Mental HealthReforms

Special issue:

> MENTAL HEALTH CHALLENGES IN ‘ Nos. 111-2

A Global Initiative on Psychiatry publication

252 MHR nr 1 2011_A4.indd 1 25-10-2011 14:43:22 Contents

Editor Editorial 3 Ellen Mercer By John Bowis and Robert van Voren

Editorial Board GIP- Celebrates World 4 Arunas Germanavicius Mental Health Day 2011 Dovile Juodkaite Robertas Povilaitis Dainius Puras Evidence-Based 5 Robert van Voren Mental Health Policy in Lithuania By Dainius Puras Graphic Design/ Printing www.bade.nl Vilnius’s Mental Health Plan: 7 A City that Cares Mental Health Reforms is a publication of By Robert van Voren Global Initiative on Psychiatry (GIP).

While MHR is distributed free of charge, Institutions of Residential Care 10 we are dependent on your support to in Lithuania: Inglorious Past, sustain the journal. Contributions are Vague Perspectives therefore welcome and may be made to: By Egle Šumskiene and Dovile Juodkaite

ABN AMRO Bank The Lessons from Reforming a System 13 ’s Gravelandseweg Branch of Child and Adolescent Mental Health Hilversum, The in Lithuania BIC: ABNANL2A By Vytautas Blazys Euro account:62.07.29.074 IBAN: NL16 ABNA 0620 7290 74 USD account: 62.07.29.244 Interpretation and Implementation 15 IBAN: NL82 ABNA 0620 7292 44 of the International Human Rights Standards in Lithuania To request additional copies please By Dovile Juodkaite contact: Lithuanian Psychiatric Association – 17 Global Initiative on Psychiatry 1990 Goals vs. the Current Situation P.O. Box 1282 By Dainius Puras 1200 BG Hilversum The Netherlands Policy Study on Prevention of 18 Tel.: +31 35 683 8727 in Lithuania Fax: +31 35 683 3646 By Ramon J. Pebenito Jr. and Arunas Germanavicius e-mail: [email protected] www.gip-global.org Empowerment Strategy for Mental 21 Health Care Users in Decision Making (Lithuanian Experience) By Arunas Germanavicius and Saulius Peciulis (Deceased)

Development of Patient’s Person of 23 Trust (POT) Program in Lithuania By Ruta Juodelyte

Primary Mental Health Care in 24 Lithuania By Eugenijus Mikaliunas

Primary Care Systems in Lithuania: 26 the Role of Psychiatrists By Robertas Bunevicius

In Memoriam Saulius Peciulis (1960-2010) 27 Melvin Sabshin (1925-2011) Collective painting during the first open day at Vasaros Psychiatric Hospital, 2004

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252 MHR nr 1 2011_A4.indd 2 25-10-2011 14:43:23 Editorial

In the fourteenth century, Lithuania was one of the largest countries of Europe, stretching from the Baltic to and incorporating Belarus and much of Poland and Russia. For two hundred years it was largely amalgamated with Poland until the 1770’s when it was swallowed by its neighbors, mainly the Russian empire. Between the wars, it was a smaller but independent entity until the Soviets and then the Germans and then again the Soviets occupied it from 1940 until March 1990.

By John Bowis and Robert van Voren

Twenty-one years ago, Lithuania was the fi rst Soviet republic to dare to do what virtually nobody ever thought would happen: it reinstated the independence it lost with the fi rst were overhauled and “Viltis,” a par- nationally. The country was an ex- Soviet invasion in 1940 and by do- ent organization of children with ample to others and reformers from ing so, set a process in motion that intellectual disabilities, became many other former Soviet republics very much contributed to the disin- the largest NGO in the country. It as well as from other Eastern and tegration of the the fol- seemed that within a decade or two Central European countries came lowing year. Independence brought Lithuania would have shed the dark to Lithuania to see what had been an enormous sense of enthusiasm shades of the totalitarian past. accomplished. and hope, and the nation set itself the task of reuniting with free and Global Initiative on Psychiatry was In 2004, Lithuania joined the democratic Europe and reforming there from the very start. During European Union, thereby fulfi ll- its outdated Soviet economy and all these years, our organization ing probably its biggest and most social structures to modern Euro- invested in mental health reforms improbable dream: it had rejoined pean ones. In the sphere of mental in Lithuania, supporting reformers, Europe within a period of less than health, this desire to reform was no assisting newly established NGOs, fi fteen years. However, joining the less strong. An independent Lithu- bringing Western expertise and European Union also meant that anian Psychiatric Association was advice, setting up projects with reform was no longer seen as a formed, a system of mental health Lithuanian colleagues and step prerequisite to becoming part of Teacher and centers to be housed in general by step helping to transform the the European family and millions of students at hospitals was devised, child and mental health landscape. In 2000, structural funds from the European Viltis adolescent mental health services we opened a regional offi ce in the Union soon found their way into Lithuanian capital, Vilnius, which maintaining the old system, rather became the region’s motor for men- than investing in innovation. Lithu- tal health reform. Projects focused anians saw their diplomas recog- on all the possible areas of mental nized in Western Europe and, as a health: community-based mental result, a mass exodus started which health care services, psychogeriat- to date has resulted in the emigra- rics, eating disorders, forensic psy- tion of approximately one-fi fth of chiatry and prison mental health, the country’s population. Among intellectual disability, user and fam- these have been many doctors and ily involvement in mental health – nurses, whose salaries in Lithuania both individual care and treatment are so low that it is virtually impos- decisions and service planning, sible to live off one salary – while patient advocacy, mental health much more can be earned working economics and developing men- abroad. tal health policy both locally and

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252 MHR nr 1 2011_A4.indd 3 25-10-2011 14:43:23 The result is a very painful situation, with a country that suffered heav- ily from the economic recession, a population that has lost many of its brightest and most active citizens to emigration, an increasingly anti- European political climate and a stagnating mental health system, where the process of reform has come to a halt because of a combi- nation of factors: a severe decrease in available funding, a lack of bright young and innovative minds, and a general attitude that further change is no longer necessary.

This edition of Mental Health Reforms is, therefore, an unusual issue. It not only reports on suc- maybe more than those filled with John Bowis is a former Health and cesses, it also very much reports stories of success and optimism. Social Services Minister in the UK, a on failures: failures to change the It functions as a warning that, after former member of the European Par- system fundamentally and perma- twenty years of investment, things liament and is currently a health policy nently, a failure to depart fully from can develop in an adverse direc- advisor and Secretary of the Board of the past of a biologically oriented tion; that investments can fail; that Global Initiative on Psychiatry. and institutionally based Soviet high optimism can eventually come Robert van Voren is Chief Executive mental health care system, a failure up against reality with sometimes of Global Initiative on Psychiatry. to continue to take the lead and unpleasant consequences. It is John Bowis: [email protected] show other countries in the region also a warning that membership Robert van Voren: how mental health services can of the European Union in itself is [email protected] be remodeled to the benefit of its no guarantee that the process of users without an abundance of fi- Europeanization will continue. To nancial means. the contrary: being “in” might be reason enough to stop changing, We decided, however, that this because it is no longer a condition journal is a very necessary issue, for being “in.”

GIP Vilnius Celebrates World Mental Health Day 2011

For the third year, GIP/Vilnius joined with the Vilnius City Mental Health Center (Vasaros Clinical Hospital) and the Ministry of Health to celebrate “World Mental Health Day 2011.” On October 7 of this year, the event titled “Let’s Make Friendship 2011” was held in V. Kudirkos Square in the heart of the city from 12-5 p.m. There were many ac- tivities organized in tents and on stage, including a museum of psy- chiatry. The Mental Health Biblioteca brought many publications on the theme and viewers admired the masterpieces of artists suffering from mental health problems. Young artists created “costumes” of depression, schizophrenia and other mental disorders and one tent allowed visitors to attempt crafts that are used in therapies for pa- tients. Mental health services in other countries were highlighted and medical student volunteer and those working on hot lines for children and youth explained their work. Psychiatrists and psychologists dis- cussed mental health issues and provided consultations. Individuals with intellectual disabilities presented musical performances on stage next to professional musicians and singers.

These events intended to celebrate World Mental Health Day and remind each of us about the essence of good mental health for both individuals and society. In addition, demonstrations of strengths and capabilities of persons with mental disorders facilitated their integra- tion into society – with friendships established among all of us.

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252 MHR nr 1 2011_A4.indd 4 25-10-2011 14:43:26 Evidence-Based Mental Health Policy in Lithuania

Since an independent Lithuania began demo- cratic reforms in 1990, there have been several attempts to introduce evidence-based mental health policy. The first step was the adoption of the Mental Health Law in 1995. Even though this was an important step, it later appeared to have no significant direct influence on the existing system of psychiatric care.

By Dainius Puras

Another important step was the demonstrated that mental health The findings from the aforemen- development of outpatient mental services continue to be ineffective tioned studies on the poor state health centers in the level of mu- and that they contribute to the in- of public mental health indicators nicipalities, starting in 1995-1997, crease of stigma and social exclu- among the population and ineffec- when the obligatory health insur- sion. Although the number of beds tive management of mental health ance system was introduced. At in psychiatric hospitals decreased, services have been used by the that time, the transformation from the number of places in large Task Force as the analytical part for the system of outpatient policlinics residential social care homes re- drawing recommendations for new (“dispensaries”) in larger cities into mained very high. Another problem mental health policy. It was agreed outpatient mental health teams as a is a lack of political will to address that the main goal was to adopt the part of outpatient general (somatic) adequately high rates of suicidal policy document, based on mod- policlinics led to some increased and other self-destructive behavior. ern principles, and not to address funding for outpatient mental health Although Lithuania had a highest the funding issues in that stage. services. This resulted in the ad- suicide rate in the world during the For this reason, Seimas (Lithuanian dition of a small number of psy- last decade of the 20th century and Parliament) approved the new chologists and social workers to the first decade of the 21st century, Mental Health Strategy on April 3, the traditional workforce previously no comprehensive suicide preven- 2007, without any larger debates. dominated by psychiatrists treating tion strategy with sustainable activi- the biomedical component of treat- ties and measurable outcomes was ment of psychiatric disorders. In implemented. The only strategic

addition, this step had the positive investment during 1995-2005 Lithuania has the highest component of de-stigmatization has been a substantial increase > > since the location of outpatient in reimbursements for modern psychiatry moved from psychiatric psychotropic medications (antide- suicide rate in the world. institutions to general medical cen- pressants and antipsychotics) and ters. improvement of the conditions of stay in psychiatric hospitals and However, these changes have residential care homes. The new Lithuanian Mental Health not been enough to change the Strategy is very clear about mov- traditional culture of mental health In 2005, a then-new Minister of ing to modern principles of mental services. Several independent Health, Zilvinas Padaiga, after the health care adopted by the WHO in studies, carried out with the help WHO Ministerial Conference on the 2001 World Health Report and of international foundations (GIP, Mental Health in Helsinki, initiated by WHO Ministerial Conference in Open Society Foundation, etc.) a Task Force for Development of 2005. These principles focus on from 1998 to 2004, convincingly a National Mental Health Strategy. the following:

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252 MHR nr 1 2011_A4.indd 5 25-10-2011 14:43:26 • community based services, only one component has been and those organizations and individuals • effective programs aimed at remains adequately funded, and who are willing to facilitate positive mental health promotion and pre- this is reimbursement of psycho- changes and to implement the Na- vention of , violence and tropic medications for the patients. tional Mental Health Strategy so that other mental health problems, The other four components – psy- basic principles of modern mental • deinstitutionalization, chotherapy, psychosocial rehabili- health care can be implemented in • promotion and protection of hu- tation, vocational rehabilitation and Lithuania. This should be the main man rights in psychiatric institu- supported housing, are still in their goal of all organizations working in tions, with independent monitor- infancy, and there is no intention in the field of mental health and com- ing mechanisms established, the recent plans of policy makers to mitted to humane and evidence– and implement the new mental health based psychiatry and mental health • mental health policy and services policy in a serious way. care for the near future. evaluation and research, so that effectiveness of invested resourc- Preliminary analysis of the failure to es could be monitored and policy implement the modern principles Dainius Puras is Head and Associ- makers could be informed about of public mental health in Lithuania ate Professor of the Centre of Child the situation. indicates that this has to do with Psychiatry and Social Paediatrics at general societal problems in Lithu- Vilnius University. He is the Chair- anian society. There is a high level man of the Board of GIP-Vilnius. of intolerance to different vulner- His email address is:

“No political will has been able groups (including mentally ill [email protected] > people) in the general population.

