In the second part of the interview with psychiatrist Konstantin Minkevich “Not Today, Not Yesterday, Not Tomorrow” we talked about reforms in psychiatry and humanisation of mental disorders.
Many people are afraid to go to hospitals, they consider them closed institutions with “Gestapo” conditions. Is this true? Or has the time of punitive medicine already passed?
If we are talking about Belarus, the situation, in my opinion, is rather sad. On the one hand, there are situations when it is quite difficult to do without inpatient psychiatric care, for example, when a person is in an acute psychotic state, be it schizophrenia or alcoholic delirium, or when suicidal tendencies are expressed. The prevailing view in psychiatry now is that there are conditions that make it necessary to admit a person to an inpatient unit and provide him with inpatient care even without his consent. But this question is open and rather difficult from the ethical point of view.
If we talk about Belarusian hospitals, in my opinion, their level is quite far from humane psychiatric care as we understand it now. Especially, if we are talking about observation wards, where patients are often fixed, there are many of them in one room, or if we remember the so-called “labour therapy”, patients are forced to clean the ward, carry food and so on. All this is the level, at best, of the last century.
I can only talk about punitive psychiatry in Belarus in the past, because I haven’t worked in the state system of psychiatric care in Belarus since 2012, so I may not know some things that are happening there right now, and after 2020 I haven’t been to the country at all. But at that time, when I was still working, there was no punitive psychiatry, as there was in the Soviet times, in the 70s and 80s, when they fought with dissidents, who could be placed in a clinic and forcibly treated there. The negative phenomena I described do not happen maliciously, but rather out of habit, out of inertia. And there is no purpose to punish, it’s just the way they treat.
As for Europe, I can tell you about Sweden. I worked in a project with Swedes, I was in an acute ward in Stockholm. The conditions there are strikingly different from those in Belarus. There is one interesting fact – emergency hospitalisation there can be carried out by the police. Plus, a general practitioner can also leave an application for it to a psychiatric hospital. Question: can this be considered a manifestation of “punitive psychiatry”, when the police or a general practitioner, who is not a psychiatrist, comes and considers it necessary to place a person in a psychiatric hospital?
However, the conditions in the hospital are radically different: there are single rooms, the number of staff corresponds to the number of patients (one to one, approximately). There is another point: a psychiatrist can come to examine the patient only three days after he gets to the clinic (before that he can be examined by interns, he is not on his own). So the patient can appeal his hospitalisation if he doesn’t agree with it. And there is a routine procedure for such cases, a judge comes, an expert psychiatrist who examines the patient, documents describing his condition and the need for hospitalisation, and if they decide that the hospitalisation was not justified, they can terminate it. This is all very different from our realities.
Why don’t hospitals rely on therapy? But only for medication treatment? This is a fact from Belarus, Poland, Georgia and Germany.
In general, most likely, the matter here is at least two things. The first is tradition: in Europe psychiatrists have a medical education and deal with medication, while psychotherapists often do not have a medical education. The second reason is that psychotherapy in inpatient settings is not very justified.
It is difficult for me to say what terms are accepted now in Europe. In Belarus, for ten years the usual period of stay in a psychiatric inpatient facility did not exceed 31 days, except for rare exceptions. In Europe, I suppose, this term is even less. And this is very little time for psychotherapy. Usually one or two sessions a week are needed. If a person stays in the hospital for 3 weeks, it turns out to be from 3 to 6 sessions. And then it is not clear what the person will do after the clinic, will he continue therapy or not? Will it be the same specialist or will it be transferred to another one? I think that to a large extent this is an organisational issue, but it also determines the situation.
It is a popular tendency now, especially in America, to get people addicted to medical drugs, these are: antidepressants, painkillers, etc. Do you think pills are the cure for everything?
