Rage Against the Cage

The cage looks like a dog kennel, but it’s bolted onto the posts of a narrow hospital bed. When a psychiatric patient is judged to be in need of restraint, orderlies bundle him into the bed and lock tight the cage — causing some mentally unstable patients to howl with fear. Barbaric? The practice has been criticized by the E.U. But it has been in use in Central Europe since the Habsburg Empire, and the Czech Republic, despite its May 1 E.U. accession, still has an estimated 2,200 caged beds in psychiatric hospitals and social-care homes.

Jan Pfeiffer has been fighting the cages for two decades, but he uses a stealthy approach. The 47-year-old Prague psychiatrist has been a major force behind two influential reports condemning the practice, yet his name appears in neither. “You can either be a bad German Shepherd who barks, or somebody who offers a helping hand,” Pfeiffer explains. “Both roles are important, but not compatible. You can’t bark at somebody, then sit down with him at a table.”

Psychiatric practitioners in the Czech Republic have stubbornly defended the use of the beds, calling them the best way to restrain patients who could harm themselves or others. “We can either use cage beds, or increase people’s medication, strap them down, or put them in solitary confinement,” says Jan Slezak, director of Social Care Home in Raby, eastern Bohemia. “We see cage beds as the best solution.”

Pfeiffer and others call such practice psychologically damaging, an excuse for poor staffing and training, and a violation of human rights. One patient, he says, spent a week caged in a south Moravian psychiatric clinic, and was neglected by staff to the point that he was forced to relieve himself through the cage’s netting and to drink his own urine to quench his thirst.

Pfeiffer chose his calling after three months at a children’s psychiatric hospital in Oparany, southern Bohemia, his first job after graduation in 1982. While in Oparany, Pfeiffer observed every morning how nurses took their children outside and stationed those who could not control their bowel movements on blue plastic buckets. “They spent all day like this,” he says. “And for the night they went to cage beds. Nobody talked to them. They had no stimulation. I found it horrifying.”

The 1989 fall of communism freed Pfeiffer to push for a radical change in the country’s approach to mental health — less institutionalization, more counseling and training.

As director of the Center for Mental Health Care Development, a Prague-based ngo, cage beds have been a small part of his agenda — but a powerful symbol of struggle for change. In 1990, he organized the country’s first Week for Mental Health, an event that opened Prague’s psychiatric hospital to the general public and featured 30 concerts on the premises. Between 1990 and 1992, he set up a complex community-based system of caring for patients in Prague, which featured 10 sheltered workshops, supported housing and a day clinic. Thanks to the activities of Pfeiffer and others like him, the Czech Republic’s psychiatric wards have 3,500 fewer beds today than in 1989, and far fewer cages.

In July, Pfeiffer landed another blow for his campaign. After author J. K. Rowling criticized the use of cage beds in a letter to the Czech government — she was responding to a Sunday Times story that Pfeiffer contributed to — Jozef Kubinyi, then Czech Minister of Health, ordered the decommissioning of all cage beds by the end of 2004. (The decision is now under review by Kubinyi’s successor.) For Pfeiffer, who heads to southern England this fall to help develop community services there, it’s an incomplete victory, since most cage beds are in social-care homes, outside the Ministry’s authority. But it’s a reassuring sign that the old system is crumbling.