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15 March 1994
Doc. 7040
1403-11/3/94-1-E
REPORT
on psychiatry and human rights
(Rapporteur: Mr STOFFELEN,
Netherlands, Socialist Group)
Summary
Amongst persons deprived of their liberty, those placed in psychiatric institutions are particularly vulnerable. The world of psychiatry is seen as a secret world about which we can glean little information.
However, the replies received to a questionnaire sent to the delegations of member states give a picture of the present situation in Council of Europe member states. They show that in many respects the human rights of this particularly vulnerable population are not sufficiently guaranteed.
In the light of these replies and basing himself on the jurisprudence of the European Court of Human Rights, as well as on the findings of the European Committee for the Prevention of Torture, the Rapporteur has drawn up a list of principles which should be included in legislations and be applied in all member states.
I. Draft recommendation
1. The Assembly observes that there is no overall study on legislation and practice with regard to psychiatry covering the member states of the Council of Europe.
2. It notes that on the one hand, a body of case law has developed on the basis of the European Convention on Human Rights and that on the other, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment has made a number of observations with regard to practices followed in the matter of psychiatric placements.
3. It notes that in a large number of member countries, legislation on psychiatry is under review or in preparation.
4. It is aware that, in many countries, a lively debate is currently focused on problems associated with certain types of treatment such as lobotomies and electroconvulsion therapy as well as about sexual abuse in psychiatric care.
5. It recalls Recommendation No. R (83) 2 of the Committee of Ministers to member states concerning the legal protection of persons suffering from mental disorder placed as involuntary patients.
6. It considers that the time has come for the member states of the Council of Europe to adopt legal measures guaranteeing respect for human rights of psychiatric patients and to this end.
7. The Assembly therefore invites the Committee of Ministers to adopt a new recommendation based on the following rules:
i. Admission procedure and conditions:
a. compulsory admission must be resorted to in exceptional cases only and must comply with the following criteria:
1. there is a serious danger to the patient or to other persons;
2. an additional criterium could be the treatment criterium: if the absence of placement could lead to a deterioration or prevent appropriate treatment being given to him;
b. in the event of compulsory admission, the decision regarding placement in a psychiatric institution must be taken by a judge and the placement period must be specified;
c. there must be legal provision for an appeal to be lodged against the decision;
d. a code of patients' rights must be brought to the attention of patients on their arrival at a psychiatric institution;
e. a code of ethics for psychiatrists should be drawn up inter alia on the basis of the Hawaii Declaration adopted by the World Psychiatric Congress in Vienna in 1983.
ii. Treatment
a. a distinction has to be made between handicapped and mentally ill patients;
b. lobotomies and electroconvulsion therapy may not be performed unless informed written consent has been given by the patient or a person, counsellor or guardian, chosen by the patient as his or her representative and unless the decision has been confirmed by a select committee not composed exclusively of psychiatric experts;
c. there must be an accurate and detailed recording of the treatment given to the patient;
d. there must be adequate nursing staff appropriately trained in the care of such patients;
e. patients must have free access to a "counsellor" who is independent of the institution; similarly, a "guardian" should be responsible for looking after the interests of minors;
f. if necessary, an inspection system similar to that of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishments should be set up;
iii. Problems and abuses in psychiatry
a. the code of ethics must explicitly stipulate that it is forbidden for therapists to make sexual advances to patients;
b. the use of isolation cells should be strictly limited and accommodation in large dormitories should also be avoided;
c. no mechanical restraint should be used.
iv. Situation of detained persons
a. any person imprisoned should be examined by a doctor;
b. a psychiatrist and specially trained staff should be attached to each penal institution;
c. the rules set out above and the rules of ethics should be applied to detained persons and, in particular, medical confidentiality should be maintained insofar as this is compatible with the demands of detention;
d. sociotherapy programmes should be set up in certain penal institutions for detained persons suffering from personality disorders.
II. Draft resolution
The Assembly, referring to its Recommendation ..... on psychiatry and human rights, invites the governments of member states to introduce the rules it sets out into their legislation and to ensure that they are implemented as quickly as possible.
III. Explanatory memorandum
by Mr STOFFELEN
Contents
Page
Chapter 1
Introduction 7
Chapter 2
Criteria for involuntary admission to psychiatric hospitals 8
Chapter 3
Procedure for the involuntary reception in psychiatric hospitals and clinics 10
Chapter 4
Legal procedure for continuation of reception 11
Chapter 5
Human rights and psychiatric treatment in general 12
Chapter 6
Lobotomy and electroconvulsion (ECT treatment) 13
Chapter 7
Problems and abuse in psychiatry (in general) 15
Chapter 8
Problems and abuse of patients in psychiatric hospitals (clinics) 18
Chapter 9
Special position of minors, aged persons and detainees 21
Chapter 10
Conclusions and recommendations 24
Appendix I
Questionnaire 26
Appendix II
Summary of replies to questionnaire 29
Chapter 1
Introduction
1. This report on psychiatry and human rights is not a report on psychiatry: it is a report on human rights. To be more precise: it is a report on the guidelines, the limits and impact of human rights, the European Convention on Human Rights and its jurisprudence, the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment and the findings and conclusions of the European Committee as mentioned in that convention. Of course, due attention will be given to relevant texts of the Committee of Ministers.
2. This report is in a way a consequence of the Assembly's resolution of 18 August 1988, on ending violation of the European Convention on Human Rights by psychiatry. In the past, our Assembly and the Committee of Ministers dealt with the same problem. In 1979 our Assembly adopted Recommendation 848 (1979) on the need for a better protection of the mentally ill, particularly in regard to involuntary placement. In 1983 the Committee of Ministers adopted Recommendation No. R (83) 2 on the legal protection of persons suffering from mental illness and placed as involuntary patients.
3. Despite these reports and these activities I discovered that hardly any literature or documentation is available on the legal position of psychiatric patients and on the day to day practice for these patients. For that reason our committee asked an outstanding expert, Ms Dinah Shelton, to present to the committee a research report. In March 1992, Ms Dinah Shelton and Mr Thomas Douraki (together with the International Institute of Human Rights in Strasbourg) presented a research study on "Human rights and the mentally ill".