I think that the “either/or” approach is rather clumsy and wrong, and pills are not a panacea or absolute evil. There are medications that are addictive, such as opiates and benzodiazepines, and it is possible that in some cases, people can become chemically dependent due to the prescription of these medications by doctors. The tendency to unnecessarily prescribe addictive medications, at least in the United States, has been observed and is well known.
As for “getting addicted” to drugs that do not cause addiction… If a person has a chronic disease that requires long-term, multi-year, or maybe lifelong treatment, it is difficult to say whether he is “getting addicted” or receiving therapy. Are people with diabetes added to insulin? Are people with arterial hypertension added to medication? This question depends to a large extent on what and how we define it.
At the same time, we cannot say that medication is a panacea and that it is the only correct treatment for mental disorders, and this is the only correct treatment, not only in the psychiatric community, but also in the public perception.
Is deinstitutionalisation of psychiatry taking place in many countries? What do you think it is connected with and can we expect such a tendency in Belarus?
I would say it is not happening, but has happened. The process began in earnest in the 70s-80s, with the participation of Franco Basaglia in Italy. Western countries, the USA have already undergone deinstitutionalisation. It is connected, on the one hand, with the growth of humanism in the attitude towards people with mental disorders, the fight against stigmatisation, the idea not to single out people with mental disorders from the masses, rather to integrate them into society. And some kind of restrictive measures of any kind, hospitalisation should be considered an exceptional case, an extreme measure.
On the other hand, I believe that the economic factor also plays a role here – it is quite expensive to keep a person normal, meeting the requirements of minimal humanism. In fact, you need to provide a person with a hotel, for some extended period of time. If there are a lot of such people, it becomes an expensive venture, and it is much easier and cheaper to somehow rehabilitate and integrate people into society.
Belarus, like the rest of the post-Soviet space, almost completely missed the wave of anti-psychiatry, which started humanization. Secondly, in Belarus the ideas of humanism, not only in psychiatry, but in general, are perceived by the society with wariness, as something so wild. And, thirdly, in Belarus the conditions of stay for people with mental disorders are still far from sanatorium or hotel conditions. And that is why the economic component is not so noticeable here.
But in general, there is a tendency that something has started to change in Belarus, but taking into account the totality of all the conditions in the country, this tendency strengthens and weakens. Approximately from the second half of the 90s and up to the 2010s, the tendency in the direction of humanisation of the attitude to patients prevailed. We can say that this was the official position of the organisers of psychiatric care in the country. Then it weakened due to a number of reasons. Now in Belarus, in general, the situation is not that conducive to humanism. And people with mental disorders are not in the vanguard, and it is not to them, first of all, that the state will provide good conditions. Therefore, so far, I think that the prospects for Belarus are not so good.
How do you feel about self-medication or self-diagnosis? Is it a popular problem?
My attitude is mixed. On the one hand, self-help is quite a good and effective thing for the majority of mental disorders, especially in a mild form. But there are a couple of nuances: in order to get quality self-help, you need to have sources of it, the same literature, and unfortunately there is very little of it in Russian, in fact there is none, it is not translated, not everyone can read English.
To diagnose yourself, you also need to be able to do it somehow. There is also the problem of subjectivity in this matter: it is always more difficult for a person to assess what is happening to him with a sufficient degree of objectivity, which is provided by diagnosis by an independent and disinterested specialist. Again, the question is: where can one get knowledge about how to diagnose a particular disorder? There is no culture of reading diagnostic manuals such as the DSM(Diagnostic and Statistical Manual of Mental Disorders) or ICD(International Classification of Diseases), and reading sources on the Internet… I cannot say that this is bad, but if a person does not understand the issue, it is difficult for him to distinguish what can be trusted. And this creates a problem – people begin to diagnose themselves not based on scientific data, but based on some myths. If it were well organised, if there were self-help literature, brochures, information posted by mental health care providers, as it is done in the USA, it would be quite a normal practice, but with the way things are now in Russian (I’m not even talking about Belarusian), effective self-help becomes rather unlikely.