together. With England and Wales only now carrying out a review of its own UNCRPD-contravening Mental Health Act, despite a decades long commitment to deinstitutionalisation, there’s no grounds for EU-departing smugness. ‘Care in the Community’, the UK’s version of deinstitutionalisation which began in the late 1980s, is often characterised as uncaring and reflective of cost-cutting.
Arguments for the return of institutions are never far from the mind of those who, despite a decade of concerted anti-stigma work, are still worried about the mentally-ill in their midst. There are continuing incidences of coercive practice and physical and chemical restraint. Community services and care provided by social safety net have also eroded. As such, the UK cannot see itself as detached from the review of practice in Europe just published. The human rights violations that once happened beneath water towers at the edge of town continue now in our hospitals and institutions built not of bricks and concrete but of policy and practice.