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Psychiatric hospitalization in Poland
0~774S3h t17 100f117-07P)3 00 0 I’crg:,m0n I’reu Llll
PSYCHIATRIC
HOSPITALIZATION
IN POLAND
LOUIS FRYUMAN The University
of Kansas. School of Social Welfare.
Twente
Hall.
Lawrence.
KS 66045.
U.S.A.
Abstract-An overview of psychiatric hospitalization in Poland is presented in the conlext of Polish political and socio-cultural developments. The areas addressed include: the characteristics or the patient population: the organization of Polish mental health service; the nature of psychiatric treatment: psychiatric legislation; patients’ rights: and the training and social status of the various mcnlai health professionals. In spite of the meager resources allocated to mental health services. and the consequent statl’ shortages and overcrowded, drab living conditions in psychiatric facilities. the care afforded patients is general11 humane and nonoppressive. Polish psychiatry has succeeded in maintaming its professional autonomy and has assumed a leadership role in the modernization of its service delivery system.
INTRODUCTIOiY Our freedom of the press notwithstanding, we know much less about developments in the field of mental health in Eastern Europe than the East Europeans know about American mental health programs. What makes matters even worse is the fact that the little we know is laden with inaccuracies and distortions. Our first error is to perceive Eastern Europe as a monolith. In actuality, the differences in mental health programs between the various East European countries is as great. if not greater. than the differences between their West European counterparts. The second error is that we tend to perceive East European mental health practices as so backward in relation to ours that there is nothing for us to learn from them. Third. we mistakenly assume that the widely differing sociopolitical orientations between the West and the East negate the possibility of meaningful mutual collaboration. Finally. we wrongly believe that psychiatric practices in Eastern Europe are hidden from public view and that any attempt by a Western mental health professional to investigate such practices is bound to be viewed with deep suspicion and mistrust. The best antidote for these misconceptions is direct contact with East European mental health professionals and on-site visits to their treatment facilities. at least insofar as Poland is concerned. Not only is the field of mental health open to public scrutiny in Poland. but psychiatric hospitalization. involuntary as well as voluntary. is not regarded as a politically or socially sensitive issue. The oppenness, lack of defensiveness. and willingness to communicate shown by Polish administrators of psychiatric facilities to foreign visitors goes far beyond what any American mental health professional could expect to receive from psychiatric authorities in his own country.
Two major historical events must be taken into account in any attempt to understand current Polish mental health services. The first and the more salient is the inipact of the Second World War. The devastation wrought b> the war upon Poland staggers the human imagination. One out of every five Poles lost
their lives. only lo”,, of these deaths being direct combat casulalties. The losses among the intelligentsia were especially heavy. due to a deliberate policy of the occupying forces. When the war ended. while the number of distraught, physically and mentally exhausted survivors was staggering. there were only 100 psychiatrists left alive and 5000 psychiatric beds available. The bulk of these beds was located. understandably so, in the Western territories that had belonged to Germany prior to World War II. Soon after liberation. thousands of pscyhiatric patients. mainly those whom the war had made homeless and alone, were sent westward by train transports and have remained there. This is the reason why. as late as 1974.40”,, of all psychiatric inpatients were residing in a cluster of hospitals in Western Poland [I]. This concentration of psychiatric facilities is not the only continuing effect of the war on Polish mental health services-in speaking with Polish psychiatric patients as well as with staff members. it is not unusual to see a direct connection between the patient’s experiences during the Nazi occupation and his current psychiatric and/or physical disorders. The second major historical development which has affected Polish psychiatry is the emergence of the Polish communist party as the ruling force in postwar Poland. Prior to World War II Polish psychiatry had been under the influence of the German descriptive. organic approach and. to a lesser degree. of the psychodynamic movement. emanating from Vienna. Once the war was over. the Soviet disease-process view of mental disorders became prominent. This development reflected the socio-political realities of post-war Poland. not any indigenous ideological developments within Polish psychiatry. As a communist society was supposed to be flawless. mental disturbance could only be attributed to a biologically-based psychopathological process within the individual himself. Social workers. trained to perceive the social environment as the matrix of deviant behavior. and clinical psychologists. trained to enhance personal growth and self-realization. were deemed superfluous. if not actually harmful. With Stalin’s death in 1953. the loosening of this doctrinaire stance began. allowing Polish psychiatry to regain its professional autonomy. Politically appointed mental health adminis617
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‘trators were gradually replaced by more capable, task-oriented professionals. The treatment focus began to shift away from the major psychoses toward neurotic and characterological disturbances. By the early 1970s clinical psychology began to blossom. In 1972, an Experts Commission, representing the leadership of the psychiatric and legal professions, was appointed to draft a comprehensive Polish Mental Health Act. The Committee’s Chairman, Stanislaw Dabrowski, a highly respected psychiatric clinician and administrator, devoted himself fully to this task and subsequently to. the passage of the Committee’s recommended draft. In spite of strong public as well as professional support for the proposed Act. it has yet to be accepted by the Polish legislature. As of the Summer of 1982, it appears that the Act is likely to be incorporated into the National Health Code rather than enacted as a separate statute. Among the factors affecting psychiatric hospitalization in Poland, the matter of secondary gain looms large. As a result of the wartime destruction of the cities, the country’s immense post-war investment in heavy industry, and the government’s avowed promise to provide adequate housing to all citizens, a critical housing shortage continues to exist. When an individual is hospitalized, not only does his family’s housing situation improve, but the patient’s income is not substantially reduced as he continues to receive his disability pension even while hospitalized. Such disability pensions are liberally granted, especially when psychiatric hospitalization has taken place. In general, Polish psychiatric patients do not receive high doses of neuroleptics, they are allowed much freedom within the institution, patient abuse is rare, and demands on the patient are minimal. Many incentives thus exist for the patient, as well as his family, not to seek his discharge. In essence, in spite of overcrowdedness and drab institutional conditions, to the majority of patients the hospital has become home. OVERVIEW
OF PSYCHIATRIC
HOSPITALIZATION
IN POLAND
Patient population In 1979 the average daily population of Polish psychiatric inpatient facilities was 38,153 patients. Although the official capacity was 29,561 beds, 42,282 beds were in actual use. Thus there were 43% more beds in use than the facilities were built to accomodate-in other words, severe overcrowding was common. The actual number of beds per unit of population was 11.9 per 10,OCO.Psychiatric beds accounted for 16.S% of all Polish hospital beds. While the Polish inpatient psychiatric hospital population has been increasing only slightly since 1065. in line with over-all population growth, the admission rate to psychiatric facilities has continued to climb (the American experience has been similar-the resident population began to fall in 1955 while admissions continued to rise until 1977). The average length of stay in Polish psychiatric facilities has con: tinued to decline, from 138.5 days in 1960 to 76.3 days in 1979. Nevertheless, the percentage of chronic patients, those hospitalized continuously for 5 years or longer, has continued to rise, accounting for 24.9”:,
of all patients in 1979. Of all admissions in 1979. 37.5”, were first admissions. 40.3”,, of all inpatients had been hospitalized for 1 year or longer. The modal age of inpatients has continued to climb. reaching 4G49 years for both and women in 1976. It is noteworthy that. as of 1978. 30.7”, of all Polish psychiatric inpatients were employed at least two hours per day. usually at the institution in which they were being treated. Although such employment is euphemistically referred to as ‘ergotherapy: little pretense is made that it bears any relationship to the patient’s treatment program or to his eventual discharge. Psychiatric diagnoses in Poland are based on the International Classification of Diseases. Nevertheless. generally fewer than half of pscyhiatric inpatients are diagnosed as psychotic and only half of those so diagnosed are deemed to be schizophrenic. Polish psychiatrists essentially restrict the diagnosis of schizophrenia to cases in which there are clearly discernable thought disorders, such as haliucinations or ideas or delusions of reference. According to the sophisticated Poznan Psychiatric Register, the only register of its kind in Poland, only 17.0% of first admissions to psychiatric facilities in Poland during 1974 were diagnosed as schizophrenic (a total of 39.2”/:, were diagnosed as psychotic and 55.9% as non-psychotically disturbed, including 13.7:); diagnosed as alcoholic). Among those admitted to outpatient clinics that year, only 5.10;, were diagnosed as schizophrenic (lZ.Sg;, were diagnosed as psychotic and 14.67; as alcoholic). The staff The psychiatrist is both the leader and the mainstay of the Polish mental hospital. She (women clearly outnumber men in Polish medicine. psychiatry in particular, though administration is still almost entirely in male hands) is a graduate of a 6-year medical school followed by a 1 year basic internship, and she either possesses or is working toward the first of the two levels of psychiatric certification. She is generally addressed as ‘Doctor’ regardless of whether she has earned the doctoral degree. In contrast. the psychologist is generally addresses as ‘Magister’ even when she has earned a doctoral degree. It is noteworthy that degrees and titles continue to be of high social importance in today’s Poland. Not only are degrees and titles used as a means of address. not only are they often noted on name plates at one’s place of residence, but it is not unusual to find them engraved on tombstones, even recent ones. The psychiatrist is recognized as the’ expert on all matters relating to ‘mental illness’, this term being restricted to a diagnosis of psychosis. Only the psychiatrist can conduct a mental status evaluation of a criminal defendant, and only she can assume the treatment responsibility if mental illness has been determined. If mental illness is not at issue, psychiatric opinion is not solicited by the courts. The psychologist is deemed to be the expert in the area of mental retardation. social maladjustment, and intrafamilial conflict. No mental health profession is vested with expertise for treating neurotic disturbances. While their number is steadily growing, there,are still very few clinicians or clinics which specialize in the treatment of the neurotically disturbed [Z]. It is noteworthy that when the Polish public was polled in 1968 as to
