09No. 2

Mental
HealthReforms
Special issue:
> Forensic Psychiatry and
Prison Mental Health
A Global Initiative on Psychiatry publication
09
‘
No. 2
Contents
Editor
Ellen Mercer
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Mental
HealthReforms
Special issue:
09
‘
3
Developing Prison Mental Health
Services in Countries in Transition:
Challenges, Constraints and
Opportunities
4
By Robert van Voren
Editorial Board
Katja Assoian
Elena Mozhaeva
Robert van Voren
Florence Baingana
Margi Kirschenmann
> Forensic Psychiatry and
Prison Mental Health
Editorial
No. 2
By Dick Raes and Robert van Voren
Seven Years in Kresti Prison:
A Unique Project to Develop Modern Prison
Mental Health Services in St. Petersburg
10
By Konstantin Antsiferov, Rob Hollander and Wendy Weijts
Risk Assessment in
Post-Soviet Countries
12
Developing Partnerships in Forensic
Psychiatry: The Pompe Foundation as
Partner in GIP projects
14
By Virginija Klimukiene
By Thieu Verhagen and Dick Raes
Initiating Reform in Prison Mental
Health & Forensic Psychiatry in
Serbia
16
Bulgaria: A European Union Member
Lagging Behind in Forensics
18
By Robert van Voren
By Petar Marinov and Vladimir Velinov
Convicted Juveniles in Georgia
Problems and Prospects
22
By Lela Tsiskarishvili
From Lunatic Asylum to National Institute
of Mental Health in Sri Lanka
25
Goals of GIP in Sri Lanka’s Forensic
Hospital System
27
Russian Summaries
28
By Dr. Neil Fernando, Marieke de Vries, and Nanthini
Sivanesan
By Robert van Voren
A Global Initiative on Psychiatry publication
Cover photo: Chernyakhovsk
Special Psychiatric Hospital,
Kaliningrad, Russia
By Elena Mozhaeva
July 2009
2
MentalHealthReforms
Editorial
In most countries around the globe,
mental health service users are
stigmatized in ways that can affect
their quality of life and position in society. However, for those who have
a mental illness and have also com­
-mitted a crime, there is a double
stigma: he/she is mad, and bad.
Virtually everywhere these individuals receive less treatment and care
than needed.
Global Initiative on Psychiatry has
been involved in the development of
projects in the field of forensic psychiatry and prison mental health for
the past eight years. In those years,
we have managed to support the
initiation of reform in more than half
a dozen countries, mainly in Eastern
Europe and the former Soviet Union,
but also in Sri Lanka. In addition,
there is good reason to believe that
projects will be implemented in
several other countries in the near
future.
It is difficult to get programs of this
sort started; governments are often
not very interested in this group of patients – they are mad and bad, aren’t
they? – and society usually does
not like the idea of forensic patients
reintegrating into society after their
treatment has been concluded. The
majority of the population believes
that such people should be locked
up as long as possible, preferably
for the rest of their lives. Penitentiary
systems are, by definition, repressive
in nature, and prisoners with mental
health problems are often considered
to be simulators who should be dealt
with in only one way: put them under
such horrible living conditions that
they want to go back to their regular
cells as soon as possible.
Part of the work of Global Initiative
on Psychiatry is to convince authorities to take prison mental health and
forensic psychiatry seriously. First of
all, forensic psychiatric patients who
have not received adequate treatment remain a threat to society, so it
is in the interest of the population as
a whole that good forensic psychiatric care programs are developed.
Prisoners with mental health problems badly affect the atmosphere in
penitentiary facilities which may, in
turn, lead to security risks. In addition, bad treatment and living conditions almost invariably lead to human
rights violations, and it is the duty of
each government to do everything
possible to prevent such violations
from taking place.
We realize that our job is not an easy
one; yet over the past years, we have
seen many positive developments
and concrete results of the work of
our partners and ourselves. This
issue of our journal Mental Health
Reforms provides you with a kaleidoscope of such projects, dealing
with a wide range of issues in diverse
countries. We do not attempt to cover
all that has been accomplished or
is being accomplished but we do
hope that this issue provides the
reader with a good overview – and, by
doing so, convincingly argues why
this work needs to be undertaken.
Robert van Voren
July2009
3
Developing Prison Mental Health Services
in Countries in Transition: Challenges,
Constraints and Opportunities
In most countries - including those that meet the criteria for
democracy- the execution of criminal law, its procedures and its
institutions can be characterized as a rather closed system.
A closed system in this sense is regarded as a complex of
interdependent organizations, regulations and facilities within
society, but with few possibilities for society to have insight,
control and influence concerning what is really going on within
this system. At the same time, this system, including the criminal
law, is usually a reflection of the attitude of governments,
politicians and citizens towards crimes and criminals.
Legislation in each country should be regarded as the source of
protection of rights, i.e. the psychological, physical and material
integrity of each individual citizen. Criminal law provides the criteria, procedures and measures for punishment of persons who
violate the above-mentioned rights and integrity. The criminal law
should address the criteria of proportionality and efficiency and
should also safeguard the legal rights of the individuals who are
confronted with the criminal law.
