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Old 13.03.2020, 02:01
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Self-harm (not only suicide) and authorised care, in hospital or at home?

Could someone please direct me to info, ideally from Switzerland, about the need for care to prevent self-harm?

Harm is generally known as to the self, or to others, in German "Selbstgefährdung" or "Fremdgefährdung".
  • Harm to others” is taken to mean threatening to kill someone else, or having tried to kill someone.
  • "Harm to self" is typically taken to mean acute suicidality, i.e. not just thoughts about suicide, but signs that the person has tried to end their lives, and/or is likely to try to end their lives very soon. I’ve heard, anecdotally, that other matters are also regarded as self-harm, such as ongoing drunkenness, neglect of basic personal hygiene and the neglect of taking in enough fluid and food, or perhaps disorientation through dementia (but I’m not sure of this).

If either type of harm is serious enough, it can legally be sufficient grounds to hospitalise the person in a locked psychiatric unit, even against their will (in German "Fürsorgliche Unterbringung"). In fact, self-harm and harm to others are the only two reasons, in Switzerland, that someone may be kept locked in a psychiatric unit against their will.

However, there must be a line, and that's what I'd like to understand. “Mere” threatening, while illegal, is not likely to be grounds to hospitalise someone, but some intensity of threat of violence will be. General unhealthy living also isn’t a reason, and yet at some point the degree of lack of self-care must be deemed as sufficient grounds for hospitalisation. I'm looking for information about the formal criteria for making that distinction of degree.

Also: if someone is not caring for themselves properly, is there an alternative to having them force-hospitalised? That’s quite a dramatic step, after all. Are there measures that can be taken from outside, ideally with, but also without, the person’s consent? Can someone (and if so, who and how) authorise that the person be watched over, observed, cared for, looked after, in their own homes, so that they don’t slip off into a degree of self-harm or self-neglect that is dangerous?

I’d be very grateful for links, please. Thank you.
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Old 13.03.2020, 02:13
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

Kesb

(all capital letters but for some reason, the system changes them).
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Old 13.03.2020, 02:36
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

Yes, I've read up on things of KESB, but can't seem to find the distinction explained. Only about suicidal people, or those threatening to kill someone, and then after that it gets rather vague. That's why I'm hoping someone can show me where there is more clarity.
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Old 13.03.2020, 09:40
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

In case you haven’t seen these:

An overview, from Pro Infirmis:
https://www.proinfirmis.ch/behindert...rbringung.html


More detail, from KT Bern Direktiont für Inneres und Justiz (note that there are likely cantonal differences, as always.)
https://www.jgk.be.ch/jgk/de/index/k...rbringung.html

A deep dive, from the Schweizerisches Gesundheitsovservatorium:
https://www.obsan.admin.ch/de/publik...r-psychiatrien

From Pro Mente Sana, a professional discussion on Erwachsene Schutzrecht. Discussion around Fürsorgerische Unterbringen starts on page 14:
https://www.promentesana.ch/fileadmi...Webversion.pdf

A question asked in Parliament:
https://www.parlament.ch/de/ratsbetr...airId=20144097

As you might expect, the criteria seem to be somewhat fluid - as anytime you are dealing with mental health issues there needs to be an individual response. It should be noted that one of the factors is the effect of the situation on caregivers/third persons. It seems to be a very fine balance between patient rights and public safety.

From the one case I know of - so grain o' salt, and all that - much seemed to depend on the reaction of the various officials involved. Given the same narrative of the situation, Doctor A might not be concerned but Doktor B goes too far too soon, and Doktor C is somewhere in the middle. Bureaucrat X might be wholly uninterested in helping while Bureaucrat Y goes the extra mile.

As to measures short of forced hospitalization, if the person won't accept help/oversight I know of no legal alternative to involving KESB. If I understand the legal basis - and my understanding is questionable - an adult is either Urteilsfähig or not, either has the competency to make his or her own decisions, regardless of how poor those decisions are, or is not. I don't know of a 'half way', but then I am not in any way qualified. All I can offer are observations from a distance, based on very limited examples.

In the former, there is little you can do you force a competent adult to act differently. In the latter, calling in KESB is the first step in the process. But be aware that it is a huge step, one that can be difficult for a family member to take.

The people I know stuck in this terribly difficult situaton are pretty much just trying to muddle through as best they can. Most call on help from the GPs, churches, various private and public mental health organizations - but that help depends on convincing the person to accept it.

Truly a difficult situation all around.
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Old 13.03.2020, 10:04
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

Blessings be upon you, melloncollie, for this helpful reply and the links, into which I shall delve. Thank you.
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Old 13.03.2020, 13:51
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

Probably best to not just read, but give KESP a call.
They will possibly ask the person involved to come in for a chat.
Sonner rather than later - also covered by insurance.
Worst case, the chat may cost 300 chf.
Its cheeper than a tooth filling and gives peace of mind
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Old 13.03.2020, 13:55
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

Quote:
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Probably best to not just read, but give KESP a call.
They will possibly ask the person involved to come in for a chat.
Sonner rather than later - also covered by insurance.
Worst case, the chat may cost 300 chf.
Its cheeper than a tooth filling and gives peace of mind
What would "that chat" be called, so that it would be covered by insurance, or cost Fr. 300? I mean: does such a KESB consultation have a name, i.e. what is the terminology for this process?
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Old 16.03.2020, 03:17
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

Thanks, melloncollie, I've now had a chance to read through the links you kindly posted.