Psychiatric
hosphalization
the help needed by a neurotic, the psychiatrist came in sixth, being preceded by the neurologist. the internist, the general practitioner. rest. and sex, in that order. One of the reasons for this finding is that the public has apparently associated the word ‘neurologist’ with ‘neurosis’. and ‘psychiatrist’ with ‘psychosis’. It seems evident that the Polish mental health establishment is currently only beginning to fully address itself to the treatment of neurotic disorders. The salary of the Polish psychiatrist who works in a clinical setting is quite meager. well below that of a Polish bus driver or miner. Salary levels for health personnel employed in industry are somewhat higher as industry produces scarce consumer goods and. even more importantly, brings in ‘hard’ currency, critically needed to repay foreign debts. Private practice in psychiatry or psychotherapy is virtually nonexistent-even the psychiatrist’s participation in semiprivate medical cooperatives is frowned upon. There are nevertheless opportunities available for the medical specialist to augment her income. She may hold more than one staff position, she may be ‘on call’ at the hospital or work in the admissions ward after her regular working hours, she may do examinations and give testimony to the court (the payment she receives for this work belongs to her even though she performs this task during regular working hours). etc. If she works hard enough, her income may approach that of a miner. Nevertheless, Polish medicine. psychiatry included, is endowed with high social prestige and professional status. Competition for admission to medical academies is fierce. Strong doubt is thus cast on the American view that high salaries are essential to attract gifted students to medical careers as well as to uphold the high social standing of physicians, a status allegedly needed to enhance their healing capacity. The psychiatric patent-staff ratio in Polish mental hospitals. 25.7 patients per physican as of 1976. compares well with American standards insofar as state hospitals are concerned. What is problematic. however. in Poland is the virtual absence of collaborative or ancillary staff except for nurses and activity therapists. both of whom continue to be in short supply. The situation is similar in outpatient clinics where, in 1978, each physician held an average of 10 interviews per day and saw 761 different patients in the course of a year. The average psychiatric out-patient was seen a total of only 4 times. Polish psychologists earn a Master’s degree. their basic professional credential, after 4 years of study. Clinical psychology. reborn only in the mid-1960s. experienced a surge of popularity and rapid expansion of training programs in the early 1970s. The function of the psychologist in the mental hospital setting continues. however, to be defined by section chiefs. invariably physicians. who also assume a supervisory and evaluatory role toward psychologists. There is much variation in this between different hospitals, and change is in the air. For instance. psychology has already been granted departmental status in some hospitals. the chief of psychology becoming directly responsible to the superintendent (still invariably a psychiatrist). In most hospitals. psychologists spend most of their time administering tests and leading treatment-related group activities. mainly group therapy. For unexplained reasons. one-to-one therapy.
in Poland
619
rare as it is, is generally limited to psychiatric practitioners. The dominant psychological approach to clinical practice is cognitive in nature. but includes elements of Gestalt Therapy, psychodrama, Transactional Analysis, and sensitivity training. Neither psychoanalysis nor behaviorism is popular. Psychologists prefer working in community-based counseling services, in industry. and in research centers. Positions in psychiatric hospitals are not deemed desirable. This is reflected in the fact that, as of 1978, there were 93 inpatients for each staff psychologist. Social work training in Poland, limited to a 2-year non-university course, prepares its graduates for employment in a social welfare district office. mainly supervising volunteer welfare workers. Each such volunteer provides direct assistance to needy individuals in his own neighborhood. For the first time in the post-war period, a Master’s in Social Work degree program was launched in 1977 (at the prestigious University of Warsaw). Professional training of social workers is strongly supported by Polish psychiatrists, especially those working in mental hospitals.
All psychiatric facilities are established and administratively supervised by local Health and Social Welfare Councils. The quality of each hospital’s treatment program is monitored either by an appointed regional consultant or by the chief of the psychiatric department of a Medical Academy, if one is located nearby. All appointments of regional consultants as well as hospital superintendents must be approved by the Psychoneurological Institute. located in Warsaw. which serves as the Ministry of Health and Social Welfare’s representative in all matters relating to psychiatry and neurology. The Institute oversees the Polish psychiatric service delivery system, studies its functioning, sets guidelines for it, and plans for its future. All patients’ complaints addressed to the Ministry are reviewed and acted upon by the Institute. In addition to its supervisory and planning functions, the Institute carries out its own extensive research, training. and treatment programs, thus providing models for quality programs throughout the country. While there was a total of 39 psychiatric hospitals in Poland in 1978, 64.57: of the patien’ts were housed in 19 institutions, each containing over 1000 beds. Most of these large hospitals were built before the war and are located in geographically remote areas. Although psychiatric wards were generally locked until the early 1970s an open door policy spurred by the Psychoneurological Institute, has gained rapid acceptance; by the end of the decade, most wards were totally or partially open. The closed wards which continue in existence tend to be specialized in nature. They may be limited to very difficult or violent patients. to those undergoing intensive pharmacotherapy, or to those whose confinement has been courtordered. The large number of court-ordered confinements. accounting, as of 1978. for about 89, of all inpatients, and the continued maintenance of some closed wards, present serious impediments to the successful implementation of the sub-regionalization program. described below. The rapid growth of community-based mental health facilities. beginning in the late 1960s. facilitated
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collaboration between outpatient and inpatient psychiatric facilities. thus enhancing continuity of treatment. In 1970 a pilot sub-regionalization program was introduced. Each county in a facility’s catchment area was assigned a specific ward and close ties were encouraged between the inpatient and outpatient staffs. By 1974 this arrangement became the official policy throughout Poland. even though much resistance to it has persisted. especially in facilities. such as medical academies and research centers. where psychiatry has not been accepted as an equal partner by other medical .specialties. Furthermore. even where the policy has been essentially followed, its implementation has been limited to new admissions. Little has thus been done to return out-of-region long-term patients to their original counties of residence, notwithstanding pressure from the central psychiatric authorities in Warsaw. The sub-regionalization policy has nevertheless accomplished its main objective of bringing inpatient and outpatient services closer together. It is not unusual to.find hospital personnel and the corresponding outpatient clinic’s staff actually taking turns working in one another’s settings. The drive toward modernization of the Polish mental health service delivery system was clearly reflected in the 1974 report of the Experts Commission. which called for the replacement of the traditional mental health services model, with the psychiatric hospital at the center. by an integrated and comprehensive network of community-based treatment and prevention programs. Three years later, in 1977. the Psychoneurological Institute’s Department of Mental Health Administration. the planning center for the Polish mental health service delivery system, painstakingly examined the problems besetting Polish psychiatric institutions and. in line with the Experts Commission’s recommendation. reversed its earlier call for the continued expansion of inpatient facilities. A report. presented by Tadeusz Dziduszko, the Head of the Department. bespeaks the candor and openness that is possible even in a large bureaucratic organization [3]. Dziduszko’s critique of the traditional service delivery system can be summarized as follows: (I) Problems
relating
to treatment
practices:
(A) Undue concern with institutional care imperatives has resulted in the neglect of patients’ psychosocial needs. (B) Traditional medical/psychiatric practices, such as the wearing of uniforms and taking of temperatures. are needless and wasteful. (C) Traditional psychiatric practices in mental hospitals such as the separation of sexes. control of correspondence. and maintenance of locked and ‘chronic’ wards. continue to infringe on the civil and treatment rights of patients. (D) The prevailing authoritarian stance of mental health professionals. the psychiatric staff in particular. hinders the development of interdisciplinary cooperation cssentiul to the expansion of psychosocial treatment programs as well as to the creation of a sound therapeutic milieu. (II) C)rgani/ational
and methodological
(A j The sub-rcgionalization program uniformly and clkctivcly implcmcnted.
