From Chains to Art Therapy

Mental health disorders are among the leading worldwide causes of disease and long-term disability. Both in Western countries and in Russia, the development of effective mental care is a priority for public health systems. This issue has a long and painful history of gradual de-stigmatization of patients, coinciding with humanization of therapeutic approaches. What are the current trends in Russia regarding this issue and in what ways is it similar to and different from Western countries? Below, IQ.HSE provides an overview of this problem based on research carried out by Svetlana Kolpakova.

Possessed or Patients?

Before the advent of classical medicine, the behaviour of the mentally ill was generally explained according to religious and mystical reasons. Aggressive or dangerous people were believed to be ‘possessed by demons,’ while quiet sick people were considered ‘God’s chosen’. Moreover, consistent observation of such people was not practiced. So, our understanding of their existence only comes from myths and folklore.

In Ancient Greece, initial attempts to rationally explain behavioural deviations were made. The first psychiatric terms appeared in manuscripts, which described specific cases, such as melancholy, mania, paranoia, and epilepsy. Then, scholars in the 3^rd and 2^nd centuries BC studied human anatomy and theorized that the human brain was the central organ to the nervous system. Investigation of the nervous system is considered one of the main achievements of Alexandrian medical science.

The Middle Ages was generally a time of stagnation in scientific thought. Mentally ill people were again perceived as being ‘possessed’ and socially dangerous. They were either executed or isolated. This era also saw the first use of asylums – the prototypes for psychiatric hospitals. This was mostly in Western European cultures. In Russia at this time, mentally ill people were sent to monasteries, as they tended to be treated with more mercy.

Revolutionary Change

Later, at the end of 17^th and the start of the 19^th centuries, thanks to accumulated scientific knowledge and changes in society and politics, psychiatry became a more independent field in medicine. As such, it went through qualitative changes. Philippe Pinel (1745—1826), chief doctor at a French hospital, drastically changed popular attitudes to the mentally ill. He freed patients from their chains and ordered the use of strait jackets only in extreme cases (for particularly violent patients). There is evidence that such an approach led to the complete recovery for some of his patients.

Despite the fact that a new system of mental health care (MHC) was not adopted by other countries at once, Pinel had his successors, who laid the foundation for scientific clinical psychiatry in the 19^th century.

The next century saw the development of outpatient forms of psychiatric care. Research has proven that in-patient treatment has a smaller therapeutic effect, and in certain cases, may even worsen a person’s psychiatric condition. In addition, society and the medical community, in general, started paying more attention to patient rights at hospitals.

In 1950, the anti-psychiatric movement arose in the Western countries, which led to deinstitutionalization – a massive reduction in the populations of psychiatric hospitals in tandem with the development of outpatient services.

Psychiatry in the Soviet Union

The Soviet Union started developing its mental health care system after 1922. Priority was given to developing a network of local outpatient care centres (i.e., psychiatric dispensaries). In the 1930s, daycare hospitals and occupational therapy centres started appearing in addition the dispensary system. In the 1960s, the psychiatric care system was a unified network, which included asylums, local clinics, kindergartens, active therapy seminars, psychiatrists at factories and production plants, homes for chronic patients, and special schools for children with mental issues.

In addition to drug therapy, art therapy and occupation therapy were used. The latter was used so widely, that some researchers during this period were inclined to define this approach as hidden labour exploitation of mental patients.

No public discussion about the violations of patient rights took place. It was believed that the relations between patients and doctors would be based on trust, and, taking into account the professional ethics and morality of the latter, there can’t be any violations on their part. However, in reality, there were many cases when patients were stigmatized both by medical staff and the society at large.

Contemporary Trends in Europe

Mental health policies vary throughout European countries, but not critically, since all European countries are guided by the WHO’s (World Health Organization) recommendations. Therefore, key areas of care can be clearly identified, including:

1. Deinstitutionalization, which can be achieved by closing psychiatric hospitals, cutting their budgets and downsizing inpatient care, especially in large, old-fashioned hospitals, in favor of smaller units. This process of deinstitutionalization has allowed the private sector, NGOs, and nonprofessional groups to organize and operate residential and other non-hospital facilities, where care is provided in more home-like conditions and atmosphere;

2. Decentralization of psychiatric care includes transferring inpatient care to general hospitals (thus integrating general health care and MHC); developing residential care facilities and outpatient services; integrating mental health with primary health care and other (non)medical facilities, and thus delegating treatment to other facilities;

3. Community care development covers a range of local facilities and agencies with catchment areas, such as housing, support facilities, patient and relative groups, NGO involvement;