When a person is found guilty of an offense, the aims of punishment are retaliation, as well as specific and general prevention,
including probation and rehabilitation especially after prison
sentences, to prevent recidivism. The closed system of the criminal law, its procedures and institutions stretches from the time
the suspect is brought to a police station to his/her release from
prison.
This article pays attention to the prison system as part of a chain
of provisions within the criminal law, the influence of the penitentiary system on prison mental health and provides examples
of efforts to improve prison mental health care in countries in
transition.
By Dick Raes and Robert van Voren
Prison mental health as
part of a consecutive chain
of provisions
Each person under suspicion
of having committed an offense
should be considered not guilty
until an independent court has as-
sessed his guilt and pronounced
a verdict. This implies that such a
person should be treated accor­
ding human rights standards.
The ‘career’ of a suspect usually
starts when he is brought to a police
station and possibly formally arres­
ted and taken into custody. There is
hardly any control on the manner in
which police officers deal with such
individuals. Next, the investigation
phase starts when evidence about
the offense in question is collected.
July2009
Keys to Kresti
Prison Ward
4
The main part of this investigation
consists of interrogation of the suspect. In many countries, the criminal investigators can interrogate the
individual without his having benefit
of an attorney. They will try to get a
confession, sometimes using methods that are not allowed according
international standards. The written
report by the interrogators is not
always a true representation of how
a confession was achieved and is
beyond control of the court. A well
known error during the investigation is the so called ‘confirmation
bias’: the investigators are selectively looking for information which
confirms their suspicion and tend
to neglect information that forms an
indication of the innocence of the
suspect.
The public prosecutor is responsible for what takes place during
the investigation phase and has to
prepare the indictment for the court
session. It should be stressed that
the state is and remains responsible for the physical and psychological condition of the suspect. When
needed, he should get the same
medical/psychological care as he
would if not in custody.
In cases of more serious offenses,
the suspect will be admitted to a
pre-trial prison (or remand prison),
in most countries a penitentiary facility with a very restricted regime.
The time spent in a pre-trial prison
should be as short as possible,
depending on the time needed
for preparation of the case for the
court session, the seriousness of
the offense and the risk that the
defendant will escape and hide in
order to avoid further prosecution
and sentencing.
During the trial, the court will interrogate the defendant, eventual witnesses and evaluate other aspects
of proof, as presented by the public
prosecutor. During the court session, there should be a so-called
balance of power, meaning that
the defendant and his lawyer have
equal rights to access all material
collected by the public prosecutor
and the lawyer of the defendant
has the right to cross examine the
witnesses and to bring forward his
own witnesses. In many countries,
this balance of power does not exist and the public prosecutor is the
most powerful party during the trial,
5
especially in Russia and the new
independent states of the former
Soviet Union. Basically the members of the court should be independent, but in many countries this
might not be true (e.g. appointed
selectively by the government). In
case the defendant is convicted
of the crime and sentenced to
prison, he will be sent to a labor
camp or another penitentiary facility, often far away from his place of
residence.
It should be clear that this chain of
facilities and provisions put a heavy
psychological burden on the defendants and convicted persons, especially for people who are already
suffering from mental problems.
They are robbed of most of their
civil rights, the circumstances in
the prison system are usually very
poor, medical and psychological
assistance is often non-existent
and there is no possibility for the
individual to complain about the
treatment he/she receives. Many
international studies have shown
that the number of offenders suffering from minor or major psychiatric
disorders is very high (the mad and
bad).
In general, this chain of regulations
and facilities is very repressive; a
prison sentence robs one of his/her
freedom. But the circumstances
within this chain add a lot of extra
suffering. Prison mental health care
should deal with all elements of this
chain, starting at the police station.
Trying to improve one element of
the chain will likely raise resistance
in other parts of the chain. Changing legislation is not enough. Implementation of a more humane approach in the whole chain is more
important, otherwise it will remain
as window-dressing.
The influence of the penitentiary system on prison
mental health
People who enter the criminal justice system run the risk of being
confronted with all kinds of negative psychological effects because
of the way the system deals with
them.
Being taken away from home without the possibility of contact with
their nearest family, being bullied at
the police station, the stress of being interrogated in certain ways, the
lack of psychological and juridical
MentalHealthReforms
assistance, the uncertainty about
the future, including the result of
the court session and ending up in
a repressive prison climate, often
in crowded cells without any privacy. As mentioned earlier, quite
a number of offenders are already
suffering from mental disorders
when entering the criminal justice
system. Forms of need assessment
are absent. ‘Quiet prisoners are the
best prisoners.’
