How to stop the dramatic increase of coercion in Norway?

First the dramatic rise of coercion in the last to decades in Norway is documented. Compulsory admissions doubled to 10 times as many as in Italy and Portugal (1). Compulsory medical treatment doubled 2017 to 2022, 10 times as many as in the German state Baden-Württemberg. Psychiatrist claim that involuntary treatment is necessary to promote health. However, UN special rapporteur for health, WHO and OHCR show that a reduction of coercion improves health. Patients describe their sufferings as nightmare and torture, resulting in a storm of complaints. The strategy of reducing coercion demanded by law with help of dialogue with psychiatry failed totally. Necessary medication-free treatment (3) e.g. Basal Exposure Therapy (4) for treatment-resistant patients is weakened. Therefore, a ban of coercion by law or court decision can be the solution, which proved partly successful (5).

Table of Contents

Coercion in psychiatric “health care” in Norway has dramatically increased in the last 2 decades

Patients' sufferings, nightmares and torture

Patients' storm of complaints

Psychiatric patients are portrayed as dangerous

Information about reduction of coercion and dialogue

Ban of involuntary treatment

Coercion in psychiatric “health care” in Norway has dramatically increased in the last 2 decades

The Norwegian "Mental Health Care Act" is full of good intentions about human rights and human dignity. Coercion should only be used when it is "strictly necessary" (Section 4-2). 20 years ago, the reduction of coercion was demanded by law and supported by all politicians. However, the strategy of achieving this through dialogue with psychiatrists was a total fiasco.

Compulsory admissions rose from 5,719 in 2001 to 9,400 in 2022 (6), 10 times as many as in Italy and Portugal. When I mention this to the Health Directorate, I get the answer: That is not certain, perhaps we have just become better at counting

Compulsory medical treatment rose from 41 per 100,000 adults per year in 2017 to 83 per 100,000 adults in 2022, 10 times as many as in the German state Baden-Württemberg. Psychiatrists are hushing up on this and the state is also silent.

Particularly worrying is the increase in the number of people convicted of being transferred to compulsory psychiatric care from 15 in 2002 to 315 in 2021. More and more beds are being occupied for convicts from 15 in 2002 to 315 in 2021, out of a total of 3,604 beds.

Norwegian fact-finding investigators write "Several are sentenced to compulsory psychiatric treatment" (Norwegian: "Flere dømmes til tvungent psykisk helsevern") and suggest that patients have become more dangerous. But it is being ignored that the legal basis has been changed: "so that criminals who have repeatedly committed socially harmful or particularly stressful crimes can also be sentenced to compulsory psychiatric treatment" (Norwegian: "slik at også lovbrytere som har begått gjentatte lovbrudd av samfunnsskadelig eller særlig plagsom art vil kunne idømmes transfer til tvunget psychisk helsevern", jf. Strafeloven § 62 første ledd siste punktum.).

Here the so-called Law of Jante triumphs, a etiquette on how to behave in Scandinavia, human rights. Personally, I think it is very problematic when this dominates everywhere.

Parallel to increasing coercion, the possibility of medication-free treatment has been severely curtailed. Science journalist Robert Whitaker has written about it: “The Dying of the Light: Norway’s “Medication-Free” Services for Psychotic Patients Are Fading Away”.

The Ombudsman has indeed determined that forced drugging is against the law: Peter Gøtzsche “Forced Drugging with Antipsychotics is Against the Law: Decision in Norway”. But leading psychiatrists have subsequently claimed, with reference to Zhu et al 2017, that there is “high probability, it can lead to recovery or significant improvement in the patient’s condition” because 80% of patients achieve minimal symptom reduction. However, there is no placebo group and minimal symptom reduction cannot achieve a high probability of significant improvement.

Patients' sufferings

“The use of antipsychotics cannot be justified based on the evidence we currently have. Withdrawal effects in the placebo groups make existing placebo-controlled trials unreliable” (Danborg et al. 2019).