4. After the oral presentation by Dinah Shelton of her report it became clear that further research was needed. It is a long tradition of the Committee on Legal Affairs and Human Rights not to present reports unless they are solidly based on facts. In the Council of Europe a factual survey of the position of psychiatric patients is badly needed. For these reasons the committee accepted my proposal to send a questionnaire to the national delegations of the member states. This questionnaire was sent on 2 december 1992 (Appendices I and II). At the moment of writing this report, the secretariat has received replies from the following seventeen countries: Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Ireland, Luxembourg, the Netherlands, Norway, Poland, Portugal, Spain, Sweden, Swiss and the United Kingdom. A summary of the replies can be found in Appendix II of the report which is based on the replies and a rather thorough further research and study of the literature and available documentation and on discussions I had with several psychiatric and legal experts, mainly in the Netherlands.
5. The report will deal with the following problems:
i. Criteria for involuntary admission to psychiatric hospitals (chapter 2).
ii. Procedure for the involuntary admission to these hospitals (chapter 3).
iii. Procedure for the continuation of an involuntary stay in a psychiatric hospital (chapter 4).
iv. Norms and guidelines for the treatment of psychiatric patients (in general) (chapter 5).
v. Guidelines for electroshock (ECT) and brain surgery (lobotomy) (chapter 6).
vi. Abuse in psychiatric practice (chapter 7).
vii. Problems and abuse in psychiatric clinics and hospitals (chapter 8).
viii. Special measures and attention for young patients, aged patients and patients in detention-houses/prisons (chapter 9).
ix. Conclusions and recommendations (chapter 10).
Chapter 2
Criteria for involuntary admission to psychiatric hospitals
6. Reading the replies to the questionnaire, the literature and documentation, I wondered whether it would be possible to find a generally accepted definition of psychiatric patients. It would be desirable to define more or less concretely when and why we speak about either psychiatric patients or people with an unsound mind (Article 5, paragraph 1 of the European Convention on Human Rights). In an excellent report on "Consumer involvement in mental health and rehabilitation services" of the World Health Organisation1 explanation is given why indeed such a generally accepted definition cannot be found.
7. The term "mental illness" is another concept fraught with difficulty. Although it may be acceptable to society as a whole, many consumers deny that there is any such thing as mental illness while not denying the reality of mental distress. Those who are unhappy with the term illness are concerned that it has stigmatising and pejorative connotations as it suggests a parallel with psychic illness with unknown aetiology.
8. The WHO experts remark that the concept "Chronic mental disability" is used frequently but needs clarification. The WHO has defined the terms impairment, disability and handicap.
9. Within WHO's framework these three terms may result from mental illness but may only be applicable at certain times, for example during an acute illness episode. Labelling those who have had episodes of severe mental illness as impairment, disability or handicap may not always be accurate and further adds to the stigmatisation of such people.
10. Since this way — or the one based on social arguments — to find acceptable criteria for involuntary admission to a psychiatric hospital cannot be followed, the best way is to consult the legal practice in member states, the European Convention on Human Rights and jurisprudence and earlier decisions of the Committee of Ministers. According to the replies to the questionnaire the material conditions are the same everywhere: the danger patients pose to themselves and to others and the necessity for patients to receive treatment. "Anti social" behaviour is an additional criterium for confinement in Portugal. Further elaborating these replies I noted that the "danger" criterium, possibly combined with the "treatment" criterium prevailed.
11. Two developments and arguments led me to that conclusion. First : more than ten years ago the Committee of Ministers in Recommendation No. R (83) 2 expressed a clear preference for the danger criterium.2 It recommended rules concerning "the involuntary placement of persons suffering from mental disorder". In this recommendation the Committee of Ministers stated that a patient may be placed in an establishment only when by reason of his mental disorder, he presents a serious danger to himself or to other persons.
12. The Committee of Ministers after this notation of its preference adds — in the actual political climate to reach a consensus: "states may, however, provide that a patient may also be placed when, because of the serious nature of his mental disorder, the absence of placement would lead to a deterioration of his disorder or prevent the appropriate treatment being given to him". The second development and argument is the European Convention on Human Rights and the jurisprudence. Studying the literature and especially a highly interesting article in a Dutch scientific magazine, I noted again that Article 5 of the European Convention on Human Rights and the jurisprudence give clear guidelines.3
13. Article 5 states inter alia: "Everyone has the right to liberty and security of person. No one shall be deprived of his liberty save in the following cases and in accordance with a procedure prescribed by law: (e) the lawful detention of persons for the prevention of the spreading of infectious diseases, of persons of unsound mind, alcoholics or drug addicts or vagrants".
14. Article 5 paragraph 4 has further relevance: "Everyone who is deprived of his liberty by arrest or detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful".
15. Convention and jurisprudence (Winterterp against the Netherlands 1979; X against the United Kingdom 1981, Nielsen against Denmark 1988 and Van der Leer against the Netherlands 1990, lead inter alia to the conclusion that the criteria for detention (involuntary reception in a psychiatric hospital) have to be very objective and so serious that deprivation of liberty is necessary.
16. The logical conclusion is that the decisive criterium is the danger criterium: if the patient represents a serious danger to himself or to other persons.
17. An additional criterium could be the treatment criterium. The experts consulted prefer to use only the danger criterium but do not oppose the idea of an additional treatment criterium: .... if the absence of placement would lead to a deterioration of his disorder or prevent the appropriate treatment being given to him. It is quite clear that the decisive criterium is very serious and objective. The additional criterium includes many subjective elements.
Chapter 3
Procedure for the involuntary reception in psychiatric hospitals and clinics
18. The replies to the questionnaire reveal that in almost all countries, with the exception of Poland and Spain, there is a specific law governing psychiatric care. It is interesting to note that practically all of these laws are either very recent or have been amended very recently. The oldest is the Irish act, which dates back to 1945, with the most recent being the act in the Netherlands, which will come into force in 1994. The act in Cyprus is currently being revised. Except in Norway and Portugal, where the acts date back to 1961 and 1963 respectively, all legislation was passed after 1980. According to the replies the reception order is issued by the medical authorities, by an administrative authority such as the prefect or by the courts. Here again the replies, European Convention on Human Rights, the jurisprudence and the decisions of the Committee of Ministers give further indications.
19. The Committee of Ministers in its Recommendation No. R (83) 2 — which is now more than ten years old — gave already a certain indication: it states in Articles 4 and 5 that a decision for placement should be taken by a judicial or any other appropriate authority, provided by law, "In an emergency a patient may be admitted and retained at once in an establishment on the decision of a doctor who should thereupon immediately inform the competent judicial or other authorities which should make its decision. Any decision of the competent judicial or other authorities mentioned in this paragraph should be taken on medical advice and under a simple speedy procedure".