Exterior of
Kresti Prison
The psychological effects of imprisonment are well known: depression,
self harm, suicidality and completed suicide. These conditions
are increased because of bullying
by guards and other prisoners,
ending low on the pecking order
list that exists in every prison, aggressive and sexual assault. These
individuals often further experience
anger without outlet because of
the repressive and dehumanizing
regime, isolation from their nearest
and dearest, lack of contact with
the outside world, poor hygienic
and nutritional conditions accompanied by increased vulnerability
for all kind of contagious diseases.
To insure the rights and the needs
of individual prisoners, the penitentiary system should develop
within the system a differentiation in
regimes, based on the availability
and the level of medical/psychological/psychiatric/nursing
care.
This differentiation should be made
for special groups of vulnerable
prisoners: prisoners with mental
disorders, with learning disabilities,
adolescents, first offenders, pedophiles and other child molesters.
The criminal law and its procedures
should insure high quality pre-trial
psychiatric assessments to make
a distinction between defendants
who are non- or diminished ac-
1
. Fazel & J.
S
Danesh, ‘Serious
mental disorders in
23000 prisoners: a
systematic review of
62 surveys’, Lancet
2002, 545-550
The starting point: conditions in penitentiary institutions in the NIS at the
end of the 20th century
The history of the Soviet Union
of the twentieth century is one of
bloodshed, terror and mass detention of large segments of society,
starting with the revolutions of the
Russian Empire in 1917, a vicious
civil war with mass arrests, and followed by the State terror unleashed
by Stalin in 1924. By 1941, onetenth of the population was incarcerated in a vast Gulag of camps
scattered all across the country,
but predominantly in the endless
stretches of forests, tundras and
deserts of Siberia and Central Asia.
Millions of citizens were murdered
by execution or hard labor in forced
labor projects.
During the Second World War, millions of Soviet citizens again perished as a result of acts of war, the
Nazi-German killing machine and
the unrelenting meat grinder of the
NKVD. The next phase of history
saw a new wave of terror that sent
millions of so-called “collaborators”
to the camps. And shortly before
the death of Josif Stalin, another
wave of terror was under preparation. The Doctor’s Plot, allegedly a
plan of Jewish doctors to kill Stalin, was, in reality, concocted by
the NKVD in order to make mass
arrests, in particular of people of
Jewish background.
zakone” was a potent force within
the penitentiary system; they maintained a strict regime and determined to a large degree the quality
of life in a cell or barrack: who slept
where and with whom, who got
the best food and other privileges.
The fact that they maintained strict
discipline made them an ally of the
administration, and often their force
was used as a means to keep discipline, the way the Nazi’s made use
of kapos. Even though these were
hardened criminals with severe
punishments for those who broke
their laws, they also had a romantic
air surrounding them. Their attitude
of untouchability was enhanced by
the many tattoos on their bodies,
indicating their crime history and
various preferences, from sexual to
political. Although the power of the
“vor v zakone” is not as strong as
it was in Stalin times, they currently
remain a force to be reckoned with,
and their relationship with the administration is a combination of
respect, fear and collaboration.
more than twenty years. However,
millions of people remained in the
camps, either because they were
considered to be hostile to the
Soviet regime, or because their
forced labor was needed for the
economy. Much of the construction
and industry in Siberia was developed by forced laborers and completely ending this free workforce
would have ruined the country.
The first description of the Gulag
after Stalin was written by Anatoly
Marchenko, and published in 1969.
Marchenko’s book showed that
although the regime had softened
and mortality rates in the “death
camps” of Vorkuta and Kolyma
had decreased considerably, life
in the Soviet penitentiary system
remained harsh and dangerous.
In the 1970s, most dissidents were
incarcerated in the prison of Vladimir and the camps in Mordovia,
later Chistopol prison became the
main prison for “politicals” while
male political prisoners were sent
to the camp complex near Perm;
Mordovia was then earmarked for
female political prisoners.
After the death of Stalin, outright torture of political prisoners
stopped. Indirectly, however, torture
or maltreatment continued through
inhumane living circumstances,
dangerous working conditions,
malnourishment and insufficient
medical care. However, life for
criminals was usually more difficult, and since ordinary prisoners
had no ambassadors in the West,
their maltreatment went much less
noticed. In the mid-1980s, however, life for political prisoners also
had become much more difficult
and the number of deaths increased quickly. In protest against
the bad living conditions, Anatoly
Marchenko, then serving a term
of fifteen years of camp and exile,
went on hunger strike, which cost
him his life in November 1986. His
death triggered the release of all
political prisoners in the USSR.
> “The history of the Soviet Union
in the 20th Century is one of bloodshed, terror and mass detentions of
large segments of society.”
>
countable for the crime for which
they are indicted, based on their
mental status while committing
the crime. The psychiatrists and
psychologists involved in such assessments should be independent
expert witnesses to the court and
not contribute to the investigations
of the public prosecutor. When
the court accepts the non- or diminished accountability, these persons
should not be punished in a regular
prison but referred for treatment
to special forensic psychiatric
hospitals.
Probably the best
description of Stalin’s regime of terror
is Conquest, R., The
Great Terror, Pimlico,
UK., 1992, a revised
edition of his original
book with the same
title published in
1968.