Politicians have heard from interna- demonstrated to implement the > tional organizations about the need new Mental Health Policy.” to deinstitutionalize mental health services and to liberate mentally ill people and the whole field of psy- chiatry from outdated stigmatizing institutions, but they never heard The four years following the adop- about this need from their voters. tion of the Mental Health Policy have On the contrary, a large portion of been marked by vague attempts to the electorate would like to have implement it. Basically, no political less liberal legislation and to isolate will was demonstrated to imple- people with mental health prob- ment the main principles of the new lems. Other stakeholders, such as policy. To do this, new incentives in professional groups of psychiatrists, funding schemes should be imple- the academic sector, and organiza- mented to fill obvious gaps and tions of mental health service users to reduce existing unbalances in and their relatives tend to lobby mental health care. However, insti- for improvement of the existing tutional care, which is overused in system and not to basic changes Lithuania on the large scale, is likely in the culture of services and infra- to be supported again and again as structure of services. Principles of a priority by the Government, even autonomy and participation of men- after the adoption of National Men- tally ill people, which have been a tal Health Policy which declares driving force in many countries, are deinstitutionalization as a basic not popular and a paternalistic ap- priority. Instead of gradually clos- proach still dominates the culture of ing large psychiatric institutions, psychiatric services. the Government, in recent years, has allocated substantial amounts In this situation, it is crucially im- of EU Structural Funds to renovate portant to establish a coalition of existing residential psychiatric insti- tutions. Also, a huge disproportion of investment in biomedical and psychosocial components within “There is a high level outpatient mental health care re- > mained; thus, municipal mental of intolerance to vulnerable health centers, officially established

as outpatient community-based groups, including the mentally care teams, have very little to do

with modern community-based ill, in the general Lithuanian > services. To conclude, out of five obligatory components needed for population.” modern community-based servic- es for severely mentally ill persons,

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252 MHR nr 1 2011_A4.indd 6 25-10-2011 14:43:26 Vilnius’s Mental Health Plan: A City that Cares

A working committee to establish a long-term policy for mental health service development in the city of Vilnius was established by Vilnius City Municipality and Global Initiative on Psychiatry in the fall of 2004. The members were Lithuanian and Dutch experts on a wide variety of aspects of mental health care: Maarten Boon, Gintautas Daubaras, Arunas Germa- navicius, Christoph Hrachovec, Henriette Kuipers, Dainius Puras, Sigita Radziukynaite, Rasa Laiconiene, Rimanta Rozanskaite, Violeta Toleikiene and Robert van Voren.

By Robert van Voren

Aleksandras Avramenko func- • orientation towards patient’s 2. Responding to people’s tioned as secretary of the work- needs, expectations: in mental health ing committee, Dr. Puras and • integration into the infrastructure this objective can relate to both, Dr. Hrachovec were appointed as of general city health as well as respect for persons (human rights, chairmen. This initiative in Lithu- social and educational services, dignity, confidentiality) and client- ania came after a World Health • mitigation of negative attitudes focused orientation. Organization (WHO) sponsored concerning mental disorders Ministerial conference where a and raising awareness about European Mental Health Declara- research evidence that mental tion and Action Plan for 2005-2010 health problems can be ef- > “An explicit mental health were endorsed. fectively tackled if modern ap-

proaches are implemented. policy is an essential and The committee concentrated on the whole field of mental health The Committee acted on the belief powerful tool for any Ministry > care, for pragmatic reasons ex- that three overall objectives of any cluding forensic psychiatry, addic- health policy can be equally ap- of Health.” tion disorders, services in jails and plied when formulating the objec- police cells and learning disability. tives of a mental health policy: However the presented model for strategic developments could also 1. Improving the health of 3. Providing financial be used as an example for the the population: the policy protection against the cost of excluded sections of mental health should clearly set out its objec- illness and establish a modern care. Of course the working com- tives for improving the mental system of health care financing. mittee was convinced about the health of the population. Ideally, necessity of collaboration and co- mental health outcome indicators An explicit mental health policy is operation with the field mentioned should be used, such as quality of an essential and powerful tool for above. life, mental functioning, disability, the mental health section in any morbidity and mortality. In devel- Ministry of Health. When prop- Fulfilling the recommendations of oping countries, however, informa- erly formulated and implemented the WHO, the principal criteria of tion systems are generally poorly through plans and programs, a a new servicing model in the field developed and ministries of health policy can have a significant im- of mental health care include the may have to use some process in- pact on the mental health of the following: dicators, e.g. access and service population concerned. A mental • service efficiency, utilization. health policy is commonly es- • sustainability, tablished within a complex body

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252 MHR nr 1 2011_A4.indd 7 25-10-2011 14:43:27 of health, welfare and general fessionals such as psychiatrists, can be a useful addition to formal social policies. The mental health psychiatric nurses, social work- mental health services. field is affected by many policies, ers, psychologists, and physi- standards and ideologies that are cians who have received special Specialized mental health not necessarily directly related to training in psychiatry. The func- services mental health. In order to maximize tion of liaison psychiatry should Specialist institutional mental the positive effects when mental be organized and financed in health services are provided by health policy is formulated, it is order to strengthen the collabo- certain outpatient clinics and by necessary to consider the social ration between somatic and psy- certain public or private hospital- and physical environment in which chiatric care. based facilities that offer vari- people live. ous services in inpatient wards. Community mental health Among the services are those pro- The components of mental health services vided by acute and high security services as recommended by the Formal community mental health units, units for children and elderly Committee are listed below: services include community- people, and forensic psychiatric based rehabilitation services, units. They meet very specific Mental health services in- hospital diversion programs, mo- needs that require institutional set- tegrated into the general bile crisis teams, therapeutic and tings and a large complement of health system residential supervised services, specialist staff, who have received • Mental health services in primary home help and support services proper training. Specialist services care include treatment services and services for special popula- are usually tertiary referral centers, and preventive and promotional tions such as trauma victims, chil- and, in general, patients who are activities delivered by primary dren, adolescents and the elderly. difficult to treat make up a large care professionals. Among them, Community mental health services proportion of their case-loads. for example, are services pro- are not based in hospital settings, vided by general practitioners, but need close working links with Dedicated mental hospitals mainly nurses and other health staff general hospitals and mental hos- provide long-stay custodial servic- based in primary care clinics. pitals. They work best if closely es. In many parts of the world, they Primary care services are eas- linked with primary care services are either the only mental health ily accessible and are generally and informal care providers work- services or remain a substantial better accepted than other forms ing in the community. component of such services. In of service delivery by persons many countries, they consume with mental health disorders. Well-resourced and well-funded most of the available human and This is mainly attributable to the community mental health ser- financial resources for mental reduced stigma associated with vices provide an opportunity for health. In modern mental health seeking help from such services. many persons with severe mental care they play a much smaller, but Training is needed for gen- disorders to continue living in nevertheless important role in the eral practitioners to improve their the community and thus promote consecutive chain of mental health mental health knowledge. community integration. High services. levels of satisfaction with com- munity mental health services are Strengthening the role of associated with their accessibility, service users and the non- “Training is needed for gener- a reduced level of stigma, and a governmental sector

> reduced likelihood of violations Patient and family councils can

al practitioners to improve their of human rights. However, they play an important role in reorga- > are sometimes associated with nizing mental health care from mental health knowledge.” resistance from the communities within. We always should realize in which they are placed, and this that patients not only are the real too needs attention. Private initia- objects of our services, but also tives, already existing in Vilnius, are the individual subjects with should be formalized. This means experiences that can lead to a bet- • Mental health services in gen- that equal possibilities for being ter understanding of the impact of eral hospitals include certain financed and accessibility for the diseases and treatment. services offered in district gen- public should be established. eral hospitals and academic or Nevertheless we know that it can central hospitals that form part of Informal community mental health be quite hard to start a function- the general health system. Such services may be provided by local ing system of patient councils and services include psychiatric in- community members other than participation. Therefore we advise patient wards, psychiatric beds general health professionals or to search close relations and affili- in general wards and emergency dedicated mental health profes- ation with already existing groups departments, and outpatient sionals and paraprofessionals. in Europe. Non-governmental or- clinics. There may also be some Informal providers are unlikely to ganizations such as GIP can be of specialist services, e.g. for chil- form the core of mental health ser- great value in the development of dren, adolescents and the elder- vice provision and countries would these contacts. ly. These services are provided be ill-advised to depend solely on by specialist mental health pro- their services, which, however,

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252 MHR nr 1 2011_A4.indd 8 25-10-2011 14:43:27 Protection of human rights should make the right decisions, Vilnius City Municipality should then implement and next evaluate establish an independent patient the course of action. Therefore, it advocacy program for clinical is very important to monitor the settings, daycare, mental health developments by a system of care centers and all other officially service evaluation and scientific acknowledged mental health care assessment. The Center of Social providers. This program should Psychiatry at Vilnius University can be totally independent from the play an important role. targeted facilities and financed through the municipality and the state. It should offer legal support for individual patients and should “Patient experiences can monitor the development of the >

protection of human rights for lead to a better understanding psychiatric patients. User orga-

nizations and non-governmental of the impact of diseases and > organizations must be invited to co-operate in this process. treatment.”

Information and preven- tion Information concerning psychiatric diseases and mental health care Follow-up problems is an important vehicle The mental health plan was adopt- for destigmatizing and improving ed by Vilnius municipality, among the health care services and the others, thanks to strong support mental condition of the population. by the then Vilnius mayor, Arturas Social welfare and health care Zuokas. Unfortunately, due to a should co-operate in this subject. combination of factors including Basically information should be his departure as mayor and the provided orally and via leaflets. financial crisis of 2008, which se- Because of the special problems verely affected Vilnius municipal- of Vilnius, one should start with ity, the majority of the proposed an overall easily accessible view improvements were scrapped about the possibilities of getting and some of the existing services care and treatment. Special atten- were curtailed. Still, the mental tion has to be paid to children and health plan is used as a refer- adolescents and to special risk ence tool during discussions and groups. The problem of the huge negotiations and in that sense the suicide rates in Lithuania asks for a work done is not in vain. When bet- profound investigation and recon- ter times come, we hope it will pro- sideration. vide the necessary guidelines for the future development of mental Funding health care services in Vilnius. The problems of financing health care, insurances and funding the system during a period of change Robert van Voren is Chief Executive and reorganization was considered of Global Initiative on Psychiatry. to be beyond the reach and ex- [email protected] pertise of the working committee. Therefore, it requires the establish- ment of a taskforce to prepare and present proposals for alternative funding mechanisms for long-term investments in the mental health care sector. Special attention should be paid to issues such as substitution, capital investments and the possibility of long-term financing arrangements.

Service evaluation and sci- entific assessment When a country wants to change mental health care facilities, it first

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252 MHR nr 1 2011_A4.indd 9 25-10-2011 14:43:27 Institutions of Residential Care in Lithuania: Inglorious Past, Vague Perspectives

In the past, big residential care institutions were built with the very best intentions and the belief that individuals with special needs are most effi- ciently served when they are concentrated in one location. Residential care institutions became part of modern society and integral to the care system and social policy, both based on society’s understanding about people with mental disabili- ties and their needs.

By Egle Šumskiene and Dovile Juodkaite

During this period of time, institu- as a last resort when all other Let’s have a closer look at Lithua- tions were broadened, recon- services were proven to be inef- nia and its system of social care for structed, and new ones were fective. It is agreed that care must the mentally disabled after twenty built with increased numbers of be individualized and tailored to years of independence, democ- residents and a variety of services the needs of a person in care, racy and commitment to respect and employees. These changes whereas standardized, universal human rights. Since the beginning significantly improved the quality and “wholesale” provision of ser- of Lithuanian independence, the of care; however, they preserved vices is not efficient and effec- in-patient social care institutions the institutional atmosphere, tive. Paradoxically, it is a difficult inherited from the former Soviet hierarchical relations between process to develop community Union prevailed. Great numbers staff and residents, numerous hu- care in Post-Soviet countries even of people with mental disabilities man rights violations and closure though it better meets the needs of live in these large residential in- to society. These characteristics persons in care and is more cost- stitutions (social care institutions, caused residential care institutions effective and useful to individuals psychiatric hospitals) which went to be placed in the same category and the whole society. Various against the goals of de-institution- as other institutions of disciplin- authors identify three main groups alization and modern social care ary society: prisons, hospitals, of reasons influencing persistence standards, based on the principle lagers. According to Foucault of residential care system: of autonomy, consciousness rais- 1995,1 the abovementioned institu- ing, empowerment and emancipa- tions are powerful tools of control • structural reasons – general sys- tion, as well as the right to the least whose aim is to discipline human tem of social security, ineffective restrictive surrounding. behavior. Two Lithuanian authors, financing, lack of political will; Ruskus and Mazeikis 2007,2 called • external reasons – Western sup- Prior to entering the European their isolating function “social cap- port of residential care institutions Union, a total of 6,095 people with sulization.” in Post-Soviet countries; and mental disabilities, or approxi- • negative attitudes in society mately 27.5 per cent of the 22,121 During the last decades of the towards residents of social care people who declared themselves 20th century, residential care was homes, in particular, and mental- as having mental disabilities, were seriously criticized and regarded ly disabled persons in general. living in social care institutions3

1 Foucault, M. (1995). Discipline and Punish: The Birth of the Prison (A. Sheridan, Trans.). New York: Vintage.

2 J.Ruškus, G.Mažeikis. Neigalumas ir socialinis dalyvavimas. Kritine patirties ir galimybiu Lietuvoje refleksija, Šiauliu universitetas, 20 07.