20. The recommendation makes a distinction between the situation that a decision was taken by a judicial authority and the case that a decision was taken by a non-judicial body or person. In the latter case that body or person should be different from the one which originally requested or recommended placement.
21. In both situations and cases the patient should be immediately informed of his rights, should have the right of appeal to a court and the assistance of a council or other person.
22. The European Convention on Human Rights and the jurisprudence give further guidance. It becomes more and more clear that it is up to a medical expert to give a formal opinion on the "need" for deprivation of liberty but that it is the task of the judge to take the formal decision.
23. The jurisprudence of the European Court on Human Rights includes the following conclusions and guidelines:
—th e deprivation of liberty should not be arbitrary; apart from emergency cases the necessity for involuntary admission for mental illness should be determined by a competent authority on the basis of objective medical expertise;—
—th e seriousness of the mental illness should be such that deprivation of liberty is necessary;—
—a periodical juridical judgment is needed for the prolongation of the detention and further deprivation of liberty.24
24. Such jurisprudence is very understandable, if one considers Article 5, paragraph 1 (e) and Article 5, paragraph 4. Article 5, paragraph 1 (e) already quoted in the previous chapter: the need that a court, that is a judicial authority, takes a decision on the need for the detention/deprivation of liberty. Furthermore the procedure should be clear: the patient should be informed of his rights and should have the effective opportunity to be heard personally by a judge except where the judge, having regard to the patients' state of health, decides to hear him through sole form of representation. He should be informed of his right to appeal against the decision ordering or confirming the placement and, if he so requests or the judge considers that it would be appropriate, have the benefit of the assistance of a council or of another person (Recommendation No. R (83) 2 Article 4).
Chapter 4
Legal procedure for continuation of reception
25. After the decision concerning involuntary admission many questions arise: what is the duration of validity? Is it possible to request a review, what is the procedure for the review etc.?
26. The replies to the questionnaire indicate that the validity of the first decision or order varies very much and that mostly it is possible to request a review of the order.
27. As I indicated in the previous chapter: European Convention of Human Rights, jurisprudence and the recommendation of the Committee of Ministers: all factors underline the need for a periodical judicial judgement on the need for continuation of the reception order. At the same time the need for thorough medical advice is abundantly clear. The recommendation of the Committee of Ministers adds to these criteria that a placement may be terminated at any moment on the decision of a doctor of a competent authority acting on his own initiative or at the request of the patient or any other interested person.
Chapter 5
Human rights and psychiatric treatment in general
28. The replies to the questionnaire, European Convention on Human Rights, jurisprudence, literature and documentation make it clear that there is no "codification" of rights of patients.
29. Nevertheless many relevant documents put together give a picture of what one could call a set of patients' rights.
i. A kind of common opinion can be noted on the right of the patient to a consented plan of treatment. Maybe the best explanation of this right can be found in the Declaration of Hawaii of the World Psychiatric Association.4 After a more general statement the declaration gives an indication of that right.
Every psychiatrist should offer to the patient what is — to his knowledge — the best available therapy and if accepted must treat him or her with the solicitude and respect due to the dignity of all human beings.
The psychiatrist aspires for a therapeutic relationship that is founded on mutual agreement, at its optimum it requires trust, confidentiality, co-operation and mutual responsibility.
The right itself is indicated:
"The psychiatrist should inform the patient of the nature of the condition, therapeutic procedures, including possible alternatives and of the possible outcome. This information must be offered in a considered way and the patient must be given the opportunity to choose between appropriate and available methods. No procedure shall be performed nor treatment given against or independent of a patients own will unless because of mental illness, the patient cannot form a judgement as to what is in his or her own best interest and without which treatment serious impairment is likely to occur to the patient or others."
The declaration states further: that if a therapeutic relationship with the patient is not possible contact should be established with a relative or other person close to the patient.
ii. Linked to this right is a second right that is the right to an exact, truthful recording of the treatment.
As indicated by the European Committee for the prevention of torture and inhuman of degrading treatment (CPT):
"The CPT attaches particular importance to the rights of patients admitted by order of the authorities. Firstly it considers it crucial that every aspect of their treatment (for example the administration of drugs with an indication of whether or not this was with the patients consent, special measures taken such as placement on solitary confinement, the use of instruments of psychical restraint, etc.) should be scrupulously recorded".5
iii. The third right is indicated in the same CPT report: "It is most important that formal machinery be established to enable patients to lodge complaints with a clearly identified responsible body. The CPT adds:
"Another significant way of preventing ill treatment is to organise regular visits to the institution concerned by an independent outside body responsible for examining the treatment of patients, to meet the latter in private and to formulate appropriate recommendations.
iv. The fourth right should be in my opinion the set of guidelines for and consideration of the CPT during visits of and study of Health Care Services in prisons (5)
—ac cess to a doctor,—
— eq uivalence of care (general medicine and psychiatric care),—
— pa tients consent and confidentiality,—
— pr eventive health care (social and preventive medicine, inter alia, suicide prevention, prevention of violence),—
— humanitarian assistance,
— professional independence,
— professional competence.
Chapter 6
Lobotomy and electroconvulsion (ECT-treatment)
30. Undoubtedly lobotomy and ECT are two forms of psychiatric treatment which cause many, sometimes very animated discussions and include the risk of infringement of human rights.
31. Lobotomy is neurosurgery on psychiatric indication. It includes making a lesion on an indicated place in the brain with the aim of treating a patient for overwhelming psychic suffering.
32. According to the replies on the questionnaire lobotomies are not performed in Belgium, Cyprus, Finland, Germany, Luxembourg, Norway, Poland, Portugal and Spain. They have not been performed in Denmark since 1983.
33. Lobotomies are rarely carried out in France, Ireland, Netherlands and the United Kingdom. In Sweden nothing is laid down in legislation as to whether the practice should be banned (along with electroconvulsion-treatment). It was not banned as it was felt there might not be any other solution in some cases. Cases are very rare and have to be reported. It is not banned in Switzerland.
34. Literature and scientific expertise indicate that certain surgeries, especially in the orbiofrontal area and (of cingulum) help usually above 50% of the patients to reduce or eliminate essential symptoms such as anguish, depression and forced symptoms while adverse effects seldom occur.
35. There are arguments to ban lobotomy, but the main trend is not to do so, but to bind lobotomy on psychiatric indications to very strict rules and regulations. Indications for neurosurgery are not: schizophrenia, addiction, fatty degeneration, anorexia nervosa, and psychopathic personality (the latter is a clear counter indication).
