Advocacy and social exclusion in mental health: A global challenge *

 

Recently,  another  “scandal”  emerged  from  the asylum’s  labyrinth  of  Mental  Hospital  of Dromocaiteion  in  Athens:  Violation  of  human rights  of  mentally  ill  persons,  limitation  of  their contractual  power  as  workers  in  a  small  social firm, decrease of the quality of care and treatment for socially excluded people suffering from mental disorders. We  are witnessing  an  “as  if”  situation where  the  gap  between  the  declarations  and practices of human  rights  is once again widening. Yet,  it  is not  just another  local “as  if” situation.  It is  remarkably notable  that 53% of  the psychiatric admissions  in  Greek  mental  health  hospitals  are involuntary  and  therefore  this  leads  one  to  admit the  existence  of  a permanent  national  scandal  for our country.

During  the actual economic crisis  in Greece, new phenomena  appear  challenging  the  limits  of  the public and psychiatric system of care: a constantly growing population,  a  “no man’s  land” people  in the  centre  of  the  metropolitan  area  of  Athens living  in  extremely precarious  conditions  as well as a dramatic increase in psychiatric admissions in mental  health  hospitals  for  homeless people with no present mental disorder.

In  the  early  70s,  under  the  influence  of  radical ideologies,  psychiatry  was  defined  through  its scientific  object  as  “the  knowledge  and  practice dealing with  the singularity of  the others, without violating the recognition and respect of the dignity of  the  suffering  person”  (B.  Doray,  Ethique  et Psychiatrie, MIRE Paris, 1985).

The  key  strategy  of  a  progressive  mental  health movement  of  this  period was  the suppression  of the  old  asylums  and  their  transformation  in  a comprehensive,  accessible  and  effective community  –  based  mental  health  system, covering the needs of the population.

The  questions  actually  raised,  in  the  era  of globalization  and  domination  of  neo  –  liberal market – oriented culture, are the following:

•  How  should  the  wider  field  of  mental health  including  psychiatric  practice  and PSR services  change,  in  order  to  respond better  and  more  accurately  to  the  mental health needs and new complexity of urban suffering,  social  exclusion, poverty,  social discrimination, lack of dignity and hope?

•  Why  do  we  raise  the  matter  of  ethical principles of psychiatric practice when the basic civil and political  rights are violated and denounced? Why is there no integrated   part  of  today’s  struggle  and  process  to improve  mental  health  care,  combining advocacy  issues  with  good  practices  and evidence  promoting  recovery  and  full citizenship? It seems that the answer of both questions ought to be the same: The core of the psychiatric scientific community  denies  these  new  realities  or underestimates  the  huge  impact  of  social determinants  on  mental  health  (Patel,  Saraceno, Kleinman 2006).

Despite  the  general  statements  of  most psychiatrists  in  favor  of  a  “bio-psycho-social model”  of  understanding  and  treating  mental illness,  there  is a huge mental health gap between official statements and strategies to promote social inclusion and defend human  rights of people with mental  health  problems  and  the  real  today’s practice.

According to the World Health Organisation (2005) “Advocacy  is  an  important  means  of  raising
awareness  on  mental  health  issues  and  ensuring that  mental  health  is  on  the  national  agenda  of governments. Advocacy can lead to improvements in  policy,  legislation  and  service  development.” Promoting  advocacy,  empowerment  and  social inclusion  requires a  radical change of  the existing psychiatric  culture  of  bio-medical  model  and  a shift  to  a  new  paradigm  of  understanding  and promoting  mental  health  under  a  global perspective.

This  change  should  include,  among  other  issues, an  in-depth  transformation  of  medical  and
psychiatric  curricula,  an  active  participation  of mental  health  professionals,  users,  families  and other  stakeholders  to  a  process  of  an  inclusive, involving  and  accountable  governance,  new political  and  social  alliances  in  order  to  promote communication  and  active  interaction  of  health, mental health and social services  in education and training,  in employment opportunities,  in housing rights,  in  transport,  in  leisure  and  cultural activities  and  the  active  protection  of  civil  and human  rights.  Involuntary admissions are a major and  thorny  issue  in  the  protection  of  human  and civil  rights.  The  way  the  psychiatric  services operate,  results  in  the  reproduction of stigma and social  discrimination  for  people  who  constantly reside in the chambers of a mental health hospitals through  a  “revolving  door”  phenomenon.  The legal  mechanisms  of  defense  of  the  human  and civil  rights  should  also  be  empowered  through good practices such as the Observatory for Human Rights or the Ombudsman.

Consequently,  if we  are  set  to  implement  its  full meaning  it  has  to  be  integrated  as  an  attitude  in today’s  practice  with  person-centred  services, recovery  oriented  services,  with  active involvement  of  users  and  families.  As professionals, we  should  invent  feasible ways  to
increase  government  budget  for  mental  health which  is  significantly  low  to non-existent  in most of  the  countries worldwide  (Mental Health Atlas, 2005). Additionally,  the  poor  existing  budget  for mental  health  should  be  wisely  spent  in  the direction  of  Psychiatric  Reform.  We  should promote deinstitutionalization and enhance the use of  local  resources  to  serve  the  needs  of  the  local population with  the existing means  for  this. Mass media  should  be  on  our  side.  The  matter  of publicity  is  an  important  one  and  our  advocation  towards  it,  should  be  aware  of  the  local  and national trends.  

