Dainius Pūras, Director of HRMI.
It is recognized today that mental health is as important as physical health, and that there is a need to seriously invest in mental health of society and each of its member. There are attempts globally to come to an agreement on the main principles about how to most effectively invest in mental health. These principles reflect two major achievements of mankind. The first one is about achievements in science. Investments should follow the direction set by the results of both natural and social sciences. Secondly, the universal human rights principles need to be applied. Following the Second world war, when the Universal Declaration of Human Rights was adopted and the UN conventions on human rights ratified by many countries, it became obvious that protection of all human rights (i.e. economic, social, civil, political, and cultural) was very important for realization of the right to mental health and for all its elements (promotion, prevention, treatment, rehabilitation, and recovery). In other words, it is important to undertake measures in the direction of addressing social inequalities, social injustice, all forms of discrimination and violence. There is increasing evidence that inequalities, exclusion, discrimination and violence are determinants that are detrimental to societal and individual mental health.
And what about the systems that are supposed to address mental health – mental health care systems? Are these systems, funded by governments, are they effective? Or maybe, on the contrary, they reinforce discrimination, exclusion and violence? There is an increasing number of experts and organizations that critically assess the status quo in systems of mental health care and psychiatry, and insist that there is the need for the shift in the old paradigm in this field. For example, the UN Human Rights Council adopted two resolutions (in 2016 and 2017) on mental health and human rights. In those resolutions UN member states are urged to take measures that should lead to changes in mental health policies and to put a stop to the unacceptably high prevalence of human rights violations in mental health care systems. Effectiveness, transparency, and relevance to human rights principles in the mental health systems is now a matter of intensive debate and is under scrutiny all over the world. There is no single country that does not have problems in the path to realization of the right to mental health. Although more often a lack of financial resources is higlighted as a major obstacle, it is more important to make clear decisions about the main principles, on which decisions are based, and in which direction financial flows are invested. The deciding factor is a combination of prevailing attitudes of the key stakeholders, and not the amount of financial resources.
So what are the successes and failures of investing in mental health in the region of Eastern Europe and Eurasia (EEE)? This is a unique region, which experienced 50 to 70 years of soviet experiment and then, in the beginning of 1990s became famous for its peaceful revolutions towards national independence and democracy. What have been the opportunities and obstacles to establish the best mental health care practices in this region, based on evidence and on human rights principles? What is the main difference between this region and other regions? We know that today all regions in the world face challenges, when addressing global mental health issues. And still the regional context can make a serious difference, and so should be taken into account when formulating and implementing mental health policies. Such kind of analysis is one of the goals of the new project, which has now been started by the Human Rights Monitoring Institute.
I would like to contribute to this analysis with my own experience. This experience could be important, as for the last 30 years I have been actively involved in changes in the EEE and have been closely cooperating with representatives of all key stakeholders.
Many questions about the Soviet medicine and psychiatry accumuluted in my mind already during my studies in the Faculty of Medicine at Vilnius University, and this was during the years 1975-1981. After graduating from university, I started working as an assistant professor at the same medical school, and then time has come for the PhD research. One of my research supervisors in 1983-1987 was professor V.Kovaliov. He was an influential Soviet psychiatrist, chief child psychiatrist of the Soviet Union, and director of one of research institutes of psychiatry in Moscow.