3
Marchenko, Anatoly,
My Testimony, Pall
Mall Press, London
1969.
2
In 1953-1955, millions of prisoners were set free, and many of the
Gulag camps were abandoned.
NKVD director Lavrenti Beria was
executed as were many of his accomplices, and successor Nikita
Khrushchev publicly denounced
the terror that his predecessor had
unleashed against his nation for
Throughout the Soviet period, and
actually up to this very day, the phenomenon of “vor v zakone” formed
an integral part of life within the
penitentiary system. “Vor v zakone”
is best described as a separate
criminal class that placed itself outside regular society and maintained
its own hierarchy and laws. “Vor v
Another important aspect of the
penitentiary system in the (ex-)
USSR worth mentioning is that of
transit prisons. Camp memoirs are
full of horrendous stories about life
in these prisons. Prisoners were
sometimes for weeks and even
months “na etap,” in transit, and
moved from one transit prison to the
next. The prisons were often huge
“holding tanks” with large communal cells where dozens of prisoners
are locked up together, often under
the rule of the “vor v zakone” and
where living conditions are such
that by the time prisoners reached
their final destination they are
exhausted and in bad health. Putting a prisoner on a lengthy “etap”
could and was used as a form of
punishment, and a very effective
one indeed.
It is this penitentiary system that
formed part of the heritage of the
Soviet Union when the country collapsed in 1991 and fell apart into
July2009
6
Case study: changing attitudes within a resisting
system (Russia)
It was an alcoholic representative
for human rights of President Putin
in North-West Russia who opened
the doors to Kresti prison for us. He
had recently been to the psychiatric department of Kresti prison in
St. Petersburg, the largest pre-trial
prison in Europe that at that time
held close to 12,000 prisoners. He
had left in shock, and from conversations it was clear that his indignation was sincere, the situation in
the psychiatric department of Kresti
prison had really touched him.
And there was reason enough
for that. About three hundred fifty
psychiatric patients were cramped
together in small moist cells, where
water was running down the walls,
ventilation was absent and where
in winter it was too cold and in
summer too hot. Sometimes more
than nine persons were locked up
in one cell of two by three meters,
sometimes with only six bunks.
That meant sleeping in turns – and
twenty-three hours behind locked
doors, with the only relaxation being one hour airing in a small courtyard that only offered a view to the
sky. The stench was unbearable,
food outright disgusting, prisoners
were seriously neglected and when
a psychosis would result in too
strong reactions, the prisoner concerned would be isolated and tied
to a rusty metal bed frame because
medicine was unavailable.
Our conversations with the prison director went unexpectedly smoothly;
he had the impossible task of running an overcrowded prison without
sufficient support from Moscow,
and, at the same time, trying to humanize conditions. All support was
welcome, he said, and he accepted
it with open arms. The task ahead
seemed to be an impossible one. It
was very clear that the psychiatric
department needed a thorough reconstruction. In addition, staff was
insufficient, medicine almost never
available and the space made it
completely impossible to create
any therapeutic environment. What
7
followed were years of negotiating,
sometimes without any result. Even
when the funds were released, we
couldn’t do anything because
every step forward was blocked until we “delivered.” Delivering meant
to pay bribes and when we refused,
the project came to a standstill
“The project’s main goal was
>to bring
about attitudinal change,
exactly opposite of current Russian politics.”
In the end, we managed to find a
way out of this dilemma, and after
almost four years of struggling we
could see our temporary success:
the reconstruction of the psychiatric department had been finished
and the new unit could be opened.
True miracles had happened. What
before had been a dark, moist
cave now had been transformed
into a prison department that could
also have fit in a prison in Western
Europe. The architects had succeeded bringing in much more
daylight, as a result of which the
central part looked much nicer. The
cells were dry, well heated, and the
number of beds had been reduced
to maximally four per cell. On top
of that, fitness equipment had been
placed in the department, as well
as table tennis and other games;
a revolutionary development in a
prison system that hadn’t changed
since the beginning of the twentieth
century.
For several months, the staff of the
department carried out a daytime
program for the psychiatric patients
like nowhere else in Russia. Prisoners were taken out of the cell in
small groups, played table tennis,
exercised on the fitness equipment
or played chess at the tables in the
center court between the cells. A
truly humane department had been
created within a terribly repressive
prison system. It seemed our project had finally succeeded.
