03 January 2009

"The Greek miracle" The beginning of the end of the Psychiatric Reform in Greece

More than twenty years have passed since the unacceptable situation of the Leros’ asylum, and by extension, of the horrific living conditions of people with mental health problems, who remained confined in the psychiatric institutions in our country for decades, raising the international outcry and the intense reactions of European Union.

At that time, the pictures from the Leros’ asylum were brought out from the native Mass Media. The item “made figures”. The Greek citizens, for the first time, looked at the tragic images of the forgotten from the state – and not only – inpatients of the psychiatric institutions. People tied in chains, piled in chambers of half-ruined army buildings, naked or covered with rags, lying on the floors of the asylum, full of excrements. The eyes of the Greek citizen were full of these “pictures of shame”.

Then our country was forced – because this country remembers its obligation when it is forced only – to abandon the “medieval” methods of dealing with the mentally ill patients and to reform the mental health services. The psychiatric reform and the de-institutionalization started on record with a regulation of the European Union in the mid 80’s. Then the Greek citizen found out, even with delay, that the human rights include the rights of people with mental health problems.

But, five years later, the “pictures of shame” appeared on the international press once more. In 1989 the London’s “Observer” compared the Leros asylum to a concentration camp and a year later the BBC’s (Channel 4) documentary "Island of Outcasts” recorded shocking scenes from the inpatients’ routine. The new images, which were the same with the old ones, reminded to the state that it had forgotten the psychiatric reform –the “threat” that the European funds would be lost must have helped their memory – and that nothing had changed in Greek psychiatric institutions, except for few solitary efforts.

Under new pressure, the Ministry of Health and Welfare, as it was called then, for now it is also “of Social Solidarity”, approved of programs of psychiatric rehabilitation and de-institutionalization, co-funded from the European Union, especially for the Leros’ asylum which was the “shame” of the country. The Ministry assigned the materializing of these programs to the management of the asylums and to scientific Associations – nongovernmental organizations, with psychiatrists on the lead, with appreciated scientific work. By all means, there were other psychiatric institutions as well in the same unacceptable condition, but neither the European journalists had found out them and consequently nor the state. By the way, even nowadays such psychiatric institutions are in operation, which “are discovered” at times and “are forgotten” later.

It is known that every reform attempt is difficult. The reform of the psychiatric program presupposed changes in legislation, administration of all levels, the relations of the employees with the patients, the attitude and the approach to the mentally

ill patients and, of course, actions for the informing and sensitization of the social mass, aiming at the ensuring of social participation… In our country the psychiatric reform has started, with a delay of twenty years, compared to other European countries, without the necessary legislative and administrative changes, without the social participation and even without the political will, since all efforts started under the pressures mentioned above.

So, the venture of the psychiatric reform was adapted to Greek reality and, of course, to Greek improvisation. In the end, instead of the creation of a services net, as it was initially scheduled, that would help the population of the country with Mental Health Centers, Psychiatric Sections in General Hospitals, Day Centers, Accommodation Community-based structures (Hostels, Sheltered Apartments), Education and Tutoring Centers and many others, the efforts, of the first years at any rate, focused on the creation of Hostels and Sheltered Apartments for the accommodation and support of a number of former inpatients of the psychiatric institutions. In this way, the disrepute for our country would come to an end and the communal funds would be absorbed for the mental health. As for the rest population, they could wait. Besides, they couldn’t lose what they had not.

In spite of all these, at least, the part of the reform that had to do with the improvement of the living conditions of people with mental health problems, and particularly their removal in Hostels and Sheltered Apartments, proceeded. The task proved to be especially difficult. Specialists on mental health, mentally ill patients, volunteers, students, professionals from different sections (lawyers, educators, sociologists, etc) worked together on the materialization of de-institutionalization programs. These programs might not have achieved to make the people with mental health problems “equivalent citizens”, for this doesn’t depend on the programs only but on further social changes, as well, but they have brought spectacular results in some cases. The European Union admitted the efforts of our country, which were also rewarded by the scientific community.

The Mass Media got round to the people with mental health problems again. The item “made figures” once more. This time the titles were different: “From Hell to Heaven”, “Night turned into Day”, “They came back to life”. The images were different, too. Houses in neighborhoods in Greece were the new places for living of the former inpatients of the psychiatric institutions. The mentally ill patients were dressed in clothes, had their personal objects, were eating in plates, were walking to a cafe, some of them started working and earn their “pocket money”, some of them found their relatives again and some others managed to narrate the splintered parts of their lives. Moving stories that “rinsed the shame” of our country.