That was a good occasion to discuss different issues with prof. V.Kovaliov. I am grateful to him for his openness during our private conversations, when he would take off his ‘mask’ and share his genuine views. He was not hiding from me that Soviet psychiatry was serving to the Soviet ideology. He warned me in ironical way, that outcomes of scietific research would be well-known by researcher in advance, because otherwise – if you discover something, which is not in line with the ideology – you could get into serious trouble. He was advising me in a friendly way, which issues I should avoid raising in my research. He was well avare of the Cold war games, when the Soviet Union and the West were criticising each other for the violation of human rights. The Soviet Union was higlighting violations of economic and social rights in the USA and Western Europe, while the Western countries were critical about the Soviet people being deprived of their civil ant political rights. Mental health and mental health care were used in the Cold war by both sides. In 1970s, the Soviet Union declared that they had defeated capitalism and in this way they eradicated all root causes of mental ill-health in social and psychological environments. The conclusion was that in the Soviet Union, if suicide or heavy drinking, or some inadequate behavior happened, the only explanation for this could have been a ‘mental disease’ caused by a brain pathology (usually schizophrenia would be diagnosed). And if suicide, or heavy drinking, or any inadequate behavior happened in the USA or any other capitalist country, then this was considered to be a natural outcome of exploitation of people by capitalists.
This is how the infamous theory of ‘sluggish schizophrenia’ was born. Interestingly, for all those years there were many followers of this theory in Lithuanian psychiatry, and even now traces of this terrible weapon (when anyone can be diagnosed with schizophrenia, with detrimental consequences of further dicrimination) may be found. By the way, prof. V.Kovaliov did not like the theory of sluggish schizohrenia, and he criticized this theory and its founder A.Snezhnevsky, who was then a director of another research institute in Moscow.
Changes, which occured in Lithuania and in the broader region 30 years ago, provided a perfect and unique opportunity for modernization of mental health care services. 30 years is a lot of time. However, today with some sadness I would conclude that 30 years was not enough for a real change, and now I think again of Lithuania that needs to abandon the legacy of mentality based on totalitarian and reductionistic Soviet psychiatry. Many different factors have accumulated to produce this effect of fierce resistance to changes in mental health care. The entire broader field of medicine (the health care system) remains until now the hostage of mechanisms that are based on corruption and reductionistic biomedical model of ‘repairing body parts’. If medical schools of universities teach future doctors that the main goal of healthcare is to diagnose disease and then to fix this disease trough defeating pathology at any cost, we should not be surprised that psychiatry has followed the same path – aiming to fix ‘mental disorder’, either on voluntary, or on an involuntary basis. The principle ‘first do no harm’ has been undermined, and this is how epidemics of human rights violations has spread in the name of psychiatry as a part of general medicine.
Another ironical and paradoxical and, to people like me, unexpected factor was that neurobiological theories, after dominating for many years in Soviet psychiatry, in the 1990s and later decades, have been reinforced by Western consultants. Many famous Western professors of psychiatry came to Lithuania and other new democracies of the region following the fall of the Soviet Union, to advise the governments that effective new types of medications need to be reimbursed and widely used to address issues such as depression, schizophrenia, and to prevent high rates of suicide. Sadly, these famous consultants did not wish to take into account the fact that the EEE region has not been influenced (as it happened in the West) by popularity of psychodynamic theory and practices and other psychological theories and practices, and that there was a vaccum in this region with providing psychosocial interventions.
So what happened in Lithuania, and very likely, in many other countries of the EEE region, that a new generation of psychiatrists, including those working in academic psychiatry, was very easily spoiled by pharmaceutical companies and consultants? These consultants brought to the EEE region the knowledge that depression and other mental health conditions are predominantly ‘caused by chemical imbalances’ in the brain and that these imbalances need to be fixed with psychotropic medications and electro-impulsive therapy. While in the West during the last 10 years there had been some ‘sobering-up’ processes towards the understanding that psychiatry has gone too far with the biomedical model, and that now biological psychiatry is in a deep crisis; this did not happen so far in the EEE region. In Lithuania, in the year 2019, it is still not recognized by healthcare authorities or by the elite of psychiatry that one of the most serious problems is currently the overuse of biomedical interventions, which is harmful to patients, and which is harmful to general reputation and image of psychiatry.