36. The conditions or rules should be:
—th e patient has had insufficient relief from other relevant, well applied treatments;—
—th ere is serious, unbearable suffering of the patient;—
—th e surgery has to offer a real prospect of an essential improvement of the condition of the patient without serious side-effects;—
—th ere has to be informed written consent of the patient or of his or her legal representative;—
—th ere has to be a second opinion/approval of a relatively small ethical committee of not just psychiatrists but also lawyers and experts in the field of medical ethics.—
—as usual, but especially in this case, a careful recording of the whole treatment.37
37. Informed written consent should mean that the patient (or his representative) after good instruction (on the desirability of the treatment, the treatment itself, the possible good effects, possible side effect, the possible consequences if the patient is not treated with lobotomy) and in good consultation consents to the treatment.
38. In the literature a clear preference can be noted for a second opinion to be given by a medical ethical committee, possibly a national one, consisting not only of psychiatrists but medical and other experts.
39. Electroconvulsion treatment is a psychiatric treatment whereby the patient via electrodes on his or her temples receives an electroshock (110 volts, 20 to 30 mill amperes) with as result a convulsion, lasting mostly fifteen to sixty seconds.
40. The replies to the questionnaire indicate that electroconvulsion therapy is used in all countries, but always in extreme cases, exceptionally for very limited indications that give rise to fears for the patient's life (serious depression). In the literature and the advice given by psychiatric and other experts I could see that the patients who receive ECT form, within psychiatric care, a specific characteristic group: mostly elderly people with serious psychiatric phenomenons. Their serious depression period is usually not their first. During a long time all other remedies and treatments have been practised in vain, in order to try to end the deep depression of the patient. ECT is usually the ultimum remedium.
41. A relatively large percentage of the patients who receive ECT treatment are women.
42. Possibly the depression has its roots in the specific circumstances of a woman (such as depressive symptoms related to the climacterium). The failure of traditional treatment can be interpreted as 'therapy-resistance'. It is not clear to what extent the depression has been treated with the methods of assistance to women. Further study of the possibilities of adjusting the treatment to the circumstances specific to women and the influence of these methods on the prevention of serious depression in middle-aged women and elderly people has to be recommended"6.
43. As for ECT the conditions and rules have to be rather strict:
—EC T has to be the ultimum remedium to release a patient from very serious depressions;—
—in formed written consent of the patient or of his or her representative is needed;—
—a second opinion by a committee consisting of not only psychiatrists (this committee can be a national or regional committee);—
—th e ECT has to fit into the plan of treatment;—
—th e treatment has to be recorded carefully.44
44. Speaking and writing about lobotomy, ECT and about abuses in psychiatric practice I cannot avoid coming — as I will explain and indicate later in the report — to conclusions on the desirability of improving — as far as possible — the inspection of the quality of medical psychiatric care.
Chapter 7
Problems and abuse in psychiatry (in general)
45. The replies to the questionnaire, literature and advice from medical experts clearly indicate more or less structural problems and abuses. Some problems and abuses exist in the whole field of psychiatric care, in and outside psychiatric hospitals.
46. In this chapter I deal with problems and abuses in general, in and outside hospitals. For a major part the main problem is sexual abuse or humiliation. Before I deal with this problem, I mention the relevant part of the summary of the replies to the questionnaire.
47. According to the replies there have been many cases of abuse or complaints. In Denmark, complaints of humiliation, intimidation, negligence or unsuitable treatment have been brought before the Ombudsman at one time or another. The replies indicate cases of sexual abuse in Norway, Poland, Sweden, Switzerland and the United Kingdom. Cases of unsuitable treatment or negligence have also been recorded in Denmark, Finland, Norway, Switzerland and the United Kingdom.
48. As I wrote in this chapter I mainly deal with the problem of sexual abuse. The literature and, to a certain extent the replies, indicate that the problem of sexual abuse in the psychotherapy and psychiatric care is a general structural problem.
49. According to the literature the controversial character of the subject makes it difficult to obtain reliable data about sexual contacts in psychotherapy.7
50. American inquiries give the following picture: "Sexual contact occurs almost exclusively between male psychotherapists and female clients. The therapist is, on average, ten years older than the client" (Bouhoutson 1983).8 Of the male psychotherapists about 10% admit to having had sexual contact with on average two clients (Holroyd and Brodski 1977).9 Sexual contact is mostly initiated by the therapists and has in 90% of the cases a negative impact on the client and on the therapeutic process (Bouhoutson a.o. 1983). The effect on the client is often more serious if she had earlier experience with sexual violence, or if the therapist is married (Feldman, Summer and Jones 1984).10
51. An extensive inquiry has been made in the Netherlands whereby 155 registered psychotherapists have been questioned. The response was 53%. Of the male responded 6% and of the female 1% responded that they had had sexual contacts with a client. A Dutch report of the State Inspection Youth Care of November 1991 showed that in forty-three of the 314 care-institutions one or more incidents of sexual abuse of young clients had been reported in the period 1988-91.
52. In the reply of the United Kingdom delegation, mention is made of a special report of a committee which studied the situation in a British mental hospital. Physical ill- treatment of some patients at that hospital was the theme of a television programme. That programme led to the decision of the Secretary of State for Health to set up an independent committee of inquiry. One of the main allegations was the allegation of a serious sexual offence.
53. In the German Magazine Der Spiegel with the title Meine Seele in Seiner Gewalt "My soul in his power" a description is given of many cases of sexual abuse, complete dependence and about humiliation. The title "My soul in his power" is particularly the symbol for the misery of one of many victims.
54. A woman enters a police station in Hamburg. "Under her clothes a body is hidden with many scars and slashes. The woman tells her story: visiting the male therapist she had to undress, she was tied up and seriously beaten. She was raped. During three days the woman tells the policeman how her therapist made her dependent, made her more and more dependent and abused her sexually. After a publication, edited by an editor in Freiburg about one case of sexual abuse, 160 women reported about their cases of abuse.11
55. According to articles in the Dutch press an inquiry of the situation in institutions for mental health, sent to 215 institutions, 184 responded. Of the forty-six general psychiatric hospitals forty-three reacted. Every year about twenty-five cases of sexual abuse are reported to the state inspection.
56. On the basis of the literature and the state of the situation in many member states one has to conclude that most probably sexual abuse in the field of psychotherapy/ psychiatric care is a serious structural problem which cannot be denied.
