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TOWARD THE LIBERATION OF MENTAL HEALTH: A REFORM OF BULGARIAN PSYCHIATRY

"Health in Bulgaria is a hostage of politics, the family, prejudice, business, health care... "

- Bulgarian Psychiatric Association, Sofia, 1994

This brochure is published by The Bulgarian Psychiatric Association (BPA). BPA was founded in 1992. It is an observer, critic and advocate in the field of mental health in the country. In accordance with the resolution passed by the BPA General Assembly in May 1994 the Association is attempting to carry out a psychiatric reform in Bulgaria.

The Bulgarian Psychiatric Association has a membership of over 300 psychiatrists and clinical psychologists. It has both individual and group members (e.g. local societies, and special interests groups). BPA is registered with the Court and is an ad hoc member of the World Psychiatric Association. The Main Office of the Association is in Sofia. Address:

Centre of Hygiene, fl.11, r.28
15 Dimitar Nestorov Street,
Sofia 1431, Bulgaria
Tel. +359 2 594 087; Fax
+359 2 591 119

Chairman: Todor Tolev M.D.

Secretary: Kimon Ganev M.D.

The General Assembly of the Association is held every year in May. An accompanying scientific meeting is organized.

The preparation of the brochure was assigned to Toma Tomov by the Executive Board of BPA in July 1994. He is responsible for all statements in this document.

A blueprint of the document had been sent out to the board members and approved. A committee that included T.Tolev, L.Sayan, E.Georgiev and G.Koichev was appointed by the Executive Board to contribute information and to endorse the interpretations and conclusions before the brochure was released. Assistance with the preparation of the brochure was received from

Kr.Denkova and M.Mladenova.

This brochure contains:

BPA'S POSITION ON PSYCHIATRY IN BULGARIA

BPA ON THE CRISIS IN BULGARIA

PSYCHIATRIC PRACTICE IN BULGARIA

TOWARD CHANGES IN THE PSYCHIATRIC PROFESSION

By distributing this brochure BPA believes that it will help in finding a solution to the crisis of the mental health system in Bulgaria. The purpose of the brochure is to provide information to those who can contribute ideas, participation, time or money, thus ensuring that crises in Bulgarian mental health care shall never happen again.

BPA'S POSITION ON PSYCHIATRY IN BULGARIA

BPA believes that Bulgarian psychiatry needs to do away with the image it has traditionally held among psychiatrists, the health system, and the society at large, of an agency for control over the mental life of the individuals.

Psychiatry is a highly professional activity, practised by free and responsible persons on the basis of agreement between them and with the help of procedures, stipulated by the rules of the profession and democratic laws.

The rules derive from experience accumulated over many years of practice;

Bulgarian psychiatry is part of world psychiatry and shares this experience. BPA believes that Bulgarian psychiatry abides by the moral code of the profession when attending to the mental health needs and psychological hardships which arise from the crisis in the society. BPA insists that the practice of psychiatric care and the changes over time of its clinical, administrative and legal procedures and rules be fully described and openly announced.

The members of BPA have first-hand knowledge of the mental health of the people in Bulgaria today. BPA aims at improvements in the institution of psychiatry, which will render it more responsive, more accessible and better able to address the change in the life style of the people in Bulgaria and the specific difficulties which they encounter at the present moment of transition.

Thirty years ago the reform in American psychiatry was taken up by the public which was stunned by facts made known about psychiatric practice in the USA. In a speech on psychiatric reform John Kennedy commented at the time that the psychiatric institutions were so despicable, that for the people held in them death was the only hope for redemption.

Bulgarian statesmen are preoccupied with the physical survival of the nation and show no concern for mental health. This reveals a deficiency in the view on human nature held by decision makers, which is typical of Balkan thinking and which destines good intentions to failure. The belief that the mental health sector is intended to cater only for individuals with psychiatric disorders is a manifestation of this deficiency. BPA wants to contribute to the overcoming of such attitudes.

