Gabriele Fischer, psychiatrist, University Clinic for Psychiatry and Psychotherapy, Vienna, Austria
Ulrike Möntmann, artist, Amsterdam, Netherlands, and Vienna, Austria
Shird-Dieter Schindler, psychiatrist, Director, Sociomedical Center Baumgartner Höhe, Center for Addiction and Substance Abuse, Vienna, Austria
At the first Accomplices’ Meeting in psychiatry and psychology, Ulrike Möntmann met with psychiatrists Shird-Dieter Schindler and Gabriele Fischer.
To begin with Gabriele Fischer addressed the handling of addicted pregnant women and the social problems that arise in treating them. She criticized the fact that pregnant addicts — the largest group is alcohol-dependent but this is not registered by the system — are treated by general practitioners. Gabriele Fischer advocates that these women be treated by specialists, as is normal practice in the case of high-risk pregnancies. Further, she criticized the lack of “a holistic view of the problem of addiction” with reference to judging whether addicts are capable of bringing up children or not. Here, a lack of communication between the youth welfare service and psychiatry exists: the role of the youth welfare service is twofold and contradictory, for on the one hand it must provide help and act in the capacity of protector and person of trust, and on the other it is an agency with control obligations that makes far-reaching decisions. There needs to be far greater objectivity and professionalism also to avoid perpetuating the stigmatization of persons who since their childhood have been caught up in a cycle of institutionalized care.
AUSTRIA’S POLICY ON DRUGS: DEVELOPMENT AND STATUS QUO
Austria’s Policy on Drugs is organized on a federal basis. The Federal Ministry distributes the budget among the various Austrian states and these in turn pass funds to the institutions which are responsible for providing public health measures in connection with addiction and substance abuse. In Vienna, a radical change is currently taking place in the direction of substitution therapy and better coordination of available treatments. This is being coordinated by Sucht und Drogen Wien (SDW — addiction and drugs Vienna).
Shird Schindler pointed out that so far this institution has assessed the mental situation of a person as being the consequence of their social situation, whereas from a psychiatric viewpoint the opposite is the case: addiction is seen as the cause of social non-functioning. Gabriele Fischer said that a two-fold diagnosis in cases of addiction is only gradually being recognised. Further, recent studies have found that 60% of addictions are hereditary. Schindler added that addiction is a highly complex psychiatric disorder and society needs to recognise this fact.
Fischer described the administrative system of Austria’s drugs and addiction policy as “an outrageous machine for burning money and at the same time a gigantic power apparatus” with antiquated structures. To prevent misallocation of funds her demand is for a centralized system. Especially with regard to pregnant addicts Fischer is of the opinion that a centralized cooperative model in which hospitals with the relevant departments, such as gynaecology, general medicine, and psychosocial medicine, work together would provide an opportunity to develop a model of treatment comprising an effective early warning system and with a focus on prevention.
Gabriele Fischer mentioned Portugal as an example of a successful model with linear structures instead of maintaining “many small fiefdoms”. There the local system of healthcare has been abolished and replaced by linear cooperation between specialist facilities, general practitioners, day centers and night clinics, and so on and the quantity of drugs for own use that can be in someone’s possession has been raised (e.g., up to 5 grams of heroin). The savings to the Ministry of the Interior and the legal system resulting from less prosecutions and repression, said Fischer, are all used to finance the treatment model.
This progressive drugs policy is one of the consequences of the fact that the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has its headquarters in Lisbon. Fischer then cited by way of contrast the findings of a study on the costs of penalization and treatment published recently in Austria: “one year of opioid therapy costs 4000 Euros; one year in prison costs 36,000 Euros.”
In view of the federalistic drugs policy in Austria, Ulrike Möntmann asked the two psychiatrists to what degree they were free to choose the type of treatment for a patient and also carry it out.