3 According to the 2001 Census.

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252 MHR nr 1 2011_A4.indd 10 25-10-2011 14:43:27 tial services in the care homes for Living places, 9 Mobile Teams, 26 adults with mental disabilities, this Foster Care services, 30 “Respite” being 193 applications less than services for families providing in 2008. Approximately ¾ of those care for persons with disabilities, were accommodated in the social 30 Specialized Social services, care homes, and only 1 in 10 of 48 Educational Support services, those received care and support and 25 services of Personal As- at home or in day centers. sistance. Furthermore, 90 families will benefi t from material support To conclude, this data show only for personal space for children/ a very minimal decrease and young people in the process of change in numbers of persons reintegration into the biological or with mental disabilities being re- extended family.8 ferred to and receiving services in the long-term in-patient social Bulgaria is starting to implement care institutions during the last 10 an EC-funded pilot project aimed The photographs in this article years in Lithuania. International at developing alternative services were taken by boys released from practices and trends related to for children with disabilities. Estab- Orhei Institution for People with deinstitutionalization provide the lishment of the abovementioned Mental Disabilities arguments that community care Family Type Placement Centres is more cost effective than institu- is an important step considering tional treatment,6 as well as provid- Bulgaria’s long-term political com- in Lithuania. This group included ing better outcomes, such as qual- mitment to close large institutions. 5,217 adults in adult facilities and ity of life and respect for human Another important development 878 children living in social care rights. Nevertheless, there is still a towards deinstitutionalization was institutions for children and young huge disproportion with regards to Bulgaria’s political decision to di- people with mental disabilities. By funding allocated to the traditional rect the entire European funding January 1, 2005, there were 5349 institutional system as opposed to (20 million Euro) towards improve- persons (2882 male and 2467 fe- modern community care. ment of community services to male) and 659 children (373 boys children and families. The Bulgar- and 286 girls) 4 in state social care Authors of the report Wasted Time, ian government offi cially declared homes. For every 10,000 popula- Wasted Money, Wasted Lives ... that none of the European money tion, there were 15.3 placed in A Wasted Opportunity? 7 ask why will be invested in institutional set- social care homes.5 some countries continue to use tings. this funding to perpetuate the Data by the Department of Sta- long-term institutionalization of tistics of the Government of the people with disabilities, an invest- Republic of Lithuania disclose fur- ment that clearly does not improve ther changes in numbers of social their lives although the European care homes as well as numbers of Union has allocated the Struc- residents. In 2005 and 2006, there tural Funds to improve the lives of were 27 care homes for adults with Europeans? Several Post-Soviet mental disabilities (including intel- countries, even those poorer than lectual disabilities), with approxi- Lithuania, are taking serious steps mately 5,429 and 5,425 residents towards deinstitutionalization. For respectively. In 2007, there were example, in the beginning of 2011, 30 social care homes with 5,400 Moldova announced that in the residents; in 2008 and 2009, there next 3 years, 136 more persons were 26 social care homes with will move from the Orhei Institution approximately 5,302 and 5,279 for Persons with Mental Disabili- Unfortunately, Lithuanian social beds respectively. It is notable that ties (Moldova) to the community, policy is far from being similarly there was only a small decrease thereby benefi tting from commu- progressive. In 2009-2010, mil- in numbers in 2009 as compared nity services. In addition, new ser- lions of euros of the EU Operational to 2008. In 2009, there were 708 vices will be developed such as: Program for Promotion of Cohe- applications received for residen- 3 Community Homes, 9 Supported sion were directed to reconstruc-

4 Even after entering the EU on May, 2004, this number slightly Institutional and community-based care. Policy Brief. WHO 2005, increased, since on 1 July 2004, there were 5344 persons (2865 page 1. male and 2479 female) living in social care intitutions for adults with mental disabilities. Data received from Department of Audit 7 European Coalition for Community Living, March 2010. Wasted and supervision of social establishments, accessed at website Time, Wasted Money, Wasted Lives ... A Wasted Opportunity? http://www.sipad.lt/main/index.php?act=menu&id=57. – A Focus Report on how the current use of Structural Funds perpetuates the social exclusion of disabled people in Central 5 This number increased, since data for 1st of January 2004 and by failing to support the transition from showed that for 10 000 population there were 14,6 places in institutional care to community-based services social care homes. 8 http://www.somato.md/index.php?option=com_content&task=vie 6 David McDaid, GrahamThornicroft. Mental Health II. Balancing w&id=118&Itemid=1&lang=en

October 2011 11

252 MHR nr 1 2011_A4.indd 11 25-10-2011 14:43:27 ania. More respondents from Lith- uania than any other country felt they would fi nd it diffi cult talking to someone with a mental health problem (52%).12 Societal opinion polls in the year 2010 also reveal negative attitudes towards people with intellectual disabilities and mental health problems with this group of people considered to be the second most discriminated group in Lithuania.13

In the beginning of the 21st cen- tury, Lithuania tried to position itself as an advanced leader of the post-Soviet region successfully im- plementing integration of disabled persons to the society and devel- oping community care, thus aiming towards deinstitutionalization. The tion of residential care institutions together with people without dis- current situation of care for men- although human rights and mental abilities, guaranteeing them ap- tally disabled persons in Lithuania health NGOs reported on severe propriate social services, thus can be summarized by adapting violations happening in these set- integrating them into the society Walker’s 1997 statement:14 with the tings. These organizations initiated and eliminating stigmatizing fac- spread of community care and in- public discussion on the future of tors. It has been widely believed tegration of disabled persons into residential care and promoted the that mentally disabled people are society, we started to believe that advantages of community care. dangerous for others and that mental health reform is moving for- Such political actions infl uence restrictions on their rights can be ward and that Lithuania is a brave public opinion, which currently j u s t i fi e d. 11 and progressive country. But it is supports the existing system and enough to take a short look at any the stigmatizing attitude towards of the existing 26 care homes for mentally disabled people. One- people with mental disabilities: third of Lithuanians believe that nicely reconstructed buildings the human rights of the disabled and frightful looks of residents will received insuffi cient attention in rather remind you that it is Potem- 20049 and that the disabled were kin’s village. thought to be the second most dis- criminated social group.10 The situ- ation of the mentally disabled has Dr. Egle Sumskiene works at the been notably problematic. Opinion Vilnius University Social Work polls have shown that every other Regrettably, the attitudinal and Department. Her email address Lithuanian would prefer to isolate discriminatory approaches to- is: [email protected] or individuals suffering mental dis- wards people with mental disabili- [email protected]. abilities in institutions caring for ties have not changed at all since Dovile Juodkaite is Director of mental patients on a regular basis. 2004, when Lithuania entered the Global Initiative on Psychiatry – Vil- Sadly, only 30.8% of respondents European Union. According to the nius at M.K. Oginskio 3, LT 10219, answered that the above men- results of Eurobarometer [2010], Vilnius, tel. +370 5 2715762, fax. tioned disabled persons should there is huge stigma attached to +370 5 2715761, www.gip-vilnius.lt live in the community, at home, mental health problems in Lithu- E-mail: [email protected]

9 The Situation of Human Rights in Lithuania and Evaluation of 13 I.Saukiene „The most discriminated are retired people, Human Rights Protection System., representative public opinion and the most unfair – courts, Seimas“, available at survey (N = 1,000), conducted by Vilmorus Market Research http://www.delfi .lt/news/daily/lithuania/labiausiai- within the framework of the National Human Rights Action Plan. diskriminuojami-pensininkaineteisingiausi-antstoliai-teismas- seimas.d?id=39551833 (last accessed 07.01.2011) 10 How Does the Community Rate the Situation of Human Rights in Lithuania?. Public opinion survey, Human Rights Monitoring 14 Politicians, from the outset sensitive to the unpopularity of the Institute, 2004. image of ‘water towers and chimney stacks’ associated with asylums and institutional care, used the term ‘community care’ so 11 Human right in Lithuania. Overview 2004. Human rights frequently in the period 1948 1979 that in the public imagination Monitoring Institute, Vilnius, 2005. it was thought of as having already been achieved. Walker, A. (1997) ‘Community Care: Past, Present and Future’, in S. Iliffe 12 An average of 22% of EU27 citizens surveyed saying they would and J. Munro (eds) Healthy Choices, Future Options for the NHS. fi nd it diffi cult to speak to a person with a “signifi cant mental London: Lawrence and Wishart. disorder”. Special Eurobarometer 345 / Wave 73.2 – TNS Opinion & Social, Mental health. Available at http://ec.europa.eu/health/ mental_health/docs/ebs_345_en.pdf (last accessed 24.11.2010)

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252 MHR nr 1 2011_A4.indd 12 25-10-2011 14:43:28 The Lessons from Reforming a System of Child and Adolescent Mental Health in Lithuania

I received an email recently asking me to write an article for Mental Health Reforms about Child and Adolescent Mental Health (CAMH) in Lithuania. My colleague also mentioned that the deadline for this job was in one week. That reminded me of the time when I had the pleasure of being a part of the GIP team and I agreed to support GIP again. This article is not a deep and comprehensive analysis of the situation in Lithuanian child and adolescent mental health, but it contains my reflections and thoughts based on experience working in different countries.

By Vytautas Blazys

After regaining independence in stead of treatment in hospitals, and vide sufficient support for the most 1990, Lithuania inherited the Soviet finally Mental Health Centers were complex patients. Secondly, GPs, style psychiatric system and Child established in every administra- pediatricians, etc. were removed and Adolescent Mental Health was tive region of Lithuania. The same from providing support for young a “Two-fold Cinderella” there; psy- center usually provides services for people with mental health prob- chiatry, as such, was not a priority both adults and children. Mental lems and this had and still has very in Soviet medicine and Child and Health Centers have been function- serious consequences. In general, Adolescent Psychiatry was not a ing for around 15 years now and we it is possible to say now that it was a priority in Soviet Psychiatry as a could learn some lessons from the mistake to put CAMHS into the pri- whole. There was no place for Cin- development of these Centers. mary level, but it is difficult to move derella among her sisters. Pediatri- this service to another, for various cians, Child Cardiologists, Child Lesson No. 1 bureaucratic reasons. Pulmonologists and other “olo- Usually Community-Based Mental gists” had their clinics in Policlinics Health Services are at the second- (Out–Patient Departments) easily ary level and tertiary level of the reachable for families; but, as you health systems in other countries, > “The training and role of could guess, Child and Adolescent but, in Lithuania, the Centers were

Mental Health specialists did not created as primary level services. mental health nurses is key to have their offices in polyclinics: they This means that patients and fami-

were exiled to Psycho-neurological lies do not need a referral from their good child and adolescent > Dispensaries usually located near General Practitioner (GP), pediatri- big psychiatric hospitals. They cian, etc. to access Child Mental mental health services.” were based there, because there Health Specialists. The main idea were no small psychiatric hospitals of this arrangement was to make at all. Nobody wanted to visit these access to the Services easier for places because everything related users. At first, we considered this Lesson No. 2 to mental health was greatly stig- to be a very progressive step, but Child and Adolescent Mental matized in Soviet society. later on we saw that it did not work Health Services were developed in very well. Firstly, there was no gate every administrative region of Lithu- After March 1990, some enthusi- keeper to the services; for this rea- ania, following a tradition that every astic mental health specialists de- son, there was quite a long waiting region should have its own special- cided to reshape the mental health list for some services. This system ists in different areas to provide system in Lithuania. One of the main also created a temptation for clini- easier access to the service for ideas was to develop Community- cians to work for a long time with families. But the consequences of Based Mental Health Services in- less complex patients and not pro- this design were detrimental to Lith-

October 2011 13

252 MHR nr 1 2011_A4.indd 13 25-10-2011 14:43:29 uanian CAMHS. Outpatient mental As there is a lack of collaboration thought that it would take around health services are financed by “per between mental health and other five years to achieve the main capita” rule in Lithuania, as in many agencies - social services, schools, changes and in 10 years’ time, the other countries; however, this didn’t etc. - other professionals do not reform would be fully completed work well for children and adoles- know what CAMHS can or cannot and we would have a new system cents because that population of do. This could lead to black and of Mental Health. Yes, many things the catchment area is so small that it white thinking. Colleagues from have changed dramatically since is not possible to have a multidisci- these agencies could think that if a 1990, but there has been only plinary team for young people since child has mental health problems, slight progress in some areas; and the money coming to the service by the CAMHS can do everything and there is still a lot to do to improve the “per capita” rule is not sufficient. there is no need for their additional the system of child and adolescent In many rural areas of Lithuania, the involvement. In fact, children and mental health in Lithuania. And this CAMHS consists only of 0.5 WTE of young people with mental health is another important lesson from child and adolescent psychiatrists problems need more support than our experience – (Lesson No. 6) for this reason. Understandably, this other children. Here is another les- to change the system usually takes “service” cannot deliver appropriate son (Lesson No. 3) from the more time and resources than ex- support for young people. Lithuanian experience – do not pected and you need to have com- blame your colleagues from child mitment and patience to achieve protection services and education, your goals. but educate them and collaborate with them.

