Post-totalitarian doubts of psychiatry

Bogdana Tudorache *
* M.D. Psychiatrist "Gh. Marinescu" Hospital Bucharest

Post-totalitarian doubts of psychiatry

Psichiatria e Territorio, vol. XII numero 1-2, 1995.

Any reference made to health - and especially to mental health or psychiatry in Romania - must necessarily be taken against the background of a simultaneous analysis of the Romanian historic context and the psycho-social problems devolving from this context.

The social ideology of the last forty years, intolerant as it was towards the diversity of opinions and options, aimed at forcibly levelling the human soul, at changing the individual into the "representative" of a doctrine which wanted to annihilate any really personal way of expression. Psychic ailment was changed into an "opinion misdemeanour" , in that kind of society. Completely absorbed by his or her experiences (which could not be added to every-day worries), the psychotic was considered as completely responsible of this "betrayal" of the society, which tried, in its turn, to retaliate by a rejection and isolation hardly hidden by the idea of a need for expert care and protection.

In order to build up communist society, certain categories were completely indesirable, starting from the assumption that minorities of all kinds had to be either assimilated, or done away with. The psychotic used to be a minority, a trash, which was not worth any effort, its existence being completely ignored. The reaction of the authorities towards psychotic suffering had become more and more intolerant and aggressive, in keeping with the unwritten rule: "he who is not like us, has no right to live".

These concepts materialized in a lack of material and ideologic interest of the Romanian socialist society and of the authorities in improving the situation of the psychotics or in any attempt at updating the outlook on the psychic suffering.

Under these typically socialist circumstances, Romanian psychiatry has had a unilateral development, during the last thirty, forty years, which was inssuficient both theoretically, doctrinally and practically, in point of patient approach, with its complex problems and multiple suffering.

Romanian psychiatry had the general evolution of European psychiatry, after WW II. After the instauration of the communist system, the country’s self-isolation, its ideologic dependence on the Soviet thinking made psychiatry totally dependent - in the first half of this interval, and partially afterwards - on the dogmas of Soviet psychiatry (by an popularized implementation of Pavlovism), fencing it into a reductionist organicism, which marked the practical, social side of this science too, triggering off mainly on the psychotic himself. The chronical character, specific to a certain extent to this medical branch, was incorporated into the notion of "irrecuperability" in a simplist way which was highly detrimental to the patient.

The purposeful isolation of Romanian psychiatry from the grat trends that inspired the European psychiatry (antipsychiatry, desalienism, social psychiatry, development of psychanalysis, etc.), led to a complete cut off of its access to modern theories, innovating trends, to a rough rejection of psychosocio-therapeutic techniques.

The logical consequence of these phenomena is the fact that the Romanian society has got only very few establishements for the protection of mental health, except the nursing home-type psychiatric hospitals, which are still the only official altemative for psychiatric care in most parts of the country.

Romania has got 22,458 beds (1 to 1,000 inhabitants) distributed as follows:

- 42 psychiatric hospitals, out of which 2 with over 1,000 beds, 36 hospitals with a capacity of 100 to 1,000 beds and 4 hospitals with a capacity of under 100 beds.

- 65 psychiatry wards in general hospitals, out of which 22 wards with a capacity of 100 - 1,000 beds and 43 wards under 100 beds. The average number of days spent in hospital is 32.7, varying according to the types of wards (neuroses - 18 days, chronical diseasses 68.5 days), while the patient hospital days relation is 13 per cent of the total patient-hospital days figure; the bed usage index is of 288.7 days.

Certain attempts at completing the psychiatric care system by creating some out-patient and semi-outpatient units, in the sixties and seventies, which should have introduced new types of activities by working from within the community, led nowhere. Such units are still playing a role of selection and control, of guiding the patients. Under this circumstances, any psycho-social intervention in Romania is extremely limited.

In fact, the staff in the field of the mental health is very reduced: 3.8 psychiatrist (even 1.4 in certain regions), 5.7 psychiatric nurses, 0.87 psychologists and only 0.53 social workers for 100,000 inhabitants. To this one can add the contents of training, which is still mainly biologistic.

Psychiatric training (resumed after a ten-year pause) lasts for three years, out of which one of theoretical courses, having no organized psychoterapy training. The psychiatric nurses have no special training other form that of the ordinary nurses; after two years of post-highschool training, they join the psychiatric services straight away. The psychology department of the university - offering for years traning - resumed its courses after a twenty-year pause. A school for social workers was created in 1990, as this profession is quite inexistent in Romania.

The structure, the contents and the form of the present-day training of Romanian professional mental health experts have unfortunately remaind almost the same; they can be altered only very slowly and with many obstacles.

In fact, that situation of Romanian psychiatry has not changed too much two years after the december 1989 events. One might even say that things have even deteriorated in certain respects , as a cosequence of the disastrous economic situation and of the unstable political status of our coutry.

Only nine per cent of the national budget and 10.65 per cent of the budget of the state administration were yearmarked for health last year, and these funds have decreased even more in 1992 (7.7 per cent and 9.94 per cent respectively). The budget of the Ministry of Health is 70 thousands millions Lei under the level of bare necessities this year, the Romanian health system being on the verge of collapse.

Under these circumstances, the Romanian psychiatry is still one of the most disadvantaged medical branches (though the psychiatric diseases are fourth cause of illness in this country), ranking in no way among the top priorities of the Romanian health care system. Thus the social, moral and biologic disaster is joining in the economic nighmare. The political instability the struggle for power - to which one may add the cold, poor food, unemployment, the extraordinary percentage of emigration ( a frightening percentage of which is represented by youngsters and intellectuals), disappointment, the lack of opportunities, the current apathy manifested even among most mental health professionals, are defining features of this post-totalitarian age. "We are experiencing now the disaster coming after the disaster; during these last two years we have passed from misery to the misery of post-misery" (Gabriel Liiceanu).

The so-much expected revival has not taken place, under these circumstances, in psychiatry either, which may be accounted for by an obstruction specific for all post-totalitarian societies brought about by the persistence of the old systems.

Several societies dealing with mental health have been created in Romania during the last two years (The Free Psychiatrists'Society, the Romanian Psychiatric Association, the Romanian Psychoanalythic Association, The Association of Clinical Psychologists, the Romaniam League for Mental Health, etc. ) as a natural outcome of the end of totalitarian darkness.

The conflictual interests on the one hand, and the attempts of certain psychiatrists to put behind their past compromises or of others to overemphasize these compromises, have unfortunately divided the Romanian psychiatrists in three categories: first those struggling for power and privileges, second, those who, despite conjunctural situations, are trying hard to be up the level required by the future of this profession and a third category - which is unfortunately represented by the greatest number of Romanian psychiatrists - relinquishing in noncommitment and apathy, who seem to have surrendered even the modest weapons they used to have.

The few attempts at making changes that have taken place of late in Romanian psychiatry (most of which are a result of certain actions made by private persons or by foreign organisations) are capable of rousing certain hopes, though they are not too conspicuous as they are still too scarce to be generalized.

Action must be taken at present at all levels. It is absolutely necessary to change individual and social mentalities, to keep a minimal balance of the economic and social life, to stir the interest of the political circles and state bodies (which are obviously concerned whith other things they deem of prior importance at present and in the near future and last but not least to create a favourable atmosphere, unfortunately, inexistent in professional circles either.

At the same time, there is a great need of getting the absolutely necessary funds, of having certain persons of organisations to cooperate with.

It seems easier to build from scratch than to mend!

But we are fully aware that this act of building or mending will be the task of whole future generations to come.

Romania ’92

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