4. De-medicalization. As psychiatric treatment has moved out of hospitals, psychiatric practice has become less medicalized, since treatment is now considered a matter of shared responsibility and competence among different specialists, including those outside of medical fields;

5. Legislative reforms and human rights are generally characterized by efforts in several key areas: upholding the civil rights of those with mental health problems and providing a legal framework for mental health policy. This involves, for instance, the regulation of involuntary hospitalization, adequate conditions for treatment discrimination-free places of work and education, social support, the right to privacy, and family life;

6. De-stigmatization. Mental illness has been highly stigmatized, which results in loss of social status, discrimination, unemployment, isolation, and a loss of opportunities in life; it also affects help-seeking, as well as the recovery process. The connection between community care and reducing stigmatization is not obvious; yet, it has been supposed that this type of care, by developing a range of stigma-reduction programmes, strategies, and anti-stigma campaigns would help to reduce negative stereotypes against MHC users and lead to broader acceptance;

7. Focus on improving patients’ quality of life. The shift in MHC policy emphasizes the concept of quality, whether quality of care or quality of life, whereby the core of the contemporary model of care is psychological and physical well-being, along with social engagement, rather than merely diminishing symptoms or survival;

8. Family involvement in treatment has become a common practice in the West, where family members are recognized as partners in the care process. Gradually, an understanding of the burden on families and other caregivers has become widespread, as well as the importance of users’ views and the implications of these for the decision-making process. Furthermore, caregivers also require support from the health care system.

Psychiatry in Contemporary Russia

The main legislation regarding MHC in Russia is the ‘Law on Psychiatric Care and Guarantees of Citizens’ Rights in its Provision,’ which was was adopted in 1992 and has been amended 18 times over nearly three decades. Under this law, three federal programmes aimed at improving the MHC system have been implemented.

Key Aims of Federal Programmes

1995–1997

 state support for up-to-date and high quality psychiatric care;

 improving the training of psychiatrists and other professionals;

 developing a new concept for the designs of psychiatric institution buildings and equipment;

 developing and reorganizing forensic psychiatry.

2003–2008

 developing networks of psychiatric care network in Russia’s regions;

 decentralization of psychiatric support;

 improving conditions in psychiatric hospitals;

 expanding outpatient services (e.g., daycare hospitals, housing, psychiatric dispensaries, and offices).

2007–2012

 elaborating and realizing consultative help, educational programs for the population regarding mental health protection and preventing suicides;

 engagement of polyprofessional teams in treatment and application of contemporary methods of psychosocial therapy and rehabilitation;

 building and reconstructing psychiatric care facilities.

The researchers analyzed legal papers and reports on the psychiatric system and the changes made thereto. They reached the conclusion that, since 1991, Russia has generally aimed at following WHO recommendations and has also been moving towards contemporary Western models and principles. Decentralization is underway; outpatient care and psychosocial rehabilitation are becoming more common; multidisciplinary team approaches are being implemented. But, of course, there still are issues of underdevelopment that require additional attention and effort.

For example, the focus on community care, which has become widespread in the West, has still not taken root in Russia. In Russia, it is believed that local dispensaries, where all mentally ill people are obliged to register, play a similar role.

Meanwhile, approaches to treatment have changed considerably: patients are now taken care of not only by psychiatrists, but also by social workers, psychologists and psychotherapists. There is also an evolving trend of integrating psychiatry with primary care and somatic medicine.

However, stigma and social inclusion are still ignored issues. The law mostly cares about reducing the negative consequences for state and society from mental disorders, such as disability and incapacity for work, crime, unfitness for military service and so forth. Policy documents primarily focus on the issue of human rights mostly with regards to inpatient treatment regulations, while no particular attention is paid at patients’ rights beyond hospital walls.

The number of psychiatric institutions has generally decreased throughout the country. For instance, the number of dispensaries (leading in outpatient treatment) decreased from 173 in 2005 to 99 in 2013 and to 92 in 2015. Moreover, the number of psychotherapeutic offices was reduced from 1,095 in 2005 to 727 in 2013 and to 676 in 2015.

In 2012–2013, 150 rehabilitation services were established in 83 of Russia’s 85 constituent regions. This trend can be explained by poor funding due to the fact that MHC has been switched to local budgets rather than federal funding. The federal budget only finances forensic psychiatric hospitals and partially funds federal organizations.

Svetlana Kolpakova concludes that the lack of state funding and the very low level of resources within civil society hamper the implementation of all aims set by federal programmes and challenge the ideas of diversity, quality and accessibility of mental health care in today’s Russia.

IQ

Study Author:

Svetlana Kolpakova, эксперт International Centre for Health Economics, Management, and Policy, HSE University in St. Petersburg

Author: Alena Tarasova, September 12, 2019