So what has been happening in the countries of the EEE region since the dramatic changes in the beginning of 1990s and until now? There is no secret that Russian psychiatry, after initial stage of self-reflection of developments during the Soviet years (e.g. on issues such as political abuse of psychiatry), later developed accordingly to political processes and regressed with democracy. This is why there should be no surprises that the shrinking space for civil society cannot positively affect developments in psychiatry and mental health care, and especially such regress can be detrimental to mainstreaminig of human right based approach in mental health care.
In this regard, it is very interesting to follow what has been happening with psychiatry and mental health care in Lithuania. In general, there have been quite many positive developments in Lithuanian society during the last 30 years, and the main principles, with independence of different powers, rule of law, and vibrant civil society, was established. Lithuania, as a member of the European Union since 2004, is enjoying its democracy. However, many positive developments in Lithuania have not influenced the field of mental health care and psychiatry that much. There have been some attempts to critically assess the Soviet legacy, but in the end, this never happened on a serious level. Maybe this is one of the decisive factors that has determined the further developments in this field. Only the facade of mental health services has been constantly decorated through all these years, without any real changes in institutional culture of services that remain reliant on social exclusion, institutionalization, overmecdicalization, paternalism and discriminatory approaches. While in the 1990s there was a vision in the country to catch up with models of mental health services that existed in countries of Western, Southern or Northern Europe, there seems to be no such vision in 2019. Independent monitoring of human rights in mental healthcare facilities is facing serious resistance. Institutional care is on high demand, and all large residential institutions are fully occupied, as there is still no diversity of needed services in the community. It is not just government authorities, but also influential representatives of psychiatry and child psychiatry, who are now against development of quality services, with sufficient number of non-psychiatric staff, at the community level.
This kind of contextual analysis is very important. It helps to monitor, if the national mental health system is following modern principles, and if investments are effective. Such an analysis helps to reflect on the present and to predict the future.
Have we learned the lessons from the huge impact of the soviet era? Interestingly, in Lithuania recently there were serious studies completed about the contextual analysis in different fields, and about the impact of propaganda, informational wars and fake news, as well as the possible impact on national security. But the mental health part of this, for example with regards to the lack of emotional literacy among population and low level of immunity to conspiracy theories – are not taken seriously. I think, it should be seriously addressed that the field of mental health care, which is becoming increasingly important, remains a hostage of outdated attitudes. This is one of most serious internal threats to well-being of Lithuanian society, as well as the wider region.
I would like to draw attention and to suggest for further discussions two phenomena that deserve, in my opinion, more serious considerations, as we discuss challenges and obstacles for the changes in mental health care in Lithuania and in the broader region. Firstly, it is the extreme insensitivity of general public, including its elite, towards people, who belong to more vulnerable groups. The fact that in 2019, which is 30 years after the Republic of Lithuania was re-established, there are still 6000 persons with disabilities locked-up in segregated residential institutions – is ignored, as a serious problem. These 6000 people did not commit any crime, but they are deprived of liberty, because they have been dignosed with a mental health condition, or have psychosocial or intellectual disability. Politicians do not seem to care, and elite – cultural, scientific, or any other elite – does not care much.
Secondly, because of soviet totalitarian experiment, people living in the EEE region were not influenced by different theories and pratices that were dominating the Western world in the 20th century. Modern psychological thories, including those about attachment and child development, or those about the role of unconscious, have influenced psychiatry and clinical psychology, and also entire culture of societal life in many parts of the world, but not in the EEE region. For example, everyone knows in many countries what ‘therapy’ means. In many countries of the EEE region talking about ‘talking therapies’ is still an unknown concept, at least when it comes to the idea that this should be reimbursed by the state, like medications are reimbursed. At many ministries of health in this region it is still possible to often come across the thinking of bureaucrats that ‘therapy’ is the science and practice of treating internal diseases, and that a therapist is a medical doctor for internal physical health diseases. Hence, there is a common presumption that only a medical doctor can do any therapy or any intervention in general, even if he/she is not trained to do this; while a psychologist or social worker or nurse are not allowed to do any talking or any other therapy, because they are not medical doctors.