defects: has not been
FRYDMAN
(B) Collaboration between inpatient and outpatient facilities is insufficient to ensure continuity of treatment. (C) Ergotherapy programs have often become tied to economic rather than treatment objectives, (D) Rehabilitation and sociotherapy programs have not been afforded sufficient organizational and funding support and too little has been done to gear these services to the particular needs of patients. (E) The hospitalized patient has remained unduly isolated from his family and community. (F) There is too much boredom on the wards. (III) Recommended
changes:
(A) The number of patients in psychiatric hospitals should be drastically decreased, thus resolving the problem of overcrowding. (B) The patients’ living conditions on the wards should be improved. (C) The patient’s ties to his community should be strengthened by facilitating closer contact with his family and friends. (D) Social service departments should be strengthened and steps taken to improve the effectiveness of social rehabilitation efforts. (E) The psychiatrist’s relationship with patients as well as with the nonmedical staff should be improved. (F) Sub-regionalization programs as well as collaboration between inpatient and outpatient facilities should be strengthened. (G) The network of less restrictive treatment programs. such as partial hospitalization. home hospitalization, and treatment on psychiatric wards of general hospitals. should be expanded and coordinated. (H) The Mental Health Act should be enacted and all treatment facilities should strive to carry out its objectives. The report was well received by Polish mental health professionals even though it was clear that the objective conditions under which Polish psychiatric patients lived and Polish mental health professionals worked were not likely to become substantially improved in the foreseeable future. In view of the country’s serious economic problems it was most unlikely that the Polish mental health service delivery system would receive the funding needed to turn its vision into reality. INVOLUNTARY
COMMITMENT
The only regulation governing involuntary commitment of mental patients in Poland is a 1952 Ministry of Health and Social Welfare directive [4] authorizing psychiatric facilities to accept a patient at his own request. at the request of a relative or guardian. or at the discretion of the admitting physician if the patient appears to be dangerous to self or others. No records have been kept regarding the type of admission involved in each case. as the issue whether the admission was voluntary or not has heretofore been deemed inconsequential. In fact. prior to 1973 only one article. a minor one, on involuntary commitment appeared in the official journal of the Polish Psychiatric Association [S]. Since that year there have been several studies, local as well as national in scope. pub-
Psychiatric hospitalization lished on this subject [6]. The percentage of involuntary admissions has been found to vary between 7 and 25”,, depending on the facility being studied as well as on the criteria used to define involuntary commitment. It is not difticult to understand why the Polish public has in the past preferred to place its faith in the family and the physician rather than in the judiciary. insofar as involuntary commitment is concerned. Polish family ties have consistently been strong (even at this time there is little evidence of a ‘generation gap’) and the Polish physician has long enjoyed the trust and confidence of the general public. While there continues to be serious dissatisfaction in Poland with the medical service delivery system. the shortages of equipment and medications in particular. the blame has been placed on inadequate funding. planning. organization. and distribution rather than on the physician himself. Politically. physicians have either supported national aspirations or remained neutral. Polish physicians were well represented in the war time resistance movement and in the rank and file of the Solidarity movement [7]. Much more concern has been expressed by the government about physicians who are too sympathetic toward patients who request medical leaves or disability pensions than by the general public about physicians who deny their rightful requests. While physicians enjoy a comparatively higher social status and standard of living than the population at large. the differences are neither substantial nor significant. Physicians fully share their patients’ struggles with obtaining suitable living quarters. securing a telephone. or buying a car. The judicial system. on the other hand. has enjoyed little sustained public trust and confidence. especially during the war time occupation and the post-war Stalinist period. The courts in Poland. as elsewhere. are essentially controlled by those in power. Polish judges continue to be political appointees, membership in the communist Polish Workers’ Party being a virtual .siftt~error non credential. As long as the medical model 01”mental disturbance reigned unchallenged and inpatient care was deemed the treatment of choice. involuntary commitment at the request of a relative or on the order of a psychiatrist raised little concern in the general public. However, as the conception of mental illness has begun to include psychosocial dynamics. and the family has gradually come to be seen as the matrix. if not the bearer. of psychopathology. the power of one relative to commit another ‘for his own good’ began to be viewed with suspicion. Several concurrent developments have speeded this process. The public has become increasingly aware that psychiatric hospitals were in actuality more likely to be holding places for difficult. socially maladapted individuals rather than intensive treatment centers for the mentally ill. The public has also become aware of the overcrowded. dehumanizing living conditions still cxistinp in some of the large psychiatric hospitals. Furthermore. the Polish judrcrary has in the past two decades undergone significant reforms which have strengthened the civil rights of the citizenry. the most striking bemg the nullification. in 1968. of the Appendage to the Criminal Code enacted in 1945 when the country was caught LIP in vtolent political strife, This appendage had grven the courts wide discretion in
h2 I
in Poland
adjudging criminal offenses to be political in nature. thus depriving such offenders of their basic rights. Finally, it is to Poland’s advantage to disassociate itself from the serious charges that have been leveled against the Soviet Union for its alleged involuntary detention and forced ‘treatment’ of political dissidents. Many attempts have been made in post-war Poland to enact a Mental Health Act. The closest such an effort came to fruition was in 1970 when a bill entrusting involuntary commitment and the fate of the confined patient to the psychiatric profession alone, was received by a committee of the Polish Legislature, the Sejm. The bill. shrouded in secrecy by its sponsors and advocates, was effectively exposed to the public by a concerned effort of social activists, members of the sociology faculty at the University or Warsaw in particular. The bill’s late was sealed when a wave of popular dissent toppled the Gomulka government. Two years later. in 1972. the Minister of Health and Social Welfare appointed an Experts Commission to draft a new. comprehensive Mental Health Act. The Commission’s 1974 report was not only officially published [g]. but a call was issued by the Commission for a thorough discussion of its proposals prior to the drafting of the final version. A yeat of intensive. often heated. debate in the mass media and among the various mental health professions. the legal profession, the academia. and the general public followed the release of the Commission’s report. This debate. free of all censorship, was virtually unequalled in the history of post-war Poland in its openness. breadth and candor. Commission members traveled all over Poland to participate and to learn from the discussions. The reactions by the public and the interested professional and lay groups were incorporated into the final draft submitted to the Minister of Health and Social Welfare in 1975. As of the Spring of 1982. after seven tortuous years of journeying through the various ministries and legislative bodies. the proposed Mental Health Act. in only a slight modified form. appeared to be. as noted earlier. on the verge of final enactment by the Sejm as an amendment to the National Health Code. Had it been enacted as a separate statute its impact would have been much greater. Nevertheless, the new legislation would still constitute a milestone in the modernization of the Polish mental health service delivery system.