Unfortunately, Russia wound up
increasingly in dictatorial waters
which had immediate consequences for the Kresti project. The
project’s main goal was to bring
about attitudinal change, exactly in
the opposite direction than that of
current Russian politics. We strived
to humanize the system, to help the
penitentiary system start dealing
with prisoners with mental health
problems as human beings, to see
them first as patients, and only after
that as prisoners. However, the system continued to view the person as
a criminal, someone who needed to
MentalHealthReforms
Kresti Prison
Psychiatric
Ward Before
and After
Renovation
he best books on
T
the subject are Baldaev, D.S., Tatuirovki
Zaklyuchennykh,
Limbus Press, St Petersburg, 2001, and
Lambert, Alex, Russian Prison Tattoos,
Schiffer Publishers,
Altgen PA, 2003
5
See for instance
Appelbaum, Anne,
Gulag – A History,
Penguin,
London,
2003, pp.261-270,
and
Solzhenitsyn,
Aleksandr, The Gulag Archipelago I,
Harper & Row, New
York, 1973
6
An extensive description of the transit
camps and their effect on the prisoner’s
psychological
and
physical state can be
found in the chapter
“The Pots of the Gulag Archipelago” in
A. Solzhenitsyn’s The
Gulag Archipelago I.
4
>
fifteen separate countries. The way
the countries dealt with this heritage
differed from one country to the
other, but without exception they all
still suffer from the Soviet past.
be taught a lesson. The ill prisoner
was preferably seen as being a
simulator; with the worst simulator
being the prisoner who pretended
he had a mental illness. He was
dealt with double harshly, and was
often locked up under even more
inhumane circumstances than the
rest.
Change in leadership of the penitentiary system in St. Petersburg
endangered the project even more.
It was probably a combination of
orders from Moscow to straighten
things out and the natural reaction
of a leader in such a repressive
organization to create fear through
a temporary reign of terror and to
show who is boss. Using a conflict
with one of the prisoners as a pretext, the prison administration took
the fitness equipment away and
stopped the day program, allegedly
because an aggressive patient had
made all this impossible. But after
a while the day program resumed;
this cycle repeated many times.
This was our dilemma. Is it at all
possible to hope that Russia will
become more humane, or do we
have to accept that a democratic
Russia has for the time being become a fata morgana again? The
article by Konstantin Antsiferov,
Rob Hollander and Wendy Weijts
follows with some additional details
on this project.
Case study: indifference
as the main obstacle
(Lithuania)
Lithuanians are a proud people,
proud of their history and also
proud of their constant resistance to foreign oppressors. In
Soviet times, it was a Lithuanian
underground publication that was
published uninterruptedly until the
collapse of the regime; the Lithuanians were the first to declare
themselves independent in 1990,
and managed to hold on in spite
of strong pressure, an economic
blockade and military action by
then-President Gorbachev. In
order to prevent a storming of the
parliamentary building, officials
placed huge concrete fortifications
around the building - a portion of
which is still visible in the form of a
monument.
In 2004, Lithuania joined NATO and
the European Union. It was truly a
milestone in the history of the nation,
marking a definite reintegration into
Europe and ending the fear of future Russian domination; yet, at the
same time, it also marked the end to
many of the reform processes. After
accession to the European Union,
the developments in the country
slowed down and eventually came
to a standstill.
Typical
The penitentiary system in Lithu- Psychiatric
ania was inherited from the Soviet Prison Cell
Union as an outdated network of
prisons and labor colonies, and a
workforce that had been educated
as a Soviet militarized machinery to
keep prisoners locked up and out
of society. In the late 1990s, many
young people joined the penitentiary service and questioned many
of the approaches. These young
people had enlightened minds
educated in post-Soviet Lithuania
with additional trainings abroad.
They started introducing new services such as those for prisoners
with alcohol and substance abuse,
and humanized life in many of the
places of detention. Clearly, since
independence, the Lithuanian
prison system made enormous
progress in shedding the Soviet
past and strives to reach European
standards as soon as possible.
At the same time, it is also clear that
much work still needs to be done
and that prisoners with mental
health problems are no less stigmatized in the prison system than
in society at large and that extra
efforts are needed to change that
situation. In spite of assurances
that new premises will be built, the
prison psychiatric department is still
housed in the pre-trial investigation
prison in Vilnius (Lukiskes prison).
Symbolically, the psychiatric department has the worst possible
accommodation in this facility - in
a wing of the pre-trial prison – but
under much worse conditions than
the pre-trial prison facility itself or
the rest of the prison hospital. The
cells are damp without any ventilation, housing four to five prisoners
in one cell. The department has
sufficient medication available, but
the quality of services provided is
questionable. The perimeter is surrounded by five fences and walls,
with prison dogs running around
between the first fence and the
actual prison building, creating an
eerie atmosphere with their constant barking.
It is hard to explain why a European
Union country such as Lithuania
has no interest in improving prison
mental health services and ending
such unacceptable conditions in a
prison located less than 500 meters from the Lithuanian parliament
building. Protests and complaints,
including by a WHO delegation in
2005, have not led to any results.
Persons with mental illness are no
priority, and neither are imprisoned
criminals; those who are a combination are double stigmatized, and
suffer the consequences.
Case study: when desire
exceeds the possibilities
(Georgia)
Georgia also inherited a Soviet
penitentiary system, housed in dilapidated buildings with some of the
most inhumane living conditions we
had seen over the years. In no way
could a therapeutic atmosphere be
established in the existing premises,
the professional level of the few
available staff was excruciatingly
low and the conditions were so bad
that, in our view, only one solution
was possible: close the department
down and start a new one somewhere else, under better conditions.