> “Most professionals are excel- Another issue related to the child Dr. Vytautas Blazys is Consultant

lent clinicians but they work in and adolescent mental health sys- Child and Adolescent Psychiatrist, > tem in Lithuania is a “psychiatriza- Ayrshire and Arran CAMHS, UK. tion” of it. Usually even non-medical His email address is an inefficient system.” treatments - different psychological [email protected] . therapies are delivered only by psy- chiatrists. But trained nursing staff and/or social workers could deliver A small CAMHS with no resources many of the evidence based thera- has a negative impact on in-patient pies - Cognitive Behavior Therapy, child and adolescent departments. Family Therapy, etc. This could al- Mental health centers are not able low for easier access for families to provide proper services for their to nonmedical (“talking”) therapies patients and they are referred for and it could help save money as in-patient treatment far from their well. homes and families - not because they need in-patient treatment, but Lesson No. 4 because there are no out-patient So, if you want to have an effective resources in the community. This is CAMHS, revise the role and train- not only a clinical or ethical issue, ing of mental health nurses in your but a serious financial problem also. country. The in-patient treatment in child and adolescent psychiatry is very ex- A big surprise for reformers was pensive and that means that if you that not all people in Child and do not have an adequate and rela- Adolescent Mental Health Ser- tively cheap out-patient treatment vices wanted to see changes in the option, you must pay much more system and this was a significant for in-patient treatment. For those obstacle. Some professionals felt trying to develop CAMHS in their that they were doing a good job countries, it very important to avoid and they did not think they needed these mistakes. to change anything. And they were right to some extent – they were Communication with colleagues excellent clinicians, but they were from outside CAMHS (Social Ser- placed in an inefficient system. vices, Child Protection agencies, schools, etc.) is an essential part Lesson No. 5 of CAMHS work, but it takes time. It is very important not to criticize Do clinicians have time for this? No, your colleagues but, rather, criticize they do not. Why? Simply because the system and try to explain your senior managers or clerks from the goals to the colleagues who are Ministry of Health do not know the doubtful about the reforms. specifics of CAMHS work. Thus, it is very important to educate them if Almost 20 years have passed since one wants to try to develop services we started reforms in Mental Health for young people in your countries. in Lithuania. Enthusiastic reformers

14 MentalHealthReforms

252 MHR nr 1 2011_A4.indd 14 25-10-2011 14:43:29 Interpretation and Implementation of the International Human Rights Standards in Lithuania

By Dovile Juodkaite

Starting with the adoption of the Every UN member state is a party an active member of the United Robertas Universal Declaration of Human to one or more of the nine major Nations and European Union, and, Povilaitis (l) Rights in 1948, the United Nations human rights treaties, thus the thus, pursued the main purposes and Dovile set a strong human rights treaty sys- universal human rights legal sys- and principles of both of these Juodkaite (r) tem which clearly established the tem applies to virtually every child, international organizations - includ- at the 10th legitimacy of international interest woman, or man in the world. ing encouraging respect for human anniversary of in the protection of human rights. rights and fundamental freedoms GIP-Vilnius With respect to human rights, the Since 1991, when Lithuania re- for all. sovereignty of the separate states gained its independence, there is limited and international supervi- were a lot of changes and demo- Lithuania has ratified most major sion is valid for the states that be- cratic reforms carried out in the international human rights instru- come accountable to international society. New and amended legisla- ments, including those with provi- authorities for domestic acts affect- tion was adopted that established sions relating specifically to the ing human rights. At the moment, the basis for a democratic state, as rights of people with disabilities.2 the UN human rights treaty system well as guarantees and protection It acceded to the International encompasses nine major treaties.1 for its citizens. Lithuania became Covenant on Economic, Social

1 the Convention on the Elimination of all forms of Racial Their Families (in force 1 July 2003); Convention on the Rights of Discrimination (in force 4 January 1969); the International Persons with Disabilities (in force 3 May 2008); the International Covenant on Civil and Political Rights (CCPR) (in force 23 March Convention for the Protection of all Persons from Enforced 1976); the International Covenant on Economic, Social and Disappearance (in force 23 December 2010). Cultural Rights (in force 23 March 1976); the Convention on the Elimination of all forms of Discrimination Against Women (in 2 EUMAP report “Rights of People with Intellectual Disabilities. force 3 September 1981); the Convention Against Torture, and Access to Education and Employment. Lithuania”, Vilnius, 2005. Other Cruel, Inhuman or Degrading Treatment or Punishment (in force 26 June 1987); the Convention on the Rights of the Child (in force 2 September 1990); the International Convention on the Protection of the Rights of All Migrant Workers and Members of

October 2011 15

252 MHR nr 1 2011_A4.indd 15 25-10-2011 14:43:30 and Cultural Rights (ICESCR) and mechanisms for the prevention not totally correspond to interna- the International Covenant on Civil of torture in places where people tional human rights standards. This and Political Rights (ICCPR), both are deprived of their liberty at the insufficient compliance is due to protecting all people against dis- domestic level. OPCAT, for the first the ongoing inappropriate prac- crimination. Lithuania ratified the time on an international level, es- tices of guardianship, involuntary Convention on the Rights of the tablished requirements, criteria and hospitalization and treatment, and Child, which specifically talks about standards for the effective national legal representation of persons mentally or physically disabled chil- preventative human rights monitor- with mental disabilities, etc. dren and their rights. It has ratified ing. Such a mechanism is an in- the European Convention on Hu- novative element of human rights man Rights (ECHR), as well as the systems, since currently human Dovile Juodkaite is Director of revised European Social Charter, rights mechanisms and institutions Global Initiative on Psychiatry – thus becoming bound by its Article are more of a reactive nature. OP- Vilnius at M.K. Oginskio 3, LT 10219, 15 on the rights of persons with dis- CAT also very clearly indicates that Vilnius, tel. +370 5 2715762, fax. abilities. It has also ratified both the human rights protection is primarily +370 5 2715761, www.gip-vilnius.lt. UN Convention against Torture, and a national responsibility of states, E-mail: [email protected] Other Cruel, Inhuman or Degrading which should be implemented by Treatment or Punishment (UNCAT), the establishment of independent as well as the European Convention national protection systems. for the Prevention of Torture and In- human or Degrading Treatment or International organizations respon- Punishment. In 2010, Lithuania also sible for human rights and protec- ratified the UN Convention on the tion against torture, inhuman and rights of persons with disabilities degrading treatment or punishment and its Optional Protocol (CRPD),3 have more than once recommend- thus bearing all legal obligations ed that Lithuania establish an inde- under this Convention. pendent human rights monitoring mechanism.5 Nevertheless, Lithu- ania has not taken these recom- mendations into account. Success- “International human rights ful implementation of the human > rights treaty standards depends organizations have, more than very much on their accessibility to the victims of human rights abuse. once, recommended that This means both familiarity with the standards and access to remedial Lithuania establish an an mechanisms. According to society’s

opinion polls, there is still a lack of

understanding and awareness independent human rights > about human rights and protection monitoring mechanism.” possibilities throughout Lithuania. Society’s opinion poll performed in 2010 revealed that 54 percent of re- spondents have information about Nevertheless, there still remain their rights. Nevertheless, 48.5 important international treaties not percent of respondents indicated yet ratified by Lithuania. Although that they didn’t know what actions under the obligation with regards to to take if their rights were violated.6 prohibiting any kind of inhuman and It is logical that people with disabili- degrading treatment or punishment ties have even less knowledge and under the UNCAT, Lithuania has not awareness about these issues than yet acceded to its Optional Proto- the general public. Thus, it can be col of 2002 (OPCAT).4 This means concluded that the human rights that Lithuania is not bound by the situation and national legislation of obligations laid down in OPCAT for Lithuania, especially with regards creation of independent national to persons with disabilities, does

3 Law on ratification of UN Convention the Rights of Persons with Lithuania carried out by the European Committee for the Disabilities and its Optional Protocol // State news, 2010, No. Prevention of Torture and Inhuman or Degrading Treatment or 67-3350. Punishment (CPT) from 17 to 24 February 2004 and from 21 to 30 April 2008. Available at: http://www.cpt.coe.int/documents/ltu 4 Optional Protocol to the Convention Against Torture, and Other Cruel, Inhuman or Degrading Treatment or Punishment 6 Saukiene “The most discriminated are persons of retirement of 2002, that entered into force in 2006, after first twenty states’ age, the most unfair – court, Seimas,“ available at: http://www. ratifications. delfi.lt/news/daily/lithuania/labiausiai-diskriminuojami-pensininkai- neteisingiausi-antstoliai-teismas-seimas.d?id=39551833 (last 5 CPT reports to the Lithuanian Government on the visits to accessed 04.01.2011).

16 MentalHealthReforms

252 MHR nr 1 2011_A4.indd 16 25-10-2011 14:43:30 Lithuanian Psychiatric Association – 1990 Goals vs. the Current Situation