PATIENTS’ RIGHTS
As of the spring of 1982. the rights of Polish psychiatric patients have not been defined by any law or administrative regulation. Section chiefs of psychiatric hospitals are vested with total responsibility for patients’ treatment and eventual discharge. The right to refuse treatment is rarely recognized by staff. Because of overcrowded facilities. staff shortages, a prevailing skepticism about the value of long-term confinement. and the absence of a profit motive. Polish psychiatric hospitals generally welcome the discharge of any non-dangerous patient whose family or community is ready to receive him. The only exceptions are likely to occur in facilities which depend
62’
Lot-rs FRYDMAN
on patient labor and are thus likely to be reluctant to discharge a patient who is a good worker. While there is no organized patients’ rights movement in Poland. several essentially autonomous expatient organizations are in existence, the largest one located in the city of Cracow. It is noteworthy that this latter group made a presentation in 1973 before the Experts Commission and that the commission gave the group’s concerns serious consideration. Most of the other ex-patient organizations are affiliated with inpatient psychiatric facilities and, in effect, serve as an arm of treatment. In general. Polish psychiatry supports the establishment of patients’ clubs and mutual support groups and does not appear threatened by the possible emergence of patients’ rights activism. While no machinery exists for reviewing patients’ grievances, all such complaints addressed to the Ministry of Health and Social Welfare are channelled through the Psychoneurological Institute for investigation and resolution. The Institute takes such communications seriously and it is not unusual for a senior member of the Institute to be dispatched to the given facility for an on-site visit. The Institute also monitors the quality of patient care by keeping in close contact with regional consultants who oversee inpatient care facilities within their districts. These consultants have at times alerted the Institute about questionable care or treatment practices in a particular hospital and have even sought the Institute’s involvement in evaluating the situation and making needed changes. Although many Polish psychiatric hospitals contain a locked ward for violent or physically threatening patients, the practice of seclusion is unknown in Poland, either as a treatment modality or as a means of control or punishment. Polish psychiatrists are surprised to hear that seclusion is allowed in the U.S., usually without the patient’s consent and in the absence of a dire emergency. The only means of physical restraint used in Poland are straps for tying a patient’s wrists to his bed. The patient generally remains in direct communication with staff members and fellow patients. The straps are removed once the patient ceases to be belligerent. Some facilities, mainly in the Warsaw area (the Psychoneurological Institute in particular), eschew all forms of physical restraint. No resultant increase in patient aggressivity seems evident. It generally appears that the more frequently restraints are used, the greater the frequency of manifested patient aggressivity. It must, however, be noted that those clinics which limit the use of restraints are likely to have more highly trained staff and better staff coverage. In regard to questionable or risky treatment procedures, Polish patients, unlike their American counterparts, as yet have no legal protection against involuntarily administered electroconvulsive (ECT) and insulin convulsive therapies and experimental drugs. Surprisingly, ECT is more likely to be used in more modern, better equipped Polish hospitals, apparently because of the availability of staff anaesthetists. Some facilities restrict themselves to unipolar ECT application, others only to b&polar; some require the use of anaesthesia, others shun it; some limit the procedure to severely depressive patients
while others also administer it to the intensely agitated; still others select it for patients manifesting catatonic-type withdrawal. Some facilities do not use ECT at all. Whatever the stance a particular treatment center takes, it seems to defend its position tenaciously. One hospital administrator confided that ECT was no longer being used in his facility because its use proved too upsetting to the staff. Not infrequently the rationale given for the use of ECT is: “We give it only because the patients want it”. Despite this claim, the author was on several occasions approached by patients who complained about receiving ECT against their wishes. This was more likely to occur in facilities which maintained that their patients sought ECT. It should be noted that when the author related these conversations to the treating psychiatrists their response tended to be more marked by concern than by defensiveness. In a small number of Polish psychiatric hospitals ECT has at times been applied to patients’ buttocks or legs, primarily in cases of suspected conversion hysteria. This particular use of ECT has been looked upon with disfavor, if not outright condemnation, by psychiatric authorites, those at the Psychoneurological Institute in particular. Insulin shock therapy is not widely used but the few hospitals that do administer it tend to do so extensively. Psychosurgery, though not outlawed or formally prohibited, is not performed anywhere in Poland. Pneumoencephalograms are used in many facilities. but only with the patient’s informed consent. In comparing psychiatric hospitalization in Poland and in The United States, there appears to be a connection between the value attached to the therapistpatient relationship and recognition of patients’ rights. In general, while American hospital psychiatrists view their relationship with their patients as sacrosanct, their Polish counterparts endow it with little reverance. This is understandable. In American psychiatric practice, especially if rooted in psychoanalytic theory, the therapeutic relationship is considered central to the treatment process. Efforts are thus likely to be made to limit unmonitored outside ‘contamination’, to keep the patient under the close scrutiny and control of the treating physician. This attitude is so deeply ingrained that in actual hospital practice the sanctity of the doctor-patient relationship is likely to be upheld even when individual therapy is virtually non-existent. In Poland, by contrast, there is little pretense that individual therapy is taking place and no tradition or rationale exists for safeguarding the transferential aspect of the doctor-patient relationship. In general, little attempt is made by the Polish psychiatrist, either directly or indirectly, to monitor or control her patients’ thoughts or behavior. except for emergency situations or when high doses of psychoactive medications have been administered. Staff control of involuntary patients, whether in the West or in the East, raises the specter of the use of psychiatry for socio-political purposes. While there is no question that psychiatry plays an important social control function in Poland as well as in the United States, there is virtually no evidence that psychiatry is. or ever has been, used to confine or forcefully ‘treat’ Polish political dissidents. Although Polish psychiatrists are in the employ of the state their loyalty has
Psychiatric
hospitalization
remained to their profession. The psychiatric leadership has zealously guarded against any subversion of its profession for social control purposes. The passage of the proposed Mental Health Act, whether as a separate statute or as a part of the more comprehensive National Health Code, would guarantee the psychiatric patient full judicial review of any substantial infringement of his civil rights. No patient could be involuntarily committed to a psychiatric facility, except on an emergency basis. without a judicial finding that he presents, because of a mental illness, a direct threat to his own life or to the life or health of others. All involuntary admissions would have to be reported to the district court within 48 hours and a commitment hearing would be required not later than 14 days following such notification. If committed. the patient would have the right. after 30 days of confinement, to judicial review of the need for continued detention. The status of each involuntary patient would also automatically be reviewed by the court 6 months following adjudication. Absent court permission, treatment modalities. psychoactive medications included, which are known to present an above-average risk to the patient, could not be administered against his will. except for life-threatening emergencies. SUMMARY
Polish psychiatry has worked arduously to recover from the devastation of the Second World War and from the subsequent socio-political climate which had impeded the development of professional vitality and autonomy. The strides made by the Polish mental health professions in the 1970s have been remarkable. The mental hospital’s position as the centrum of psychiatric practice has been effectively challenged, a well-planned sub-regionalization policy has been implemented, inpatient facilities have made substantial progress in shedding their restrictive regimen, the training of clinical psychologists has blossomed, professional training of social workers has been launched, and a very progressive Mental Health Act is inching its way toward enactment. The leadership of Polish psychiatry appears highly capable and energetic. Barring catastrophic setbacks to the Polish nation, continued progress in the modernization of the Polish mental health service delivery system. the protection of patients’ rights included. can well be expected.
623
in Poland REFERENCES
1. All of the statistical data presented is based on data provided by the Department of Mental Health Administration of the Warsaw Psychoneurological Institute. Tadeusz Dziduszko, Director. Personal communication 2. Notable among these exceptions is the inpalient cognitive and insight therapy program at the Clinic for the Treatment of Neurosis, directed by Stefan Leder at the Psychoneurological Institute. and the Rasztow Residential Treatment Center, originally established by Jan Malewski, a psychoanalytically trained psychiatrist. 3. Dziduszko T. Zadania Szpitali Psychiatrycznych w Programie Poprawy Jakosci Psychiatrycznej Ochrony Zdrowotnej (The Task of Psychiatric Hospitals in Improving the Quality of Mental Health Services). Unpublished paper presented at the Regional Conl’erence of Psychiatric Consultants in Gdansk. Poland. 1978. 4. Instrukcja nr 120/52 Ministra Zdrowia z dnia IO grudnia 1952 r./nr PL 9/14169/52 w sprawie przyjmowania i wypisywania ze szpitali psychiatrycznych. !DZ. Urz. Min. Zdrowia z dn. 15 XII 1952 r. nr 24 poz. 240, 5. Treter A. Uwagi na Temat Dobrowolnosci i Przymusu w Psychiatrii (Comments on the Subject of Voluntariness and Involuntariness in Psychiatric Treatment). Psychiat. PO/. 111, 479-484. 1969. 6. See, for example. Hernacka B. er al. Dobrowolnosc I
Przymus Hospitalizacii Psvchiatrvcznei (Voluntary and involuntary psychiatric hospitalization). Psvchiar. PO/. VII. 185-190. 1973: Dabrowski S. et ~1. Hospitalizacja Przymusowa (involuntary hospitalization). Psv chat. PO/. X, 601-610. 1976; Sidorowicz S. Przymus w Przyjmowaniu do Szpitala Psychiatrycznego (Involuntary psychiatric admissions). Psrchiut. PO/. X, 4650. 1976; Chlopicki K. er al. Analiza Przyjec Chorych do Kliniki Psychiatrycznej SAM (An analysis of admissions to a medical academy’s psychiatric ward). Psychiat. PO/. X, 173-181. 1976. 7. An American psychiatrist who studied Polish medical care policies and practices in the Spring of 1981 reports. for Instance, that 757, of the Psychoneurological Institute’s employees. the medical staff included. had joined Solidarity and that medical students had succeeded in eliminating Marxist courses from the required curriculum. Webster T. G. Special report: Health policy issues and the predicament in Poland. New Enyl. J. Med. 306, 308-312. 1982. 8. The Commission’s major proposals were oublished in the I July issue of &em .hdowu. Tez; Dotyczace Regulacii Prawnei Ochronv Zdrowia Psychicznego (Assumptions underlying . psychiatric legislation). Guzctu sad. 13, 5-6, 1974.
