The first thing you notice once you pass through the entrance gate of the Sha’ar Menashe Mental Health Center is the green lawns. Then the cypress and palm trees appear, followed by the concrete paths, well-kept spaces and the buildings. A chance visitor might think the large and pastoral complex is just another one of the many kibbutzim in the area, in northern Israel near the town of Pardes Hannah. Only the silence and the sign at the entrance reminds you that you are in a psychiatric institution, where the most violent patients in the mental healthcare system reside.
Last Wednesday, the director general of the Health Ministry, Moshe Bar Siman Tov, arrived at the psychiatric medical center for an urgent visit. He did so in response to a massive public and media onslaught against the hospital and its head, Prof. Alexander Grinshpoon. What brought the relatively anonymous medical center into the limelight were the events in its maximum-security wing, the sole psychiatric-legal facility in Israel.
The case of Daniel (a pseudonym used to protect his privacy) has been reported at length on Reshet Bet of Israel Radio lately. Daniel, a psychiatric patient in his 30s, has been kept in isolation for over two months. His condition has been described as harsh and inhuman, akin to being kept in a cage or in solitary confinement. This quickly led to a social networking campaign: “Free Daniel!” Within a day, demonstrators carrying signs appeared outside Grinshpoon’s home, three nights in a row, and later at the gates to Sha’ar Menashe, demanding Daniel’s release.
The events opened a new and important chapter in the public debate about psychiatric hospitalization. This story is not optimistic and does not have a rainbow at the happy ending. It is a tragedy with many participants, partners, layers and dilemmas. Daniel represents only one person in the complicated world of mental illness and its treatment in Israel.
Knives and other weapons
The maximum-security wing at Sha’ar Menashe is easy to find. The brown stone buildings are surrounded by tall chain-link fences fitted with sensors and security cameras, and it looks a bit like the prisons in the movies. “All the security guards here are officers or noncommissioned officers from combat units who passed the highest level training there is,” says the hospital’s security officer, Yaniv Madar.
He is standing in front of two large wooden panels, each covered with dozens of knives, tear gas canisters and other weapons confiscated from patients — or their families. “It can be a mother who smuggles a knife at the request of her son, who is afraid or anxious,” he says.
Every person who enters the complex, from family members to cleaners, must carry an emergency call button in case they are attacked. In case of such a call, a team of trained and practiced staff will rush to the scene, accompanied by security guards. “We have 50 to 60 such incidents a month,” says Madar.
After being briefed and receiving an emergency response button, the door opens into the ward. It was inaugurated in 1997 at the initiative of the Health Ministry. The great majority of its patients suffer from various forms of schizophrenia, with an emphasis on the paranoid and manic-depressive forms, which are often characterized by such symptoms as a persecution complex, delusions, obsessions, hallucinations — which can often lead to uncontrolled violent outbursts.
The 128 patients in the ward, only men, range from 18 to 80. They live in four wards in the wing. All of them have been involuntarily committed. Two-thirds of the residents are violent criminals who have been diagnosed as unfit to stand trial after their arrest or during legal proceedings. Among them are 53 murderers.
Those sent here by the criminal justice system will not be tried for their actions and will not be punished. They will be institutionalized until a psychiatric review board decides otherwise and releases them. It can be in a year’s time, 10 years or never. Until then, they will remain in the high-security wing.
The rest of the patients, about 30 percent, are here on the orders of the Health Ministry’s district psychiatrist, usually after they have been transferred here from other psychiatric hospitals because of uncontrollable violent outbursts. Then there are the handful of patients sent by the courts for psychiatric examination and evaluation, who remain for only a short period.
The number of patients can reach 140 at times, and the wing is run by 117 staff members, including psychiatrists, social workers, nurses, psychologists, criminologists, occupational therapists and other staff. They have all undergone special training to deal with violence. It does not always help, and often a staff member is out recovering from an attack.
Each room is shared by two or three patients. In addition, each ward has three isolation rooms, where patients can be kept for different periods of time, from a few hours to a few weeks — and in some cases even years.
Every isolation room is 16 square meters in size, with a large window with bars that looks out over the yard and two beds fixed to the floor, even though only one person lives in the room: One is for sleeping and the other is to hold his belonging, such as books or water bottles. Far up the wall, near the ceiling, are two speakers and a projector, which can play music or show a movie or TV show that the person chooses. Daniel, for example, prefers to listen to hard rock. Music helps the patients “silence the other voices they hear,” says one of the staff members.
The room is constantly watched by a camera. Outside the room is a narrow hall with a bathroom and shower at the end. “The shower head is designed so the patient cannot commit suicide,” says Grinshpoon. Most of the interaction with the patient is conducted through the bars: Providing food, psychological treatment or meeting with the psychiatrist who evaluates the patient’s condition every few months.
The solitary patients are allowed to receive items to relieve the boredom, as long as they are not dangerous. “I bring them things such as books, puzzles and clay,” says occupational therapist Yunes Dawa’a. Most patients in solitary confinement remain for limited periods, sometimes waiting for a new drug to take effect and improve their condition. As part of the process of weaning the patients off solitary confinement, attempts are made to bring them out of the isolation room.
As part of the process, they go out into other parts of the ward — where there are no other patients, such as the lobby or yard — accompanied by staff members. The amount of time outside and the frequency depend on the patient’s condition, but also on the availability of staff.
