Mental Healthcare Reforms in Post-Soviet Russia OLGA SHEK

OLGA SHEK OLGA Acta Universitatis Tamperensis 2350 Mental Healthcare Reforms in Post-Soviet Russia OLGA SHEK Mental Healthcare Reforms in Post-Soviet Russia Negotiating new ideas and values AUT 2350 AUT OLGA SHEK Mental Healthcare Reforms in Post-Soviet Russia Negotiating new ideas and values ACADEMIC DISSERTATION To be presented, with the permission of the Faculty Council of Social Sciences of the University of Tampere, for public discussion in the auditorium F212 of the Arvo building, Arvo Ylpön katu 34, Tampere, on 6 April 2018 at 12 o’clock. UNIVERSITY OF TAMPERE OLGA SHEK Mental Healthcare Reforms in Post-Soviet Russia Negotiating new ideas and values Acta Universitatis Tamperensis 2350 Tampere University Press Tampere 2018 ACADEMIC DISSERTATION University of Tampere, Faculty of Social Sciences Finland Supervised by Reviewed by Docent Ilkka Pietilä Docent Meri Koivusalo University of Tampere University of Tampere Finland Finland Professor Suvi Salmenniemi University of Turku Finland The originality of this thesis has been checked using the Turnitin OriginalityCheck service in accordance with the quality management system of the University of Tampere. Copyright ©2018 Tampere University Press and the author Cover design by Mikko Reinikka Acta Universitatis Tamperensis 2350 Acta Electronica Universitatis Tamperensis 1856 ISBN 978-952-03-0652-6 (print) ISBN 978-952-03-0653-3 (pdf) ISSN-L 1455-1616 ISSN 1456-954X ISSN 1455-1616 http://tampub.uta.fi Suomen Yliopistopaino Oy – Juvenes Print Tampere 2018 441 729 Painotuote ACKNOWLEDGMENTS I would like to thank my supervisor, Ilkka Pietila, for his continuous guidance of my PhD studies. His useful advice helped me during the research and writing of the thesis. I am truly grateful for his dedication to working together on our articles. I appreciate all his contributions of time and knowledge. I am particularly grateful for the assistance given by Kirsi Lumme-Sandt, as well as for her contribution to my second article as a co-author. She supported me greatly and was always willing to help me. My sincere thanks go to my former supervisor, Pauliina Aarva, who provided me with an opportunity to join her project “Health Policy, Values and Changing Society in Russia” at the University of Tampere. I thank her for her useful advice and collaboration on my articles. The encouraging atmosphere in the group helped my development as a researcher. I would like to thank project participants Marja Rytkönen, Alexandra Dvorianchikova, Elena Taranuhina and others for their useful advice and positive work environment. I wish to thank the professors at the University of Tampere – Prof. Juhani Lehto, Prof. Matti Joukamaa and Prof. Marja Jylha – as well as at the European University in St Petersburg – Prof. Elena Zdravomyslova and Prof. Anna Temkina – who gave useful feedback and insightful comments on my work. I also wish to acknowledge the collaboration of Dr Silke Graeser, co-author of one of my articles, and my colleagues, Dr Pia Solin and Dr Leena Tervonen-Goncalves, for sharing their enlightening views on the work on the thesis. I would also like to thank the anonymous reviewers for their valuable advice and comments on the manuscripts. I express my gratitude to Tiina Kangasluoma for providing much- needed assistance with administrative tasks, as well as Virginia Mattila, Dr Merl Storr, Dr Susanne Cohen and Dr Gavin Daker-White for doing a great job proofreading the article manuscripts and giving advice on English translations. I gratefully acknowledge the funding sources that made my work on the thesis possible: the study was financially supported by CIMO, DPPH, the University of Tampere Foundation and HES. This study definitely would not have been possible without the participation of Russian mental health professionals and caregivers for people with mental disabilities, who kindly agreed to take part in the research and shared valuable information. Thank you! I would also like to thank my friends from all the countries (Russia, Finland, Spain and the United Kingdom) where I stayed while doing my PhD, for the shared good times over recent years. Finally, and most importantly, I thank my family for their love and confidence in me. I am deeply appreciative of the support given to me by my parents, Elena and Oleg, and my grandmother, Nina, as well as my parents-in-law, Isabel and Mario. The biggest thank you of all goes to my husband, Francisco, and my son, Victor, who were so supportive and patient throughout the long journey to thesis completion. ABSTRACT This thesis provides insights into the process of mental healthcare reform in post- Soviet Russia. The reforms started in Russia in the early 1990s, following the collapse of the Soviet Union. They were triggered by a desire to