There is a Law, but Mental Patients Have It No Better

The official date, Day of Mental Health, marked in Ukraine the week before last was yet another occasion to raise the issue of the mentally ill, as Kyiv Mental Health statistics point to 2.5% of the capital’s residents afflicted with various psychological mental disorders. By 2001, the local mental hospitals had 59,900 such patients under regular care (among them 13,200 children). The causes are obvious: multiplied social stress and the constant struggle to survive existing simultaneously with countless basic needs that are not only never met but more often than not ignored or overlooked by society. The recently enacted law On Psychiatric Assistance (considered progressive by many) still causes much heated debate and discussions, initiated primarily by those who see the problem from inside but are unable to lobby for a decision at the top, the relatives of mental patients. The Turbota [Care] Association was set up in Ukraine, modeled on the US National Alliance for the Mentally Ill. It made every effort for the psychiatric aid law to become a truly powerful instrument, rather than remain on paper, as has been so often the case. Unfortunately, far from all amendments and suggestions by the relatives were taken into consideration; in all likelihood, they were ignored during parliamentary hearings, as the bill was passed last year with the audience half empty, several minutes before the end of the sitting.

Liudmyla Malushenko, chairperson of the Society of Mental Patients’ Relatives, told The Day: “Previously, the relatives of mental patients were reluctant to discuss their problems; they were embarrassed, and physicians also avoided such topics. The result was that most such problems remained hidden from society. This might have been the reason why a solution to the problem remained up in the air. The psychiatric aid law actually offers mental patients no social protection. And I also think that its provisions violate the civil rights of the patients and those around them. The law does not improve but aggravates the situation. After all, it allows a mental patient to accept or refuse treatment, thus threatening other people in one way or another in contact with him.” She added that the authors of the law should have known better than anyone else that a mentally afflicted individual cannot make adequate decisions, that a mere 4% of mental patients volunteer to undergo treatment, and that it is practically impossible to predict when the mental condition of a given individual aggravates to the degree when it becomes socially hazardous as recognized by experts — and as required under the law — for such a patient to be subject to involuntary institutionalization. The alternative is a four-stage judicial procedure. Apart from the fact that it is very protracted, it is quite expensive. WHO regulations read that access to a mental hospital must not be any more complicated than that to any other medical institution. In Ukraine, Ms. Malushenko went on to say, this supposedly democratic law has resulted in many mental patients being left on the street, another public risk factor, because there is no way to tell what a person suffering from false sensory perceptions (hallucinations) or hearing voices may do next. In addition, the law does not protect a mental patient’s home, while fraudulent practices here are quite widespread. Ms. Malushenko believes a mental patient’s home should be under constant official oversight just like in the case of orphans.

The main problem, however, is the social protection of mental patients, she said. There are subsidies for taking care of such people (with official disability status, of course). But the amount thus allocated, 18 hryvnias, is lamentable. Second, it is payable only to low- income relatives and guardians. To prove such low-income status, one has to produce dozens of statements and affidavits, meaning red tape that such relatives cannot afford precisely because their incomes are low. And the pension due a mentally afflicted citizen is 40-60 hryvnias; often such people are unable to work, and no one is willing to risk employing them. All this means that mental patients are not only unable to survive on their own but also cause their relatives to live in misery, because they have to look after them, meaning they have no time to earn a living. The law On Social Aid to Physically Handicapped Children and Those Handicapped from Birth was enacted in November 2000, stipulating living-wage-level pensions for Group 1-2 invalids plus 50% worth of costs for their care. Here, again, we find injustice. Only those crippled since childhood can expect such payments; if an individual becomes physically handicapped at the age of 18 or being officially registered as such after 16, he or she is automatically ineligible. Since 1997, the city state administration has promised to allocate a special bus for relatives that would deliver them to the Pavlov Mental Hospital in Kyiv, for climbing the stairs, carrying bags bulging with food, is very difficult, especially in winter. And the inmates will not survive without their relatives’ help. Their hospital rations are meager and many medications administered on an empty stomach tend to have the reverse effect. Thus (Ms. Malushenko stressed), the law is a far cry from modern civilized legislation; rather, it is meant to facilitate malfeasance with regard to and by mental patients. And the expensive judicial procedure will cost the state many times more than social protection of such patients and their relatives, anyway.

Certainly, every argument can be met with an attempt to refute it. Yury Yudin, head of the mental health protection department of the capital’s health care directorate, told The Day, “This law is the result of work done by the Verkhovna Rada committee, allowing for the remarks and suggestions duly received. I must say that most of them were actually taken into consideration. I further believe that the objections voiced with regard to the law On Psychiatric Aid are unfounded, because the issue of precisely which articles in it we ought to feel ashamed about has never been raised. Let me tell you again that most suggestions were taken into account, except that they were introduced in dry legal formulations. I consider unfounded the allegation that the judicial procedure provided for by the law is making hospitalization harder. Our Kyiv courts have dealt with a few cases, but those had nothing to do with any shortcomings of the law; they resulted from the absence of legal experience and well-adjusted procedures along these lines. In fact, before it comes to legal proceedings, a mental patient must go through several stages: examination by that patient’s physician, hospital examination, and examination by a board of medical experts. At any stage this patient could be found not to require hospitalization and may be even signed out. I think that we need more information about cases in which problems arise in conjunction with a patient’s aggressive behavior. Actually, all such issues can be settled and I think that the problem at issue was trumped up. Considering the social aspect, the law has it in black and white that, while a patient is at a mental hospital, his right to his home remains inviolable; the state also secures employment quotas at various enterprises, institutions, and organizations, meaning the employer is under the obligation to accept mentally ill individuals. The law further provides for social aid, even if perhaps not on the desired scale. I believe, however, that such issues should regulated not by the law, but by legislative acts. Otherwise, the document will be doomed from the outset.”

INCIDENTALLY...

The Center for the Medical and Social Rehabilitation of Mental Patients opened on October 10. Inna Hokun, project coordinator, says it was set up exclusively at the expense of foreign donors: “Domestic businessmen considered such investment exceptionally unprofitable, because it will be quite some time before the actual revenues could be seen.” People with mental disorders will be forwarded for outpatient treatment by their physicians, mostly when diagnosed as schizophrenic, aged between 18 and 60. The center architects are propagating a “biopsychosocial” approach to such patients, taking into account not only the actual mental condition, but also the social factors at play. The center’s medical personnel is made up of psychiatrists, social workers, nurses, and work therapists. The rehabilitation technique is also interesting, based on an individual approach to every case, with every patient to be treated under an individually developed rehabilitation program.