Varga Benedek szerk.: Orvostörténeti közlemények 145-146. (Budapest, 1994)

TANULMÁNYOK - ESSAYS - Pisztora, Ferenc: A „No-restraint” és az „Open-door” irányelveinek megvalósítási kísérletei és értékelése a hazai pszichiátriában

SUMMARY In order to understand the problems and dilemmas of Hungarian psychiatry regarding no-restraint, and open-door strategy, it is indispensable to comprehend the 18th century beginnings, the original principles and objectives of this healing approach. The first representatives of this method appeared between the second half of the 18th century, (V. Chiaruggi, Ph. Pinel, W. Tuke), and the first half of the 19th century (E. D. Esquirol, B. A. Morel, V. Magnan, J. Conolly), during the times when the main principles of keeping the mentally ill in asylums were those of security, guarding and separation. There were four reasons which led to the elaboration of restraint itself: (a) overcrowded institutes; (b) high proportion of restless and agitated patients among the sick-population; (c) outnumbered and undereducated medical staff; (d) and that the typical method of contemporary psychiatry preferred to apply sudden, unexpected and drastic effects assuming their healing power. As a result mechanical restraint was developed with a wide variety of means, regarding always as a principal objective to keep the patient isolated from the rest of society, and to obstruct him or her to make any harm either to himself or herself, or to the others. Thus restraint consisted all forms of coercive and restrictive measures, sush as mere physical limitation of motion, meals, relaxation, sleep, intellectual activities, and any other forms of personal liberty there might be. Consequently, the program of no-restraint intended to get rid of all of these measures and to guarantee the greatest possible level of liberty for the patients. This guiding principle of no-restraint appeared in the methods of psychiatric therapy, the objectives for the reorganization of psychiatric institutes, and in the legal actions taken to secure the civil rights of the mentally ill through parliamentary enactment. The realization of open door strategy belongs to the development of no-restraint in a wider sense. Just like in other countries the elaboration of this method—with more or less success—has been started in Hungary at the end of the last century as well, and is still in progress. The cardinal principle of this method is not to keep the doors of mental hospitals or wards by all means open, but to create a social milieu, an atmosphere in which any further harm for the patients that may occur as a result of their residence, are likely to be avoided. The open door strategy stands not for an unlimited but the greatest possible level of liberty for the mentally ill. Through in very many cases there really were psychiatric disorders due to the methods of restraint, last century authors appeared to be quite single minded blaming restraint as the only reason for all restless, or maniac behaviour, and supposing that apathetic inactivity had been entirely the result of Anstalt-damage or hospitalization. Among the many positive experiences during the attainment of no-restraint and open door strategies in Hungary, there were also some negative tendencies and abuses which could be briefly summarised in the following critical comments: (1) It was already L. Epstein, J. Konrád, and /. Hollós who pointed out that the over-estimation and equally the ill-timed and misplaced application of no-restraint could lead to no positive effects and consequently it might result a mistrust in the system itself. They claimed that instead of frequently referring to the words ,,no-restraint" or ,,open-door" strategies, or overemphasizing its possibilities —which, according to their view, was often reasoned by the exhibitionism, and exaggeration, even dramatization of professionals, and had not go further but to formality—the real understanding and appropriate employment of the principles of the systems was required. (2) Furthermore, although the system is beneficial there is no need to regard it as a taboo, or impassable barrier in therapy, J. Konrád was convinced that there are a number of forms and means of transitional restraint that might be grounded as well, and it is the experience, knowledge and moral of the physician that could guarantee that what forms of limits are required, and that there would not occur any abuse. L. Epstein even suggested that we should not create an impenetrable restraint for ourselves, and he found it much more convenient to moderate all sorts of stategies, and avoid the mechanical repeat of a single one.