However, all these years, there were difficulties and disappointments, in many cases not for the illness itself, but because of passive living of decades, the thoughtless doses of medicine, the riveting, the punishments, the maltreatment, the former inpatients had suffered in the psychiatric institutions. Other difficulties had to do with the prejudice and the ignorance of Greek citizens, who admitted, as has been mentioned above, the rights of people with mental health problems but they did not want them in “their own” neighborhood. “Take them somewhere else”, they suggested. They often invoked the risk, because “the neighborhoods were full of harmless residents” until de-institutionalization. But, as we have said before, every attempt of change is difficult, and in this particular case, as it was something totally new in our country, the difficulties were expected, wherever they came from.

So, several years have passed and, trying to make an account, we can say that something did change in the psychiatric area. Everything we wanted may not have been done, it may not have been done with the way we had dreamt of, small oases may have been created in a desert landscape. Let’s see, however, what it finally changed: Legislative arrangements were made for the mental health services. Mental Health Centers, Psychiatric sections in General Hospitals, Day Centers and other services supporting people with psychosocial problems have been already in function. The efforts for the de-institutionalization were spread to all important psychiatric institutions. The beginning of the end of the institutional care was signaled with the closing of the first asylums. Almost four thousand people, former inpatients of psychiatric institutions, live in houses (Hostels, Sheltered Apartments) throughout Greece. The number of those who are supported in their surroundings, without the need to be moved in psychiatric institutions is even larger. There are specialists on mental health, who have worked with different orientation from that of traditional psychiatry. There are volunteers, citizens of all ages, who have known these efforts closely and they help towards the sensitization of further community. There are students who have been trained in this different way of work and we can hope that they will go on it. There is everything we have learnt throughout this attempt. Of course, there are psychiatric institutions and people who live in them even today. There is still a huge deficiency of mental health services in the community. Much more are necessary to be done.

But unfortunately, in 2005, that is twenty years after the regulation of European Union for the psychiatric reform and fifteen years after the overall start of the de-institutionalization programs, we discovered that the Ministry of Health had “forgotten” to record all the necessary funds for the mental health in the budget! The fact took by surprise everyone involved in the psychiatric reform. Many of them considered it as an “unfortunate coincidence” and others rendered the fact to lack of experience and documentation from the new leadership of Ministry of Health, now also of Social Solidarity. Nobody, I dare say, had realized that, at that time, they started to “forget” the de-institutionalization, the psychiatric reform and the obligations of our country towards the European Union.

Over the last three years, the Ministry of Health has actually proved that was not only an “unfortunate coincidence” but the systematic downgrade of the provided mental health services, through their sub funding, which gradually reached the 50%. This “new aspect” led the efforts for the psychiatric reform to a dead end. There is the danger not only the progress for the reform of the mental health services to stop but everything made till now to be collapsed as well. The Psychosocial Rehabilitation Units, whose the responsibility of operation was assigned to scientific, non-profit making organizations by the state and to whom the accommodation and support of more than two thousand former inpatients of psychiatric institutions, besides the diagnosis – cure - support has been assigned, risk terminating their operation in near future! The money they have taken from the Ministry of Health is not enough, not even for covering their operation expenses (rent for buildings, electricity bills, water bills, food etc). The mental health professionals, who were trained and worked with particularly low salaries and under hard conditions in order to offer a quality of life to people with mental health problems, are rewarded with dismissals, with forced resignations or choose to work without being paid for even eight months! The mental health professionals, an important asset for the state, is being lost.

It is easy for everyone to understand that, under these conditions, the future of those helped by the Psychosocial Rehabilitation Units is doubtful. Are they going to be abandoned? Are they going to be packed in some buildings? Are they going to go back in the existing psychiatric institutions? Are the already closed psychiatric institutions going to open again to “welcome” them? “No”, the Ministry of Health answers the last years, and claims that it supports the psychiatric reform, while, at the same time, the Units are led to closing and the provided services are inevitably downgraded.

