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Members of the Trialogical Action Group who together authored the Berlin Manifesto in August and September 2019 and/or translated it into English in October 2019 (in alphabetical order): Stephan B. Antczack, Gamma Bak, Burkhard Bröge, Uwe Brohl-Zubert, Julia Eder, Dietlinde Gogl, Sabine Haller, Jacob Helbeck, Ingrid E. Johnson, Ute Krämer, Thomas Künneke, Anja Lehmann, Peter Lehmann, Tina Lindemann, Ule Mädgefrau, Yvonne Mahling, Peter Mast, Katrin Nordhausen, Jann E. Schlimme, Uwe Wegener, Stefan Weinmann, Gudrun Weißenborn, Claudia Wiedow, Jenny Ziegenhagen
Berlin Manifesto for a Humane Psychiatry
When examining the situation of psychiatry in Germany today, the picture is alarming: More and more psychotropic drugs, more use of electroshock, many avoidable coercive measures, the expansion of hospital, residential and forensic beds, and often inaccessible and inadequate outpatient services. In addition, there is an overabundance of bureaucratic and economic requirements in all areas of psychiatric care. These are some of the deficiencies that prevent care for people in psychological crises to — always — respect human dignity.
The consequences are serious and damaging. The long-term recovery rates of people with psychosocial disabilities have not improved over the last 20 years. The mortality rate of people who are given psychiatric diagnoses and who receive conventional treatments remains very high. Psychotropic drugs are prescribed far too often, for far too long, and in far too high dosages. This has a negative effect on all involved: persons with mental health problems, their family members, and those working in psychiatric services. From a human rights perspective, the reform of mental healthcare and support services is progressing far too slowly! This contradicts the UN Convention on the Rights of Persons with Disabilities (UN-CRPD), which provides a legal framework for all forms of support for individuals in mental distress. The convention has been ratified by Germany in 2009.
A growing number of people do not want to accept this intolerable situation anymore. This manifesto has been drafted by individuals with lived experience of mental distress, family members, and psychiatric professionals as well as formal caregivers from Berlin. We have drawn up the following demands as guiding principles for a reform of the entire mental health and psychosocial support system in Germany. To bring these ideas to life is not only the responsibility of mental health professionals, of family members and users/consumers/survivors of psychiatric services; it’s everybody’s business and a task for the whole of society.
Guiding Principles for a Humane Psychiatry
People in their pursuit of happiness and well-being are the measure of our actions. The human rights principles established in international conventions such as the UN-CRPD must feed into all mental healthcare and support structures. A broad public debate including all stakeholders in the mental healthcare and psychosocial support system is necessary. The debate should avoid and counteract the stigmatization of people with psychological impairments.
Our demands are as follows:
1. Autonomy and self-determination
A humane psychiatry in accordance with the UN-CRPD guarantees the right of users/consumers/survivors to decide for themselves which type of psychiatric and psychosocial support services they want to use and how to do so. In crisis situations, if and when it is more difficult to determine the person’s own preferences, intensive individual support must be offered. Supported decision-making also helps to avoid coercive measures. Any support provided to better coordinate the use of services must remain “help for self-help.”
2. Economic security
Care should not address the individual alone, but must also take into account the social and economic situation of users and their respective environment. Income security and adequate housing are a prerequisite for any therapeutic success. It is a common experience that individuals who have limited working capability or who receive reduced-earning-capacity-pensions due to their impairments frequently fall into precarious economic situations. By contrast, measures to guarantee economic security must always be adjusted to the person’s needs.
3. Taking into account individual social networks
Mental or emotional crises as well as long-term impairments always arise and exist within a social arrangement and have an impact on it. Therefore, the inclusion of the person’s social network is necessary and must be guaranteed throughout the whole process of care and support. This requires the improvement and extension, as well as a greater variety, of crisis support services (e.g., crisis rooms, crisis pensions) that are low-threshold, accessible, and outside psychiatric hospitals. Outpatient and community care must take precedence over in-patient treatment. This requires, among other things, a bed reduction in acute psychiatric services, especially in large, overcrowded, and confusing mental health wards. These steps are necessary to open all mental healthcare and support structures to the whole society.
4. Transparency of mental health support systems
Users/consumers/survivors need comprehensive information about their rights as well as about available support services. This applies in particular when a variety of mental health care and support services are available locally. Being able to choose how and when care and support are provided complies with the human right of individuals that their will and preferences are respected while at the same time taking into account the realities of their lives. Transparency and diversity of services must be guaranteed for all phases of the recovery process. Psychiatric and psychosocial support systems should be financially transparent and their organization should be clear. Compliance with human rights principles in the whole mental healthcare and support system should be monitored regularly. Violations must be sanctioned effectively.
We need more participation at all levels. This requires a paradigm shift from a medical treatment model towards a support model. Mental health professionals cannot produce recovery; they can only accompany and facilitate it. In accordance with the principle of helping individuals to help themselves, users/consumers’ autonomy must be strengthened. Professionals should be experts in raising awareness and building capacity to take self-responsibility. Participation, however, is more! Ultimately, psychiatric and psychosocial support systems cannot be planned without experts with lived experience, as stated in the slogan “Nothing about us without us.”
Many of these demands have been discussed among experts for years. They are part of successful models and are included in the recommendations of the council of experts of the Federal Ministry of Health (in Germany). It is astonishing that they do not yet constitute the foundation of our mental healthcare and support systems.
To achieve this, we need commitment at all levels of society. Fundamental issues concerning public services as well as social and health policies are at stake. The “Psychiatrie-Enquête,” the German expert commission’s Report on the State of Psychiatry, initiated significant improvements in psychiatric care since 1975. However, against the background of a bureaucratization and marketization in mental health services, these reform approaches have been worn down and lost in many aspects.
It is time to change this!
We invite you to support our efforts to achieve a more humane psychiatry in Germany. In signing the Berlin Manifesto you can call for the inviolability of human dignity in all areas of psychiatry!