The Czech mental health care system

Caged bed, photo: Jan Silpoch, Tyden, 19.7.04

As Radio Prague has been reporting, the use of so-called "caged" and "netted" beds, used to restrain agitated and aggressive patients in Czech mental institutions, has been making the headlines following mounting criticism from various organisations, the media, and human rights activists. In this week's Talking Point, we ask experts in the field about the state of the Czech mental health care system.

Last week, Health Minister Jozef Kubinyi ordered all psychiatric institutions to stop using caged beds immediately and recommended they take the necessary steps to end the use of netted beds by the end of the year. The decision was taken in reaction to recent media attention and a plea from the author of the popular Harry Potter children's books J.K. Rowling, who labelled the use of such beds as "torture". But according to Human Rights Commissioner Jan Jarab, reform of the mental health care system has been on the government's agenda for more than a year now:

"Public debate about these issues has been well underway at least for one year and there had been articles in the Czech media, there was a seminar in the Senate on these issues in psychiatry and the Ministry of Labour and Social Affairs had prepared its new guidelines and a draft act. Also, the Health Ministry has participated in a large European project for the comparison of restrictive measures used elsewhere, after all the seminar in the parliament last year was devoted to the use in medical establishments. So, I do think that here the criticism from abroad only joins into a chorus of discussion here and actual measures which were already taken and which will of course take some time to be felt."

In the Czech Republic, mental health care reform is especially complicated as it involves two ministries. Psychiatric care falls under the Health Ministry, while the Ministry of Social Affairs is responsible for residential care for people with mental disabilities. According to some estimates, over four percent of the Czech population, around 300,000 people, are diagnosed with mental disabilities.

Lucie Ripova is a lawyer and human rights advocate. She also works for Kolumbus - a non-governmental organisation for users of psychiatric care, providing free legal help to people with mental illnesses. She says even those directly affected disagree over whether or not to use netted beds:

"We strongly support the decision of the Health Ministry to abolish caged beds. With regards to netted beds, the opinions among users differ. We have those who say they hate them, don't want them and have had bad experiences with them. Other users say that if they have to be subjected to restriction, they prefer the netted beds."

But experts agree that international criticism should not just focus on caged or netted beds. Discussion should concentrate on the quality of mental health care and the quality of life of those with mental illness. Budgeting, a lack of staff and expertise, patients' lack of access to legal support, and the absence of a system of efficient external control are important factors that need to be addressed before the use of netted beds is discontinued.

Human Rights Commissioner Jan Jarab, agrees that caged or netted beds are not the issue. They were invented some one hundred years ago and used predominantly in Central Europe as a kind of humane alternative to straight jackets. What should be controlled, he says, is how and when restrictive measures are taken. Today, there is a fault in the system because caged and netted beds are being used not only as a last resort and alternative to high doses of medication, but also simply because it is more comfortable for the staff:

"The problem here is that we have the apparent abuse of these caged beds precisely because they are not as drastic as these other measures. You wouldn't tie a person up just because your nurses need a break and you probably wouldn't give that person a big shot of drugs because your nurses need a break but you might put that person in a netted bed because they need a break and you might feel that that's okay and that is totally unacceptable and something which we should really address by having clear methodical guidance and rules to minimise the use of this and other methods of restriction. We don't want to have this replaced on the whole by other and perhaps worse methods of restriction. What we want is to create an institutional culture where all methods of restrictions will be used only as a last resort."

Apart from an efficient control system, which will set down the ground rules when restrictive measures can be used there is also the need for a change in the unfavourable staff: client ratio. This will require financial but also human resources. There is a lack of qualified staff - here nurses are usually secondary school graduates, while abroad they are university graduates. Furthermore, some doctors and nurses are not familiar with contemporary trends in psychiatric care and other ways of controlling aggression. Lucie Ripova:

"The lack of staff is a problem but I would say a bigger problem is the lack of educated staff - staff who know how to handle agitated patients. Abroad, when patients are agitated, the staff does not use caged or netted beds. They walk with the patient, for example, and try to calm him down. There's also a special technique how to tackle a patient. It must be a very specific way so that the patient is not hurt. But you have to be trained for that."

But according to Mr Jarab, the ministries are on the right track:

"The inherited attitudes and the ways in which clients are treated from a biological viewpoint rather than from a psychologically sensitive one is what I think the biggest problem is that we have and it is really an institutional culture that we need to reform. That won't do by decree; it has to be done through an educational process. The ministries are now opening up to this idea and they are sending people who should be trainers of trainers to the UK to undergo such learning."

Dr. Jan Pfeiffer, the director of Prague's Centre for Mental Health Care Development - an NGO facilitating the reform process in mental health care, furthermore points out that financing repeatedly goes to the big hospitals, leaving numerous smaller institutions with little resources:

"These institutions are much lower budgeted than other general hospitals. You also see that conditions are much worse than in other hospitals. You still find places where there are ten to fifteen patients in one room and there are two or three toilets for sixty people and the Bohnice hospital is one of the best ones."

What the country needs is a far more flexible way of financing which would enable the development of alternative services, community based services, half-way houses and family care.

LR: "The mental institutions are very far from their homes and there is a lack of daily crisis centres and the basic right to live and be treated in the community is denied. There is a lack of work and supported housing for those with mental disabilities. That is also why many of them have to spend part of their lives in hospitals, just because they have no place to go."

Dr. Pfeiffer: "There are many children with mental disabilities who probably should be at home, and their families would probably be willing to take care of them if they were properly supported and financed. I think about 30,000 Czech crowns a month are given to institutions for the care of one child. With this amount, the family could take quite good care of the child. So, that's one step that has to be taken."

On Sunday, Deputy Minister for Labour and Social Affairs Ludmila Mullerova proclaimed that 400 million Czech crowns would be allocated to support a three-year plan that would help institutions deal with finding alternatives to using caged and netted beds. With Minister Kubinyi's ambitious plan to stop the use of such beds by the end of the year, the country's human rights activists and experts in the field of mental health care hope establishments will be forced to speed up the introduction of more community care and other modern practices.