By Dainius Puras

Lithuania experienced amazing health policies and services. One My interpretation is that the psychi- times in 1989-1991. The pervasive of the first tasks of the new Board atric profession has decided, at this fear of 50 years of dictatorship was to evaluate the extent of politi- moment of its development in Lithu- disappeared and the entire nation cal abuse of psychiatry in Lithuania ania, to take from modern psychia- seemed to have wings, willing to during Soviet years. Although this try only one component, and this is reestablish its own country and to idea was not accepted by some modern psychopharmacotherapy, build democracy. Needless to say, of the leading psychiatrists, some and not to change the culture of psychiatry had a lot to rethink and fragile consensus still was found. mental health services from the change after being a part of Soviet During one of the next Congresses, pattern of paternalistic approach psychiatry for 50 years. Separation the decision was made by the LPA to patients and the pattern of psy- from the All-Union Society of Psy- that political abuse of psychiatry chiatry having power over the other chiatrists, Neurologists and Nar- did take place in Lithuania during stakeholders. This is why the LPA cologists was not that easy as Soviet rule. Interestingly, this deci- has not been on the side of human many leading Lithuanian psychia- sion was made by voting, as it was rights activists when the issues of trists had been very close to the impossible to reach consensus. violations of human rights in psychi- Moscow school of psychiatry. While Even more interestingly, the next atric institutions have been raised. many other professional groups vote was on whether or not the LPA Also, the LPA voice is not heard in (such as, for example, psycholo- regrets and apologizes about the the current situation when modern gists or architects) in Lithuania facts of political abuse of psychia- principles of mental health care are separated from Soviet structures try, and the result of this vote was ignored by the Government and quickly and without any hesitation, “no.” institutional care is strengthened for Lithuanian psychiatry it took instead of moving to deinstitutional- some more time. The First Found- These first several years of the LPA ization policies. ing Congress of the Lithuanian Psy- activities were marked by the spirit chiatric Association (LPA), which of democracy and hot debates, The current situation in the Lithu- took place on January 13, 1990, with an open and enthusiastic anian Psychiatric Association does appeared to be unsupported by search for truth and the way to go. not resemble, in any way, the spirit the majority of psychiatrists in Lith- However, this spirit started to fade of the LPA during the first years. uania (only about 40 professionals away in the end of the 1990s, and This may be not surprising as we attended, or about 10-15 percent), this kind of unexpected regressive watch similar signs of disappoint- but the basic problem was that development continues through the ment and nostalgia for the years of the elite of psychiatry (academic first decade of the 21st century. It communism among a large portion leadership and directors of psychi- is my subjective view that opportu- of the population in Lithuania. It atric hospitals) were reluctant. But nistic tendencies have dominated is likely that psychiatry is not very political events were developing in the activities of the LPA, with the different from the society at large; 1990 with such enormous speed increasing role of pharmaceuti- or, to say it in other words, society that after 4 months, on April 7, the cal companies and the lack of will has the psychiatry that it deserves. Founding Congress of the LPA took among the psychiatric community Hopefully, both society and psy- place in Vilnius with almost univer- of Lithuania to develop the culture chiatry will have a new stage of sal attendance of psychiatrists. of self-regulation so that high ethi- progressive development in the cal standards could become the nearest future in Lithuania. I was elected President of the LPA highest priority for the members at this Congress. My vision was of the LPA. During the last con- very clear. We needed to reestab- gresses of the LPA, there were no Dainius Puras is Head and Associ- lish the reputation of the psychiatric open discussions about the most ate Professor of the Centre of Child profession through open dialogue controversial aspects of the psychi- Psychiatry and Social Paediatrics at with society and with the new gov- atric profession during the period of Vilnius University. He is the Chair- ernment, and to move to develop transition in Lithuania, and the pro- man of the Board of GIP-Vilnius. modern mental health services grams of the LPA meetings have Dr. Puras is a Member and expert based on the principles of protect- been dominated by presentations of the UN Committee of the Rights ing human rights of mentally ill peo- on effective psychotropic medica- of the Child. His email address is: ple and evidence-based mental tions. [email protected]

October 2011 17

252 MHR nr 1 2011_A4.indd 17 25-10-2011 14:43:30 Policy Study on Prevention of Suicide in Lithuania

Introduction: Lithuania’s The problem of suicide in Lithuania is a serious and enduring crisis that has not yet been resolved in over 20 years since independence from the Soviet Union. Lithuania is home to the world’s highest suicide rate. In 2009, for example, there were 31.5 suicides per every 100,000 people. Lithuania’s suicide rate is triple the average of the European Union of 10.1 per 100,000 and twice the average of the region. Every year since the early 1990s, there have been over 1,000 suicides in a country of only 3.4 million, with the suicide rate for men seven times higher than women (58.5 vs. 8.8), especially be- tween 30-49 years of age and living in rural areas. This policy study carried out in 2009-2010 adopted quantitative comparative analysis as well as qualitative analysis from interviews with national experts on mental health policy. Dr. Dainius Puras, ex-Dean of Faculty of Medicine, Vilnius University, former President of Lithuanian Association of Psychiatrists and co-author of Lithuania’s 2004 emergency suicide bill, describes the state of suicide in Lithuania: “It’s an epidemic,” he says. “If it wasn’t suicide, but an infectious disease that was killing over 1500 people a year…the government would spend millions…There is a lot of cynical thinking in Eastern Bloc countries, that it is maybe better to let the weak die.”1 However, despite the world’s highest suicide rates and clear evidence that the phenomena is relatively new to Lithuanian society, there has been no concerted mental health policy effort to reduce the suicide rate to lower levels over time. Therefore, this article shall examine two questions: Why did suicide emerge as a major problem in Lithuania over the past twenty years and why has the government not done much more to prevent suicides?

By Ramon J. Pebenito Jr. and Arunas Germanavicius

Trends - 1924-2009 However, from the onset of formal is still larger than the pre-transition A review of Lithuania’s suicide mor- Lithuanian Independence in 1991, suicide rate of 26/100,000. More- tality statistics firmly establishes the and the beginnings of political, over, it presents an alarming new recent trend of extremely high rates social, and, most significantly, eco- trend after years of decline. This as a new phenomenon emerging nomic transition, an explosion in the new trend is likely related to the from the transition period of the Lithuanian suicide rate occurred. ongoing economic crisis, which 1990s with no roots in broader Lith- From about 26 per 100,000 in began in Lithuania in 2007-2008 uanian history. According to Danute 1990, suicide rates nearly doubled and persists to this day. Gailiene, the suicide rate during the to about 47 per 100,000 in 1996. Pre-War Independence period was Suicide mortality is most prevalent Causal Factors 8 per 100,000. During Soviet occu- among males, particularly among For an issue as complex as suicide, pation the suicide rate increased to rural middle-aged to elderly males. a number of possible explanations 16 per 100,000 in 1962 and later to The latest Eurostat figures show exist. However, scholars in the field 36/100,000 in 1984. However, much a steady decline in suicide rates of sociology going back to Emile of the increase is from 1970–1984, followed from 1995-2007. This Durkheim and health experts in the during which time the rates grew by ended in 2007 with a suicide rate of present day generally agree that 44.6%. With the beginning of the 28.4/100,000. From 2007 to 2008, economic and social disruptions Perestroika period, a sharp decline suicide rates increased to 30.1, and usually have an adverse effect was observed in 1986, from 36 per the suicide rate increased again for upon a society’s suicide rates. Lith- 100,000 to 27 per 100,000 by the 2009 with a rate of 31.5/100,000. uania is no exception. Many schol- beginning of Lithuania’s regained While this rate is smaller than the ars have observed that Lithuania’s Independence.2 all-time peak of the mid-1990s, it difficult socio-economic transition

1 Webster, Jason. “Lithuania’s ”. Insight News 2 Gailiene, Danute, “Vicious Circle: Suicides in Lithuania After TV. Insight News Television Ltd. 2004. Accessed April 22, 2008 Independence”. Psichologia, 2005. Accessed February 15, 2011 http://www.insightnewstv.com/d74 http://www.leidykla.vu.lt/fileadmin/Psichologija/31/7-15.pdf

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252 MHR nr 1 2011_A4.indd 18 25-10-2011 14:43:30 Policy Study on Prevention of Suicide in Lithuania

from living under Soviet occupation of helplessness, and social exclu- favored slower privatization of in a command economy towards sion.”3 Suicide and other forms of state-owned enterprises and more democracy and a market-based external mortality also increased deliberate liberalization of trade economy likely contributed to the throughout the former Soviet Union and price controls, Lithuania and massive increase in suicide rates during the 1990s, but not to the ex- the other Baltic countries adopted throughout the 1990s transition tent of Lithuania. What accounts for a radical and swift transformation period. this variation? that caused considerable social stress, anxiety, and hopelessness For example, Eidukiene unambigu- After the fall of the Soviet Union, Lith- among its people. As these reforms ously cites the suicide crisis as in- uania and the other Baltic countries were implemented, unemployment fluenced in large part by “the state embarked on an extremely rapid, and inflation exploded.4 Lithuania’s of anomie in contemporary society, Neo-Liberal economic transition first independent government was conditioned by decades of Soviet program to move from communism so unpopular as a result of these occupation and the dramatic transi- to capitalism. Lithuania, Latvia, and reforms that, in 1992, they lost a tion period,” adding “the exception- Estonia’s “shock therapy” approach parliamentary election to a party ally high suicide rate is a symptom was directly contrasted by the more dominated by former communists, of society’s anomie[...] The period gradual reforms of other post-com- led by Mr. Algirdas M. Brazauskas. of radical reforms which Lithuanian munist countries, like those in the society is still experiencing is bring- Caucasus, or neighboring Belarus, Budrauskaite, et al, place the ing about a crisis of values, togeth- Ukraine, or ex-Satellite countries Lithuanian state at the center of er with increasing psychological such as Romania and Bulgaria. its speedy economic transforma- and social insecurity and feelings While these gradual countries tion: “The government of Lithuania

3 Lithuanian Human Development Report 1998. State and Human 4 Svejnar, Jan. “Transition Economies: Performance and Development. United Nations Development Program, 1998 p. 78 Challenges.” The Journal of Economic Perspectives Vol. 16, No. 1, (Winter, 2002) p. 16

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252 MHR nr 1 2011_A4.indd 19 25-10-2011 14:43:31 planned to achieve a radical struc- psychosocial interventions, com- pecially rural men, and an overall tural change in ownership and a munity based approaches, and GP systemic transformation towards rearrangement of the institutional involvement in public health.”6 community-based solutions. How- structure. Priority was given to the ever, these recommendations are adjustment of the legal framework Likewise, the role of the general not new. Reformers in the country for functioning of a market economy, practitioner/family doctor is mar- as well as international groups like liberalization of prices, privatization ginalized in the Lithuanian health the WHO have long-criticized the of enterprises and liberalization of system. General practitioners are health system in Lithuania. The total trade and external sector.”5 Despite poorly-paid, under-trained, and absence of political will among poli- these vast changes in the economy often un-incentivized to diagnose cymakers to challenge the powerful and the new experience of mass and pro-actively help patients who health system establishment and unemployment for Lithuanians, no may suffer from mental illnesses confront medical elites at the larg- corresponding social outreach pro- est institutions grams were developed to facilitate has created a socially cohesive transformation paralysis at the from the communist system to the > “Lithuanian reformers and policy reform intense competition, uncertainty, international organizations, level. There can and instability of emerging capi- be no long-term talism. During the early transition including WHO, have long solution to the

period, many were left vulnerable suicide crisis in

and felt excluded from the new criticized the health system Lithuania until Lithuania, and inevitably turned to > this political will alcohol. The seminal 2009 Lancet of Lithuania.” emerges. article by Stuckler, King, and Mc- Kee, “Mass Privatization and the Post-Communist Mortality Crisis: a Cross-National Analysis,” helps like depression, alcoholism, or from Ramon J. Pebenito Jr. was a 2009- establish the acute sensitivity that physical illnesses such as cardio- 2010 Fulbright U.S. Student Fellow health outcomes in the transition vascular disorders. Many GPs sim- to Lithuania and was affiliated with economies of the former Soviet ply refer their patients to specialists the Clinic of Psychiatry, Faculty of Union and Communist Bloc bear in large hospitals. Lithuania’s sui- Medicine, Vilnius University. He towards macroeconomic transfor- cide rate is the world’s highest, but holds a Master’s Degree in Po- mations. it is also among Europe’s leaders litical Science from George Mason for external mortality, mortality from University, Fairfax, Virginia, USA. The Absence of Suicide heart disease, circulatory illness, He is currently a Master’s Degree Prevention Policies and certain forms of detectable candidate in the field of global po- The abject failure of the Lithu- cancer. Yet, despite the clear fail- litical economy and finance at the anian government to put forth a ings of the health system and the New School for Social Research systematic policy response to the potential to reduce avoidable mor- in New York City, New York, USA. ongoing suicide crisis in the coun- tality from suicide, heart disease, Email: [email protected]. try is directly tied to its failure to and cancer using evidence-based Arunas Germanavicius is Assoc. comprehensively reform its national interventions at the municipal level, Professor at the Clinic of Psychiatry health system. In many ways, the government resources continue and at the Public Health Institute, Lithuanian health system strongly to prioritize large institutions, both Faculty of Medicine, Vilnius Univer- resembles the defining characteris- somatic and psychiatric. sity, Lithuania. tics of Soviet times: inefficient, cor- Email: [email protected] rupt, and organized on the biomed- In conclusion, in ical principles of epidemiological Lithuania is a priority of the highest containment of infectious diseases. order. The steps required to lower Germanavicius observes, “Despite the suicide rate in the long-term are sporadic efforts […] the direction clear: stronger GP involvement in of investments remains based on mental health to detect depression historical principles: emphasis on and alcohol, larger public invest- psychiatric institutions, medica- ment in public health and social tions, and social exclusion […] outreach programs to provide neglect of public health approach, support for vulnerable groups, es-

5 Budrauskaite, Aline, Jypara Mamytova, Katarina Mlinareviæ, 6 Germanavicius, Arunas, Dainius Puras. “Case Lithuania: and Alla Savina. “Trade Policy and Economic Growth: Cases of Current Situation and Future Prospects of Mental Health Care Belarus and Lithuania.” Privredna Kretanja I Ekonomska Politika Reform.” Psychiatrisch centrum Sint-Hiëronymus. 2005. Date No. 90 (2002) p. 74-76 accessed: Nov. 3, 2008. http://www.hieronymus.be/documenten/ Germanavicius.pdf

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252 MHR nr 1 2011_A4.indd 20 25-10-2011 14:43:31 Empowerment Strategy for Mental Health Care Users in Decision Making (Lithuanian Experience)

These authors conceptualize the nature of empow- erment as the transformation of mental health care users from a position of slavery (where users have no rights to their own opinions) to an empowered position, where they are treated as respectable partners in the system. This concept includes all aspects of the mental health care system, including rehabilitation, social integration and participation in decision making at all levels. There are two aspects of empowerment – the individual aspect and organi- zational (institutional) aspect.