PSYCHIATRIC
HOSPITALIZATION
IN POLAND
LOUIS FRYUMAN The University
of Kansas. School of Social Welfare.
Twente
Hall.
Lawrence.
KS 66045.
U.S.A.
Abstract-An overview of psychiatric hospitalization in Poland is presented in the conlext of Polish political and socio-cultural developments. The areas addressed include: the characteristics or the patient population: the organization of Polish mental health service; the nature of psychiatric treatment: psychiatric legislation; patients’ rights: and the training and social status of the various mcnlai health professionals. In spite of the meager resources allocated to mental health services. and the consequent statl’ shortages and overcrowded, drab living conditions in psychiatric facilities. the care afforded patients is general11 humane and nonoppressive. Polish psychiatry has succeeded in maintaming its professional autonomy and has assumed a leadership role in the modernization of its service delivery system.
INTRODUCTIOiY Our freedom of the press notwithstanding, we know much less about developments in the field of mental health in Eastern Europe than the East Europeans know about American mental health programs. What makes matters even worse is the fact that the little we know is laden with inaccuracies and distortions. Our first error is to perceive Eastern Europe as a monolith. In actuality, the differences in mental health programs between the various East European countries is as great. if not greater. than the differences between their West European counterparts. The second error is that we tend to perceive East European mental health practices as so backward in relation to ours that there is nothing for us to learn from them. Third. we mistakenly assume that the widely differing sociopolitical orientations between the West and the East negate the possibility of meaningful mutual collaboration. Finally. we wrongly believe that psychiatric practices in Eastern Europe are hidden from public view and that any attempt by a Western mental health professional to investigate such practices is bound to be viewed with deep suspicion and mistrust. The best antidote for these misconceptions is direct contact with East European mental health professionals and on-site visits to their treatment facilities. at least insofar as Poland is concerned. Not only is the field of mental health open to public scrutiny in Poland. but psychiatric hospitalization. involuntary as well as voluntary. is not regarded as a politically or socially sensitive issue. The oppenness, lack of defensiveness. and willingness to communicate shown by Polish administrators of psychiatric facilities to foreign visitors goes far beyond what any American mental health professional could expect to receive from psychiatric authorities in his own country.
Two major historical events must be taken into account in any attempt to understand current Polish mental health services. The first and the more salient is the inipact of the Second World War. The devastation wrought b> the war upon Poland staggers the human imagination. One out of every five Poles lost
their lives. only lo”,, of these deaths being direct combat casulalties. The losses among the intelligentsia were especially heavy. due to a deliberate policy of the occupying forces. When the war ended. while the number of distraught, physically and mentally exhausted survivors was staggering. there were only 100 psychiatrists left alive and 5000 psychiatric beds available. The bulk of these beds was located. understandably so, in the Western territories that had belonged to Germany prior to World War II. Soon after liberation. thousands of pscyhiatric patients. mainly those whom the war had made homeless and alone, were sent westward by train transports and have remained there. This is the reason why. as late as 1974.40”,, of all psychiatric inpatients were residing in a cluster of hospitals in Western Poland [I]. This concentration of psychiatric facilities is not the only continuing effect of the war on Polish mental health services-in speaking with Polish psychiatric patients as well as with staff members. it is not unusual to see a direct connection between the patient’s experiences during the Nazi occupation and his current psychiatric and/or physical disorders. The second major historical development which has affected Polish psychiatry is the emergence of the Polish communist party as the ruling force in postwar Poland. Prior to World War II Polish psychiatry had been under the influence of the German descriptive. organic approach and. to a lesser degree. of the psychodynamic movement. emanating from Vienna. Once the war was over. the Soviet disease-process view of mental disorders became prominent. This development reflected the socio-political realities of post-war Poland. not any indigenous ideological developments within Polish psychiatry. As a communist society was supposed to be flawless. mental disturbance could only be attributed to a biologically-based psychopathological process within the individual himself. Social workers. trained to perceive the social environment as the matrix of deviant behavior. and clinical psychologists. trained to enhance personal growth and self-realization. were deemed superfluous. if not actually harmful. With Stalin’s death in 1953. the loosening of this doctrinaire stance began. allowing Polish psychiatry to regain its professional autonomy. Politically appointed mental health adminis617
618
LOCK FKYDMAS
‘trators were gradually replaced by more capable, task-oriented professionals. The treatment focus began to shift away from the major psychoses toward neurotic and characterological disturbances. By the early 1970s clinical psychology began to blossom. In 1972, an Experts Commission, representing the leadership of the psychiatric and legal professions, was appointed to draft a comprehensive Polish Mental Health Act. The Committee’s Chairman, Stanislaw Dabrowski, a highly respected psychiatric clinician and administrator, devoted himself fully to this task and subsequently to. the passage of the Committee’s recommended draft. In spite of strong public as well as professional support for the proposed Act. it has yet to be accepted by the Polish legislature. As of the Summer of 1982, it appears that the Act is likely to be incorporated into the National Health Code rather than enacted as a separate statute. Among the factors affecting psychiatric hospitalization in Poland, the matter of secondary gain looms large. As a result of the wartime destruction of the cities, the country’s immense post-war investment in heavy industry, and the government’s avowed promise to provide adequate housing to all citizens, a critical housing shortage continues to exist. When an individual is hospitalized, not only does his family’s housing situation improve, but the patient’s income is not substantially reduced as he continues to receive his disability pension even while hospitalized. Such disability pensions are liberally granted, especially when psychiatric hospitalization has taken place. In general, Polish psychiatric patients do not receive high doses of neuroleptics, they are allowed much freedom within the institution, patient abuse is rare, and demands on the patient are minimal. Many incentives thus exist for the patient, as well as his family, not to seek his discharge. In essence, in spite of overcrowdedness and drab institutional conditions, to the majority of patients the hospital has become home. OVERVIEW
OF PSYCHIATRIC
HOSPITALIZATION
IN POLAND
Patient population In 1979 the average daily population of Polish psychiatric inpatient facilities was 38,153 patients. Although the official capacity was 29,561 beds, 42,282 beds were in actual use. Thus there were 43% more beds in use than the facilities were built to accomodate-in other words, severe overcrowding was common. The actual number of beds per unit of population was 11.9 per 10,OCO.Psychiatric beds accounted for 16.S% of all Polish hospital beds. While the Polish inpatient psychiatric hospital population has been increasing only slightly since 1065. in line with over-all population growth, the admission rate to psychiatric facilities has continued to climb (the American experience has been similar-the resident population began to fall in 1955 while admissions continued to rise until 1977). The average length of stay in Polish psychiatric facilities has con: tinued to decline, from 138.5 days in 1960 to 76.3 days in 1979. Nevertheless, the percentage of chronic patients, those hospitalized continuously for 5 years or longer, has continued to rise, accounting for 24.9”:,
of all patients in 1979. Of all admissions in 1979. 37.5”, were first admissions. 40.3”,, of all inpatients had been hospitalized for 1 year or longer. The modal age of inpatients has continued to climb. reaching 4G49 years for both and women in 1976. It is noteworthy that. as of 1978. 30.7”, of all Polish psychiatric inpatients were employed at least two hours per day. usually at the institution in which they were being treated. Although such employment is euphemistically referred to as ‘ergotherapy: little pretense is made that it bears any relationship to the patient’s treatment program or to his eventual discharge. Psychiatric diagnoses in Poland are based on the International Classification of Diseases. Nevertheless. generally fewer than half of pscyhiatric inpatients are diagnosed as psychotic and only half of those so diagnosed are deemed to be schizophrenic. Polish psychiatrists essentially restrict the diagnosis of schizophrenia to cases in which there are clearly discernable thought disorders, such as haliucinations or ideas or delusions of reference. According to the sophisticated Poznan Psychiatric Register, the only register of its kind in Poland, only 17.0% of first admissions to psychiatric facilities in Poland during 1974 were diagnosed as schizophrenic (a total of 39.2”/:, were diagnosed as psychotic and 55.9% as non-psychotically disturbed, including 13.7:); diagnosed as alcoholic). Among those admitted to outpatient clinics that year, only 5.10;, were diagnosed as schizophrenic (lZ.Sg;, were diagnosed as psychotic and 14.67; as alcoholic). The staff The psychiatrist is both the leader and the mainstay of the Polish mental hospital. She (women clearly outnumber men in Polish medicine. psychiatry in particular, though administration is still almost entirely in male hands) is a graduate of a 6-year medical school followed by a 1 year basic internship, and she either possesses or is working toward the first of the two levels of psychiatric certification. She is generally addressed as ‘Doctor’ regardless of whether she has earned the doctoral degree. In contrast. the psychologist is generally addresses as ‘Magister’ even when she has earned a doctoral degree. It is noteworthy that degrees and titles continue to be of high social importance in today’s Poland. Not only are degrees and titles used as a means of address. not only are they often noted on name plates at one’s place of residence, but it is not unusual to find them engraved on tombstones, even recent ones. The psychiatrist is recognized as the’ expert on all matters relating to ‘mental illness’, this term being restricted to a diagnosis of psychosis. Only the psychiatrist can conduct a mental status evaluation of a criminal defendant, and only she can assume the treatment responsibility if mental illness has been determined. If mental illness is not at issue, psychiatric opinion is not solicited by the courts. The psychologist is deemed to be the expert in the area of mental retardation. social maladjustment, and intrafamilial conflict. No mental health profession is vested with expertise for treating neurotic disturbances. While their number is steadily growing, there,are still very few clinicians or clinics which specialize in the treatment of the neurotically disturbed [Z]. It is noteworthy that when the Polish public was polled in 1968 as to
