Mental health policy and practice across Europe: an overview

414 Mental health policy and practice
far outweighs continuity. The management of change then becomes the problematic
issue. This invariably invokes the function of leadership with the
core elements being an adequate interpretation of reality (providing a vision
attuned to the zeitgeist) and containment (providing certainty amidst the lack of
evidence, since evidence to support visions is never adequate) (Alford 2001;
Barker 2001).
We know of one attempt in the former eastern bloc countries to formulate a
context-relevant vision for psychiatry in the region, the GIP-supported Association
of Reformers in Psychiatry. 3 In line with the human rights spirit of the
time and the quest for participatory involvement, this body developed a vision
of community psychiatry built on personalized, lifelong case coordination
with support from social care and rehabilitation programmes. It targeted individuals
with social impairments that were considered to be too disturbing for
local communities if such individuals were trusted to reside unassisted within
them. One contribution of this group was to express this vision in a long list of
statements about mental illness, psychiatry and psychiatric reforms and to test
if these were shared by local stakeholders. It appeared that they were not; at
least, not with any enthusiasm (Tomov and Butorin 1997; Geneva Initiative on
Psychiatry 2000).
In hindsight, it should have been possible to predict this. The rapid decline of
strong central authority since 1989 had frustrated the dependency needs of all
citizens. In the minds of many the issue of how to develop self-sufficiency and
interdependence, which was the order of the day, had been eclipsed by anxiety
at the loss of a dependable state and by anger directed at the authorities for
abdicating from their incontestable obligations to protect the weak. Under the
circumstances it was easy to read into the community psychiatry project the
further withdrawal of institutions from exercising control (in this case over
madness).
It is now clear that there are many preoccupations related to the social transition
of those who are ‘well’ in former eastern bloc countries and these push
mental disorders to the bottom of the social agenda. It appears that the community
mental health vision cannot call forth either champions or leadership.
This suggests that it would be unwise, under the circumstances, for mental
health policy reform to place too much emphasis on community care for the
severely mentally impaired. By the same token however, if the heavy toll of
transition on mental ‘wellness’ is recognized and if the priorities of reform policies
are construed in terms of attending to those affected by the process of
change, the chances of gaining public support may improve significantly.
Most analysts are beginning to recognize this, as the strain of transition on the
emotional and group life of people becomes more apparent (Dahrendorf 1990).
Previously, mental well-being, and its promotion, were non-issues in the region
because the notion of a mental disorder was confined to severe disabling illness.
Mental illnesses were seen as involving a dispensable minority, which should
be left entirely to the public sector to manage. These days, however, the salience
of mental health is invoked by growing awareness of the rates of violence,
homelessness, crime, prostitution and drug addiction. Communities have been
taken by surprise by this surge in irrationality, and the response, so far, has been
confusion, disbelief, frustration and the search for someone to blame.