The use of isolation is still controversial. “Isolation violates basic human rights of the patients, even when they are committed against their will,” says Sharon Primor, a lawyer from Bizchut – The Israel Human Rights Center for People with Disabilities organization. “It is a limitation of freedom of movement, the right to be friendly with other people, the right to receive visitors. Much research data exists on isolation, the helplessness and uncertainty, the fact that the patient is dependent on the staff — all these cause mental trauma, harm and a lack of trust,” she says.
Hanan (a pseudonym) sits in one of the rooms. He asks the psychologist if his mother is coming to visit today. He has been in the high-security wing for years, the last eight in isolation. When I asked him how he spends his time, he points to the religious texts open on the bed, but it is his mother’s visit that interests him.
“He’s been through a lot. He set a synagogue on fire and did a lot of things,” says Hanan's mother. “He has been here for almost 20 years, and will never go free. His condition does not allow it. They are making efforts and he gets psychological treatment and is treated well.”
He is sometimes allowed to leave the room, but is not allowed outside in the fresh air enough, she says. There is not enough staff.
For his meetings with his mother, which are held in the visitors room, Hanan is brought in a wheelchair, or with his upper body in special restraints that limits the movement of his arms. This is necessary after he attacked and beat his mother during a visit. He hears voices, she says. “He is intelligent and he learns, but he can suddenly turn aggressive and violent in an instant, and then wake up and recognizes it's me,” she says. She will visit again in two weeks. In the meantime, they will talk on the phone.
Daniel’s case sparked sharp criticism against the psychiatric system in general, and Sha’ar Menashe in particular. On Thursday, a demonstration was held outside the center. “Prof. Grinshpoon, this is a hospital, not a torture center,” called the protesters. The hospital has patients who have been in isolation for over a decade without their basic rights, and psychiatry is above the law in Israel, said the protesters, calling on Grinshpoon to resign.
The father of one of the patients in the wing tells Haarez that the patients are not being treated properly. The staff has no interpersonal skills, certainly not at the level necessary to deal with the residents at the hospital, he says. The patients are invisible and are outside society and they and their families are unable to complain and do not have the courage or desire to do so, says the father. The feeling is the staff is dealing with the dregs of society, he adds.
In addition to the solitary confinement, the conditions in the wing have given renewed attention to the question of restraining patients in psychiatric wards. In March, a report was released that showed 23.2 percent of patients in psychiatric hospitals and wards were restrained against their will at least once, 3 to 9 times the percentage in Europe.
During their hospitalization, Daniel and others were restrained every day for three weeks before being moved into isolation. In some ways, isolation is considered a more lenient alternative to being restrained. But restraints are used on a daily basis in the wing, in cases of extreme violence or immediate danger.
A few hours after Bar Siman Tov's visit, he released a statement: "The Health Ministry supports the work of the medical staff in the mental health center in Sha'ar Menashe and the mental health system in general. It was important to come, see and hear directly the people — the [staff] and the patients. I met devoted people, professional and caring, who do their work out of a true desire to help the most difficult patients, who sometimes because of their illness can even harm themselves and the staff. It is clear to me that none of the staff is pleased to isolate or restrain patients and the resources provided to the system in order to minimize such phenomena today are inadequate."
But such announcements from the Health Ministry and a few cases at the hospital are not enough to cleanse the conscience of the psychiatric profession, or remove the responsibility of the Israeli health system. "You are not human," called out the protestors outside Sha'ar Menashe at the psychiatrists: "You need help, too."
"We are developing skills today how to identify the patient's distress in advance in order to provide him with an answer with talk therapy or drug treatment in order to prevent restraint," said Grinshpoon. "And still, in the end, every patient is an individual case and we cannot know who the next patient will be and commit 100 percent not to be forced to restrain him," he said.
A senior official in one of the psychiatric hospitals admits that today psychiatry is busy defending itself and the present crisis is being viewed as an opportunity to demand more resources. No one is stopping to think, "maybe we were not okay," he said. The official response is missing soul-searching, and instead of fixing things they are releasing more and more position papers, said the official.
Primor says no data is readily available on the average time spent in isolation or the number of patients in Israel who are put in solitary confinement, but it is even more common than the use of restraints, because it is considered less harmful.
Not all patients are under restraint or in isolation in the high-security wing. The patients have a wide range of rehabilitation activities and other treatments — psychological, group therapy and physical activity. Various classes are given, and some patients have even completed college degrees inside the institution.
Some are allowed out, wearing orange shirts and accompanied by staff, to the shopping center in the complex, so they develop and preserve their social skills. Some improve and leave the high security wing, and are hospitalized in regular psychiatric hospitals. The lucky ones can complete the process and receive treatment and rehabilitation within the community.
The events of recent weeks revolving around Daniel's case have given the staff that has been treating him a bad feeling. "We hear these things and feel hurt," says Hamud Zaher, who is in charge of the department. He says they feel they need to defend themselves, but they are the ones who call the families and tell them to come visit. "I personally talk to the mothers of the patients and convince them to come visit the patients. I tell them: 'Come and see how his condition has improved,'" says Zaher. These feelings came out strongly during the meeting with Bar Siman Tov, and at the end many staff members burst into tears.