Psychiatric
hosphalization
the help needed by a neurotic, the psychiatrist came in sixth, being preceded by the neurologist. the internist, the general practitioner. rest. and sex, in that order. One of the reasons for this finding is that the public has apparently associated the word ‘neurologist’ with ‘neurosis’. and ‘psychiatrist’ with ‘psychosis’. It seems evident that the Polish mental health establishment is currently only beginning to fully address itself to the treatment of neurotic disorders. The salary of the Polish psychiatrist who works in a clinical setting is quite meager. well below that of a Polish bus driver or miner. Salary levels for health personnel employed in industry are somewhat higher as industry produces scarce consumer goods and. even more importantly, brings in ‘hard’ currency, critically needed to repay foreign debts. Private practice in psychiatry or psychotherapy is virtually nonexistent-even the psychiatrist’s participation in semiprivate medical cooperatives is frowned upon. There are nevertheless opportunities available for the medical specialist to augment her income. She may hold more than one staff position, she may be ‘on call’ at the hospital or work in the admissions ward after her regular working hours, she may do examinations and give testimony to the court (the payment she receives for this work belongs to her even though she performs this task during regular working hours). etc. If she works hard enough, her income may approach that of a miner. Nevertheless, Polish medicine. psychiatry included, is endowed with high social prestige and professional status. Competition for admission to medical academies is fierce. Strong doubt is thus cast on the American view that high salaries are essential to attract gifted students to medical careers as well as to uphold the high social standing of physicians, a status allegedly needed to enhance their healing capacity. The psychiatric patent-staff ratio in Polish mental hospitals. 25.7 patients per physican as of 1976. compares well with American standards insofar as state hospitals are concerned. What is problematic. however. in Poland is the virtual absence of collaborative or ancillary staff except for nurses and activity therapists. both of whom continue to be in short supply. The situation is similar in outpatient clinics where, in 1978, each physician held an average of 10 interviews per day and saw 761 different patients in the course of a year. The average psychiatric out-patient was seen a total of only 4 times. Polish psychologists earn a Master’s degree. their basic professional credential, after 4 years of study. Clinical psychology. reborn only in the mid-1960s. experienced a surge of popularity and rapid expansion of training programs in the early 1970s. The function of the psychologist in the mental hospital setting continues. however, to be defined by section chiefs. invariably physicians. who also assume a supervisory and evaluatory role toward psychologists. There is much variation in this between different hospitals, and change is in the air. For instance. psychology has already been granted departmental status in some hospitals. the chief of psychology becoming directly responsible to the superintendent (still invariably a psychiatrist). In most hospitals. psychologists spend most of their time administering tests and leading treatment-related group activities. mainly group therapy. For unexplained reasons. one-to-one therapy.
in Poland
619
rare as it is, is generally limited to psychiatric practitioners. The dominant psychological approach to clinical practice is cognitive in nature. but includes elements of Gestalt Therapy, psychodrama, Transactional Analysis, and sensitivity training. Neither psychoanalysis nor behaviorism is popular. Psychologists prefer working in community-based counseling services, in industry. and in research centers. Positions in psychiatric hospitals are not deemed desirable. This is reflected in the fact that, as of 1978, there were 93 inpatients for each staff psychologist. Social work training in Poland, limited to a 2-year non-university course, prepares its graduates for employment in a social welfare district office. mainly supervising volunteer welfare workers. Each such volunteer provides direct assistance to needy individuals in his own neighborhood. For the first time in the post-war period, a Master’s in Social Work degree program was launched in 1977 (at the prestigious University of Warsaw). Professional training of social workers is strongly supported by Polish psychiatrists, especially those working in mental hospitals.
All psychiatric facilities are established and administratively supervised by local Health and Social Welfare Councils. The quality of each hospital’s treatment program is monitored either by an appointed regional consultant or by the chief of the psychiatric department of a Medical Academy, if one is located nearby. All appointments of regional consultants as well as hospital superintendents must be approved by the Psychoneurological Institute. located in Warsaw. which serves as the Ministry of Health and Social Welfare’s representative in all matters relating to psychiatry and neurology. The Institute oversees the Polish psychiatric service delivery system, studies its functioning, sets guidelines for it, and plans for its future. All patients’ complaints addressed to the Ministry are reviewed and acted upon by the Institute. In addition to its supervisory and planning functions, the Institute carries out its own extensive research, training. and treatment programs, thus providing models for quality programs throughout the country. While there was a total of 39 psychiatric hospitals in Poland in 1978, 64.57: of the patien’ts were housed in 19 institutions, each containing over 1000 beds. Most of these large hospitals were built before the war and are located in geographically remote areas. Although psychiatric wards were generally locked until the early 1970s an open door policy spurred by the Psychoneurological Institute, has gained rapid acceptance; by the end of the decade, most wards were totally or partially open. The closed wards which continue in existence tend to be specialized in nature. They may be limited to very difficult or violent patients. to those undergoing intensive pharmacotherapy, or to those whose confinement has been courtordered. The large number of court-ordered confinements. accounting, as of 1978. for about 89, of all inpatients, and the continued maintenance of some closed wards, present serious impediments to the successful implementation of the sub-regionalization program. described below. The rapid growth of community-based mental health facilities. beginning in the late 1960s. facilitated
620
Louts
collaboration between outpatient and inpatient psychiatric facilities. thus enhancing continuity of treatment. In 1970 a pilot sub-regionalization program was introduced. Each county in a facility’s catchment area was assigned a specific ward and close ties were encouraged between the inpatient and outpatient staffs. By 1974 this arrangement became the official policy throughout Poland. even though much resistance to it has persisted. especially in facilities. such as medical academies and research centers. where psychiatry has not been accepted as an equal partner by other medical .specialties. Furthermore. even where the policy has been essentially followed, its implementation has been limited to new admissions. Little has thus been done to return out-of-region long-term patients to their original counties of residence, notwithstanding pressure from the central psychiatric authorities in Warsaw. The sub-regionalization policy has nevertheless accomplished its main objective of bringing inpatient and outpatient services closer together. It is not unusual to.find hospital personnel and the corresponding outpatient clinic’s staff actually taking turns working in one another’s settings. The drive toward modernization of the Polish mental health service delivery system was clearly reflected in the 1974 report of the Experts Commission. which called for the replacement of the traditional mental health services model, with the psychiatric hospital at the center. by an integrated and comprehensive network of community-based treatment and prevention programs. Three years later, in 1977. the Psychoneurological Institute’s Department of Mental Health Administration. the planning center for the Polish mental health service delivery system, painstakingly examined the problems besetting Polish psychiatric institutions and. in line with the Experts Commission’s recommendation. reversed its earlier call for the continued expansion of inpatient facilities. A report. presented by Tadeusz Dziduszko, the Head of the Department. bespeaks the candor and openness that is possible even in a large bureaucratic organization [3]. Dziduszko’s critique of the traditional service delivery system can be summarized as follows: (I) Problems
relating
to treatment
practices:
(A) Undue concern with institutional care imperatives has resulted in the neglect of patients’ psychosocial needs. (B) Traditional medical/psychiatric practices, such as the wearing of uniforms and taking of temperatures. are needless and wasteful. (C) Traditional psychiatric practices in mental hospitals such as the separation of sexes. control of correspondence. and maintenance of locked and ‘chronic’ wards. continue to infringe on the civil and treatment rights of patients. (D) The prevailing authoritarian stance of mental health professionals. the psychiatric staff in particular. hinders the development of interdisciplinary cooperation cssentiul to the expansion of psychosocial treatment programs as well as to the creation of a sound therapeutic milieu. (II) C)rgani/ational
and methodological
(A j The sub-rcgionalization program uniformly and clkctivcly implcmcnted.
