Lolita Shengelia Doctoral student, Ilia State University, Tbilisi

1. Lolita ShengeliaDoctoral student, Ilia State University, Tbilisi Post-communist Transformation of the Society and the Mental Healthcare System in Georgia

2. How the process of societal transformation in Georgia after the disintegration of the Soviet Union was reflected in the reform of the healthcare system, and in particular – with regard to the mental health institutions? • What were the characteristics of the Soviet psychiatry? • What has changed since and what is the legacy? • What are the main problems in contemporary Georgian psychiatry? • What are the current trends and ways forward in dealing with mental health problems?

3. Characteristics of the Soviet psychiatry: Diagnostics • Soviet psychiatry rejected Western approaches to mental disorders such as psychoanalysis, and single-mindedly adhered to the reflex theories of Ivan Pavlov. The most striking feature was the political abuse of psychiatry originated from the concept that persons who opposed the Soviet regime were mentally ill. • Popular diagnosis of “sluggish schizophrenia” provided a handy framework to explain “anti-social” behavior – as, according to Snezhnevsky and his colleagues in Moscow, schizophrenia could be present with relatively mild symptoms and only progress later. Such patients were supposed to be able to function almost normally in the social sense, while their symptoms could resemble those of a neurosis or could take on a paranoid quality, and could become “reform delusions”, or “struggle for the truth”.

4. Politics and patient rights abuse • Psychiatric confinement of sane people was a particularly cruel form of repression, while Soviet punitive psychiatry was a key weapon of both illegal and legal repression in late Soviet period, involving misuse of psychiatric diagnosis, detention and treatment for the purposes of obstructing human rights of certain groups and individuals. • Soviet psychiatric hospitals were often used by the authorities as prisons in order to isolate political prisoners from the rest of society, discredit their ideas, and break them physically and mentally.

5. Characteristics of the Soviet psychiatry: Treatment The first special hospital secret Soviet punitive psychiatry was Kazan prison psychiatric hospital NKVD, which started to be used for political purposes as early as in 1935. However, the developed system of political abuse of psychiatry started to be extensively used at the end of Stalin's reign, in the later Soviet era. Two approaches to psychiatric treatment developed: • One system was punitive psychiatry that served the Communist repression and was led by the Serbsky Institute of Forensic Psychiatry in Moscow. • The second system was composed of psychotherapeutically oriented clinics and was exemplified by the Leningrad Psycho-neurological Institute named after Bekhterev.

6. Relations with international psychiatric community • The use of psychiatry for political purposes has been a major subject of debate within the world psychiatric community during the second half of the 20th century. • The issue became prominent in the 1970s and 1980s due to the systematic political abuse of psychiatry in the USSR, where approximately one-third of the political prisoners were locked up in psychiatric hospitals. • As a result, the Soviets psychiatrists were forced to withdraw in 1983 from the World Psychiatric Association.

7. Psychiatry and perestroyka • The Soviet system of punitive psychiatry was destroyed only in 1988, when 16 special type psychiatric hospitals under the jurisdiction of the Interior Ministry were transferred to the Ministry of Health, while five of them were completely eliminated. 776,000 patients with psychiatric diagnosis were released . • Articles #70 and #190 of the criminal code referring to the anti-Soviet propaganda and slander against the Soviet system as socially dangerous activities were abolished. A decree of the Presidium of the Supreme Soviet was adopted on January 5, 1988, regulating “conditions and procedure for the provision of psychiatric care." • Soviet psychiatrists returned to the World Psychiatric Association conditionally in 1989.

8. Psychiatry in Soviet Georgia Psychiatric hospitals in Georgia combined components of both systems: • The psychotherapeutically-oriented approach, which still was flawed and outdated due to international isolation, and lack of access to more advanced modern approaches and medication. • The punitive psychiatry was also used for the repression of political dissidents, although this latter was used relatively seldom (e.g. the notorious case of Nazi Shamanauri, of 1982).