57. Of the many recommendations mentioned in the literature I select the most important ones.
—It is essential that every institution of mental health and every union of therapists has a written code of conduct. In that code one has to stipulate explicitly that sexual behaviour of the therapist/psychiatrist is forbidden. Such a behaviour has to be qualified as abusing the dominant position of the therapist and abusing the confidence of the client.—
—Th e termination of a contract for psychiatric care in order to start a sexual relation with a client has to be qualified as unpermissible.—
—Cl ients/patients have to receive at the beginning of a psychotherapeutic/psychiatric relationship information material in which a description is given of what is permissible in a relation between the therapist and the client and what is not permissible.58
58. The introduction and functioning of "patients' confidential counsellors" is of utmost importance. Such a counsellor works in a psychiatric hospital, but is employed by an independent foundation in order to guarantee his or her independence.
Chapter 8
Problems and abuse of patients in psychiatric hospitals (clinics)
59. Four sources give together a rather clear picture about problems and abuse in psychiatric care:
—Ge neral conclusions of the State Inspection for Mental Health in the Netherlands.—
—Re port of the committee of inquiry in the United Kingdom. 12S
—Sp ecific reports of the CPT (European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment).—
—Th ird general report of the CPT.60
60. A more or less general picture of problems and abuses in hospitals and clinics for mental health is, for instance, given in the 1992 report of the Foundation of patients' confidential counsellors for mental health care.13 In 1992 the counsellors received 11 548 complaints. The character of the complaints is as follows (in main lines).
a. treatment 18,6%
b. forced reception 11,1%
c. way of treating clients ` 9,5%
d. limitation of liberty 7,7%
e. stay 7,7%
f. application of force 7,3%
g. wish to be transferred to another clinic 5,7%
h. personal problems 5,2%
i. wish that the reception be ended 4,2%
j. other categories 4,2%
k. general legal questions 3,9%
l. protest against transfer 3,0%
m. management of money 2,7%
n. protest against discharge 2,2%
o. others 6,9%
61. A few examples better illustrate the problem.
a. Treatment: a client had to take seventy-five pills every day and would like to see that number reduced.
b. Forced reception: a client has been received after a decision of the judge, but wants to go home. Is that possible?
c. Way of treating clients: a client asks the help of the counsellor in a discussion with a male nurse on her complaint of sexual abuse.
d. Application of force: a client has been a year in "separation". She wants compensation.
62. This can be compared with a report on research into serious problematic behaviour of mentally handicapped in intramural mentally deficient care. "One of the many findings is that a relatively large number of patients has to take heavy medication daily. It is very difficult to give a judgment about the use of medicine. One notes that a tremendous quantity of medicine is used as medication to regulate behaviour. Normally there is not a specific diagnosis. The medicines are used on the basis of a vague picture, to combat the symptoms. In addition one notes that medicines of this kind are used for a long time ... Both isolation and restraint of patients occur on a large scale."
63. The second source is the impressive report of the committee of inquiry: serious, sober and balanced, concrete and with dignity.
64. "Our terms of reference were to investigate allegations of treatment and improper care of patients ... and to examine the system designed to process and adjudicate upon patients' complaints at Ashworth".
65. "Three of the four cases which we investigated in depth, taken together with the general overview of the huge number of complaints made by patients (many of a serious nature) did disclose some physical ill-treatment, varying however from minor assault by a nursing-assistant and an improper use of seclusion to the medium physical assault and, an allegation of a serious sexual offence."
66. "The fourth case demonstrated unexceptionable nursing care although someone responsible for his care and treatment should have spotted the intent of his suicide."
67. "There seemed however to have been a lack of good management in handling the consequences of the patient's self destruction. Our inquiry has turned out to be about a number of cases of improper nursing care, an inadequate psychiatric service and a failure on the part of management either to encourage and support compliance with the U.K.C.C — code of professional conduct for nurses or to investigate the allegations properly."
68. The committee presented ninety recommendations, all over and accepted by the government. I mention in this report a few recommendations which apparently have a more general value.
Inquiries
—We recommend that all employees be informed that they are obliged to co-operate fully in any inquiry reasonably instituted by their employer.—
—We recommend that the government should consider setting up a committee to undertake a thorough review of public inquiries. The review committee should consider the establishment of a permanent secretariat and legal team, to undertake support duties as a means of concentrating resources and building expertise.Pa
Patient's complaints
—We recommend that all staff should be trained in understanding their role and function within the complaints' system.—
—Re ferral to the police should be restricted to those cases where there has been a physical injury (of more than a minimal amount) or some other serious criminal offence. —
—We recommend the immediate establishment of a patients' advocacy service.Ca
Care and treatment
—Th e culture of denigration and devaluing of patients needs to be addressed immediately.Co
Control and restraint
—We recommend that forthwith no mechanical restraint be used and to that end we recommend that the Special Hospitals Service Authority (SHSA) determines a strategy which seeks to reduce the number of control and restraint interventions dramatically.Se
Seclusion
—We recommend the phasing-out and ultimate ending of seclusion. We suggest it be done within the next two to three years enabling the relevant authorities to work out other options.In
Incident reporting
—We recommend that a system of reporting all incidents (untoward events) occurring in the hospital must be established.69
69. The CPT reports to authorities in many countries about the findings after their visits inter alia to psychiatric hospitals.
70. Many conclusions of the CPT have a general value. I select a few.
Patient's treatment
—Ac commodation in large dormitories is not compatible with modern patient treatment standards.—
—A distinction has to be made between mentally handicapped and mentally ill patients.—
—Th e practice of routine use of isolation cells for the observation of newly admitted patients should cease.—
—Th e decision on placement of patients in isolation has to be taken by a physician and the reasons for making such placement has to be recorded in writing and made available to the patient, unless clinically inappropriate.—
—Th e CPT considers that external control and supervision of the quality of medical care provided in an hospital is an important safeguard for both patients and staff.71
71. Lastly, many of the recommendations of the CPT in its third general report about health care services in prisons are of great value and are relevant for psychiatric care in hospitals and clinics. It is for the sake of the clarity of the report that I deal with these recommendations in the next chapter.
Chapter 9
Special position of minors, aged persons and detainees
72. The replies to the question in the questionnaire about "the admission of particularly vulnerable persons: minors, elderly, mentally handicapped" were clear. With the exception of Finland, minors, old people and the mentally handicapped are subject to the same regulations as adults. Generally they are represented by their legal representative. The age at which a minor's consent is required varies. In the Netherlands it is fixed at twelve. In Luxembourg the law prohibits the confinement of elderly people solely on the grounds that their mental faculties have diminished because of ageing.