defects: has not been
FRYDMAN
(B) Collaboration between inpatient and outpatient facilities is insufficient to ensure continuity of treatment. (C) Ergotherapy programs have often become tied to economic rather than treatment objectives, (D) Rehabilitation and sociotherapy programs have not been afforded sufficient organizational and funding support and too little has been done to gear these services to the particular needs of patients. (E) The hospitalized patient has remained unduly isolated from his family and community. (F) There is too much boredom on the wards. (III) Recommended
changes:
(A) The number of patients in psychiatric hospitals should be drastically decreased, thus resolving the problem of overcrowding. (B) The patients’ living conditions on the wards should be improved. (C) The patient’s ties to his community should be strengthened by facilitating closer contact with his family and friends. (D) Social service departments should be strengthened and steps taken to improve the effectiveness of social rehabilitation efforts. (E) The psychiatrist’s relationship with patients as well as with the nonmedical staff should be improved. (F) Sub-regionalization programs as well as collaboration between inpatient and outpatient facilities should be strengthened. (G) The network of less restrictive treatment programs. such as partial hospitalization. home hospitalization, and treatment on psychiatric wards of general hospitals. should be expanded and coordinated. (H) The Mental Health Act should be enacted and all treatment facilities should strive to carry out its objectives. The report was well received by Polish mental health professionals even though it was clear that the objective conditions under which Polish psychiatric patients lived and Polish mental health professionals worked were not likely to become substantially improved in the foreseeable future. In view of the country’s serious economic problems it was most unlikely that the Polish mental health service delivery system would receive the funding needed to turn its vision into reality. INVOLUNTARY
COMMITMENT
The only regulation governing involuntary commitment of mental patients in Poland is a 1952 Ministry of Health and Social Welfare directive [4] authorizing psychiatric facilities to accept a patient at his own request. at the request of a relative or guardian. or at the discretion of the admitting physician if the patient appears to be dangerous to self or others. No records have been kept regarding the type of admission involved in each case. as the issue whether the admission was voluntary or not has heretofore been deemed inconsequential. In fact. prior to 1973 only one article. a minor one, on involuntary commitment appeared in the official journal of the Polish Psychiatric Association [S]. Since that year there have been several studies, local as well as national in scope. pub-
Psychiatric hospitalization lished on this subject [6]. The percentage of involuntary admissions has been found to vary between 7 and 25”,, depending on the facility being studied as well as on the criteria used to define involuntary commitment. It is not difticult to understand why the Polish public has in the past preferred to place its faith in the family and the physician rather than in the judiciary. insofar as involuntary commitment is concerned. Polish family ties have consistently been strong (even at this time there is little evidence of a ‘generation gap’) and the Polish physician has long enjoyed the trust and confidence of the general public. While there continues to be serious dissatisfaction in Poland with the medical service delivery system. the shortages of equipment and medications in particular. the blame has been placed on inadequate funding. planning. organization. and distribution rather than on the physician himself. Politically. physicians have either supported national aspirations or remained neutral. Polish physicians were well represented in the war time resistance movement and in the rank and file of the Solidarity movement [7]. Much more concern has been expressed by the government about physicians who are too sympathetic toward patients who request medical leaves or disability pensions than by the general public about physicians who deny their rightful requests. While physicians enjoy a comparatively higher social status and standard of living than the population at large. the differences are neither substantial nor significant. Physicians fully share their patients’ struggles with obtaining suitable living quarters. securing a telephone. or buying a car. The judicial system. on the other hand. has enjoyed little sustained public trust and confidence. especially during the war time occupation and the post-war Stalinist period. The courts in Poland. as elsewhere. are essentially controlled by those in power. Polish judges continue to be political appointees, membership in the communist Polish Workers’ Party being a virtual .siftt~error non credential. As long as the medical model 01”mental disturbance reigned unchallenged and inpatient care was deemed the treatment of choice. involuntary commitment at the request of a relative or on the order of a psychiatrist raised little concern in the general public. However, as the conception of mental illness has begun to include psychosocial dynamics. and the family has gradually come to be seen as the matrix. if not the bearer. of psychopathology. the power of one relative to commit another ‘for his own good’ began to be viewed with suspicion. Several concurrent developments have speeded this process. The public has become increasingly aware that psychiatric hospitals were in actuality more likely to be holding places for difficult. socially maladapted individuals rather than intensive treatment centers for the mentally ill. The public has also become aware of the overcrowded. dehumanizing living conditions still cxistinp in some of the large psychiatric hospitals. Furthermore. the Polish judrcrary has in the past two decades undergone significant reforms which have strengthened the civil rights of the citizenry. the most striking bemg the nullification. in 1968. of the Appendage to the Criminal Code enacted in 1945 when the country was caught LIP in vtolent political strife, This appendage had grven the courts wide discretion in
h2 I
in Poland
adjudging criminal offenses to be political in nature. thus depriving such offenders of their basic rights. Finally, it is to Poland’s advantage to disassociate itself from the serious charges that have been leveled against the Soviet Union for its alleged involuntary detention and forced ‘treatment’ of political dissidents. Many attempts have been made in post-war Poland to enact a Mental Health Act. The closest such an effort came to fruition was in 1970 when a bill entrusting involuntary commitment and the fate of the confined patient to the psychiatric profession alone, was received by a committee of the Polish Legislature, the Sejm. The bill. shrouded in secrecy by its sponsors and advocates, was effectively exposed to the public by a concerned effort of social activists, members of the sociology faculty at the University or Warsaw in particular. The bill’s late was sealed when a wave of popular dissent toppled the Gomulka government. Two years later. in 1972. the Minister of Health and Social Welfare appointed an Experts Commission to draft a new. comprehensive Mental Health Act. The Commission’s 1974 report was not only officially published [g]. but a call was issued by the Commission for a thorough discussion of its proposals prior to the drafting of the final version. A yeat of intensive. often heated. debate in the mass media and among the various mental health professions. the legal profession, the academia. and the general public followed the release of the Commission’s report. This debate. free of all censorship, was virtually unequalled in the history of post-war Poland in its openness. breadth and candor. Commission members traveled all over Poland to participate and to learn from the discussions. The reactions by the public and the interested professional and lay groups were incorporated into the final draft submitted to the Minister of Health and Social Welfare in 1975. As of the Spring of 1982. after seven tortuous years of journeying through the various ministries and legislative bodies. the proposed Mental Health Act. in only a slight modified form. appeared to be. as noted earlier. on the verge of final enactment by the Sejm as an amendment to the National Health Code. Had it been enacted as a separate statute its impact would have been much greater. Nevertheless, the new legislation would still constitute a milestone in the modernization of the Polish mental health service delivery system.
