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Ukraine: a psychiatrist’s point of view. Reports, thoughts, articles (1999–2004)
Y. Yur’yev

SYSTEMS OF PSYCHIATRIC HELP: POSSIBLE MANAGING AND REFORMING MODELS

Y. Yur’yev

* Publication details:
Yur’yev, Y. (2004). Systems of psychiatric help: possible managing and reforming models. In: Yur’yev, Y. Ukraine: a psychiatrist’s point of view. Reports, thoughts, articles (1999–2004), pp. 148–159. Dnipropetrovsk: Porogi.

The fact that mental health protection programs should become a priority for the majority countries of the world, as for those social consequences they cause, has become obvious for the recent years. Mental diseases (including alcoholism and drug addiction) are considered to be the main worldwide threat to health and life productivity according to experts. The development of medicodemographic crisis in Ukraine first of all concentrates researchers’ attention on the following processes: birth rate decrease, death rate increase, and deterioration of qualitative health characteristics, especially mental health.

However, today we are not able to give any objective estimation to the psychiatric help for the population according to the update requirements.

Unfortunately the priorities do not change when the fact of depopulation is realized as a long-term demographic reality. The reproduction perspectives of the population are connected not only with the mental health rate but also are based on the fact that miserable financial support covers numerous programs instead of concentration on the most important areas thus being unjustified in the terms of deep social-economic crisis.

Today our society and government face very difficult and long-term problem of psychiatric help system reforming. The main point is making the system successfully developing organism built in new link systems between the government and the society. It is obvious that the transforming realization is possible only after new managing system creation in order to manage all the institutes of the contemporary Ukrainian society involved in the process. Today the mental health level of the nation is a question of national safety; and the solution of the problem depends on the reforming result; and for the long-term perspective — what the Ukrainian nation and its institutes are going to be in the third millennium. In the terms of crisis and serious mental health deterioration of the population the reforming concept of the psychiatric help, the aim of which is to change the help accent to the out-of-hospital conditions, hasn’t been justified yet. It hasn’t been able to justify itself because of the presence of huge amount of people that need professional psychiatric help and because there is no contemporary psychosocial system of rehabilitation. The solution of the problem is impossible without using the worldwide experience.

So, for instance, the Spanish psychiatry of the end of 20th century differs from the one existed in Spain before 1914. Having had a difficult way of governmental reforming and having overcome the dictator period of Franco, and having become a member of European Unity, the Spaniards not only adopted the E. Kraepelin’s ideas system but also filled it up and made an effective system of psychosocial rehabilitation for people with mental disorders.

The reforming period started when E. Kraepelin was invited to the National Congress of neuropsychiatrists that took place in December 30th, in 1924 in Barcelona where the following very important decisions were taken:

  1. Immediate revising of the legislation in the part, concerning a patient.
  2. Reconstructing of the psychiatric help on the scientific basis.
  3. Making a requirement for all the doctors-psychiatrists to have special methodical preparation.
  4. Establishing obligatory position of a psychiatrist in social and private hospitals for people with mental disorders.
  5. Organizing psychiatry courses on the high level in all the Spanish universities with the main psychiatry course.
  6. Admitting modern classification of mental disorders, for example, Kraepelin’s classification.

Speaking of the French influence on Spanish psychiatry we should use the words of Peres de Ajal who said: “France was an intellectual supporter, we were using its way repeating mistakes and obtaining profits. But it pushed us not only to some deeds but also to actual critics”. It was a period of realizing the own creativity powerlessness. The formation of two independent psychiatric schools, in Madrid and Barcelona, was a result of development. The First International Congress on psychosocial rehabilitation in 1995, Barcelona, and the 10th World Congress of psychiatrists in 1996, testified their achievements.

Philosophy and medicine have much in common even if at the first sight they are obviously different. First of all both of them deal with human’s life. Especially it concerns psychiatry, the most humanitarian sphere of medicine. Every notion used by psychiatrists in everyday work, personality, consciousness, psycho disorders, delirium etc., is principal philosophic categories. Modern psychiatry can’t be developing basing on medicine texts only. Klemens Dikhopher’s monograph covers period from antique to modern times and opens theological, philosophical sources, works on national psychology, linguistics and historic cultural works that gives us opportunity to look upon Spanish psychiatry basics in a new way. His monograph is devoted to the psychopathology and psychiatry development. According to his point, human dignity respect, mercy, Christian theories about human equality in front of God have been forming a definite attitude to the notion of mental disease for centuries.

