Jan Pfeiffer - striving to reform outdated system of care for mentally ill
Rob Cameron's guest in this week's One on One is Dr Jan Pfeiffer, a psychiatrist and leading advocate of reform for mental health care. As head of the Centre for Mental Health Care Development, Dr Pfeiffer is striving to outlaw such practices as keeping patients in cage or net beds, a practice which has been abandoned in much of the developed world. The Czech Health Ministry recently banned such beds in psychiatric institutions after protests in the international media. But hundreds of them are still used in social care homes, a situation Dr Pfeiffer says is unacceptable.
Jan, How would you evaluate the general level of care in this country for people with mental illness?
"It's very difficult to say in general, because there are very big differences in the quality of care in different places. There are places where you can get really quite good high quality care, including community care and good inpatient care. But you can also find places which are quite neglected, where the only resources for mentally ill persons are outpatient psychiatrists, a few in rural areas, and a big asylum or psychiatric hospital. In places like that you don't get really good care."
But surely there's been a huge improvement since 1989, since the fall of Communism. People realise that mental illness is just an illness like any other.
"I don't think they realise yet that this is an illness like any other. But I think the situation is much better, there's been a lot of publicity about mental health, but of course there's still a lot of prejudice against people with mental illness."
The Czech Republic's mental health care system has come under scrutiny in the international media in recent months because of the use of cage or net beds. Can you tell us exactly what cage or net beds are - where they're used and why they're used?
"It's just a bed, and all around the bed is a net, or in some cases bars. It means you can't get out. They are used mainly in social care homes, mainly for people or children with a mental handicap, who are agitated or self-harming. But they are also used in healthcare, and in the psychiatric system they are used mainly - mainly - for people with Alzheimer's or elderly people who are confused and agitated. And sometimes also for people with psychosis, in acute cases."
These beds were recently banned - at least in psychiatric institutions - after an outcry in the international media: there was an article in the Sunday Times and also a programme on BBC's Radio 4. That campaign was joined by the author of the Harry Potter books, Joanne Rowling, and in the end the Czech Health Ministry decided to ban cage and net beds in mental institutions. Do you think it was a good thing that the pressure to ban them came largely from the international media and Ms Rowling's own initiative?
"I think it's good that this decision was taken. I think it's not good it was taken after this international pressure. It would have been much better of course if the local people had decided by themselves. Information that this method of restraint is not in line with European human rights has been around for more than two years. But this decision has started a discussion about the whole system. Unfortunately the minister who took the decision - Mr Kubinyi - has gone, and we don't know the viewpoint of the new minister."
And of course cage and net beds are still used, as you said, in social care homes, and there are many more cage and net beds in care homes than in mental institutions.
"We don't know exactly, but they do of course have many more beds - about 70,000 beds - and at least 1,000 of them are cage beds. The Ministry of Labour and Social Affairs [which is ultimately responsible for social care homes] has not decided to ban them fully. They've prepared some methodological recommendations to use them only in acute situations. But I think this does not go far enough, and it's not proper."
Why do you actually oppose the use of cage or net beds? They do have many advocates in this country. People working in the system say they are actually a good thing.
"I think the first thing is the risk of neglect. When you put someone in a cage bed, it's true that the person can't move and therefore can't harm himself, and you think he's OK. But of course he's not OK, because he's suffering, he's not in welcoming surroundings. And very often - and I know these cases - the staff don't take care of basic physiological needs such as the need to go to the toilet and so on. Sometimes these people are neglected all night, and in the morning the staff just come and clean them."
In other words treating them like animals in a zoo.
"Well, that's a strong expression but I think you can say that, yes."
What are the alternatives that are used in other countries which no longer use such beds?
"It's not easy to answer in a few words, but the first thing is that you have to think why the person is aggressive, why the person is in the situation that he needs to be put in a cage bed. You have to think of ways of preventing such a situation, and in many cases you can, because it's about the atmosphere in the department, about the attitude of the staff, and of course about the number of staff."
Moving away from cage beds, what are the other big problems in the Czech mental health system?
"Probably the biggest problem is the lack of support in the community. The lack of support where the people are living. Preventing them from losing contact with normal life and being sent to these big psychiatric hospitals where some of them stay for years, even for life. We have a huge number of big psychiatric hospitals, about 10,000 beds for 10,000,000 people. Some of them are bigger than 1,000 beds. They're worlds of their own, with their own rules, which are far away from normal life."
Do you think that the fact that people are usually shut away in institutions says something about Czech society? Or is it a reflection that this was a Communist country, and that was how the Communist regime dealt with the problem?
"I think it was everywhere. It's just the philosophy of the 19th century. In the democratic part of the world, this system of big asylums was found to be inhuman and stigmatising. That's why the system was changed. But it didn't happen in the Communist bloc, where this system to keep people locked away somewhere was in line with the general thinking of a totalitarian regime and that's probably why the system hasn't changed and why the time has come to do that."
"It's very complex. It's about attitudes of society. It's about political will. It's about financing. It's about training. It's very complex to close down 10,000 beds and replace them. It's not easy. And of course, as I said, it's not starting from zero, many things are happening here, and there are many examples of good practice. But of course the rigidity of the people is probably the biggest obstacle to changing things."
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