73. Poland indicates that terms of confinement are relatively good for minors, but bad for the handicapped.
74. On this base I do not feel the need to come to my conclusions.
75. The question of the position of detained persons/prisoners is different. The CPT formulated, in specific reports on the situation in specific countries and in the third general report, several important and relevant conclusions and recommendations. Studying all these reports I concluded that one recommendation in the specific reports and fourteen recommendations (of the fifty-two recommendations) are the most important and relevant. That is to say fifteen recommendations in all.
i. The CPT wishes to stress the role to be played by prison management in the early detection of prisoners suffering from a psychiatric ailment (for example depression, reactive state etc.) with a view to enabling appropriate adjustments to be made to their environment. This activity can be encouraged by the provision of appropriate health training for certain members of the custodial staff.
ii. Access to a medical doctor
When entering prison, all prisoners should without delay be seen by a member of the establishment's healthcare service. It is also desirable that a leaflet or booklet be handed to prisoners on their arrival, informing them of the existence and operation of the health care service and reminding them of basic measures of hygiene.
iii. Equivalence of general medicine care
A prison health service should be able to provide medical treatment and nursing care as well as appropriate diets, physiotherapy, rehabilitation or any necessary special facility, under conditions comparable to those of patients in the outside world.
iv. Psychiatric care
In comparison with the general population, there is a high incidence of psychiatric symptoms among prisoners. Consequently, a doctor qualified in psychiatry should be attached to the health care service of each prison and some of the nurses employed there should have had training in this field.
v. Patients' consent and confidentiality
Freedom of consent and respect for confidentiality are fundamental rights of the individual. They are also essential to the atmosphere of trust which is a necessary part of the doctor/patient relationship, especially in prisons, where a prisoner cannot freely choose his own medical doctor.
vi. Patients' consent
Patients should be provided with all relevant information (if necessary in the form of a medical report) concerning their conditions, the course of their treatment and the medication prescribed to them.
vii. Confidentiality
Medical secrecy should be observed in prison in the same way as in the outside community. Keeping medical dates should be the doctor's responsibility.
viii. Preventive health care
The task of prison health care services should not be limited to treating sick patients. They should also be entrusted with responsibility for social and preventive medicine.
ix. Hygiene
It lies with prison health care services — as appropriate acting in conjunction with other authorities — to supervise catering arrangements (quantity, quality, preparation and distribution of food) and conditions of hygiene (cleanliness of clothing and bedding; access to running water; sanitary installations) as well as the heating, lighting and ventilation of cells. Work and outdoor exercise arrangements should also be taken into consideration.
x. Transmittable diseases
A prison health care service should ensure that information about transmittable diseases (in particular hepatitis, Aids, tuberculosis, dermatological infection) is regularly circulated, both to prisoners and to prison staff.
xi. Suicide prevention
A person identified as a suicide risk should, for as long as necessary, be kept under a special observation scheme.
xii. Prisoners with personality disorder
There are always a certain number of unbalanced, marginal individuals among the patients of a prison health care service, who have a history of family traumas, long standing drug addiction, conflicts with authority or other social misfortunes. They may be violent, suicidal or characterised by unacceptable social behaviour. Usually they are incapable of controlling or caring for themselves.
The needs of these prisoners are not truly medical, but the prison doctor can promote the development of socio-therapeutic programmes for them, in prison units which are organised along community lines and are carefully supervised.
xiii. Typical examples of this kind of prisoners are those who are the subject of a short-term fatal prognosis, who are suffering from a serious disease which cannot be properly treated in prison conditions, who are severely handicapped or of advanced age. The continued detention of such persons in a prison environment can create an intolerable situation. In cases of this type, it lies with the prison doctor to draw up a report for the responsible authority, with a view to suitable alternative arrangements being made.
xiv. Professional independence
The health care staff in any prison is potentially a staff at risk. Their duty to care for patients/sick prisoners may often enter into conflict with considerations of prison management and security. This can give rise to difficult ethical questions and choices. In order to guarantee their independence in health care matters, the CPT considers it important that such personnel should be aligned as closely as possible with the mainstream of health care provision in the community at large.
xv. Professional competence
Prison doctors and nurses should possess specialist knowledge enabling them to deal with the particular forms of prison pathology and adapt their treatment methods to the conditions imposed by detention.
Chapter 10
Conclusions and recommendations
76. This report on psychiatry and human rights is a report on the impact of human rights (European Convention on Human Rights, jurisprudence, the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment and the conclusions of the CPT) on psychiatry.
77. It is written mainly for two reasons:
—Fi rstly, so far there is no survey of the legislation and practice of and for the mental health care in the member states, not to speak about the impact of human rights legislation and jurisprudence on psychiatry. Reason enough to try to write such a survey and to give such guidelines.—
—Se condly, in many countries lively discussion is going on on problems such as lobotomy, ECT, sexual abuse in the psychiatric care, situation in mental health hospitals and clinics.78
78. Such a situation includes an invitation to a rapporteur to write a report on the practice and guidelines for such a practice.
79. It is a very good tradition of the Committee on Legal Affairs and Human Rights only to write reports if they are based on facts.
80. For those reasons, first we invited an expert to present her views. After that we collected much information given in reply to our questionnaire. All that, together with literature, documentation and advice given by other experts forms the basis for this report. It enabled us to come to many conclusions and recommendations:
Criteria for involuntary reception are:
81. The danger criterium: if the patient represents a serious danger to himself or to other persons.
82. An additional criterium could be the treatment criterium: if the absence of placement would lead to a deterioration of his disorder or prevent that appropriate treatment be given to him.
83. The essence of the recommendations on the procedure for involuntary reception in psychiatric hospitals and clinics is that a judge should decide.
84. It would be very desirable if patients' rights were recognised and laid down in legislative rules. For lobotomy and ECT a combination of rules and recommendations would be needed:
—in formed, written consent;—
—se cond opinion to be given by a small committee of not only psychiatric experts;—
—ac curate recording of the treatment;—
—po ssibly improvement of the inspection by forming an (additional) inspection in analogy with the CPT, or, in other words: a national CPT. 8
85. A range of rules are needed or at least are very desirable to combat the structural problem of sexual abuse and other forms of ill treatment. The essence of the draft recommendation of our committee is further our invitation to lay down our recommendations in a new recommendation to the Committee of Ministers and further on an invitation to the governments of the member states to include our recommendation in the legislation and policy and practice of that country.APPENDIX I
Questionnaire
I. Admission procedure
1. Does a law exist on involuntary admission to psychiatric hospitals? If so, could you send a copy?
2. What formal and substantive conditions apply to involuntary admission to psychiatric hospitals?
3. Are these conditions embodied in a law or in official regulations? If so, what sanctions are prescribed in the event of non-compliance with these conditions?
