Mental health policy and practice across Europe: an overview

Policy in former eastern bloc countries 405
rights and related ethics (Shorter 1997). With advances towards democracy and
civil society, concern grew over the apparent abuse of the human rights of
people in custody. The detrimental consequences of this practice on individual
development and quality of life triggered the process of deinstitutionalization.
After 1989, concern for human rights penetrated the new democracies and
entered public debate through the publications of human rights organizations
like the Helsinki Committee. According to one World Bank study, at least
1.3 million children, people with disabilities and the elderly in the eastern bloc
live in 7400 large, highly structured institutions. These institutions absorb
much of the limited financial resources that could be used to create alternative,
community-based support systems for people with mental health needs. In
Lithuania, for example, 1.75 per cent of the national budget is used for the
institutional care of vulnerable individuals (Tobis 2000).
Custodial care, which has remained in most former eastern bloc countries,
appears to be inherent to the notion of ‘governance’ espoused by totalitarianism.
Systems of institutional care had also been introduced in the social, health
and education sectors as separate legal entities. In most countries, infant homes
and psychiatric hospitals were governed under the auspices of ministries of
health, special boarding schools for disabled and socially deprived children were
the responsibility of ministries of education, while responsibility for special
psychoneurological facilities for both the mentally ill and children and adults
with intellectual difficulties rested with ministries of social welfare. The three
systems had little in common in terms of coordination. However, they were
identical in their mission to socially exclude ‘substandard’ individuals. Any
moral doubts related to this practice must have been abated by the boundless
trust in centrally-planned economies and the common belief that the evils of
human nature had forever been relegated to the other side of the Iron Curtain.
Looking back, it can be seen how the failure of the economy to bring prosperity
left totalitarian rule with no option but to eliminate the less fit. The ability to
adjust production technologies and work roles to better suit the limited competencies
of disabled people suggests prosperity rather than economies of survivalism.
It can also be argued, on the basis of research, that raising children in
institutions while both parents were alive and well has negatively affected the
social capital of countries like Bulgaria (Markova 2004). The difficult question
faced now is whether political change is enough to make a difference to this
institutional legacy – particularly when the prospects for economic growth in
the region are considered to be certain with the advent of democracy and free
markets.
In answering this question it is essential to take into account the serious social
defences that institutional systems develop. In practice this means that the process
of deinstitutionalization will be slow and the reallocation of staff will be as
difficult and time consuming (if not more so) as the reallocation of institutionalized
mental health patients to alternative systems of care. Retraining staff into
new professional roles and skills will be crucially important.
Another essential barrier that requires considerable attention is the peculiar
type of ‘patienthood’ that develops under systems of care provision that are
excessively paternalistic. Self-stigmatization, a most unfortunate product of
this kind of care, severely limits the impact that consumers can have through