According to what I've now read, a FU (fürsorgliche Unterbringung) brings the person into care (even against their will) in a locked unit, only if
  1. they have a psychiatric weakness (sorry, that's a literal translation)
  2. the person is in grave danger of a deterioration in their health (this appears to mean not only suicide, but also serious neglect)
  3. the aim is to help them to regain their self-determination and responsiblity over themselves, and
  4. only if there is no other way for the treatment to be carried out.

As far as I understand about the KESB, they get involved if guardianship is needed. This is not the case here, at all, is the man is fully aware of his need for care. He knows, fully, that he's not coping, but he is rational and can still take decisions. He is not acutely suicidal and of no danger to anyone else, but can't manage to take care of himself properly.

He is disturbed but not dangerous, and he is capable of taking responsible decisions over his own life, with some support in the decision-making process. He is, however, due to his psychiatric condition, not able to be reliable in carrying out the decisions, nor in planning basic aspects of life, he doesn't shop, cook or clean properly, his home is in disarray, his paperwork slipping behind, his body becoming unkempt, and altogether his life is getting more and more neglected, and he's on the brink of going down a steep spiral.

The thing that he needs is that kind of observation andcare, but not to be locked up, and he needs the provided by someone who went to his home. That would suffice. That's his personal view, and also that of the treating doctors and his remaining social contacts. So, point 4. above is not fulfilled, because they hope that there is, indeed, another way for the treatment to be carried out, than in a locked unit.

He lives alone, but his friends and relations are taking strain because he is unstable and needs more care than they can give, partly because they live far away, partly because his general level of tension is exhausting to others. He is not against help, and would welcomem it, and work cooperatively (within the limits of his psychological resources) with that person/ those people.

This seems to be where the matter is difficult to explain. As far as I have understand from the people involved, they're trying to motivate for more care for him at home, but are failing.
  • The psychiatric nurse does go by, but the medical insurance says this is now at the maximum limit, and the nurse cannot persuade the medical insurer to cover more hours.
  • The doctor thinks the Disability Office should be paying for this care, with HLE (Hilflosenentschädiung = helplessness compensation, a top-up pension over and above the existing disability pension) but cannot seem to persuade the Disability Office of the need.

It would seem such a silly waste of time, effort and money, were they to "have to" let his condition deteriorate, and only once he lived in full neglect could he then get "helped" by being locked up. That'd be temporary, and then he'd be back in his own home again, still needing care.

His doctor hopes to prevent that cycle, but can't seem to find the correct terminology or arguments to justify why someone should go round to the man's home, and not just pop in to check that he's okay and then tick a box, but to spend hours there, every day or most days, to help him try to re-build his life. What would this kind of support be called? Beobachtung? Überwachung? Lebenstraining?
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Old 16.03.2020, 09:04
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

Doro, if the person will accept help, has he or the family investigated psychosozial Betreuung via Spitex?

http://www.spitex-zuerich.ch/angebot...ale-betreuung/

(This is ZH, but most cantonal Spitex service offer similar.)

Generally speaking the cost of this should be covered by the basic insurance - but there are limitations. And if the insurer is alread balking, that could be a problem. Does the man have the ability to pay on his own? If so, there are private psychiatric Spitex-like services - but they are expensive.

Also, forgive the obvious, but what does the Gemeinde/cantonal social services department recommend?

A friend is a social worker, much of her work involved 'Familienbetreuung', where she monitors at-risk families/people in their daily lives. But I don't think she spends hours per day with the clients, rather a visit for a short time to check up on complicance with strategies the client and she developed together. I'm afraid I don't know more than that, as she - of course - is cognizant of the need for privacy and may not talk about her work to third parties except in the most general terms.

If the man or his family have already gone these routes, or if he needs to be monitored a fair portion of the day, in-patient care might be the only option. AFIAK there isn't much in-between check-ups and in-patient placement. At least not available via the public system. But again, my understanding of the system is very limited.

If the man has sufficient assets he could look at hiring someone privately. For instance, I've seen a few people offering 'Betreuung' help on the '24' platforms. But I cannot stress enough - this will be expensive, and not covered by insurance.
And if his condition is severe enough he should not be in a situation where he could harm the person who is his employee - nor be in a position of employer. And there is of course the issue of whether a private person would be sufficiently qualified.

Would the man consider voluntarily entering an in-patient program? Perhaps a short-term therapy program? He wouldn't exactly be 'locked up' if it was a voluntary admission. But again, there is the expense.

You probably already know about these as it seems the GP is already involved.

Unfortunately, there doesn't seem to be a lot of public help in the middle ground - the system, as I understand it from my limited third hand involvement - is pretty much geared towards guardianship if a person is not able to conduct his or her life on his or her own.

Also, search for some of VLH's old posts. IIRC, she had some kind of on-going public guardian relationship. You might find some insights there.

Honestly, if family and friends are exhausted, if funds are not plentiful, involving KESB is likely the way to go. If the man is cooperative there might be a solution short of guardianship or being 'locked up'.

I really feel for the friends/family who are trying to help, and for the man himself. Especially in this time of national crisis, where services are likely to be strained to the max.
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Old 16.03.2020, 09:33
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Re: Self-harm (not only suicide) and authorised care, in hospital or at home?

Found this while browsing around: Wohn-Coaching from the Psychiatrische Universität Zürich:

https://www.pukzh.ch/unsere-angebote...wohn-coaching/

HOWEVER - there is a note on the page that due to the Coronavirus crisis some lectures and programs have been suspended. I don't know if this program is included in that suspension.

Nonetheless, something to look into for a later, calmer time.
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