BPA sees as its immediate task to help its own members expand the views they hold about the role, the subject matter and the methods of their profession. It believes that in this way Bulgarian psychiatry can break away from the traditionally held belief that it is an agency for control over the mental life of the public.

BPA ON THE CRISIS IN BULGARIA

Mental health is developed through the interactions of the individual with the other humans in the environment. The field of mental health abounds in theories and methods of assessment concerning the capacity of human groups and communities to bring about mental ill-health.

Seen from this perspective life in Bulgaria has acquired characteristics which provide evidence for the view that an existential crisis enveloping the Bulgarian community. Life in Bulgaria today is associated with a high risk of mental ill-health for the individual. More specifically BPA wants to call attention to the following negative trends:

(i) Self-destructive behaviour is on the increase and is met with less and less concern on the part of the community.

(ii) Learned helplessness (the belief acquired through experience, that you have no control over your life situation) has become the most frequent attitude of mind.

(iii) Violence has acquired the status of a conventional type of human interaction.

(iv) Human rights are not just violated or not recognized: they are altogether disavowed as a dimension of existence in Bulgaria.

(v) Dishonesty and greed, called forth by the lack of certainty of survival, are beginning to be regarded as within the order of things.

(vi) Partiality and mysticism are salient features of social interaction in all spheres - civic, professional, political.

*** On the following pages each of the above six assertions is illustrated, expanded and elaborated.

SOME DEMOGRAPHIC DATA ABOUT BULGARIA (1992)

The population of the country is almost 8.5 million and dropping at a rate of 2.2 per 1000 per year (the birth rate is only 10.5 per 1000; the death rate is rising, especially among mature adults; emigration is high) Children (0-14 years) constitute 18% (they used to be 23% in 1970) The elderly (65+ years) constitute 15% (they used to be 10% in 1970)

Unemployment (1991) - 12%

Inflation (Dec.1991-Oct.1992) - 60.8%

(Forecast for 1994 - over 100%)

(All statistical data in the Brochure are taken from official sources of The National Institute of Statistics if not stated otherwise.)

SELF-DESTRUCTIVE BEHAVIOUR

Number of Drug Addicts: 1304 (1991)

(Their number now (1994) is estimated at 5000) Suicides per 100 000: 14.6 (1991)

(The rate is on the increase since 1970; presently it is above the average for Europe.)

Alcohol Consumption per person (in litres): 9.0 (1991) (The average for Europe is around 7,0 litres) Deaths due to traffic accidents per 100 000: 10.2 (1991) (The average for Europe is about the same.)

Drug addiction is most common among the 20-25 year olds. Experimenting with narcotic drugs has been reported by approximately 20 000 subjects from schools, in some cases as early as the age of 14. In the first 6 months of 1994 eleven persons died of overdose. In the city of Sofia an average of 7000 doses of heroin are sold every day.

("Mrs. P.R.'s depression does not respond to medication. Her younger son (age 17) has dropped out of school, breaks into houses with friends and is registered with the police. His elder brother (age 28) has been recuperating since almost a year from a severe alcohol problem that damaged his peripheral nerves. The husband of Mrs. P.R. has been drinking since he was young. Every day of their lives they await his return home with worry.

Both spouses are medical doctors." From a case presentation session.) Self-destructive behaviour is most common among the young. They do not regard themselves as being of value or worthy of being taken care of:

Because patriarchal mores do not respect individuality (in the hierarchy of values of the Bulgarians "family" comes before "individual"); Because Bulgaria cannot provide for a secure life for its youth: the adult generation of today lives "on loan" from its children (it survives on money borrowed at interest from the West and the next generation will have to pay it back); Because following the sudden abolishment of the totalitarian system of external control over the life of the individual, it was revealed that many people lacked internalized agencies of control. Many individuals are now given to overindulgence to the point of self-harm.