In 1951 the WHO announced, after John Bolwby published his study on attachment, that it is harmful for young children to stay in institutional care (‘baby homes’), because for healthy development of the child it is crucial to have stable emotional relationship with primary care-taker. This evidence was taken seriously in many countries. But Soviet ideology promoted a very different concept – that state is sort of a better mother, this is why it is quite OK for children to live in residential care institutions. After many decades, it is still often very difficult to convince politicians and other key stakeholders in the EEE that children should not be growing up in state institutions. Also, it is very difficult to convince health authorities, that equally important it is to reimburse not only medications, but also psychotherapy and other psychosocial interventions. There is lack of understanding that to a large extent mental health support is about targeting social relationships, and not only the brains of people.
One of the major internal threats in countries like Lithuania, which remains not adequately addressed, is ongoing stagnation in the field of public mental health and psychiatry. This stagnation has affected not only governmental agencies, but also universities that traditionally have very important role. Many decisions that should have been made a long time ago, such as de-institutionalization, are being postponed. Each next government continues what the previous governments had done, i.e. feeding new investments into an ineffective system of segregated services, which reinforces exclusion, stigma and hopelessness. For example, Lithuanian authorities are often presenting as an achievement the fact that Lithuanian has 115 outpatient mental health centers, and even suggest this model for replication in other countries. However, independent analysis demonstrates that these centres are not effective, as they provide mainly biomedical interventions and they fail to stop institutionalization, reduce high rates of suicide and provide quality services to children and adults with complex mental health conditions. These centres do not serve as real community based services and they instead serve for feeding large segregated residential institutions and psychiatric hospitals.
Interestingly, 30 years after the ‘singing revolution’ today, Lithuania is still discussing whether it is ready for serious changes in mental health care system. The ‘moderates’ are the winners, while those who urge to start essential changes (like such reforms that happend in many European countries 50 and more years ago) are considered radicals, and their suugestions get rejected. This kind of a cautious approach to changes seems to result in endless decorating of ineffective system and feeding the infrastructure of outdated residential institutions and segregated psychiatric hospitals. One of preliminary conclusions might be that more radical changes are very much needed as they would likely be more effective.
In Lithuania, the most popular view among politicians and mental health professionals is that in general Lithuania is successful with changes within the mental health care system. There are some projects, which serve for replication of Lithuanian experiences in other countries of the EEE region. In fact, there are many progressive pilot initiatives, often provided by civil society, in the mental health field in Lithuania. However, the question remains, are these alternatives to the system of traditional psychiatric services supported by the government and national budget or health insurance system, and can they be sustainable?
These could be questions for discussion within the new project by the Human Rights Monitoring Institute. Which shifts of paradigm that are well known to have happened in global mental health history, have happened in Lithuania and broader EEE region, and which of them are still waiting for their time to come? Which of the five obligatory components of community care for persons with psychosocial disabilities (as per the WHO recommendations – psychotropic medications, psychological interventions, psychosocial rehabilitation, occupational/vocational rehabilitation, and supported housing) are available in Lithuania and EEE region in 2019? Which components of existing Lithuanian mental healthcare system could be recommended for replication in other countries? What good practices from other countries could be implemented in Lithuania? What measures are undertaken in Lithuania to reach a healthy balance between investments in reimbursement of psychotropic medications and psychosocial interventions? Is independent monitoring of human rights in mental health care systems in place? How application of non-consensual measures in psychiatric services is being monitored, and what measures are undertaken to reduce or eliminate coercion in mental health care systems in Lithuania and the EEE region?
The project “Mental Health and Human Rights: Supporting the Paradigm Shift in Lithuania and the Broader Region of Eastern Europe and Eurasia” is supported by a grant from the Foundation Open Society Institute in cooperation with the Public Health Program of the Open Society Foundations.