4. Who is, or who are, actually responsible for the reception order?
Does the law or a regulation hold somebody responsible for a reception order?
5. Is there any possibility to withstand a reception order?
6. For which period will a reception order be given?
When will an involuntary admission be revised?
7. Is it possible to complain about reception order procedures?
Is the right to complain embodied in a law or in official regulations?
8. Are there legal sanctions on incorrect admission procedures?
II. Conditions of admission and treatment
9. Will it be possible for an involuntary patient in a psychiatric hospital to break up an admission?
10. Is it possible to complain about lasting admission?
Is the right to complain embodied in a law or in official regulations?
Are there legal sanctions on incorrect continuation of the admission?. If so, what type of sanctions?
11. What types of treatment are practised?
— Is lobotomy performed? If so, in which indications?
Who is, or who are, actually responsible for the decision to perform lobotomy?
Does the law or a regulation hold somebody responsible for the decision to perform lobotomy?
—Is electroconvulsion therapy (ECT) performed? Wh
Who is, or who are, actually responsible for the decision to perform ECT?
Does the law or a regulation hold somebody responsible for the decision to perform ECT?
12. Is informed consent required for:
— lobotomy?
— electroconvulsion therapy?
13. Are you aware of any cases of abuse of patients?
—ab use of authority in applying the involuntary admission procedure—
—se xual abuse—
— improper medical treatment
— humiliation, intimidation
— neglect
— material, housing, circumstances
—in voluntary sterilisation14
14. Is it possible to complain about medical, psychological or social treatment? Is the right to complain embodied in a law or in official regulations? Are there legal sanctions on improper treatment?
15. Are specific provisions on psychiatry included in the code of medical ethics?
16. Is there a text prescribing that the police should be informed of accidents involving patients in a psychiatric hospital ?
III. Admission of particularly vulnerable persons:
minors, elderly, mentally handicapped
17. What are the conditions governing the admission to institutions of
— minors
— elderly
— mentally handicapped?
18. Are representatives entitled to intervene on behalf of
— minors
— elderly
—me ntally handicapped?Ar
Are legal provisions made to make it possible for representatives to intervene for the above mentioned groups?
IV. Situation of detained persons (detention pending trial
or serving a prison sentence)
19. What are the rules applicable to persons in need of
psychiatric treatment?
a. during the period of detention pending trial;
b. when serving a prison sentence.
20. Who takes the decision?
APPENDIX II
Summary of replies to the questionnaire
Introduction
1. A questionnaire was sent to the national delegations on 2 December 1992. The following countries replied: Belgium, Cyprus, Denmark, Finland, France, Germany, Greece, Ireland, Luxembourg, Netherlands, Norway, Poland, Portugal, Spain, Sweden, Switzerland and United Kingdom. The following countries also sent reference texts (acts of parliament, articles of codes): Belgium, Denmark, Finland, France, Ireland, Luxembourg, Netherlands, Switzerland and United Kingdom.
2. Finland appended to its reply the text of a paper presented by Mrs Paula Kokkonen at the Ghent Medical Congress (18-22 August 1991). In it she highlights the difficulty of defining mental illness and concludes that the definition is dependent on culture. This problem is apparent from some of the replies. Poland, for example, puts drug addicts and alcoholics in the same category as the mentally ill.
3. The United Kingdom also provided the report by the Committee of Inquiry into complaints surrounding Ashworth Hospital, which was submitted to parliament by the Secretary of State for Health in August 1992.
4. Although the following summary is not exhaustive, it nevertheless paints an overall picture of the state of psychiatry in Europe from the human rights point of view.
I. Admission procedure and conditions
5. In almost all countries, with the exception of Poland and Spain, there is a specific law governing psychiatric care. It is interesting to note that practically all of these laws are either very recent or have been amended very recently. The oldest is the Irish act, which dates back to 1945, with the most recent being the act in the Netherlands, which will only come into force in 1994. The act in Cyprus is also currently being revised. Except in Norway and Portugal, where the acts date back to 1961 and 1963 respectively, all legislation was passed after 1980.
6. The substantive conditions are the same everywhere: the necessity for patients to receive treatment and the danger patients pose to themselves and to others. The "Anti-social" behaviour is an additional criterion for confinement in Portugal.
7. The reception order is issued by the medical authorities, by an administrative authority such as the prefect or by the courts.
8. Order issued by the medical authorities
This applies in Denmark (if the order is contested the case is brought before the courts), Finland, Ireland, Luxembourg, Norway, Poland, Sweden, Switzerland and the United Kingdom.
9. Order issued by an administrative authority
In France, the compulsory hospitalisation order is issued by the prefect.
10. Order issued by the courts
This applies in Belgium (the public prosecutor issues the order in emergencies), Cyprus, Germany, Netherlands, Portugal, Spain.
The duration of validity varies from country to country: forty days in Belgium, three months in Cyprus and Finland, six months in the Netherlands when it is the first time, subsequently one year or even two, six months in Norway and Spain. In Switzerland there is no statutory time-limit and in Poland the order can be made for an unspecified length of time.
11. In almost all the countries apart from Poland it is possible to request a review of the order: in some cases the request has to be supported by a doctor's declaration (Belgium). The request may be addressed either to the courts (Portugal) or to an independent authority. Most countries have such an authority. A person or a committee is responsible for helping patients, examining their complaints, monitoring treatment or any cases of abuse and compiling reports.
12. France has psychiatric hospitalisation committees for each département (annual report). In Denmark, there is a complaints committee at regional level and a patients' advisor is appointed. Germany has an independent person, as does Ireland, where a psychiatric hospital inspector is obliged to compile one report per year for public hospitals and two for private hospitals. In Luxembourg, a five-member committee is attached to every establishment. In the Netherlands an adviser is responsible, in Norway a supervisory committee and in the United Kingdom a medical officer. Criminal sanctions are prescribed for non-compliance with admission procedures in almost all countries: Belgium, Cyprus, Denmark, France, Ireland, Luxembourg, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and, in exceptional cases, Poland.