Clinical psychiatry has rich experience with human behaviours like loss of control and self-destruction. Clinical psychiatry restores self-control by resorting to the use of hospitalization and medication. It employs these methods temporarily until the therapist helps him and his primary group to regain control by relating therapeutically to the patient. Present-day standards demand that human dignity in the course of these procedures be fully respected.

LEARNED HELPLESSNESS

In 1994 patriarchal virtues do not secure survival in Bulgaria. ("You cannot live on a government salary; good education does not get you a job; compliance does not bring promotion; parsimony does not make you well-off; prudence does not give you solace ..." From an interview with a Bulgarian social worker, 1994).

However, the world view contingent on the ethics of paternalism is unchallenged: ("Firstly, we ask them to register as unemployed ...They ask whether they are obliged to do it and whether they can search for a job ontheir own once they register ..."

"What do you answer to this?"

"That we keep them under surveillance and that we must be convinced that they do not have paid work ... We must be certain of it before they get social assistance ..."

"How do you do the surveillance?"

"We question the neighbours ... We make unannounced visits: they must be at home. If we do not find them, it is almost certain that they work somewhere. Such people never get assistance..."

"I think that the job of the unemployed is to find a job. I think that your job is to encourage him by giving him more financial help the more successful he is in getting a job: in principle you should give most to the one who is about to start a job ..."

"(With a hurt look) You understand nothing about social assistance!"

From an interview at a Labour Office.)

In Bulgaria the ethics of paternalism (typical of the social arrangements of slavery, patriarchy, totalitarianism, etc.) has a history of many centuries and is rooted deeply in its traditions. In this culture democratic values penetrate slowly. The ethics of paternalism are passed down through the upbringing and education of children. Its carriers are not aware of the fact that they profess it or that they could resist it. They regard themselves as destined to have a paternalistic attitude of mind and be unable to do anything about it even when it makes them suffer.

The matters of the unconscious were declared out of bounds until recently in Bulgarian mental health. Admitting to the existence of unconscious mental processes could invite doubts as to the true motives of people, including those who were in the positions of control. The benevolence of the mother, the doctor or the leader could be questioned. Selflessness could turn out to be a cover for love of power. The ethics of paternalism declared questions of such kind to be a breach of propriety; thus it outlawed the unconscious and bred helplessness.

The mental health professions train their members to cope with the problem of unconscious motives. This begins while at university and lasts through out the working life of the person. One's own motivation and that of the colleagues and patients one works with are studied in various ways. This professional approach builds on the agreement that in one's acts unconscious motives could be present, that other people could discern them and could discuss them if the group norms permit this. In Bulgaria some of the mental health professions are beginning to adopt this style of work and manage to cope with helplessness. Psychiatry is not among them.

VIOLENCE

1980 1990

Investigated criminal acts 34 204 64 084

Sentences issued by court 30 012 12 403

Crime rates rise fast, while the number of criminals sentenced falls fast. An impression is formed that violence gains the upper hand over civil order, laws and institutions and becomes the norm that regulates relations as it was before the time of civilization.

The rate of this regress is astonishing. The crimes reported to the police in 1992 outnumber by 46 098 those reported in the course of 1991: an annual increase of 27%. Good mores certainly have more resilience than these figures suggest as they tend to become "second nature" in the course of civilization.

Civic societies respond to violence with reservedness, particularly from those in power; paternalistic communities regard a violent act as evidence legitimizing the exercising of organized violence. The peace and propriety that these societies secure are actually based on violence, which, however, is disguised beyond recognition with the help of the ethics of paternalism. The family and the school are two of the institutions through which this is achieved. The dividing line between training and the violation of the human rights of the child is easily crossed over. Total regimes thrive on such soil too; only, they utilize violence professionally, not haphazardly.

