Transcript Slide 1

LAY AND PROFESSIONAL APPROACHES TO PEOPLE
EXPERIENCING MENTAL ILLNESS IN CIS COUNTRIES
Prof. Shula Ramon
Anglia Ruskin University, Cambridge
26th October 2007
Paper presented as part of a CEELBAS study day on:
Mental health and intellectual disability in Post-Socialist Eastern
European: From Institutionalisation to Integration?
University College London
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Historical background
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Like Western Europe, the Soviet block built up in the 2nd half of the 19th century a
system of institutions in which to treat, control, and hide from the view of ordinary
people all of those perceived as deviant, children as well as adults. This was
intensified during the 20th century, based on the assumption that the bigger the
institution is the better.
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However, while in the West doubts about the usefulness of the institutions have
emerged forcefully from the middle of the 20th century, eventually leading to some
efforts at deinstitutionalisation, this is yet to happen in the CIS countries.
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We need therefore to revisit both the main reasons for having institutions in the first
place and the reasons for closing them down to map the beliefs location of the CIS
countries.
• The current situation
• Before we do so, we need to be aware of the increase in
psychiatric morbidity and suicide in all of the CIS
countries (Jenkins, Klien, Parker, 2005), due to:
• Impact of regime and socioeconomic change
• Breakdown of old support systems
• Greater social inequality
• Ease of consuming drugs and alcohol (not only Vodka is
available..)
• Impact of political conflict in the region: refugees and
internally displaced people (e.g. Azerbaijan, Georgia,
Armenia, Russia, Chechnia)
• Historical Reasons given for putting and keeping
people in institutions
• *they need special attention;
• *being on their own, with "their own kind" is better for
them;
• *the institution provides a safe place and thus defends
them from the outside world;
• *they may be dangerous for the rest of us; if they are on
their own the danger will be contained;
• *it is upsetting to see them; it is therefore better not to
have to see them on a daily basis.
• *they will be re-educated in the special setting.
Evidence on institutional living
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1.life in the institutions was highly regimented: everyone had to do the same at the same time.
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2.people had no choice, even with the most basic things, such as what to eat, dress, when to get
up and when to go to sleep, with whom to be.
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3.lack of respect marked institutional life: not only did not people have the right to choose, but they
had to obey the staff on everything; it was taken for granted that the staff knew better what was
good for the residents. Those who disobeyed were punished either by the withdrawal of the few
extras that you could get for good behaviour, or by being beaten up, left to stay in seclusion.
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4.you had no opportunity to mix with any ordinary person, or pursue any ordinary activities.
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5.evidence of abuse by staff and by other residents in institutions (Stanley, Manthorpe and
Penhale, 1999)
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6.the totality of institutional life (Goffman, 1961)
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7.Institutions with a “human face” do not overcome the problems outlined above
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8.The specificity of mental illness: longitudinal research on recovery which highlights around 5060% of recovery, as against the traditional view that only 30% recovered
(Warner, 1985, Harding, 1987, Harrison, 2001) and as against the focus on chronicity
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Achievements of
Deinstitutionalisation
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95% of all children with physical, mental and psychological difficulties do not enter
institutions in countries such as Britain, Denmark, Finland, Italy, Norway and
Sweden.
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85% of resettled long stay patients from British psychiatric hospitals evaluated their
lives in the community as much more satisfying than their life in the hospital;
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Most of them showed improvement in self care and social skills, but no change has
occurred in relations to their symptoms
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Very few of them (less than 5%) required a re-admission
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Less than 1% became homeless or committed an offence
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None committed homicide
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Users as Experts in Experience: evidence of cultural shift
• The problems with deinstitutionalisation in Western
Europe
• Lack of belief in its viability;
• Lack of appropriate services
• Lack of training for staff
• Insufficient investment in public awareness raising
work
• Lack of sufficient funding
• The lure of mini institutionalisation
• Congregation in poor areas and the risk of
victmisation
• Use of failures of the new system for media
sensationalism
• We need now to attempt to understand
why the doubts about institutional life have
not had the same significance in the CIS
countries, before and after the demise of
Communism, as they had in Western
Europe.
The perceptions of lay people and their politicians:
• Betting on the strong
• Disregard for the weak
• Pity without respect
• Fear of being infected
• The high level of stigma of any disability, but especially of mental
illness
• Invalidity status for life and its implications for recovery
• Implications of these beliefs re investment in
• deinstitutionalisation, community mental health services, welfare
• benefits, a valued social role, adequate professional training
Issues for Professionals
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A rigid and dictatorial diagnostic system in the Soviet Union era
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Use of psychiatry for political purposes – container of social control –
possible in a police state, but also a reflection of lay people’s fear of mental
illness
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Lack of a tradition of autonomous thinking and professional behaviour, with
a few notable exceptions (e.g. Dr. S. Gluzman)
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Lack of lobbying activity beyond traditional trade union issues
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The inclusion of people with alcohol problems together with those
experiencing mental illness
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Loss of in-service training with the demise of the old regime
The Service system
• Institutions for life, with even less
opportunities today for any useful activity or
programme for residents than was the case
under the old regime
• Outpatient clinics which offer only
appointments
• No rehabilitation services
• No primary care or secondary care
community mental health services
• No preventative work
What has changed in the CIS
countries?
• Less money for institutions forces a degree of rethinking
• Professionals who had the courage to begin to think differently, yet
without full rethinking (e.g. the Ukrainian Independent Psychiatric
Association; the refurbishment of a department in a psychiatric
hospital in Baku by the staff and with their own money)
• Professionals who have bothered to learn new ways of working: the
move to counselling and psychotherapy and its significance
• Professional protest against lack of learning opportunities (Warsaw)
• Relatives from well to do families who have been influenced by the
West (private school of autistic children in Kiev, the Moscow Steiner
school)
• International NGOs: activities and dilemmas (OSI, Hamlet Trust,
HealthProm)
• Local NGOs : activities and dilemmas (Tblisi day centre, the Steiner
School in Moscow)
Ways forward:
• Massive and long awareness raising among professionals, ordinary
people, celebrities, politicians, the oligarchs
• Introduction to the Strengths approach (Saleeby, 1992),
• Introduction to the Recovery model (Romme and Escher, 1993,
Roberts and Wolfson, 2004, Wallcraft, 2005, Ramon et al, 2007)
• Turning existing hospitals to largely self-managed communities in
the first phase (see the Italian psychiatric reform: e.g. Henry, 1990)
• Let those who cannot live outside of the institution (due physical and
mental difficulties) live in group homes on the grounds of hospitals ,
as in Trieste.
• Enable those who can live in the community – the majority of
residents in current CIS institutions – to move gradually to live in the
community in group homes, with structured activities, including
income generating ones, which enable social inclusion.
• Prevent new admissions through the use of
crisis intervention teams and short stay asylum
facilities in the community, early intervention
teams
• Work with users and carers as partners
• Begin with pilots
• Learn from both Western European successes
and failures:
• Nip mini-institutionalisation in the bud
• Be ready for a long haul: remember that it takes
ten years to close fully an institution!