Mental health policy and practice across Europe: an overview

Policy in former eastern bloc countries 415
Framing the problem: the psychosocial dynamics of change
In established democracies the wider acceptance of civil society values has made
it possible to put mental health reform onto the public policy agenda. The
former eastern bloc countries, however, are still struggling to contextualize
these values within the economic, political and social domains. Their leaders
and the demands of globalization are pushing for reform, including reforms in
mental health care. But for many, what is happening is experienced as a hostile
intrusion into their environment. They cannot see opportunities for themselves
in these developments, or they may view these changes as involving them in
activities that are counterproductive to social progress. Basically, they respond
as their ancestors did to crisis, by revitalizing kinship networks. As a result,
clans re-emerge, familism (division into kin and alien) becomes a fundamental
line of distinction, and meritocracy is hampered in finding its way into community
affairs (Stability Pact for South Eastern Europe 2004). Paradoxically, the
values that emerge and are reinforced in this process are exactly those that the
architects of transition were intent on replacing with the values of democracy.
In order to comprehend this, it is important to acknowledge the role of psychological
and social defences in resistance to change (Jaques 1955). The defensive
mode of functioning in individuals and organizations is triggered by the
anxiety stemming from the preoccupation with differences brought about by
change. This manifests itself in many ways: refusing to accept difference at face
value, attributing negative meaning to it, a selective perception of only its negative
consequences, jumping to pessimistic conclusions, and so on. Caught in
this mode of functioning, individuals may more readily experience emotional
distress and social impairment, develop disorders of sub-threshold or clinical
severity, or have their pre-existing conditions aggravated. Those who have been
well are prone to such problems as well as those who have had a history of
psychiatric illness.
At the level of service provision the massive effects of the stress of transition
may call into question the established boundaries between primary health and
specialist services (Thornicroft and Tansella 1999). This may raise the need to
reconsider the very principles of service provision in a country in terms of
assigning priority status not only to severe disorders but also to those mental
health problems triggered by transition. Governance structures should respond
by shifting policy and directives respectively. They may conduct surveys to
assess the scope of the problem or engage in public and professional debates to
elicit attitudes. Straightforward as this may seem, it misses the fact that when
minds are in defensive mode people find it difficult to be constructive and
may employ their organizations as a shield against change. The mental health
system is certainly not immune to being used as a social defence against the
anxiety of change by its employees. In this context, an additional task for management
is to turn the minds of those in the system of care away from this
defensive mode so that they can start responding rationally to new policies,
directives and work tasks.