"At home they beat me and lock me out. I must bring in 20 leva every day. We roam the streets for hours on end, get into bars and shops asking for food and coins..."(A schoolboy of 14)

"In our school there are 5 or 6 groups of boys who harass everybody: they take your clothes and money and hit you ... I am afraid to go out after dark." (A girl of 17) D. Kiulanov et al., 1991

As the power of the state dwindled violence spilled into the streets of Bulgaria. The paternalistic nature of the institutions became obvious. However, their incapacity to equip individuals to live with democracy has not been exposed; their double standards have not been challenged. Romantic visions of the patriarch and family life under him are called to memory whereas family violence is disavowed. Victims comply in a conspiracy of silence because they experience guilt and shame for being victims. Victimization (instilling guilt in the victim for being abused) is widely practiced by parents, teachers, doctors, policemen. Many of these people and dangerously ignorant of the consequences of the "ordinary" violence which they practice without being evil.

The mental health professions neither shy away from nor become rightfully indignant with violence. They create settings which enable people to put in words the pleasure, the thrill, the satisfaction associated with inflicting pain and the suffering, the debasement, the shame from being subjected to violence. By naming the experience it becomes possible to put one's acts associated with it under one's control. Victims of family violence are offered help through a programme of psychotherapy in Sofia.

DISAVOWAL OF HUMAN RIGHTS

("A: This text reveals that millions of Gypsies were destroyed by the Nazis. But the Jews that were murdered, were many more. B: This text has been written as part of a book about the Gypsies with facts from their history that have not been widely known until now. A: They are not familiar with many other facts of their history and culture. They learn their history from us. And tend to get proud of it immediately. You must think twice before deciding what information you want to release to them." From a dialogue between Bulgarian human rights activists, 1994)

The mentally sick are yet another minority whose rights are denied without their having a say in it. Bulgarians, including psychiatrists, loose their civic humility in situations with the sick. In situations involving sickness the patriarchal culture prescribes to the healthy the right to take charge fully, and to the sick the need to regress to dependence.

This is a paternalistic pattern. It reduces the potential richness of human relationships to a power hierarchy: the child obeys the mother, the wife obeys the husband, the young obey the old, the patient obeys the doctor. As a result of this pattern Bulgarian culture gives precedence to the conservative stand, resists change, re-enforces that which is already established.

The paternalistic pattern removes early and easily any uncertainty from the situation, the tension of the participants drops. This is what makes this pattern so attractive. However, by sticking to it one deprives oneself of the possibility of gaining insights on matters of mental ill-health and human rights.

Psychiatry adopts features from the culture in which it is practiced. The paternalistic pattern of Bulgarian psychiatry is encouraged by a legislature which is insensitive to the human rights of the mentally sick and by a lack of public interest in the psychiatric institutions and their in-mates. In such settings the psychiatric institution evolves a tendency to monopolize the field, especially when the other helping professions (social work, nursing, clinical psychology, psychotherapy) are underdeveloped.

In the beginning of 1994 a book was published which presented in Bulgarian the internationally recognized principles of therapist behaviour and the norms of professional ethics as stipulated in documents of professional bodies, the Council of Europe and UN. Only 200 copies were sold six months later.

The popular movements in support of the rights of the mentally sick have a long history in the democratic world. They enable the care consumers to state their point of view. Progress in psychiatry owes much to their contributions. In 1993 Bulgarian psychiatrists initiated together with psychologists, patients, nurses, volunteers and relatives of patients a mental health association. For two years now Bulgarian media has been responding to the World Mental Health Day.

DISHONESTY AND GREED

The Mafia-type organizations become possible because of the peculiar propensity of humans to operate with double moral standards: one set of rules, which one observes in dealings with one's own kin, and another set, which applies to relations with individuals outside one's immediate circle. Human minds evolve double standards at all times under all regimes. The psychic apparatus of the individual has always used splitting and projection when construing the world of one's relationships. These unconscious defense mechanisms operate without regard to the person's profession, level of education or social status. In totalitarian settings there is no one to counterbalance the paranoid black-and-white world view which results from such primitive processes in the mind. In democratic societies however, there are academic and other spaces where schools of thought evolve which regard knowledge as a social construct and consider scientific facts as "made" rather than "found". The mission of such thinkers is to prevent minds from getting caught in the trap of certainty, which is so typical of black-and-white thinking. Lack of certainty keeps the mind alert, and living like this may give problems to individuals with a small capacity to contain anxiety. These are usually people with a history of unhappy childhoods and traumatic experiences. Choosing to be certain in your version of the world provides inner peace. Such a choice predetermines one's life course: one begins to avoid encounters which might throw doubt on one's choice. Life under guardianship is tolerable to minds that have chosen to be certain. The democratic changes through which Bulgaria is going put these minds to the test: the encounters that cast doubt on their choice become too many to be avoided.