The reactions of scientific parts and the voluntary organizations, the families of people with mental health problems, the Greek and international scientific community and the Organizations for mental health, did not manage to “remind” the Ministry of Health of its responsibilities. Not even the new publications on the press, which have brought us many years back, with headlines as: “Mental health is dying”, “Tombstone on the psychiatric reform”, “Back in the psychiatric institutions” managed to aware the “socially liable” Ministry. Even the statements – warnings of the counselor for mental health of the World Health Organization, who mentioned the problem reminding the unfavorable situation of our country when basic human rights were violated in the Greek Psychiatric Institutions and the publicity on the Leros’ case, seemed to have been ignored by the state.

All this period, those in charge from the Ministry of Health, instead of focusing on the efforts for the solution of the problem, they were devoted to a public relations policy with only aim to justify the sub funding of Psychosocial Rehabilitation Units, “proving” that these Units do not operate properly and cost a lot of money. That is, after many years of operation of the Units – and after the continuous requests of the scientific Associations for valuation of the quality of their services – the Ministry of Health decided that they do not operate properly, without carrying out any valuation! We heard the other “argument” even from the Minister of Health: “The cost of the Psychosocial Rehabilitation Units is too high”, “Every mentally ill patient costs a lot to the state”. We have never learnt the cost of the Units with the cost of which analogous service was compared and estimated as expensive or we have never learnt in what way every mentally ill patient could cost less. Is the solution of Leros “cheaper”? We are not sure even for this. Figures from other European countries show that the cost for every mentally ill patient is all the same between the Psychosocial Rehabilitation Units and the psychiatric institutions. The Ministry of Health decided that the cost is too high, without any relevant study. Unfortunately, the dialogue with the ones in charge is being conducted with figures and arbitrary conclusions. Everything is valuated with a cold and ruthless sense. We haven’t learnt, yet, how much the state “valuates” the mental pain, the physical and emotional abuse, the social exclusion. We haven’t even been informed how much money the state can afford so as the people with mental health problems not to remain confined in psychiatric institutions, not to be abused, not to be riveted, not us to see “images of shame” again. We haven’t heard a word from anyone in charge about the difference between the quality of a person who lives in a psychiatric institution and a person who lives in a hostel in the community. But it seems that the quality of life, the dignity, and the human rights have nothing to do with the Ministry of Health and Social Solidarity! And this “Social Solidarity” that has been added lately and it concurs temporally – by accident? – with the beginning of the end of the psychiatric reform, isn’t it a tragic irony? I wonder if the end of the psychiatric reform signals the end of social state, as well.

But this is not the only paradox. More are happening, too. For instance, the non-governmental organizations, which run Psychosocial Rehabilitation Units, which actually the Ministry of Health criticizes, have been multiplied recently! That is to say, at the same time, the Ministry sub finances the existing Units while it assents to the operation of more! Fortunately, an explanation for this has been given by the Ministry: “You know how it is done, when there is money everyone comes to take some”. What an unanswerable argument!

The official position of the Ministry towards the problem of the difficult financial situation of the Units is that there is no sub funding from its side but that the Administrations of scientific Associations embezzle the funds for the mental health, although at the same time it accepts that not all Associations are embezzlers. So, the Ministry of Health “discovered that somebody robs it” – to be precise, the organizations, whose the Ministry itself has undertaken the supervision and their funding – and instead of handing the “thieves” over the law, it chooses to lead all these Units to an end of their operation. If this is not a state of justice, then what is it? What’s the cause of this position of the Ministry? The inefficiency of the state to handle the “thieves”, as it calls them? Is the servicing of some interests? Is the attempt of the state to throw the poorer in the institutional “gorge of Kaiadas” and drive the financially powerful to private clinics? Is the lack of programming and planning for mental health? Or is the lack of political will and complete insensibility for the mental health from Greek citizens?

The psychiatric reform made a start with twenty years’ delay in our country compared with other European countries. It took twenty years to the results of these efforts to come into view and to be spread throughout the country. The state itself has managed to wipe out the vision of those who have been working for the psychiatric reform, the hope of thousands of our fellow-beings who suffer from mental illness or other disabilities and to lead the program of mental health in collapse, in only three years.

From the efforts we have made to protect or preserve anything left from these we have created, we have come out beaten, disappointed and exhausted. It seems that we are powerless against the omnipotence of the socially liable state and the “modest and humble” politicians who govern this country. Nothing else left but to inform all our citizens, who are still interested in the human values, for this situation.


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