We had been asked by the Georgian Ministry of Health to reform
forensic psychiatric services in the
country after a corruption scandal
had resulted in the dismissal of all
forensic psychiatrists by the Minister; yet the Ministry’s understanding
of the scope of their request was
minimal. We were facing not only low
professional standards, corruption,
lack of professionals and bad living
conditions, but also the absence of
collaboration between the Ministries
of Health and Justice and complete
lack of coordination within the ministries themselves.
What we had, however, were very
enthusiastic and reform-minded
officials, including actively involved
deputy ministers and young mental
health professionals. The ministers
and their deputies also were young,
which resulted in an interesting
combination of lack of experience
in governance, a quick grasp of the
needs due to first-class Western
education, and a drive to change
things overnight.
However, there clearly was no
chance of a quick solution to the
immense problems. We decided
that the only way to help Georgia
structurally and sustainably was
by dealing with the issue in an allencompassing manner, tackling the
whole chain of services. Georgia
became the only country where
we managed to take this global approach. An inter-Ministerial committee was established, that met on a
regular basis, involved all stakehold-
July2009
8
ers including the deputy ministers of
health and justice and discussed all
the issues collectively. After some
compromises, many decisions were
taken during these meetings.
In the course of four years, we managed to agree to develop a new
pre-trial assessment center in Tbilisi,
built with Georgian money and according to European standards,
the result of collaboration between
Dutch and Georgian architects.
With a delay of half a year due to the
August Russian-Georgian war, we
now expect the center to open before the end of 2009. Also, renovations started at a newly established
central forensic psychiatric facility in
Qutiri, and in spite of the war, reconstructions are continuing, again with
Georgian funds. And, last but not
least, an agreement was reached
to open a new prison mental health
department in the newly built prison
in Gldani just outside Tbilisi, and
hopefully also this department will
be opened in 2009.
Trainings were organized for doctors, nurses, social workers and other personnel, including the guards.
A permanent link was established
between a Dutch forensic psychiatric hospital and the hospital in Qutiri,
and an agreement was reached
with the Georgian government that
GIP will provide intellectual support,
while all construction and material
needs will be financed by the Georgian government. Until now, they
have stuck to their word. A true professional exchange has developed
with the Georgians; implementation
of the projects is based on real partnership.
top-down, but are even more difficult
than the opposite: changes from
bottom-up. Basically, efforts to bring
about change should be aimed at
all levels of a society but will meet
a lot of resistance. For example, it is
amazing that the expansion of the
European Union to include countries
in Eastern Europe neglects human
rights related to the fate of prisoners
in these countries. Obviously these
have a very low priority.
Nevertheless, NGOs try to find likeminded partners in these countries
to create ways (and money) to work
from the bottom of the penitentiary
system to bridgeheads higher in
the hierarchy. As described above,
these efforts are not always successful and these changes take a lot of
time, because experience shows
that changes only can be achieved
in very small steps forward.
Conclusion – what lessons
can be learned
It is our view that each project concerning the improvement of prison
mental health requires extensive
preparation to make the project ap-
Prison mental health as a
mirror of society: what is
achievable in the coming
years?
The criminal law, its procedures and
institutions, constitutes a closed system within the wider system of society, including politicians, bureaucrats
and citizens. To start with the penitentiary system, the way the director
deals with his staff will be reflected
in other layers of his organization, to
end up with the attitude of the guards
toward the prisoners.
Where democracy is lacking, there
are hardly any possibilities of influencing the existing system. Eventual
changes should be implemented
9
MentalHealthReforms
Lukiskis
Prison, Vilnius,
Lithuania
plicable in each different country.
Preferably this preparation should
be carried out together with local
partners who want to participate as
change agents. During this preparation, attention should be paid to
possible changes in each part of
the chain that has been described
above. Support of the project by the
ministries involved is very important
in the sense that the bureaucracy
takes his own responsibility in the
process of change. Unfortunately,
the regimes in these countries are
not as stable as we would like for
implementing the projects and their
sustainability.
Dick Raes is Professor in Forensic
Psychiatry, member of the board of
GIP and his email is: d.raes@wxs.
nl. Robert van Voren is Chief Executive of Global Initiative on Psychiatry.
His email address is rvvoren@gipglobal.org. .
Editor’s Note: For further background (and fascinating reading),
please note the attached information
of a new book by Robert Van Voren:
Seven Years in Kresti Prison:
A Unique Project to Develop Modern Prison
Mental Health Services in St. Petersburg
As mentioned in the previous
article, in 2002, a unique cooperation started between Dutch
and Russian professionals
working in the prison system.
The goal of this project was
to improve the care for mentally disturbed prisoners in the
Kresti-prison – St. Petersburg NW region Russian Federation.
Because of the uniqueness of
this project, we would like to
make a few additions from our
own experiences.