By Arunas Germanavicius and Saulius Peciulis

The most important factor of indi- seven members and meets twice vidual empowerment is the fulfill- a month. The concept of Patient ment of all personal rights, fixed councils in Lithuania is imple- > “Sadly, there is still no in national law and strategy of the mented by consultation of mental improvement of the mental health health users from the Netherlands. strategy for Lithuanian mental care system. These personal rights A good first step in user empower-

include the participation in decision ment is the participation of users’ health services to include users

making about treatment of each representatives on the Board of mental health care user. A major the hospital. Only an independent in planning, implementation > problem in Lithuania is the fulfill- Patient council has the real capac- and monitoring services.” ment of the right of user to defend ity to be heard by professionals him/herself in court when decisions and to elaborate on the most quali- are being made about compulsory fied proposals for improvement of treatment (this right is fixed in na- services at the hospital level and by users groups in Lithuania of tional law, but almost never works even more – at the level of national long term care facilities for severely practically). policy and international practices. mentally ill people showed that This means that users should be none of the six institutions had us- Institutional aspects of empower- regarded as professionals, should ers’ councils despite the official le- ment include working with users or- have job descriptions, and receive gal requirements for such councils ganizations. In Lithuania, there are payments for their expertise. This in social care homes. (“The Cata- two types of users’ organizations: latest thesis was never implement- logue of Social Services” and “Nor- 1) Self-help organizations, which ed in Lithuania and has hardly been matives for Social Care Homes”) are active in rehabilitation and so- acknowledged even in developed (Samsanaviciute Zina et al., 2005; cial integration (patients clubs are democratic health and social care internet reference: http://sena.sam. counted here); and systems. lt/lt/main/news?id=76377 ). A year 2) Patient councils, a more ad- later, a human rights monitoring vanced form of organization, which The Lithuanian experience shows project found that only a very small represents the rights of users and that empowerment of users through number of institutions visited do is elected by all patients of a men- the patient council concept is one have such Patient councils (inter- tal health care unit. In Vilnius, the of the best possible ways of em- net reference: http://jga.lt/uploads/ mental health care center (Vasaros powering users in participation of studijos/zmtesiu_stebejimo_uz- str. 5, Vilnius) Patient council has decision making. However, local darose_inst_ataskaita.pdf). A plau- five years of experience working data shows that its implementation sible relationship was hypothetical with the hospital administration and is very slow. A study of human rights between a better quality of care other professionals. It consists of and conditions of care undertaken and existence vs. an active role of

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252 MHR nr 1 2011_A4.indd 21 25-10-2011 14:43:32 patients in users’ councils, but was never proven in a scientific way. It is also important to note that often administrations of such institutions do not understand practically the positive role of users’ councils and the concept of users’ involvement remains only on paper.

It is regrettable that after 20 years of independence, Lithuanian men- tal health care services do not have a general strategy for ways that mental health care users could be active partners in planning, imple- menting and monitoring services. VASAROS Professionals still maintain very LIGONINE defensive positions about differ- ent roles in services by splitting traditionally into service providers and service recipients (Lithuanian Psychiatric Association has de- leted patient rights and wellbeing protection from the aims of the statute of this organization). Mod- ern concepts of social psychiatry that emerged in the United States, Western Europe, Australia and oth- er progressive places around the globe, has had almost no influence on mental health services in Lithu- ania. Only slight and very formal shifts towards users’ involvement have been observed (e.g. Ministry VASAROS of Health/Ministry of Social Welfare and Labor sometimes invites rep- resentatives of user organizations LIGONINE during the preparation of some legal documents; some user or- Vasaros ganizations have been involved in Hospital before the committee deciding on the list and after the of state-reimbursed medications, renovation but it is frequently manipulated by pharmaceutical companies and movement that could enhance professionals). That is why mental transition of Lithuanian psychiatry health care users’ organizations in towards modern social psychiatric Lithuania still remain weak, scat- community-based services. Also tered and do not have a strong we hope that this example might be voice in decision making. We defi- useful for other countries, especial- nitely believe that if the Lithuanian ly with similar cultural and historical users’ movement was strong, the experiences. usage of European Union structural program finances for modernizing Dr. Arunas Germanavicius is As- Lithuanian psychiatric hospitals in sociate Professor at the Clinic of 2009-2011 would not be allocated Psychiatry and at the Public Health for buying ECT (electro-convulsive Institute, Faculty of Medicine, Vil- treatment, so-called electroshocks) nius University, Lithuania. Email: machines or for observational video [email protected]. Dr. cameras. Saulius Peciulis was a Senior Re- We still believe that some of these searcher at the Clinic of Psychiatry first positive examples of user at Vilnius University. (See obituary involvement and empowerment on page 27.) in Lithuania (users’ clubs and councils) might develop into a na- This article was never published tionwide consortium or umbrella before. It was written shortly before organization, and a productive the death of Dr. Saulius Peciulis.

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252 MHR nr 1 2011_A4.indd 22 25-10-2011 14:43:33 Development of Patient’s Person of Trust (POT) Program in Lithuania

The idea of POT position came from the Netherlands where it has been working since 1982. After be- ing modified and adapted for the Lithuanian situation, POT started its activity in Vilnius in 2006, under the coordination of GIP-Vilnius office. POT services are included in the Vilnius City Mental Health Strategy and financed from the Vilnius city council sponsored health program.

By Ruta Juodelyte

Ruta Juodelyte (L) and Klementina Gecaite (R).

Ruta Juodelyte and Klementina Gecaite are patients’ persons of trust. Email: paciento. patiketinis@ gmail.com The purpose of POT is to create full support of the client in his/her During the years of implementation, and establish a representative relation with the healthcare institu- POT has proved to be successful model of mental health service us- tion. The person of trust assists the and necessary for both – mental ers’ rights protection. POT is seek- patient in realizing his/her rights by health service users and in-patient ing equal opportunities for persons performing three essential func- and out-patient mental health ser- with mental health problems to tions of the position: (1) mediation vice providers in seeking mental integrate into society and contrib- and representation in case of com- healthcare services of better qual- ute to construing a chain of mental plaints (2) provision of information ity and respectful for human rights. healthcare services in Lithuania on patient’s rights and (3) identifi- For more information please contact according to the priorities adopted cation of the shortcomings in pro- [email protected] in National mental health strategy: viding mental healthcare service. or call +370 5 2715760. (1) guarantee of human rights, (2) provision of services that meet pa- tient‘s needs, (3) encouragement of autonomy and participation, and (4) > Persons of trust have been successful for strengthening of patients, their fam-

ily members and nongovernmental users and providers in seeking a quality

organizations. mental health care system with respect for > Essential features of the POT posi- tion are independence from mental human rights. healthcare institutions and the

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252 MHR nr 1 2011_A4.indd 23 25-10-2011 14:43:33 Primary Mental Health Care in Lithuania

Since 1996, 80 community mental health centers have been established in Lithuania that work at

the community medicine level and are controlled by the municipality. Psychiatrists are the key people

at these centers. On January 1, 2006, there were 224 psychiatrists, 110 medical psychologists,

160 clinical social workers, and 220 mental health nurses working in these centers. The population

of Lithuania is approximately 3.5 million in 10 districts and 60 municipalities.

By Eugenijus Mikaliunas

The goals of these centers are as The benefit of this growth of the The positive aspects of this system follows: mental health center movement is are: A. To educate families as to how to evident: • People can consult with a psychi- live with the patients; • The quality of services improved atrist without waiting for a referral B. To prepare the community to ac- as provided by teams of mental from the general practitioner, cept the patient, thereby reduc- health specialists. thereby decreasing stigma and ing the stigma in the community; • The disease diagnostics improved avoiding delay in treatment; and and were quicker; treatment and • Psychiatrists diagnose diseases C. For psychiatrists to establish the rehabilitation also improved. more accurately and faster than modes of operation for this new • There are expanded possibilities other professionals. strategy. to get consultation not only from psychiatrists, but also from medi- The mental health centers are pro- If these goals could be accom- cal psychologists, clinical social gressive; but, also, substantially plished, the treatment results would workers, mental health nurses, expensive compared with services increase. The main tasks for the and, in some cases, from psy- extended by the family doctor. psychiatrist working in a commu- chotherapists and rehabilitation nity based mental health center in specialists. Lithuania are as follows: • Psycho-neurological dispensa- A. To diagnose mental disorders; ries didn’t do follow-up care; no B. To prescribe drugs (if necessary); one provides follow up care. > “Mental health centers are C. To consult with the families of • There is a positive influence over

patients; patients and staff on stigma re- progressive but substantially

D. To provide instructions and con- duction. sultation with the psychologists, • There is close contact with the more expensive than the > nurses or social workers related family doctor in the team. In the services of the family doctor.” to the treatment; and future, such work will be funda- E. To provide strategies for preven- mental and work closely with day tion of mental disorders. hospitals, rehabilitation centers, patient’s societies, clubs, pa- The center psychologists do the tient’s families clubs, vocational The pro-capita financing system for psychological diagnostic work and rehabilitation centers and other primary mental health care relates provide psychological assistance community services. to the costs based on the number to the patients, as ordered by the • The result of such work is that the of individuals living in a particular psychiatrists. number of beds will decrease in catchment area, rather than on the psychiatric institutions. volume or content of service. The

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252 MHR nr 1 2011_A4.indd 24 25-10-2011 14:43:33 benefit of the pro-capita financing This work is certainly needed; one system is that the entire Lithuanian suggestion is that the mental health

population, without exceptions, can center coordinates the work but > Day rehabilitation outpatient access mental health services in that public health officials would do

an emergency situation and those the actual work. centers should be established > individuals with health insurance have the possibility of access- Some primary mental health care near mental health centers. ing a wide variety of ambulatory centers are legally and financially services. On the other hand, the independent, but the majority are disadvantage is that this financial dependent on polyclinics. This system may discourage a higher independence question depends treatment in order to evaluate quality and quantity of work. on the intentions and initiative. It is their effectiveness. likely, in my opinion, that the situa- In addition to treatment issues, psy- tion will remain the same as it is at There are about 400 psychiatrists chiatrists in primary mental health present because those who are in in Lithuania, half of them working care in Lithuania are responsible for favor of independent mental health at the community based Mental ensuring public safety (e.g., issuing centers have already eastablished Health Centers and the other half at permissions and health certificates them, while those who don‘t want inpatient services. Thus, there is a for fitness to drive a car, own a the independence will prefer the balance; and every service, at the weapon, etc.) and prevention of status quo. If a change is to be time of state transformation, devel- mental disorders. In Lithuania, both made, the persons with the interest oped its field in accordance with the family doctor and mental health would be responsible for imple- available reserves and finance. In center psychiatrists are responsible menting this change. Europe, psychiatrists with equal for these work tasks. All information professional preparedness gather about an individual’s health history The next steps of this strategy are: different experiences, depending received from the family doctor and • To establish rehabilitation day on whether one works in a wealthy treatment institutions is stored at the outpatient departments (centers) or developing country, whether in work place of the specialist. In the near these mental health centers, outpatient or inpatient services. future, it would be better to gather where the multidisciplinary team this information and prophylactic would give psychosocial rehabili- Professor Eugenijus Mikaliunas health control would be easier by tation services; is the Director of Siauliai hospi- establishing e-health projects. In • Psychiatrists, working with the tal branch mental hospital, M. K. the future, specialists from public team, will prescribe not only psy- Ciurlionio g. 12, Šiauliai, Lithuania. health offices should be working on cho-pharmacological treatment, Tel.: +370 41 524181, the prevention of mental disorders. but also alternative methods of e-mail: [email protected]

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252 MHR nr 1 2011_A4.indd 25 25-10-2011 14:43:34 Primary Care Systems in Lithuania: the Role of Psychiatrists

Lithuania has witnessed a substantial increase in community mental health care centers over the

years. This has served as a good stimulus for the move from predominantly in-patient mental health

care of past years.