II. Treatment
13. Lobotomies are not performed in Belgium, Cyprus, Finland, Germany, Greece, Luxembourg, Norway, Poland, Portugal, Spain. They have not been performed in Denmark since 1983.
14. Lobotomies are rarely carried out in France, Ireland (but patients are sent to the United Kingdom for this purpose) Netherlands (between 1972 and 1985 four per year) and the United Kingdom. In Sweden, nothing is laid down in legislation but there were discussions as to whether the practice should be banned (along with electroconvulsion therapy) when the law was being prepared. It was not banned as it was felt there might not be any other solution in some cases. Cases are very rare and have to be reported. It is not banned in Switzerland.
15. Electroconvulsion therapy is used in all countries, but always in extreme cases, exceptionally, for very limited indications that give rise to fears for the patient's life (serious depression). In all cases, informed consent is, as a rule, required from the patient or from the person responsible for the patient.
16. In Switzerland, there is controversy over the interpretation of legal texts. Some believe that a person who is lawfully confined may receive all kinds of treatment whilst others contend that the terms of confinement do not cover treatment.
17. In France, the fact that some therapeutic practices are being challenged has been raised in Parliament. The Health Minister responded by referring reports to be compiled by the département committees for examination.
Abuse
18. There have been cases of abuse or complaints: in Denmark, complaints of humiliation, intimidation, negligence or unsuitable treatment have been brought before the ombudsman at one time or another. In Finland, patients are offered freedom of movement in the hospital on condition that they agree to be sterilised.
19. Sterilisation is authorised in exceptional cases in Germany, the Netherlands, Norway and Switzerland, which mentions cases of forced sterilisation.
20. There have been cases of sexual abuse in Greece, Norway, Sweden, Switzerland and the United Kingdom (see the report by the committee of enquiry), in Poland (cases of abuse with no further details).
21. Cases of unsuitable treatment or negligence have also been recorded in Denmark, Finland, Norway, Switzerland and the United Kingdom.
Ethics
22. Only some countries have a code of ethics with specific rules for psychiatry. This is the case in Greece, Portugal, Sweden, which adopted the Declaration of the World Psychiatry Congress in Hawaii and the United Kingdom where the law is accompanied by a code of practice. In all other countries the general code of ethics is applicable.
III. Particularly vulnerable persons
23. Except in Finland, minors, old people and the mentally handicapped are subject to the same regulations as adults. They are generally represented by their legal representative. The age at which a minor's consent is required varies: in the Netherlands it is fixed at twelve. In Luxembourg the law prohibits the confinement of elderly people solely on the grounds that their mental faculties have diminished because of ageing. Poland indicates that terms of confinement are relatively good for minors, but bad for the handicapped.
Accidents
24. As a general rule, the police are only informed in the event of death or else the law does not stipulate that the police have to be informed. In the United Kingdom, whether or not the police are called depends on the seriousness of the accident.
IV. Detained persons
25. Detained persons requiring care in psychiatric hospitals are sometimes cared for in appropriate prisons (France) and sometimes transferred to psychiatric hospitals. The transfer order is issued by the courts, the Department of Justice (Ireland) or the investigating judge (Switzerland).
Reporting committee: Committee on Legal Affairs and Human Rights.
Budgetary implications for the Assembly: none.
Reference to committee: Doc. 5929 and Reference No. 1609 of 3 October 1988.
Draft recommendation and draft resolution unanimously adopted by the committee on 1 March 1994.
Members of the committee: Lord Kirkhill (Chairman), MM. Schwimmer, Jansson (Vice-Chairmen), Amaral, Andriukaitis, Arnalds, Bentkowski, Berti, Bindig, Borg, Bucar, Candal, Columberg, Croze, Deasy, Espersen, Fogas (Alternate: Fico), Franck, Frunda, Fry, Fuhrmann, Galanos, Guenov, Guzzetti, Hagĺrd, Mrs Haller, Mrs Holand, MM. Hunault, Inönü, Mrs Jaani, MM. Jaskiernia, Karas, Karcsay (Alternate: Hörcsik), Kempinaire, Mrs Lentz-Cornette (Alternate: Mrs Err), MM. Loutfi, van der Maelen, Maginas, Polli, Rathbone, Robles Fraga, Rodotŕ, Rokofyllos, von Schmude, Severin (Alternate: Lupu), Mrs Soutendijk-van Appeldoorn (Alternate: Jurgens), MM. Soysal, Stoffelen, Tabajdi, Trojan, Vinçon (Alternate: Jeambrun), Vogel, Mrs Wohlwend, Mr Zapatero.
N.B. The names of those members who took part in the vote are printed in italics.
Secretaries to the committee: Mr Plate, Ms Coin and Mrs Kleinsorge.
1 1 1. "Consumer involvement in mental health and rehabilitation services", World Health Organisation WHO/---/MEP/89.7.
2 1 1. Recommendation No. R (83) 2 of the Committee of Ministers to member states concerning the legal protection of persons suffering from mental disorder placed as involuntary patients.
3 2Involuntary admission: European developments, Maatschappij, December 1992, pages 1339-1343, Johan Legemaate.
4 1Declaration of Hawaii, as approved by the General Assembly of the World Psychiatric Association in Vienna on 10 July 1983.
5 1Report of the CPT on the visits to a German hospital (in Hochweitzchen) 199.
6 1Experiences with ECT, medical inspections of the mental public health, Research Series No. 6, Rijswijk, the Netherlands, January 1991.
7 1Sexual contacts in psychotherapeutic relations G; Aghassy M. Noot, June 1990, Ministerie van Sociale Zaken en Werkgelegenheid, Netherlands.
8 2Bouhoutson a.o. "Sexual intimacy between psychotherapist and patient", Professional Psychology, 1983.
9 3J.C. Holroyd and A. Brodski "Psychologists' attitudes and practices regarding erotic and non-erotic physical contact with patients", American Psychologist, 1977.
10 4Feldman-Summer and Jones "Psychological impacts of sexual contact between therapists and other healthcare practitioners and their clients", Journal of Consulting and Clinical Psychology, 1984.
11 1Der Spiegel, No. 35, 1993.
12 1Report of the Committee of Inquiry about the situation at Ashworth Special Hospital (1992).
13 2Report 1992, Stichting Patienten Vertrouwenspersonen, (Foundation of patients' confidential counsellors for mental health care), Utrecht, May 1993.