PATIENTS’ RIGHTS
As of the spring of 1982. the rights of Polish psychiatric patients have not been defined by any law or administrative regulation. Section chiefs of psychiatric hospitals are vested with total responsibility for patients’ treatment and eventual discharge. The right to refuse treatment is rarely recognized by staff. Because of overcrowded facilities. staff shortages, a prevailing skepticism about the value of long-term confinement. and the absence of a profit motive. Polish psychiatric hospitals generally welcome the discharge of any non-dangerous patient whose family or community is ready to receive him. The only exceptions are likely to occur in facilities which depend
62’
Lot-rs FRYDMAN
on patient labor and are thus likely to be reluctant to discharge a patient who is a good worker. While there is no organized patients’ rights movement in Poland. several essentially autonomous expatient organizations are in existence, the largest one located in the city of Cracow. It is noteworthy that this latter group made a presentation in 1973 before the Experts Commission and that the commission gave the group’s concerns serious consideration. Most of the other ex-patient organizations are affiliated with inpatient psychiatric facilities and, in effect, serve as an arm of treatment. In general. Polish psychiatry supports the establishment of patients’ clubs and mutual support groups and does not appear threatened by the possible emergence of patients’ rights activism. While no machinery exists for reviewing patients’ grievances, all such complaints addressed to the Ministry of Health and Social Welfare are channelled through the Psychoneurological Institute for investigation and resolution. The Institute takes such communications seriously and it is not unusual for a senior member of the Institute to be dispatched to the given facility for an on-site visit. The Institute also monitors the quality of patient care by keeping in close contact with regional consultants who oversee inpatient care facilities within their districts. These consultants have at times alerted the Institute about questionable care or treatment practices in a particular hospital and have even sought the Institute’s involvement in evaluating the situation and making needed changes. Although many Polish psychiatric hospitals contain a locked ward for violent or physically threatening patients, the practice of seclusion is unknown in Poland, either as a treatment modality or as a means of control or punishment. Polish psychiatrists are surprised to hear that seclusion is allowed in the U.S., usually without the patient’s consent and in the absence of a dire emergency. The only means of physical restraint used in Poland are straps for tying a patient’s wrists to his bed. The patient generally remains in direct communication with staff members and fellow patients. The straps are removed once the patient ceases to be belligerent. Some facilities, mainly in the Warsaw area (the Psychoneurological Institute in particular), eschew all forms of physical restraint. No resultant increase in patient aggressivity seems evident. It generally appears that the more frequently restraints are used, the greater the frequency of manifested patient aggressivity. It must, however, be noted that those clinics which limit the use of restraints are likely to have more highly trained staff and better staff coverage. In regard to questionable or risky treatment procedures, Polish patients, unlike their American counterparts, as yet have no legal protection against involuntarily administered electroconvulsive (ECT) and insulin convulsive therapies and experimental drugs. Surprisingly, ECT is more likely to be used in more modern, better equipped Polish hospitals, apparently because of the availability of staff anaesthetists. Some facilities restrict themselves to unipolar ECT application, others only to b&polar; some require the use of anaesthesia, others shun it; some limit the procedure to severely depressive patients
while others also administer it to the intensely agitated; still others select it for patients manifesting catatonic-type withdrawal. Some facilities do not use ECT at all. Whatever the stance a particular treatment center takes, it seems to defend its position tenaciously. One hospital administrator confided that ECT was no longer being used in his facility because its use proved too upsetting to the staff. Not infrequently the rationale given for the use of ECT is: “We give it only because the patients want it”. Despite this claim, the author was on several occasions approached by patients who complained about receiving ECT against their wishes. This was more likely to occur in facilities which maintained that their patients sought ECT. It should be noted that when the author related these conversations to the treating psychiatrists their response tended to be more marked by concern than by defensiveness. In a small number of Polish psychiatric hospitals ECT has at times been applied to patients’ buttocks or legs, primarily in cases of suspected conversion hysteria. This particular use of ECT has been looked upon with disfavor, if not outright condemnation, by psychiatric authorites, those at the Psychoneurological Institute in particular. Insulin shock therapy is not widely used but the few hospitals that do administer it tend to do so extensively. Psychosurgery, though not outlawed or formally prohibited, is not performed anywhere in Poland. Pneumoencephalograms are used in many facilities. but only with the patient’s informed consent. In comparing psychiatric hospitalization in Poland and in The United States, there appears to be a connection between the value attached to the therapistpatient relationship and recognition of patients’ rights. In general, while American hospital psychiatrists view their relationship with their patients as sacrosanct, their Polish counterparts endow it with little reverance. This is understandable. In American psychiatric practice, especially if rooted in psychoanalytic theory, the therapeutic relationship is considered central to the treatment process. Efforts are thus likely to be made to limit unmonitored outside ‘contamination’, to keep the patient under the close scrutiny and control of the treating physician. This attitude is so deeply ingrained that in actual hospital practice the sanctity of the doctor-patient relationship is likely to be upheld even when individual therapy is virtually non-existent. In Poland, by contrast, there is little pretense that individual therapy is taking place and no tradition or rationale exists for safeguarding the transferential aspect of the doctor-patient relationship. In general, little attempt is made by the Polish psychiatrist, either directly or indirectly, to monitor or control her patients’ thoughts or behavior. except for emergency situations or when high doses of psychoactive medications have been administered. Staff control of involuntary patients, whether in the West or in the East, raises the specter of the use of psychiatry for socio-political purposes. While there is no question that psychiatry plays an important social control function in Poland as well as in the United States, there is virtually no evidence that psychiatry is. or ever has been, used to confine or forcefully ‘treat’ Polish political dissidents. Although Polish psychiatrists are in the employ of the state their loyalty has
Psychiatric
hospitalization
remained to their profession. The psychiatric leadership has zealously guarded against any subversion of its profession for social control purposes. The passage of the proposed Mental Health Act, whether as a separate statute or as a part of the more comprehensive National Health Code, would guarantee the psychiatric patient full judicial review of any substantial infringement of his civil rights. No patient could be involuntarily committed to a psychiatric facility, except on an emergency basis. without a judicial finding that he presents, because of a mental illness, a direct threat to his own life or to the life or health of others. All involuntary admissions would have to be reported to the district court within 48 hours and a commitment hearing would be required not later than 14 days following such notification. If committed. the patient would have the right. after 30 days of confinement, to judicial review of the need for continued detention. The status of each involuntary patient would also automatically be reviewed by the court 6 months following adjudication. Absent court permission, treatment modalities. psychoactive medications included, which are known to present an above-average risk to the patient, could not be administered against his will. except for life-threatening emergencies. SUMMARY
Polish psychiatry has worked arduously to recover from the devastation of the Second World War and from the subsequent socio-political climate which had impeded the development of professional vitality and autonomy. The strides made by the Polish mental health professions in the 1970s have been remarkable. The mental hospital’s position as the centrum of psychiatric practice has been effectively challenged, a well-planned sub-regionalization policy has been implemented, inpatient facilities have made substantial progress in shedding their restrictive regimen, the training of clinical psychologists has blossomed, professional training of social workers has been launched, and a very progressive Mental Health Act is inching its way toward enactment. The leadership of Polish psychiatry appears highly capable and energetic. Barring catastrophic setbacks to the Polish nation, continued progress in the modernization of the Polish mental health service delivery system. the protection of patients’ rights included. can well be expected.
623
in Poland REFERENCES
1. All of the statistical data presented is based on data provided by the Department of Mental Health Administration of the Warsaw Psychoneurological Institute. Tadeusz Dziduszko, Director. Personal communication 2. Notable among these exceptions is the inpalient cognitive and insight therapy program at the Clinic for the Treatment of Neurosis, directed by Stefan Leder at the Psychoneurological Institute. and the Rasztow Residential Treatment Center, originally established by Jan Malewski, a psychoanalytically trained psychiatrist. 3. Dziduszko T. Zadania Szpitali Psychiatrycznych w Programie Poprawy Jakosci Psychiatrycznej Ochrony Zdrowotnej (The Task of Psychiatric Hospitals in Improving the Quality of Mental Health Services). Unpublished paper presented at the Regional Conl’erence of Psychiatric Consultants in Gdansk. Poland. 1978. 4. Instrukcja nr 120/52 Ministra Zdrowia z dnia IO grudnia 1952 r./nr PL 9/14169/52 w sprawie przyjmowania i wypisywania ze szpitali psychiatrycznych. !DZ. Urz. Min. Zdrowia z dn. 15 XII 1952 r. nr 24 poz. 240, 5. Treter A. Uwagi na Temat Dobrowolnosci i Przymusu w Psychiatrii (Comments on the Subject of Voluntariness and Involuntariness in Psychiatric Treatment). Psychiat. PO/. 111, 479-484. 1969. 6. See, for example. Hernacka B. er al. Dobrowolnosc I
Przymus Hospitalizacii Psvchiatrvcznei (Voluntary and involuntary psychiatric hospitalization). Psvchiar. PO/. VII. 185-190. 1973: Dabrowski S. et ~1. Hospitalizacja Przymusowa (involuntary hospitalization). Psv chat. PO/. X, 601-610. 1976; Sidorowicz S. Przymus w Przyjmowaniu do Szpitala Psychiatrycznego (Involuntary psychiatric admissions). Psrchiut. PO/. X, 4650. 1976; Chlopicki K. er al. Analiza Przyjec Chorych do Kliniki Psychiatrycznej SAM (An analysis of admissions to a medical academy’s psychiatric ward). Psychiat. PO/. X, 173-181. 1976. 7. An American psychiatrist who studied Polish medical care policies and practices in the Spring of 1981 reports. for Instance, that 757, of the Psychoneurological Institute’s employees. the medical staff included. had joined Solidarity and that medical students had succeeded in eliminating Marxist courses from the required curriculum. Webster T. G. Special report: Health policy issues and the predicament in Poland. New Enyl. J. Med. 306, 308-312. 1982. 8. The Commission’s major proposals were oublished in the I July issue of &em .hdowu. Tez; Dotyczace Regulacii Prawnei Ochronv Zdrowia Psychicznego (Assumptions underlying . psychiatric legislation). Guzctu sad. 13, 5-6, 1974.