Last but not  least, nothing  is ever good  if  there  is no  monitoring  and  evaluation.  WHO  refers  to evidence and ethical based practices which are not partial  but  part  of  a  whole  life-whole  system approach.  Thus,  monitoring  and  evaluating  the process of change  is absolutely vital  to ensure the success  of  our  work.  WAPR’s  challenge  is  to advocate towards a change of the political agenda of  International  Organisations  emphasizing  on  a better  mental  health  care  and  respect  of  human dignity.  

S. Stylianidis
VP of WAPR, Greek Counterpart for mental health in WHO,
Ass. Prof. of Soc. Psychiatry, Panteion University

*Editorial, WAPR (World Association for Psychosocial Rehabilitation) Bulletin, December 2010

Island of Outcasts

                       

Island of Outcasts (1990) Director: Jane Gabriel

"The Greek mental institution of Leros, housed on the island of the same name, has received significant journalistic attention. In September of 1989, the London Observer printed a front page account of the hospital, describing it as a "concentration camp." Following the British report, a barrage of Greek press about the island and institution was ignited. All accounts have discussed aspects of the hospital and its horrific patient conditions: patient neglect, absence of medical personnel (for some 1150 adults there are only two psychiatrists), patients who are kept naked throughout the year, inadequate diet, etc. The film "Island of Outcasts" represents another British endeavor detailing the hospital's conditions. It shatters common images of Greek islands as romantic tourist hideaways with tranquil beaches, crystalline blue waters and convivial natives. Rather, a grim and haunting portrait of the island and its mental institution is conveyed..."

Anthropology of East Europe Review (Vol 11, Nos. 1-2, 1993): Island of Outcasts (film review), Amy V. Blue, University of Kentucky 

Up In the Air - Psychiatric Health Services

The structures most strongly affected by the economic crisis since 2008 are those of mental health care, created under the psychiatric reform program and passed under the authority of the State over the last five years.

The policies of deinstitutionalisation are in danger of being shipwrecked

The future of hundreds of patients who are accommodated in hostels or sheltered apartments, and thousands of other people, who are supported by other mental health programs, seems uncertain. Most services are functioning at below capacity due to insufficient funding. The payment of wages to employees only recently reverted to normality. The EU is threatening to cut its subsidy to Greece if the pact signed last year with the Ministry of Health to address the problems within the mental health services, is not fulfilled. The ministry has not even proceeded to the consultation with the involved parties (service providers, service users and their families etc) that had been announced.

Recently closed were two homes for adolescents, one belonging to SOS Villages and the other belonging to the association APHCA. In March APHCA applied to the Government to suspend operation of a further five units, which have been in operation for the past 17years.Three hostels designed for the deinstitutionalisation of adults (mostly from the Leros mental hospital), one protected apartment and the hostel "Melia", which houses for a few months children of parents with severe mental illness.

Four trade unions representing staff from the mental health associations (SEPSAEKO, PEPSAEE, Perivolaki, and APHCA) describe a "tragic situation" in the field, which compromise "the stability, security, continuity of therapeutic care and respect for people suffering from mental disorder”. The de-institutionalization of patients and their reintegration into society has been achieved after many years work, but this work is likely to be blown sky-high if the sheltered accommodations are closed or if the staff change. One unit leader of those which are threatened with closure explains, "Patients who have roots together in these neighborhoods will be uprooted if they go elsewhere or if they lose people who are reference points for their treatment" he says.

The worst, however, indicate the employees, is that if the existing structures within the mental health service are reduced during the current economic crisis, they will not be replaced by something else. And this will be a great loss for society, who, maybe after the injury to its pocket inflicted by the economic crisis, will perhaps also see the injury to its mental health.

Agg. B.

Article from the Greek newspaper Eleftherotypia (translated by: the iron chicken)

Leros: Freedom is Curative (w/ english subtitles)

                                   

Director: Andreas Loukakos

Dir. of Photography: Stephane Cattan

Editing: Stephane Cattan

Producer: Noredin Mokassabi

2003

John Henderson obituary

Psychiatrist, reformer and adviser to Greece on mental health

Henderson was an early pioneer of social psychiatry

John Henderson, who has died aged 80, was an influential figure in psychiatry, mental health and human rights around the world. Long after official retirement, he continued his work with startling energy through a vast array of voluntary and non-governmental organisations right across Europe – especially Mental Health Europe, which he helped to found in the late 1990s.

In particular, he supported colleagues and activists working for the reform of the Greek mental health system. The appalling institutions for mentally ill people and those with learning disabilities on the Greek island of Leros, in the south-east Aegean, became more widely known from the early 1980s. When full, the institutions had housed around 3,000 people. During John's tenure at the World Health Organisation (WHO) in Europe, and as part of its accession to the European Union, Greece made a request for special assistance to reform and modernise its mental health system away from institutional care.