("It will be a big error if we give in to the West...We should not commit hara-kiri... We must present an unbiased picture of our psychiatry; we also have big achievements... We have seen how they do it: we are no worse!"

Statements made at meetings of the Board of the BPA)

Minds that are plagued by certainty operate with an image of the world as a place of only limited wealth: if you allow for the other to have much this automatically indicates that you have little. One comes to identify one's own needs not through a dialogue with oneself, but by looking into the yard of the other.

* - Splitting: A way of maintaining a positive Self not by cultivating positive features but by drawing one's boundaries in such a way as to leave out of the territory of one's Self all undesirable (negative) components.

Projection is a mechanism whereby negative components of the Self are attributed to others. Therapy in groups is the most rapidly growing approach in mental health work during the last years. The feeling of belonging and mutuality, the experience of support, understanding and trust and the courage that one encounters in such a setting, are part of the mechanisms of the group process, which enhance the capacity of the individual to live through crises. The group format is unsurpassed in developing mental health skills.

PARTIALITY AND MYSTICISM

("By creating bureaucracies people force themselves to relate to each other as parts of a fine machine: in good synchronization, predictably, similarly... In this way they try to gain the upper hand over nature with its inherent wastefulness, precariousness and transience... Bureaucracies impose rank on interactions by eliminating horizontal relationships.."

Excerpt from a conference brochure "From bureaucracies to networks and back.")

All bureaucratic hierarchies utilize individuals to their ends, but the paternalistic regimes have the capacity to abuse them. This follows upon the fact that guardians under such regimes may misappropriate the right to decree reality. ("This is not abuse: this is training, treatment, care..", the guardian says.)

When the guardian steps out of the role of protector and takes the role of perpetrator, he does nor announce this transition. On the contrary, he blurs and mystifies it, thus creating deliberate obstacles for the victimto make sense of the new nature of their relationship, to accept or reject it: ("It does not hurt you as much as you say!" "I do it for your good." "I do it because you deserve it.", the guardian\perpetrator says.) The feeling of helplessness and hopelessness comes naturally to the victims of paternalistic regimes.

The general practitioners in Bulgaria tend not to diagnose these feelings.The care of people who develop them implies case formulations demanding a stable personal relationship which gets the doctors in conflict with the bureaucracy.

Bulgaria has the highest mortality rate of brain haemorrhage in Europe. Health education involves everybody and the style of living that guarantees survival is widely known. Nobody adopts it. Mystical explanations and rituals for health are practiced instead.

Licensed physicians put themselves at the service of self-styled healers to practice rituals for health. Scientific terms and constructs are incorporated in explanations about illness which derive from mystic beliefs about non- physical interactions between objects. It is gradually becoming apparent that the educational institution has failed its mission at all levels.

Empowering the patient is a key component of the therapeutic task in cases with helplessness and hopelessness. The therapist's behaviour plays a crucial role in this. He avoids taking the paternalistic stand in particular. The biggest difficulty in conducting such therapy is in avoiding the temptation to act omnipotent. The health institution should be sensitive to this aspect of the work of its therapists. The bureaucracies should give way to team work. Many institutions disavow this problem, they avoid facing the anxiety and panic arising from the awareness of their own transience. One such institution is the Bulgarian psychiatric system.

Common signs of disavowal are moves to consolidate bureaucracies.


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