conform to international standards for patients’ rights within a mental healthcare system that had previously been sharply criticized for ineffectiveness and political abuse. In this study, the development of Russia’s mental health policy is considered in its social and historical context and with reference to the World Health Organization’s guiding principles. The thesis provides a historical review of Soviet psychiatry in order to gain a greater sense of the significance of mental healthcare reforms in post-Soviet Russia. The thesis focuses on policy issues such as patients’ rights, deinstitutionalization, service users’ inclusion and participation, and the prevention of stigmatization. These internationally recognized principles have provided the basis for the development of mental health policy in many countries, and could be deemed central to the analysis of the reforms in Russia. Methodologically the study is based on interpretive policy analysis (Yanow 2000), which focuses on the meanings that policies have for a broad range of policy-relevant publics. This research started from the premise that the meanings that different interpretive communities attach to mental health policy are important for its development and implementation. In this thesis, policymakers, the media, mental healthcare staff, and the relatives of people with mental illness are considered key interpretive communities. Each study (article) provides insights into how policy principles were interpreted by a particular interpretive community. For the conceptual basis, I drew on social constructionist theory, which claims that discourses (such as those on mental healthcare reform) are tied to the cultural, social and political contexts of the particular society. I also used the concept of path dependency to analyse whether and how the Soviet background has influenced mental healthcare development. The research aimed to answer the following questions. What kinds of similarities and differences appear in different interpretive communities’ interpretations of the new mental health policy principles, and how do these interpretations relate to either support for or opposition to mental healthcare reforms? How do different interpretive communities see the role of various actors (such as policymakers, the mass media, state institutions, non-governmental organizations, service users and their caregivers) in the reforms? How are interpretations of mental health policy constructed in terms of distinctions from and links to the Soviet historical background? The study methods were qualitative, consisting of qualitative content analysis and thematic analysis. The research material included mental health policy documents, mass media texts from selected newspapers, and interviews with mental health professionals and family caregivers of people with mental disabilities. The results of the study revealed that the policy discussion on patients’ rights and the reorganization of mental healthcare was a significant advance over the Soviet past. However, the policy documents did not pay attention to the issues of stigmatization or users’ empowerment. The media response to the new policies was largely ambivalent. Support for patients’ rights was accompanied by fears about the detrimental effects of the liberalization of psychiatry on public safety. The research revealed that negative media responses to the reforms preceded the policy programme for deinstitutionalization, creating an unfavourable climate for its implementation. There were also multiple gaps between policy planning and practice in Russia. The way the policy was introduced by the government and represented by the mass media contributed to a distrust of the reforms among citizens affected by the policy. Deinstitutionalization met with little support from professionals or family caregivers. The professionals criticized the new policies and were suspicious of reform, arguing for the preservation of the existing system. They perceived psychiatric institutions as a means for the social control and protection of people with mental illness and their families. Simultaneously, caregivers were strongly concerned about the high risk of losing the support they received from existing services. In sum, the results of this study demonstrate that transferring mental health policy ideas across national boundaries is a complex process. This underlines the importance of seeking balance between internationally driven initiatives and the readiness and willingness of the receiving country to accept the proposed changes. TIIVISTELMÄ Väitöskirjassa tarkastellaan mielenterveyspalvelujen reformien prosessia, joka alkoi Venäjällä 1990-luvun alussa Neuvostoliiton hajoamisen jälkeen. Reformien taustalla oli pyrkimys saattaa potilaiden

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