Lopes Ibor is considered to be a classic of modern Spanish psychiatry of the XXth century. Being a psychologist and professor of psychiatry in Madrid Universidad for many years he was the head of World Psychiatric Association. According to his conception “fear affect” (“life fear”) is one of main sensations that leads to physical disorders, that he considers being depression equivalent. Works of Kierkegaard and Heidegger, philosophers and existentialists, made Lopes Ibor realize the psychopathologic sense of “life fear” term. This fear, as a presentiment of non-existence, is a dynamics change in the personality structure. Lopes Ibor’s ideas are of great value, as they lead to realizing not only matters occurring to one person but to all the society in the historical development, to realizing of psycho health changes according to social cataclysms. Today the modern society needs to estimate objectively the presence of the changes occurring in the individual consciousness of a modern person. These changes make the basis for a person to understand himself and the environment in general.

The history of human development shows us that a human being learnt to live in a world with destructive reality laws (the consequence is a demand for illusion and myths that led to the cinema, television, computer virtuality, drug addiction and alcoholism occurrence).

However the payment for all of these is the increasing disintegration of both individual and social consciousness, which we can watch now; it is displayed in suicide number increase, drug addiction, aggression, alcoholism etc.

For the last years the number of serious psycho problems has been increasing in many countries of the world (but especially it concerns the countries of the former SU that are overcoming the history crisis period). These changes can be considered as “identity crisis”, that is usually defined as self-feeling loss, as incapability to adjust to changing circumstances, as the gap between the new situation demands and settled earlier settings and views. Speaking of identity crisis is possible in the case when the majority of social categories, through which a person has defined his own place in the society, seam to lose its boarders and value (G. M. Andreyeva).

The identity crisis involves personality changes; the self-perception loses integrity. A serious transformation is caused to professional identity. Many people suffer now from “cultural shock”. In the result of experienced events the basis of identity is destructed, the transformation of the world’s picture that was formatted from the birthday and included the wide range of images, settings, up to the self-realization as a citizen of a definite country. The state of psycho-emotional distress covers such emotions as health fear, fear to lose a job, fear to become an invalid, fear for the kids’ and relatives’ future. This is very common for Ukraine.

For 5 years (1994–1998) Sociology Institute colleagues in cooperation with “Socis” organization were holding an inquiry of 9,044 respondents from all the Ukrainian areas and Crimean Republic. The sample population included people under 17 y. o. The further data analysis made a permission to state a social disintegration, progressing deterioration of psycho health and general national disposal. In 1998 23.9% of interviewed people enlisted themselves to the lowest step of social hierarchy and 45.5% pointed the difficulty of adjustment to the new social conditions. And if in 1994 approximately the half of respondents pointed no life satisfaction, in 1998 more than 70% enlisted themselves to that category.

The structure and dynamics of stressful situations occurring to the population in the present history period is depicted in the following table.

Table 1

Answers to the question: “Mark, please, what of the following stressful situations you have found yourself in for the current year”

Situations 1994 1995 1996 1997 1998
Having serious financial difficulties (having no money to buy first-need things) 34.0 36.4 40.1 44.0 46.1
Being disappointed in people meeting meanness and betraying 29.8 6.6 29.7 27.1 27.0
Having a close person who suffers from a serious disease 24.9 26.8 26.1 23.9 24.8
Losing social optimism and hope for better living in your country 24.8 29.1 29.6 29.3 32.2
Losing your strength belief, willing to do nothing 18.5 19.6 20.8 20.9 21.5
Feeling your helplessness in front of the power arbitrariness 16.5 20.6 19.9 21.9 24.1
Recovering from a serious disease or operation 14.2 16.9 12.4 11.3 13.9
Losing your job 9.9 11.2 11.2 13.1 14.4
Having serious conflicts with surrenders 9.8 8.0 9.3 8.0 7.6
Experiencing some criminal affair (being robbed, offended or attacked) 7.9 10.3 7.9 7.4 7.9
Losing much money because of some unproductive financial deal 4.0 5.7 5.5 3.8 3.6
Bringing an action against somebody, asking a lower for help 3.1 3.6 3.4 3.4 5.0
Being at the edge of committing a suicide 2.6 2.9 2.9 1.9 3.1
Dealing with other stressful situations 4.5 4.8 58.4 5.4 7.3
Having no any stressful situation during a year 19.0 22.0 20.4 21.2 14.6
No answer 0.9 0.3 0.0 0.1 0.3

On the analysis we can see that the majority of respondents are dealing with hard, uncontrolled chronic macro stresses that are aggravated by national motivation change and lead to the stress of social changes. There is an accumulation of alarming psychosomatic disorders and depressions.

Let’s compare the managing and reforming processes of a psycho health system on the examples of other countries.

