Exaggeration on the
Road to Progress
Ilya E. Averbuch, M.D.*
In the sixties and seventies a radical change came over psychiatric institutions.
New psychotropic drugs made it possible to improve dramatic- ally the treatment, maintenance and well-being of patients in mental hospitals. Many patients were discharged; many closed wards were opened; all departments became mixed in the sense of sexes; the use of private clothes was permitted and encouraged, and so on.
On this splendid way to humanization, there was also some exaggeration.
It became evident over time, that some of the patients that had been discharged needed to be returned to institutions because they were dangerous, or incapable of maintaining themselves, or be- came victims of exploitation.
Attempts to exclude completely the means of physical restraint failed, and it was necessary to reapply them again from time to time.
It became clear that it was wrong to forbid – as too brutal – electro-convulsive treatment, and it was necessary to reinstate its use.
Later it became obvious that our enthusiasm about new drugs was a bit exaggerated, and we had to use them cautiously because of their numerous side effects.
Recently many questions have arisen about mixed psychiatric departments as well. We all had the impression that on the whole it was good for many patients. Many of them became more interested in their appearance, more active, more calm. But here also it slowly became evident that our enthusiasm was excessive.
Gradually it became clear that for some patients close contact with representatives of the opposite sex is not a sedative factor, and far from that: they became more excited, more aggressive, more brutal, more hypersexual. Other patients became shy, more withdrawn, anxious, and frightened. There are women for whom it is difficult when a man touches them, or when they see a naked or half-naked male (and that is not a rare event with our patients).
But all this is nothing compared to the very important and very difficult question: What must be our attitude to sexual relations between patients? Are we to regulate it, to stimulate, to organize decent conditions for them, or to prevent, or to pretend that we don’t know about it?
It is very strange, but up until now there has not been a single investigation, a single research project, a single serious paper on this topic. The whole subject has been abandoned, left to the common sense of various physicians, and in fact to the nurses.
Every nurse understands that overt sexual abuse must be prevented, but what should they do if there is mutual agreement?
The same common sense tells us that the question must be answered individually. It depends on place, time, circumstances, and – even more – on the patients involved.
For chronic patients, there is generally no need to prevent sex, if it occurs privately and with mutual agreement. But for acute patients, especially for virgins and for married women, it may have catastrophical consequences.
Who is to decide? Is a physician to prescribe sexual recom- mendations together with medicines?
In the absence of clear instructions there is room for a great deal of damage, sometimes irreparable.
I have some female patients who, while in a manic state, had sexual relationships within the hospital, and after improvement in their mental state were very sorry about this. I know a family where the husband continues to reproach his wife for an incident which occurred in this context more than ten years ago. I know marriages that have broken up for this same reason as well as pregnancies, abortions, and more. Every psychiatrist is aware of this.
However, a part of us thinks that the price is not too high for a better “milieu,” for a better imitation of domestic surroundings. But I am very much in doubt.
I resist the temptation to give you more examples for the sake of time.
I will also restrain myself from going into the question about religious patients. Some of my very progressive colleagues are most sure that all religious beliefs are only superstitions.
Let us talk science. But the trouble is, as I stated previously, there isn’t any science in this subject, not a single scientific research paper. It is a province of impressions and beliefs. And this is very dangerous, because in the area of “scientific beliefs” there is a tendency to extremes. There are many psychiatrists who think that their beliefs are “gospel truths,” and the beliefs of their opponents are not only wrong but also biased. On the subject we are talking about, they have only one explanation if you begin to speak about separate departments in mental hospitals: you have been bought or forced by religious fanatics! I have heard similar accusations when the Sarah Herzog Memorial Hospital – Ezrath Nashim organized separate departments.
And if I mention Ezrath Nashim, I’ll say a few words about our experience.
It has now been exactly a year since we separated men and women and we have not observed any negative consequences. Our patients have not deteriorated, not become more apathetic or more aggressive. Rather, everybody is satisfied: patients, their relatives, personnel. And not only the religious ones! Every other day I receive requests for hospitalization from other districts in Jerusalem and other cities, but must refuse them because it is not permitted by regulations.
My own positive impression from my experience does not push me to demand the total separation of all mental departments. Far from that.
I have known all my medical life that there is not one medicine that helps all ill, and there is not one solution that is good for all.
There is only one thing that I insist on: there is a place for divided departments side by side with mixed departments. There is a need for an individual approach.
And even if you don’t agree with me, I ask you to think about this issue in an open way.
Source: ASSIA – Jewish Medical Ethics,
Vol. II, No. 2, May 1995, pp. 42-43
* Presented in the Third International Congress on Psychiatry, Law & Ethics. Jerusalem, November, 1991.