By Konstantin Antsiferov, Rob
Hollander and Wendy Weijts
Activities for
Prisoners in
Kresti Prison
Psychiatric
Ward.
Photo taken by
Theo Lammers
The Kresti prison, built in 1827,
is one of the largest prisons in
Europe. At the banks of the river
Neva, the prison was originally
built for 950 prisoners. During our
first visit, 12,000 prisoners were
held in Kresti, and by the time our
project started, still approximately
7400 prisoners were detained. In
the Kresti, there are several wards
housing prisoners with HIV/AIDS
(1200), prisoners with tuberculosis
(700) and prisoners with severe
psychiatric disorders (270).
We would like to point out here that
the renovation of the prison ward,
our first priority, was accomplished
mostly through the work of the convicted prisoners. They constructed
two types of cells within the ward.
One type of cell was built for patients in an acute psychiatric phase
and hosted two prisoners. The
other type of cell was for stabilized
patients and hosted four prisoners.
The light green walls, the windows,
the clean environment and the
equipment for activities made the
total metamorphose complete. The
new psychiatric department now
10
MentalHealthReforms
meets the international construction
standards for prison mental health.
The daily activities introduced have
been mentioned previously; those
activities were planned to create ‘a
sense of purpose’ into the lives of
the mentally disordered detainees.
Through offering them regular and
meaningful activities in their lives,
their self-esteem would be raised. It
is also important to note that these
activities create some ideal moments for observation - observations that lead to very useful insights
and can be used in the assessment
of behavior and possibilities of
treatment of the (individual) patient.
In the past seven years, we spoke
about this subject with many of our
Russian colleagues. Many times
these talks seemed as useless as
the daily lives that the patients have
to endure. But, in the end, there
were some success stories to be
told: daily programs for patients
were introduced and frequently the
patients are now undertaking more
meaningful activities with each
other. As we have recently been
told, this is a unique development
in the Russian prison system.
It is hard to determine if and how
all attitudes will be changed because of this project. In the Russian prison system, the convicted
prisoners (sanitary) play a very
important role. The authorities
consider them as personnel for
the prison and they are employed
in many different jobs. Not only do
they do the cleaning, cooking and
maintenance work, often they are
also responsible for the security
within the prison. Once we visited
a prison with only eight guards who
were responsible for 2000 inmates.
In reality, this is not manageable for
the guards, so special prisoners are
assisting those guards in different
ways. The system where convicted
prisoners take care of other prisoners is highly undesirable but a
harsh reality due to a lack of money
for the prison authorities.
In the Kresti, the sanitary assist the
doctor in his/her consultation with
patients on the psychiatric prison
ward. The sanitary are also responsible for discipline amongst the
patients with mental disorders. Despite our effort to establish a fixed
team of guards who are trained to
deal with mentally ill prisoners, we
did not succeed in this. In the end,
we chose to develop an instruction manual for the sanitary that
work in the psychiatric ward and
discussed the selection criteria of
those sanitary with the prison director. This manual was printed on
big key-shaped plastic cards. The
symbolism of these keys is to open
doors and gave a small entrance
to the psyche. The keys gave short
instructions about how to deal with
inmates with psychiatric problems.
For example: how can one manage his attitude when a prisoner
is anxious or depressed. The keys
may result in attitude changes of the
sanitary on the psychiatric department and give some sustainability.
effective and efficient and support
implementation.
The Kresti prison annually receives
more than 3500 prisoners. It is
impossible for the psychologist to
see all new prisoners so we introduced a screening instrument to
detect psychiatric problems at an
early stage. In a pilot setting, we
have trained some junior inspectors in using the questionnaire
with newly arriving prisoners. The
outcome of the screening can be
an indication that the new prisoner
needs consultation of the psychologist. The prison authorities
found this screening instrument
Recommendations
During the project we tried to introduce the subject ‘prison mental
health’ in the Russian system. We
visited the Pushkin Institute that is
responsible for training prison staff
throughout the Russian prison system in order to establish some sort
of collaboration. Unfortunately, this
was an unfulfilled goal.
> “It is impossible for the
Working in the Russian prison system is often a matter of patience,
improvising skills and good personal relationships with important
key holders. During this project,
many of the key holders changed.
One example is that the Kresti got
a new director who was not as enthusiastic as the former one. This
resulted in a temporary withdrawal
of the day program and recreational facilities. It took a considerable
amount of time for him to agree and
support the project, especially the
>
psychologist to see each of the
3500 patients who come to
Kresti each year.”
Instruction
Manual for
Kresti Prison
Psychiatric
Ward.
Photo taken by
Theo Lammers
day program. We had some nice
conversations and peppered discussions. Sometimes it felt like two
steps forward and one step back.
However, every visit ended with a
toast of vodka and the words: “to
our friendship.”
In order to implement new methods, those methods must be
adapted to the Russian situation.