In "Use of coercion in mental health care - experiences from patients, relatives and employees" (Lauveng et al. 2021) by the National Center for Experiential Competence in Mental Health, August 2021, 44% of surveyed patients consider long-term medication to be very harmful, 22% harmful and 7% not harmful. 9% consider long-term forced medication to be very useful and 44% not useful. Among employees, 62% find long-term forced medication to be very useful and 4% useless. 70% of patients feel violated, 68% have distrust and 57% have nightmares from the treatment according to Lauveng et al. 2021.

The Ministry writes in Ot. Prp. No. 11 (1998-1999): “In connection with the ongoing legislative work, a patient has written to the Ministry that he feels the forced treatment with neuroleptics as a mental torture that is disabling him.”
The visit report of the Civil Ombudsman’s Torture Prevention Unit in Sørlandet Hospital, Kristiansand 7-9 September 2015 states: “However, patients who were forcibly medicated had mostly negative experiences that were described as, among other things, “terrible”, “cruel”, and “torture”.
“The dialogue seminars showed that some patients describe the use of coercion with strongly negative words such as insult, torture, communism and Nazism, and it was particularly coercive treatment with antipsychotics that was criticized in this way (The researcher explains: How patients experienced coercion. Experience competence 17 August 2018)
Mette Ellingsdalen Lived life anthology: Discrimination, coercion and torture

Patients' storm of complaints

Approximately 40% of involuntary hospitalizations were forcibly medicated in 2015. In 2010, 821 complained about forced medication. In 2023, 1,808 patients complained about forced medication (Directorate of Health Control of Forced Medication in Mental Health Care 2023) (7). The fact that decisions on forced medication are in practice unlawful and without judicial review is unworthy of a civilized constitutional state.

In 2023, 3,166 patients complained about 4,798 decisions in the control commission (Directorate of Health Control of Forced Medication in Mental Health Care 2023) (7). Courts received 512 lawsuits..

Psychiatric patients are portrayed as dangerous

How is this development of ever-increasing coercion possible? In Norway, on average, 5 murders per year are committed by psychiatric patients. That corresponds to a risk of 1 in a million, as Norway has 5 million inhabitants. Nevertheless, the press exaggerates every murder to create a mood against forced reduction.

This is also used as an argument against drug-free treatment and for coercion (BBC: How Norway is offering drug-free treatment to people with psychosis):

But Dr Tor Larsen, a specialist in acute psychosis, worries about this idea. He points out that most patients with untreated psychosis do not realise they are ill so will not agree to be treated with or without drugs - and drug-free units operate on a voluntary basis...

"So in cases where people have devastating psychosis, it might be important to give them treatment even on an involuntary basis."

He cites as an example the random murder of 67-year-old Bjorg Marie Skeisvoll Hereid in a graveyard in 2019 by a psychotic man with an axe. The murder shook the quiet town of Haugesund in the south-west of Norway and made national headlines.

The press picks up on such cases, creates hysteria and politicians call for action and possibly decide on more coercion.

That is why it is important that Inger-Mari Eidsvik, with the support of ICJ (International Commission of Jurists), is suing the state with allegations of human rights violations in the implementation of forced medication, isolation and restraint.

Information about reduction of coercion and dialogue

Norwegian authorities launched several campaigns to reduce coercion based on the fact that coercion is in tension with ECHR Article 3 (prohibition of torture). However, coercion rises now for more than two decades as shown above.

The Council of Europe promotes “Voluntary Measures in Mental Health Services”.

The United Nations Special Rapporteur on the right to health Mr. Pūras has called for a sea change in mental health care around the world “We need little short of a revolution in mental health care to end decades of neglect, abuse and violence”

The Council of Europe mentions Basal Exposure Therapy (BET) combined with Complementary External Control (CER) – Norway in “Hospital-Based Initiatives” as Good practices for reducing and preventing coercion in mental health settings in the Council of Europe..