9. Psychiatric institutions as a better alternative • Sometimes, Georgian prisoners would apply certain efforts (and corrupt practices) in order to simulate psychic disease - as staying in clinic was considered to be preferable to penitentiary institutions. • This would include quite renowned cases, as was e.g. imprisonment in 1970s of underground millionaire Lazishvili, who after pronged struggle achieved being transferred to Asatiani mental clinic (after the change of political leadership). • Sometimes, simulating mental disease would be used even to avoid military service.

10. Global Trends in Psychiatry During the last decades, changes took place in diagnosing and treating mental disorders at global scale. According to contemporary more flexible understanding, the concept of mental disorder is objective but a "fuzzy prototype" that can never be precisely defined, or alternatively that it inevitably involves a mix of scientific facts and subjective value judgments.(A. Pering) A number of trends are observed: • Humanization: Prioritizing of human rights and patient rights perspective; promoting inclusion, eliminating discrimination and isolation of persons with mental disorders • De-stigmatization: Efforts to eliminate the stigma of mental illness • New classification of disorders, new approaches, techniques and medicines in treatment of mental disorders

11. First steps Independence brought around many important changes, as Georgian medicine struggled to overcome transitional difficulties and adapt to international standards to diagnosis and treatment of mental disorders, social protection of persons with disorders, and protection of their human rights. However, there were a number of problems and obstacles to progress: • Lack of financial resources, due to prolonged economic crisis, even to maintain existing institutions, many persons with mental disorders left without care; • Changing profile of mental disease, due to great increase of the number of persons suffering from PTSD (caused by violent conflicts , civil war and high criminality), depression and despair, lack of treatment. • Conflict between attempts to introduce modern approaches, and the inertia and legacy of the Soviet psychiatry and institutions; lack of professionalism and professional ethics among staffs, and even semi-feudal tradition of hereditary occupation of administrative positions.

12. Psychiatric Institutions in Georgia Psychiatric residential institutions/hospitals: Asatiani clinic in Tbilisi , Tbilisi mental health center in Gldani, clinics in Bediani, Kutiri, Batumi and Surami. Despite the fact that the state budget for psychiatric grew since 2006 from 4 million lari to 10 million, and is increasing, progress is still very modest. Monitoring in 2010 by the ombudsman’s office discovered universally: • Poor living conditions, anti-sanitary • Outdated methods of treatment • Degrading and humiliating treatment of patients • Undereducated staff

13. Psychiatry in Georgia: Contemporary problems To sum up, the following problems continue to haunt treatment of mental disorders in Georgia: • Ineffective institutions, lack of options for treatment, including community based models • Insufficient funding and disastrous living conditions at institutions • Disrespect of patient rights and human rights, frequent inhumane treatment of patients • Lack of advanced training, particularly among the middle level medical staff and paramedics • Personnel policies not based on meritocratic principles, Corruption, clientelism and poor management

14. Legal framework: Law on psychiatry In 2005 the Law on psychiatry was adopted. According to this law: • Psychiatric care for persons suffering from mental disorders should be guaranteed by the State and providedaccording to the principles of legality, humanity and observance of human and citizen’s rights.

15. Trends and prospects • Introducing European standards, strengthening the rights of service users and their caregivers/relatives; • International support, including GIP, and the increased role of private initiatives and charities; • Increased acceptance of the significance of inclusion, self-help, self-support and self-advocacy; • Replacing patronizing, patriarchal attitude by less prescriptive and more collaborative approach; • Promise to build new clinics and introduce community based system

16. Open questions • It is not yet clear whether Georgian approach to treating persons with mental disorders will be able to overcome the Soviet legacy, reflected in disregard to the patient rights, stigma, and reliance on large institutions while neglecting community based models and plurality of treatment options. • Much will depend on whether Georgia will continue moving closer to European standards in all aspects of social policy and social protection.