By Robertas Bunevicius

However, this move has created two parallel primary care systems, one for general medicine and an- other for mental health, thus seg- regating psychiatry from general medicine at the primary care level. The system limits the involvement of primary care (family) doctors in mental health and causes the sta- for such activities, these specialists tus of psychiatrists to be vague. If may provide considerable profes- they are working in primary mental sional expertise in these fields. > “A deeper integration of

health centers, they may be treated Public health centers and public

as primary care physicians; if they safety institutions should provide community medicine and mental are working in secondary or tertiary such services but could call on the > level facilities, they are treated as specialists when needed. health care is needed.” specialists. A significant percent- age of psychiatrists serve as man- I would suggest a deeper integra- agers of the primary mental health tion of community medicine and centers rather than working as mental health care where mental maintains close ties with Eastern psychiatrists. health services were provided by counterparts instead of moving community health care centers forward towards modern Western The costs of the provision of prima- along with general medical servic- psychiatry. ry care are constant and strongly es. These centers should include dependent on the population living psychiatric nurses and psycholo- in a particular catchment rather gists and psychiatrists could serve Robertas Bunevicius is Director, than on the volume or content of as consultants. It would be the Institute of Psychophysiology and services. This does simplify the responsibility of municipalities to Rehabilitation, Lithuanian Univer- financial administration of primary implement such changes but the sity of Health Sciences in Palanga, health care but it does not stimulate respective laws would need to be Lithuania. Phone: +370 460 30012 an increase of quality and quantity changed. Fax: +370 460 30014; of services provided. http:www.pri.kmu.lt. We have not achieved integration of His email address is: [email protected]. While public safety and prevention psychiatry to general medicine nor is not a direct responsibility of the at the primary care, secondary or psychiatrist, who is overqualified tertiary levels. Forensic psychiatry

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252 MHR nr 1 2011_A4.indd 26 25-10-2011 14:43:34 In Memoriam

SAULIUS PECIULIS (1960-2010)

“When your roof is falling down – the sky opens to you.” With such sayings, one of the famous Lithuanian mental health care users, Saulius Peciulis, was constantly cheering people around him. He fought stigma, acknowledg- ing that “stigma begins in the hospital, when other mental health care users are treating you like jail inmates.”

In his famous book, Ten Secrets to a Successful Life for People with Mental Problems (2002, Vilnius), which is also translated into English and Russian, he emphasized that the role of the psy- chiatric professional is not merely as a treatment provider, but they “should be occupied ... with the education of users as personalities and their moral training.”

Saulius was one of the great dreamers about mental health reform in Lithu- ania; he also practically implemented his ideas in his role as president of Vilnius “Kulgrinda” users club, estab- lished in 1994. suicide was very helpful not only for an argument for creating “First Psy- From 2005 until his death, S.Peciulis him, but also for other users who re- chosis Services,” thus stopping hos- worked as senior researcher at the ceived inspiration to live for life. pitalizing young patients together with Clinic of Psychiatry, Vilnius University. long term patients in acute psychiatric His PhD in social sciences (economy) He was a great lecturer and it was great wards. from Moscow State Lomonosov satisfaction to hear and watch him dur- University gave him the perspective ing his lectures. One of the first great Saulius Peciulis was not only an ac- of a researcher with a user’s back- public international appearances of tive and productive user. He was at ground, able to contribute greatly to Saulius was in 2002 during the World the beginning of the Sajudis move- the European Union project “EMILIA” Psychiatric Association congress in ment (Lithuania liberation organization (“Empowerment of mental health care Yokohama (Japan), when he debated from SSSR, established in 1988), very users through education, support and psychiatric reform towards community active politically, later an economic action,” Framework 6, Life Long Learn- mental health with Prof. T. Tomov and adviser for First Prime Minister and ing). Together with other users and Dr. D. Puras. Later, together with the woman of Independent Lithuania - Ms. professional researchers of the Vilnius prominent user from the United States, Prunskiene. He also established the Clinic at Vasaros 5, he co-authored Mr. Joel Slack, they together made the Lithuanian Stock Exchange and some “Training Program for Suicide Preven- “Respect Seminars” in Lithuania for other very important economic founda- tion for Mental Health Users” – first of mental health care users in 2004. Sau- tions of newly re-created state. such users-led training programs. I lius was inspired by Joel’s arguments remember his very fragile and, at the on stigma: “Stigma is social death ... Saulius Peciulis’s work and activities same time, very flexible and strong Just as stigma begins with ourselves, are inevitable parts of the positive attitude towards participants when he it must end with ourselves.” S.Peciulis development of Lithuanian modern led the course giving examples of his writes about stigma – as a phenom- history and social psychiatry moving personal breakdown due to psychosis, enon which begins with other users in towards a modern system of care. The his long path to recovery with periods a psychiatric hospital as they relate to only thing he wished – that it would go of hope and hopelessness, sometimes a newly admitted inmate. These ideas much faster! thinking about suicide. Saulius’s at- are based on his own experience and titude that all types of religions prohibit should be very seriously regarded as Dr. Arunas Germanavicius

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252 MHR nr 1 2011_A4.indd 27 25-10-2011 14:43:34 In Memoriam his hints, and answered with the usual big grin psychiatric body that unites psychiatric asso- on his face: “You could say: both.” ciations around the globe. Here he showed his MELVIN SABSHIN unique diplomatic skills, meandering through His membership, which he ended in the early the minefield of, on one hand, supporting the (1925 -2011) 1950s when he became disenchanted with the fight against political abuse of psychiatry in the political course of the party, haunted him well USSR (the reason why I met him for the first into the 1970s when he was already at the APA. time in the early 1980s), on the other hand the His FBI-file is 400 pages thick and documents realities of being on the board of a global or- the intense scrutiny by the FBI, his dishonor- ganization including those who did not support able discharge from the US Air Force as being his position vis-à-vis the USSR, and the chal- “politically unreliable,” the interrogations by the lenge to promote improved mental health care FBI in the late 1950s and the fact that he was worldwide. Typically of him, he befriended both not allowed to join government commissions those who vehemently fought Soviet psychiatric even when being Medical Director of the APA abuse and, at the same time, the East German because of this political past. member on the same WPA executive, Prof. Jochen Neumann, with whom he remained In spite of FBI resistance, he became Director close friends until his death. He was instru- of the Psychiatric and Psychosomatic Institute mental in finding the final compromise in 1989, of Michael Reese Hospital (IPP) and later also which led to the return of the Soviets to the WPA To capture Melvin Sabshin in a short obituary is Acting Dean of the Medical School of the from which they had been forced to leave in almost a contradictio in termine, yet one thing is University of Illinois. Here he met his second 1983, without giving up his ethical stand and absolutely clear: those who knew Melvin Sab- wife, Edith Goldfarb, a trained psychoanalyst his support for human rights. shin invariably remember his imposing stature, like himself, who became his constant and lov- his supreme intellect and his analytic and ever ing companion until her death in 1992. Edith’s During the last years of his life, physical ail- questioning mind, as well as the typical broad death left him deeply depressed and disorient- ments increasingly impaired his ability to move smile on his face and the big cigar stuck in the ed, until he met and married Marion Bennathan around and participate in professional life as corner of his mouth. in 2000, with whom he spent the rest of his life actively as he would have liked. However, his living mostly in London, and who cared for him mind was unaffected, and when needed, he Melvin Sabshin, former Medical Director of with much love and affection until his death. would gather all his strength and dominate the American Psychiatric Association (APA), the discussions. In 2008 he published his passed away on June 4, 2011. He had his In 1974, Melvin Sabshin moved from Chicago to memoirs, “Changing American Psychiatry,” roots in Russia, which may explain his keen Washington D.C., after having been appointed and during the subsequent two years, we met interest in the issue of Soviet political abuse Medical Director of the American Psychiatric frequently while working on my book “Cold War of psychiatry in the 1970s and 1980s. At the Association (APA). Under his 23-years of lead- in Psychiatry” in which he figures as one of the beginning of the twentieth century, his parents ership, the APA would become the most pow- two main characters (the other being his friend emigrated from an area that is now in Belarus, erful psychiatric empire in the world. During his Jochen Neumann). He often left me wondering fleeing from anti-Semitism under the Tsar, and tenure as Medical Director, Sabshin became, who determined the course of the long inter- were socialist activists before and after their in fact, the intellectual leader of the psychiat- views. In fact, he quickly made the project to emigration. Born in 1925, Sabshin grew up in ric profession in the United States. During his a large degree his own, all the time pushing New York, being a brilliant student and gradu- tenure, among many other accomplishments, me to dig deeper and to find better answers to ating in 1940 from High School shortly after he was instrumental in developing one of the difficult questions. It was an exhilarating period having turned fourteen years of age. Then, at largest psychiatric publishing houses, (Ameri- that unfortunately came to an end when the the young age of 14, after active lobbying by can Psychiatric Press) and was instrumental in book was finished. his mother, he was admitted to the University of developing and promoting one of the leading Florida, from which he graduated in 1943 at the classifications of mental disorders, the Diag- The last time we physically met was during the age of seventeen. nostic and Statistical Manual (DSM); DSM-IV is presentation of the book in October 2010. Frail, dedicated to him as a sign of his involvement: hardly able to walk, exhausted, he gathered all In 1944, Melvin Sabshin entered Tulane Uni- “To Melvin Sabshin, a man for all seasons.” his strength during the presentation, quickly versity in New Orleans, Louisiana, after having taking the lead and turning the discussion to spent one year in the US Army as a volunteer. During his time at the helm of the organization, his favorite subject – the DSM classification, in Here he became politically active in the civil the APA became probably the most revered which he strongly believed and which, in his rights movement, defending equal rights for organization in international psychiatry, with view, had been one of the important tools in blacks (for instance by refusing to enforce Ellen Mercer directing the Office of Interna- curbing and finally ending the political abuse separation between white and colored at the tional Affairs and greatly expanding the APA’s of psychiatry in the USSR. blood bank at Charity Hospital in New Orleans) international network, e.g. developing links with and eventually even joining the American . Many older psychiatrists worldwide re- Melvin Sabshin is survived by his wife, Marion; Communist Party, a fact he kept concealed un- member this period as the heydays of the APA, his son James Sabshin, M.D., a neurosurgeon; til I interviewed him for the first time in February when APA Annual Meetings were considered four granddaughters, two of whom are psychi- 2009. It was a typical Melvin Sabshin situation: the most interesting international events in atrists, and by many friends all over the globe. I had to find out myself, but when I deducted world psychiatry. He truly was a unique personality. this from a sequence of hints he made in the course of the interview and asked whether he From 1983-1989 Melvin Sabshin also functioned Robert van Voren had been a member only in spirit or also factu- as a member of the Executive Committee of the This obituary was earlier published in ally, he was visibly pleased that I had caught World Psychiatric Association (WPA), the main The Psychiatrist, September 2011

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252 MHR nr 1 2011_A4.indd 28 25-10-2011 14:43:35 Russian Summaries