Considering different developing models of psycho health protecting systems we should look through the experience of Israel.

The process occurring in the modern psychotherapeutic services of Israel are depicted in the article of E. Lobov (1998). These processes reflect national values and realities, general reforming tendencies of the public health services.

Since its foundation (1948) the health protection of Israel has been developing in the condition of poor resources, mass immigration (only for the first years of independence the population of Israel increased twice). Having 5.7 million people 80% of them are immigrants or Israeli in the first generation (the end of 1996).

Israel is considered to be an industrial country with developed economy and with the average 1700$ income for a person. The average life term is 77 years; the suicide level is 7/100,000 of the population (it hasn’t been changed for the last 30 years).

In the history of Israeli psycho health protection system there were some events that influenced its further development significantly.

  1. 1972 — the social psychiatry “script” was chosen.
  2. 1972 — the country was divided into regions of public health services.
  3. 1978 — the agreement on rationalization of psychiatric help between the government and hospital cash departments.
  4. 1995 — state health insurance law was accepted.

Since the beginning of 70s the Health Protection Ministry has started to reform the psychiatric help policy according to the theoretical principles of social psychiatry. The decrease of bunks for insane people has been planed (by 1980 their number has made maximum), for the last 15 years 1/4 of hospital places has been liquidated. There has been reorganization of psychiatric hospitals into centres of psycho health that include diagnostic department, the department of intensive short-term help, the hospital, outpatient clinics (according to the USA sample). There are medical psychologists, social workers and even clinical anthropologists working in the centres.

Today hospital services include specialized hospitals, psychiatric chambers of general patients, outpatient clinics, and private hospitals. The number of state psychiatric hospitals is decreasing up to 2/3; the same process occurs to the psychiatric bunks in hospital of general treatment (not more than 3.5% of psychiatry fund); and private hospitals have 40% of psychiatric bunks.

Another system of psychiatry help has been forming: family doctor — psycho health protection service — psychiatric hospital.

The number of outpatients’ clinics was increased up to 50% from 1988 to 1993. The government funds almost all the rehabilitation services. Services for children and adolescents, “hot” phone lines ERAN for help in crisis situations, rehabilitation centres for drug-addicted people have been founded and are functioning now.

But the general crisis leads to the quality and quantity decrease of given services and makes the idea of valid medical care uncertain. There is gradual decrease of psychiatric service expenses. For the last 15 years only 5% of general health protection payments has been given to psychiatric services (and 15% in 1978). And the governmental participation in scientific researches is minimal; the specialty is becoming less prestigious. The hospital personnel ignore new philosophy of the social psychiatry because they don’t have any economic stimulus in their work. Besides the number of chronic patients with long hospitalisation makes 1.5% of the general population (approximately 1/3 of invalids are insane people).

The psycho health protection centres foundation is the single achievement of the reforming. In general the service hasn’t realized and hasn’t fulfilled the prevention function that is the priority to the social psychiatry.

Psychiatric reform arouses the problem of effective and adequate help supply to the population but in the modern society high settled aims should be paid for.

Today Israel is joining the World Health Organization and the course “Health for Everyone by 2000” that has speeded up the formation of long termed policy as for the psycho service planning. The report of Netanyahu Commission (the member of the Supreme Court of Israel) showed the urgency of fundamental reforms in psycho health protecting system and put the basis of a new insurance low in health protection. The new low about obligatory governmental medical insurance has changed the legal and financial context of psychiatric system. Public Health protection services stop being a straight supplier of medical service. The department of psychiatric service is being reorganized. Psycho health centres have become economically independent as it is in the British national Health protection system.

However, today the reforming fulfillment is being put aside from year to year according to the differences of participation level and financial principles between Public health protection services, hospital funds and financial Ministry.

On the sample of Russia we can judge the approaches of programs realization on the psychiatric help development. These approaches are depicted in the article of the chief psychiatrist of the Public Health protection service B. Kazakovtsev (1998), where he gives the list of measures that were taken in order to reform the psychiatric help system in Russia.

Taking into the consideration the increase of mental disorders and criminal increase among insane people the Security Council of Russia took a decision named “Psycho Health of Russian Population as a problem of national security” dated back to 23.07.1997.