“World Health Organization (WHO)Guidance on community mental health services: Promoting person-centered and rights-based approaches” including “BET Unit, Blakstad Hospital, Vestre Viken Hospital Trust Norway”, and “WHO-OHCHR new guidance to improve laws addressing human rights abuses in mental health care” are not seen by psychiatrists and not used by Norwegian authorities.

Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, A/HRC/35/21 states: “Develop a road map to radically reduce coercive medical practices, with a view to their elimination, with the participation of diverse stakeholders, including rights holders.”

Reduction of coercion is possible, however these suggestions are totally ignored by Norwegian psychiatrists and not used by authorities.

Psychiatrists claim that forced treatment is necessary to obtain health. However the reports of the United Nations Special Rapporteur on the right to health, WHO and OHCHR show that reduced forced treatment improves health and recovery of patients.

The study “Conflict and Antagonism in Global Psychiatry” of Jeppe Oute et al. 2023 shows that leading international psychiatrists reject and argue strong against the United Nations Special Rapporteur on the right to health, WHO and OHCHR

Ban of involuntary treatment

The “Urgent Appeal to Norway calls to discontinue forced treatment and hospitalization immediately” by the UN Working Group on Arbitrary Detention, the UN Special Rapporteur on the Rights of Persons with Disabilities and the UN Special Rapporteur on the Right to Health. 30. January 2017 (ref. UA Norway 1/2017).

The Committee on the Convention on the Rights of Persons with Disabilities (CRPD) finds “forced treatment by psychiatric and other health and medical professionals is a violation of … freedom from torture (art. 15)” (General comment no. 1, 2014, CRPD/C/ ).

Committee on Economic, Social and Cultural Rights 2 April 2020 E/C.12/NOR/CO/6: Incorporate into the law the prohibition of the enforced administration of intrusive and irreversible treatments such as neuroleptic drugs and electroconvulsive therapy.

The constitutional court in Germany found psychiatric coercion laws unconstitutional. “Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience “ (6) shows that to ban and abolish forced treatment is realistic and works.

Walter Keim

Netizen: http://walter.keim.googlepages.com
KEIM, Walter. Paradigm Shift to Promote a Revolution of Treatment of Schizophrenia to Achieve Recovery. Medical Research Archives https://esmed.org/MRA/mra/article/view/4866
Case Keim Against Germany: No Right to Information Law in Bavaria:https://t.co/krZaa1Jyok http://wkeim.bplaced.net/files/enforce_access_to_information.html

References:

Rains et al. 2019. Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study. The Lancet Psychiatry 6(5). http://dx.doi.org/10.1016/S2215-0366(19)30090-2
Flammer et al. 2029. The Case Register for Coercive Measures According to the Law on Assistance for Persons with Mental Diseases of Baden-Wuerttemberg: Conception and First Evaluation Psychiatr Prax;46(2):82-89. doi: 10.1055/a-0665-6728
Robert Whitaker 2024. The Dying of the Light: Norway’s “Medication-Free” Services for Psychotic Patients Are Fading Away https://www.madinamerica.com/2024/07/the-dying-of-the-light-norways-medication-free-services-for-psychotic-patients-are-fading-away/
Heggdal et al. 2016. Basal Exposure Therapy: A New Approach for Treatment-Resistant Patients with Severe and Composite Mental Disorders. Front Psychiatry;7:198. doi: 10.3389/fpsyt.2016.00198
Zinkler, M. Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience. March 2016 Laws 5(1):15. DOI: 10.3390/laws5010015
Mental health care – compulsory mental health care with 24-hour stay. Directorate of Health (Psykisk helsevern – tvungent psykisk helsevern med døgnopphold. Helsedirektoratet): https://www.helsedirektoratet.no/statistikk/samdata-spesialisthelsetjenesten/psykisk-helsevern-tvungent-psykisk-helsevern-med-dognopphold
Directorate of Health Control of coercive use in mental health care 2022 (Helsedirektoratet Kontroll av tvangsbruk i psykisk helsevern 2022): https://www.helsedirektoratet.no/rapporter/kontroll-av-tvangsbruk-2022/sammendrag