By Elena Mozhaeva

В обществе высок уровень нетерпимости Редакционная статья к уязвимым группам, и значительная часть Джон Боуис и Роберт ван Ворен электората хотела бы убрать психически больных ‘’с глаз долой’’. Принципы автономии и удержания Этот выпуск Mental Health Reform отличается от психически больных в сообществе не пользуются других. В нем отражены не только успехи, но и популярностью, а в культуре психиатрических неудачи в реформировании системы психического служб продолжает доминировать патернализм. Для здоровья в Литве. В частности, речь идет о изменения ситуации представляется необходимым сохраняющемся доминировании биологического создать коалицию сил, заинтересованных в подхода и акценте на стационарах, недостаточном реализации Национальной стратегии психического учете интересов пациентов, о консервативной здоровья. позиции Литовской психиатрической ассоциации и т.д. Пусть этот номер послужит предостережением: как оказалось, после двадцати лет вложений в План Вильнюса в области охраны психического реформирование дела могут пойти в обратном здоровья: Небезразличный город. направлении, оптимизм созидательности может Роберт ван Ворен столкнуться с жесткой реальностью, подчас с неблагоприятными последствиями. Пусть это будет Осенью 2004 муниципалитет Вильнюса и предупреждением о том, что членство в Евросоюзе Глобальная инициатива в психиатрии (ГИП) создали само по себе не гарантирует процесса дальнейшей рабочую комиссию по разработке долговременной европеизации страны. политики развития служб психического здоровья. В нее вошли литовские и нидерландские эксперты, представляющие самые разные аспекты проблемы. Доказательная политика в области С учетом рекомендаций ВОЗ, была разработана психического здоровья в Литве модель стратегического развития, которая Дайниус Пурас представлена в статье. Этот план был утвержден муниципалитетом Вильнюса, но потом, в силу ряда С началом в Литве в 1991 демократических факторов, большинство запланированных шагов реформ, в стране неоднократно предпринимались были отменены, а некоторые из уже существующих попытки введения доказательной политики служб подсокращены. Но план не потерял своей в области психического здоровья. Так, был ценности, и на него продолжают ссылаться в принят Закон о психическом здоровье, создана дискуссиях и переговорах. Возможно, его черед сеть муниципальных центров психического придет в будущем. здоровья, принята новая национальная стратегия психического здоровья с акцентом на службах на основе сообществ, эффективных программах Учреждения интернатного типа в Литве: развития психического здоровья, профилактики бесславное прошлое, неясное будущее суицидов, насилия и пр., деинституциализации, Эгле Шумскиене и Довиле Юодкайте продвижении и охране прав человека в психиатрических заведениях, мониторинге Учреждения интернатного типа заслуженно работы служб и т.д. Вместе с тем, политической обвиняют в выполнении функции ‘’социальной воли в отношении следования этим принципам капсулизации’’ и ставят в один ряд с тюрьмами, не наблюдается. Приоритетом правительства больницами и лагерями. Литва унаследовала остается институциональная помощь. Большие систему ухода за инвалидами по психическому средства вкладываются в ремонт крупных здоровью от Советского Союза. К сожалению, психиатрических больниц, огромные диспропорции литовская социальная политика оказалась не существуют в финансировании биомедицинского очень прогрессивной и больше ориентировалась и психосоциального компонентов в системе на поддержание существующего положения, чем внебольничной помощи, фактически адекватно на деинституциализацию и интеграцию в условиях финансируется лишь психофармакотерапия. помощи на основе сообщества. Присоединение

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252 MHR nr 1 2011_A4.indd 29 25-10-2011 14:43:35 к Евросоюзу не повлекло за собой прекращения в области опекунства, недобровольной дискриминации инвалидов по психическому госпитализации и лечения, законного заболеванию в населении. Сейчас в стране представительства инвалидов по психическому существует 26 интернатов для психохроников: заболеванию. здания недавно реконструированы, но достаточно взглянуть в испуганные лица обитателей, чтобы понять – это всего лишь очередная ‘’потемкинская’’ Литовская психиатрическая ассоциация – цели деревня. 90-х и нынешняя ситуация Дайниус Пурас

Уроки реформирования системы психического Отделение в прошлом от Всесоюзного общества здоровья детей и подростков в Литве психиатров оказалось нелегким, так как ведущие Витаутас Блазис литовские были тесно связаны с ‘’московской’’ школой. Первые годы деятельности ЛПА Доставшаяся Литве в наследство от СССР система были отмечены духом демократии и горячими психического здоровья детей и подростков дебатами, но потом энтузиазм 90-х сменила была ‘’дважды Золушкой’’ - и среди психиатров регрессия с доминированием оппортунистических и в общей медицине. Для нее не было места тенденций, усилением роли фармкомпаний и в поликлиниках, легко доступных населению. нежеланием самих психиатров развивать культуру Ее помещали под крыло ПНД или крупных саморегулирования. Складывается впечатление, психиатрических больниц. После 1990 в Литве что психиатрическая профессия решила взять из появились центры психического здоровья на современной психиатрии лишь один компонент основе сообществ (ЦПЗС), которые обслуживают – современную психофармакотерапию – и не как взрослых, так и детей. Опыт их работы менять культуру служб психического здоровья и позволяет извлечь некоторые уроки. Так, было не уходить от патерналистского подхода. В целом, ошибкой создание ЦПЗС в первом эшелоне психиатрия не очень отличается от общества в помощи -это привело к длинным листам ожидания, целом, т.е. общество имеет ту психиатрию, которую избыточным затратам на простые случаи и заслуживает. Хочется надеяться, что и общество, и недостатку поддержки сложных пациентов. психиатрия в ближайшем будущем войдут в новую Существующая система финансирования не фазу прогрессивного развития. позволяет создать в ЦПЗС мультидисциплинарные бригады. Ощущается недостаток сотрудничества ЦПЗС с коллегами из служб защиты детей Исследование политики превенции суицидов в и системы образования. Не используются в Литве полной мере возможности психиатрических Рамон Дж. Пебенито (мл.) и Арунас Германавичус медсестер в проведении семейной и когнитивно- поведенческой терапии. Некоторые врачи не видят Показатель суицидов в Литве – один из самых необходимости в реформировании системы: сами высоких в мире. Многие ученые связывают они - отличные клиницисты, но помещены при его с трудностями социально-экономического этом в неэффективную систему. Поэтому важно перехода от Советской оккупации к демократии критиковать не коллег, а систему, и пытаться и рыночной экономике, особенно в странах разъяснить цели сомневающимся. И последнее: Прибалтики. ‘’Шоковая терапия’’ в Литве, Латвии для изменения системы обычно требуется и Эстонии сильно отличалась от постепенных больше времени и ресурсов, чем изначально реформ в других пост-социалистических странах. предполагалось, и, кроме того, нужны преданность В Прибалтике начались радикальные и быстрые делу и терпение в достижении целей. перемены, и они стали причиной значительного социального стресса, тревоги и чувства безнадежности в населении с неизбежным ростом Интерпретация и соблюдение международных алкоголизации. Система здравоохранения при стандартов прав человека в Литве этом сохраняет худшие черты советской: она Довиле Юодкайте неэффективна, коррумпирована, организована на биологических принципах эпидемиологического После получения независимости в 1991 Литва сдерживания инфекционных болезней. ратифицировала большинство основных Плюс полное отсутствие политической воли международных инструментов прав человека, поднять проблемы и потребовать изменений у в т.ч. относящихся к правам инвалидов. Но на могущественного истеблишмента здравоохранения сегодняшний день, ситуация с правами человека и и медицинской элиты. Никакого долговременного национальное законодательство Литвы, особенно разрешения кризиса с суицидами в Литве быть не в части людей с ограниченными возможностями, может без появления данной политической воли. не полностью соответствуют международным стандартам, так как продолжаются нарушения

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252 MHR nr 1 2011_A4.indd 30 25-10-2011 14:43:35 Стратегия усиления пользователей служб снижение стигмы в обществе; (3) утверждение психического здоровья в части принятия нового способа действий для психиатров в рамках решений (Литовский опыт) данной стратегии. Система ЦПЗС имеет много Арунас Германавичус и Сайлиус Печулис преимуществ в силу приближенности к пациенту, связей с врачами общей практики и наличия Авторы рассматривают природу усиления мультидисциплинарных бригад, осуществляющих как трансформацию потребителя помощи в вмешательства. На ЦПЗС также возложена сфере психического здоровья и его переход с обязанность выдачи разрешений и справок о положения раба (с отсутствием права на свое допуске к управлению транспортными средствами мнение) в положение ‘’усиления’’, когда к нему и владению оружием. относятся в системе как к уважаемому партнеру. Данная концепция включает в себя все аспекты По причине подушевого принципа финансирования системы оказания помощи, в т.ч. реабилитацию, система ЦНПЗ оказывается заметно дороже, социальную интеграцию и участие в принятии по сравнению с услугами домашних врачей. решений на всех уровнях. Выделены два аспекта Большинство центров являются самостоятельными усиления: индивидуальный, т.е. реализация все в юридическом и финансовом смысле личных прав и их фиксация в национальном заведениями, но большинство действует при законодательстве и стратегии развития системы поликлиниках. На будущее планируется создание помощи, и организационный (институциональный), при центрах реабилитационных дневных представленный организациями самопомощи стационаров, а также назначение психиатрами и советами пациентов. К сожалению, данная не только фармакотерапии, но и других видов концепция реализуется очень медленно. В Литве лечения. после 20 лет независимости все еще нет общей стратегии превращения потребителей помощи в партнеров по планированию, соучастию в работе Системы первичной помощи в Литве: роль и мониторингу служб психического здоровья. психиатров Профессионалы продолжают защищать свои Робертас Буневичус позиции и не хотят изменения ролей в системе. Развитие в новой Литве системы помощи на основе сообщества в виде ЦПНЗ стало хорошим Развитие в Литве программы доверенных лиц стимулом к отходу от доминировавшего в прошлом пациентов стационарного лечения. С другой стороны, Рюта Юоделите создание ЦПНЗ привело к формированию двух параллельных систем первичной помощи – одной Идея доверенных лиц пациентов (ДЛП) пришла для общей медицины и другой для психического из Нидерландов, где ДЛП работает с 1982 здоровья, т.е. психиатрия оказалась отделена года. Эту программу несколько изменили и от общей медицины в первом эшелоне помощи. адаптировали к условиям Литвы, и она была Это привело к размыванию статуса психиатра в впервые запущена в Вильнюсе в 2006. ДЛП ЦПНЗ, который нередко оказывается в роли врача независимы от служб психического здоровья и общей практики. Центры также должны в большей выполняют функции посредников и представления мере использовать возможности психиатрических интересов пациентов в случае жалоб на условия медсестер и психологов, оставив за психиатрами содержания или терапии, обеспечения информации функцию консультанта. о правах пациентов, выявления недостатков в работе служб психического здоровья. Опыт ДЛП оказался успешным как в стационарных, так и Памяти ушедших в амбулаторных заведениях и способствовал повышению качества оказания помощи и Сайлиус Печулис (1960-2010) уважению прав человека в отношении пациентов. Мелвин Сабшин (1925-2011)

Первичная помощь в сфере психического здоровья в Литве Эугениус Микаулинас

С 1996 года в Литве было создано 80 центров психического здоровья на основе сообщества (ЦПЗС), подчиненных муниципалитетам. Основными целями ЦПЗС являются: (1) обучение семей, имеющих психически больных; (2) подготовка сообщества к принятию пациента и

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252 MHR nr 1 2011_A4.indd 31 25-10-2011 14:43:35 Other themes addressed by Global Initiative on Psychiatry to be covered in future issues of Mental Health Reforms:

• Community Mental Health Care • User Involvement in Mental Health Services • Mental Health and Human Rights • Substance Abuse Prevention

Global Initiative on Psychiatry Global Initiative on Psychiatry (GIP) is a federation of international not-for-profit or- ganizations for the promotion of humane, ethical and effective mental health care worldwide. The federation is registered in Hilversum, The Netherlands, and works closely with its federation members in Bulgaria, , Lithuania, The Nether- lands, the and the United States, and a country office in Tajikistan, as well as with numerous NGOs, governmental and international organizations.

In addition to being a major contributor to improved mental health care systems in Central and Eastern Europe and the Newly Independent States (CCEE/NIS), GIP also works in other regions of the world such as Africa, Indochina and the Indian sub-continent. In all regions our goal is to empower people and help build improved and sustainable mental health services that are not dependent on continued external support.

Photography The photographs in this issue were taken by the staff of GIP, authors of the articles, or other parties. The individuals portrayed were aware that their photographs might be published.

GIP-Hilversum (International Office) GIP- GIP’s General Board P.O. Box 1282 49A Kipshidze Str., Benedetto Saraceno, Chair (IT) 1200 BG Hilversum Tbilisi 0162, Georgia John Bowis, Secretary (UK) The Netherlands Tel.: +995 32 235 314 / +995 32 214 006 Bram de Wolf, Treasurer (NL) Tel.: +31 35 683 8727 Fax: +995 32 214 008 Melvyn Freeman (SA) Fax: +31 35 683 3646 e-mail: [email protected] Ganesan (LK) e-mail: [email protected] www.gip-global.org Clemens Huitink (NL) www.gip-global.org Joseph Mbatia (TZ) Galia Petrova (BG) GIP-Sofia GIP-Vilnius Dainius Puras (LT) 1 Maliovitsa str. M.K. Oginskio g. 3 Dick Raes (NL) Sofia 1000, Bulgaria LT-10219 Vilnius, Lithuania Peter Tyrer (UK) Tel.: +359 2 987 7875 Tel.: +370 5 271 5760 / +370 5 271 5762 Davit Gzirishvili (GE) Fax: +359 2 980 9368 Fax: +370 5 271 5761 e-mail: [email protected] e-mail: [email protected] www.gip-global.org www.gip-global.org / www.gip-vilnius.lt Mental

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