In order to strengthen the governmental attention to the national psycho health as a factor of national security there is a need to do the following:

  1. To address the requirement of the fulfillment of all the stipulated constitutional guarantees for health protection, medical care and stipulated measures according to the Russian Low “About psychiatric help and guarantees of citizens’ rights” to the organs of Russian Federation.
  2. The Government of Russian Federation should considerate the urgent prevention measures as for the sick rate, invalidity and criminality among people with mental disorders and prolong the fulfillment of the federal psycho health enhancing program up to 2000, providing the necessary support.
  3. The Executive power of the Russian Federation should work out and affirm the regional programs on psychiatric help development, on the development of social psychological services, suicide clinics net, crisis hospitals and hot phone lines. The hostels for citizens with mental disorders should also be established.
  4. The Public Health protection organs should not permit psychiatry being used for non-medical aims.
  5. Federal and regional organs coordinating the activity of mass media should activate healthy life propagation, should forbid alcohol, smoking advertising on television and in the press.

This is not the full list of settled measures that influenced psycho health improvement in Russia. Organizational principles of net and modular projecting of psychiatric hospitals and psychiatric departments in the structure of multi-profile hospitals were worked out in Russia. Besides, a whole range of directive documents as for the cooperation of different level specialists was made up (psychiatrists, psychotherapists, medical psychologists, lowers and law-enforcement organs).

In many regions the building or reconstruction of psychiatric establishments has been initiated or planned. The Human rights Council made a decision to considerate the problem of organizing better protection of patients’ rights. It is well-known fact that the health protection of the population is considerate in 3 levels:

For example, the feature of the psycho health prophylactic conception and the cooperation of different professionals (doctors, psychologists, church representatives) in Poland are based upon the following principles:

As for the mentality and organizational principles of psychiatric help in the USA L. Dragunskaya said (1998) the following. The feature of the development of the American society, its culture and legal conscience is connected with people who rescued from Europe looking for liberty, liberty of their conscience first of all. Every state, every social group should have some value reference points in order to develop effectively. In American legislative culture society is considered as a combination of different groups, every of which has the right for own lifestyle.

The basic life values in Anglo-Saxon and American culture are personal responsibility and dignity of a financially independent citizen. They are reproduced to this culture as:

The American health protection system has been formed according to this background. So, mentality, legislative culture and financial specification make the basis for its organization.

The main thesis is considering the rights and interests of an insane person. Neither the government nor the state nor the city can make a citizen take a treatment or social readaptation against his will, “if only he’s got cholera or made an attempt to kill the President”. So, the medical side in the case of making a destiny of a sick person is not pressing. That’s why the obligatory and free of charge for a sick person psychiatric help can be given only according to the judge decision. The judge having no knowledge of clinical disease criteria is ruled by reasonable sense, taking into consideration the opinion of the police, neighbours, social workers. He is trying to decide whether the patient’s behaviour is dangerous for surrenders or for himself.

So, the personal apply for psychiatric help is a privacy of a citizen. There is a wide range of methods and forms of the psychiatric help; and the possibility to get the help is the free choice realization that is the background of the developed society.

For example, only in the system of suicidological help for youth people there are hundreds of centres, hot phone lines, educational, religious and scientific researching programs in the USA (1992). The national scientific researching suicidological centre, the Suicidologists Association, the National Institute of Psycho health are working on that topic nowadays.

Analysing the way psycho health reforms are being conducted in other countries we can see that the realization of importance of great changes in the sphere of human being has been formed only in XX century.

All the processes occurring in the world depict that there is a change not only in the individual consciousness but also in the social psycho health. And here, psychiatry as a system of human knowledge plays the role of a structure that has responsibility for health of the population in future, at the same time having the ruling function of the society.

Thus we can speak only about making a state system of managing the psycho health sphere that should have long-term reforming program.

  1. Speaking of our country it can be the foundation of the State Committee of psycho health protection of the whole nation that will have the Ministry rights and will be governed by State Secretary.
  2. The foundation of the National Human Institute that will be the most important scientific researching centre on coordinating such spheres of human knowledge as genetics, neurobiology, psycho-neurology, chronomedicine, philosophy, psychology, sociology and others.
  3. The development of long-termed financial program dealing with psycho health treatment of the nation.
  4. The reforming of the region psycho help systems.

In crisis condition there is a need for concentrating the efforts on the most important ways of psycho health protection. These directions are:

Possible reforming ways:

  1. To organize the psycho health departments in big cities.
  2. To develop long-termed regional programs on psycho health protection.
  3. To decentralize free choice of the reforming model of psycho help system that meets definite region requirements.
  4. To organize the help system according to the vector: family doctor — psycho health protecting service — psychiatric hospital.
  5. To organize and develop regional centres and specialized help systems; suicide prophylactics in narcogenic state for people with posttraumatic stressful disorders.
  6. To develop social organizations such as associations of patients and their relatives, professional associations.
  7. The psycho health protecting systems should be free from taxation.

If we want to organize an effective and long-term functioning system it should meet the following criteria:

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