The psychiatrists replied that the Ministry does not intervene directly with regard to treatment because, unlike in Germany, treatment is subject to the Medical Practitioners and Medicines Acts, which stipulate that “we must give patients the newest therapies available and also the latest medicines.” However, political regulation is still possible, for example, through decisions to close certain facilities or whether certain new medicines will be licensed. As a senior university professor Gabriele Fischer is relatively independent, Schindler said, with the “hard-won freedom to do more or less what she wants”.
Like Gabriele Fischer, Shird Schindler is not directly dependent on the SDW because his institution belongs to the hospital network. However, since reorganization there is now a cooperation agreement with the SDW “as a partnership of equals”. The influence of politics, however, has become noticeable; sections have been closed down, treatment contracts awarded, and areas of responsibility changed. This now means that patients with an addiction cannot be treated for longer than 28 days; after that, if further treatment is necessary, they must be referred to a SDW treatment center. In spite of the considerable restrictions, Schindler thinks that there are positive aspects to the reorganization because due to cooperation with the SDW follow-up treatment or care after admission during a crisis situation is better guaranteed.
Ulrike Möntmann wanted to know whether the different affiliations and (un)freedoms lead to isolation within their field of expertise. To what extent can knowledge gained and information about successful therapies be disseminated under such constraints?
Gabriele Fischer refers to her situation vis à vis certain authorities as “self-imposed isolation” but she does not see any problem with disseminating the results of her work.
Gabriele Fischer had to leave the meeting early; discussion continued and focused on the history of the origins of various institutions in Vienna. Asked about how his training related to his current professional practice, Schindler replied, “That has more to do with religions, but not in the sense of systems of faith […] Everyone wanted to help the people, everyone had different concepts and views as to where the problems lay, everyone accepted these patients and devoted a great deal of energy and effort to them. Those who began to build the institutions in Austria 30 or 35 years ago were certainly very charismatic people”.
Schindler gave examples of Viennese institutions — the Anton Proksch Institute, in the meantime the largest addiction clinic in Europe; the Sociomedical Center Baumgartner Höhe, Center on Addiction and Substance Abuse; Grüne Kreis Association for the Rehabilitation and Integration of People with Addictions — which were all founded at around the same time with scant funds but animated by the humanist ideal of offering help, but have developed in different directions due to differing ideological and therapeutic concepts. Further split-offs due to ideological grounds have led to the foundation of several small institutions, for example, the Zukunftsschmiede, psychoanalysis-oriented in-patient therapy in the area around Vienna.
SOCIAL PARADIGM SHIFT: SWITZERLAND
Via discussion of the different ideological views of how to deal with addictions, the conversation turned to the progressive drug policies of Switzerland, which is otherwise a rather conservative country. Schindler said that because of a very extreme situation, which Swiss politicians had ignored for a long time, a very slow but constant process of rethinking had taken place there in which addiction was ultimately understood as an illness by the general public. In spite of curtailing certain liberal measures, such as closing the public rooms for drug fixers (“Fixerstüblis”), in Switzerland 80–90% of the population consider addiction as a psychiatric problem and not as “moral degradation” or “an amusement of own choice”. For the psychiatrist this manifestation of common sense in regard to addiction is an crucial objective and important parameter for drugs policies.
Austria, with the exception of Vienna, is still a long way behind Switzerland. Many changes to existing laws to implement different drug policies lack a political basis due to the public’s non-acceptance of addiction as an illness.
For Ulrike Möntmann drug policies in the Netherlands, which are often seen from outside as progressive, are rather based “on an incredibly pragmatic outlook on life”. Schindler said that measures in Vienna such as the “Karlsplatzsäuberung zur Volksberuhigung” – an installation of a police-monitored “protection zone” on Karlsplatz to reassure the general public where there used to be an open drug scene – are also examples of such a pragmatic approach. The problem of addiction is not solved by banishing addicts from certain public places, they are only relocated to other places. However, the citizens see this as a positive development because they are no longer accosted or inconvenienced in any way.
Transcription and text: Nina Glockner
Translation: Gloria Custance & Isaac Custance