Controversially, a special programme was agreed in 1984. However, by 1987 nothing had happened to change conditions in Leros, very little money had been spent and there were moves in the European parliament to end the programme. Then an Observer journalist, John Merritt, and an independent film- maker, Jane Gabriel, decided simultaneously to draw the world's attention to Leros with dramatic press coverage swiftly followed by two powerful documentaries broadcast on Channel 4.

Such was the public outrage that a compromise was agreed by the European commission for the assistance programme to be renewed and extended for five years from 1990. John was asked, as part of this deal, to lead an independent team of experts working for the European commission to monitor and evaluate the progress of the reforms. For five years the European Commission Independent Team of Experts (ECITE) spent six to eight weeks a year in Greece reviewing progress in Leros and – just as importantly – reviewing the changes to the mental health system that would make the institutions on Leros and elsewhere in Greece redundant. It was a challenging assignment.

The outside experts were not always welcome or popular, and it required all of John's diplomatic skills and firmness to win the trust and co-operation of politicians, bureaucrats, officials, the medical profession, the staff and the patients of the institutions. The work that led to the eventual closure of the worst parts of the institutions in Leros and at other sites involved many people from Greece and elsewhere who came to change the terrible conditions. The contribution of ECITE under John's leadership was to keep the show on the road when it seemed that the political and administrative blockages would bring the reforms grinding to a halt.

The work of ECITE ended in 1995, with the worst abuses, at least, on the way to being dealt with. However, John and other team members were regularly invited back by the Greek government and by the organisations running the new services to monitor progress – especially when momentum was in danger of being lost. As recently as last June, John spoke at a memorable meeting in Brussels in front of EC commissioners, MEPs and officials as, once again, the reform programme was brought back from the brink of collapse.

Gabriel summed up John's contribution in Greece and more generally: "I remember some remarkable times with him and how he managed to maintain a cheerful equilibrium when all around was either as grim as it gets – or worse.

"He was a man who inspired a quiet optimism, and more than once kept me going in the Leros days, by insisting that improvement would come, and in that case, of course, he was right."

Born in the town of Galashiels, Borders, John attended Central secondary school in Aberdeen and Melville College, Edinburgh. He studied medicine at Aberdeen University, graduating in 1954, and undertook national service with the Royal Army Medical Corps, in Kenya (1955-57). He then trained as a psychiatrist at Kingseat and Cornhill hospitals in Aberdeen.

After becoming a consultant in 1963, John took up the post of physician superintendent, first at Bilbohall hospital, in Elgin, and then at Bangour, in West Lothian. In 1976, after two years at the Scottish Office, he took up his first international posting as a regional adviser in mental health for WHO in south-east Asia, and then moved to the European regional office in 1980.

The thread that ran through John's life's work was his belief that psychiatry should be about helping people with mental heath problems to have the possibility of a better life. That meant caring about the whole person and the circumstances in which they lived. He was one of the early pioneers of social psychiatry, a firm believer in the abilities and capacities of people living with and recovering from mental illness, and always a fierce critic of the discrimination and human rights abuses that were – and unfortunately still are – rife across many parts of Europe and the rest of the world.

John was kind, supportive and encouraging to those who were trying to do the right thing in challenging circumstances. It was this combination of stern authority, compassion and an in-depth knowledge of psychiatry and mental health as practised throughout the world that made him such a potent force for change.

He is survived by Toshie, his wife of 52 years, four sons – two of whom work in mental health – and 10 grandchildren.

Two weeks before his death John finally agreed to the wishes of his sons and colleagues to establish a foundation in his name to help continue the mental health work he so passionately believed in across Europe.

• John Henderson, psychiatrist and reformer, born 29 November 1929; died 4 January 2010

Bob Grove, guardian.co.uk

Mental Health Europe’s Message

Mental Health Europe’s Message for the European Year 2010 for

Combating Poverty and Social Exclusion 

Research has shown clear bidirectional links between mental health and poverty. People experiencing poverty are particularly vulnerable towards developing mental health problems. Conversely people with existing mental health problems are more likely to experience poverty. Uncertainties about the future dominate their daily lives.In the context of the European Year 2010 for Combating Poverty and Social Exclusion, Mental Health Europe therefore calls on policy-makers and other stakeholders to:

1. Implement the European Pact for Mental Health and Wellbeing, which was launched in 2008, into all policy areas (health, social policies, housing, employment, training, justice, fundamental rights etc.).

2. Foster measures for mental health promotion and prevention of mental health problems through adequate social protection and inclusion policies.

3. Reduce stigma and discrimination against people with mental health problems, also with the support of the media.

4. Ensure a minimum level of income which allows all people to live a life in dignity.

5. Make labour markets truly inclusive, support flexible working schemes and ensure decent pay. Keeping people in their jobs is the best way to prevent poverty and social exclusion.

6. Ensure access to quality health care and social services.

7. Invest in human resources and skills development in order to apply an effective lifelong learning strategy.

8. Place the fight against mental health problems and homelessness high on the political agenda.

9. Protect the most vulnerable members of society by promoting social justice as well as the mental health and wellbeing of the population – a decisive factor for social cohesion in Europe!

Mental Health Europe