The first reaction from the authorities is often a negative one indicating that they cannot implement new
methods; but when we insisted,
their opinions changed completely. We also needed to be flexible
in our approach; many times, we
encountered changes within our
program and had to keep from
being frustrated while adapting
to the new situation. After seven
years of work within the Kresti, we
developed some unique relationships and accomplished many of
our goals. This was not possible
without the support of many. We
are very thankful for that.
Konstantin Antsiferov is the GIP
representative
in
St.
Petersburg and his email address is
Antsiferov@inbox.ru.
Wendy
Weijts and Rob Hollander work in
the Dutch prison mental health service and are active in many of GIP’s
projects. They can be reached at:
roberthollander1999@yahoo.com
and wweijts@yahoo.com.
>
>
July2009
11
Risk Assessment in
Post-Soviet Countries
By Virginija Klimukiene
A risk assessment is “a statement
on the likelihood that a certain undesirable event will take place in
the future.”1 Risk assessment is a
routine practice in the field of forensic psychiatry: every 6 months, the
court receives the reports from the
hospital and must make decisions,
based on these reports, as to either
prolong the present compulsory
treatment measures or to change
them into lighter or stricter ones. In
most of the post-Soviet countries,
the court will release a forensic
psychiatric patient from the hospital
only when it is obvious that the mental state of the patient has changed;
in other words, when his/her risk of
reoffending is significantly reduced.
However, one could argue that the
changes in mental state and the reduction of risk to reoffend is not the
same. These factors depend on the
approach to Mental Health we take
as a baseline: a biological approach
emphasizes the medical treatment
of mental disorder as a keystone
to prevent criminal behavior in the
future. A bio-psycho-social approach to Mental Health takes into
consideration all – biological, social
and psychological – factors, which
determine (future) offenses, therefore a reduction of risk will be related
to both medical treatment and resocialization, i.e. management of all
risk factors.
Post-Soviet countries gained their
independence 15-18 years ago
and have taken their unique way of
development. However, the neighboring countries often take rather
similar steps and speed in development. Taking into consideration the
lack of the precise knowledge about
the situation of risk assessment in
every particular Post-Soviet country,
the author presumes to group the
countries and present one state
from each group: the Baltic States
in this article will be represented
by Lithuania; Russian Federation,
Republic of Belarus and Ukraine will
be represented by the Russian Fed-
12
The Author
Presenting on
HCR-20
eration; and Caucasian and Central
Asian countries by Georgia.
Lithuania
1
.W.G.Philipse. PreM
dicting Criminal Recidivism. Empirical
studies and clinical
practice in forensic
psychiatry. – Printed
in The Netherlands
by Febodruk, Enschede, 2005.
MentalHealthReforms
In 2004 – 2007, GIP implemented a
project titled “Reorganizing forensic
psychiatric services in Lithuania”
financed by MATRA (hereinafter
Rokiskis MATRA Project). This project aimed to develop a contemporary system of forensic psychiatric
service delivery in the Republic of
Lithuania that adequately provides
care to this specific group of patients and protects society from the
criminally insane. The provision of
adequate care to forensic psychiatric patients and protection of society
from the criminally insane is directly
related to the assessment of risk to
offend in the future, because of the
following:
1. R
isk assessment helps to ascertain the main factors contributing
to the criminal behavior of the
particular patient;
2. It serves as a background for the
development of individual plans of
treatment and risk management;
3. It enables the evaluation of the
effectiveness of measures taken
during the treatment;
4. It helps in reporting to the court
regarding the changes of obser-
vational conditions and prolongation or end of hospitalization.
In Lithuania, as in most Post-Soviet
countries, risk is mainly assessed on
the basis of so-called unstructured
clinical judgment approach, which
implies, that “the clinician is, as it
were, his own risk assessment tool“
(M.Philipse, 2005). It means that
the final conclusion is determined
subjectively (and often implicitly) by
each individual clinician. The above
mentioned project has revealed a
deep need to develop Lithuanian
versions of world-widely recognized
and used risk assessment tools.
HCR-20 Violence Risk Assessment
Scheme 2nd version (developed in
1997) was chosen from a long list of
instruments, because it is designed
to assess the risk of people who
have some Mental Health disturbances. In addition, it is quite easy
to understand and apply. HCR-20
represents the structured clinical
judgement approach rather then
actuarial one; it does not require
a long validation process and the
creation of local norms; and it also
impacted the decision to pilot the
risk assessment in Lithuanian forensic psychiatric setting on the basis
of this instrument.
In May 2007, three groups of 20
professionals each from Rokiskis
forensic psychiatric hospital were
trained on risk assessment and
application of HCR-20 in practice.
Participants of these trainings had
different educational backgrounds:
including psychiatrists, psychologists, social workers, occupational
therapists and nurses. Rokiskis
MATRA Project had a fundamental
impact on creating multidisciplinary
team work in Rokiskis hospital and
trainings on HCR-20 were designed
to teach ways that this instrument
could be handled by all team members (one of the indirect tasks of
HCR-20 is to structure the meetings
of multidisciplinary teams). Thus we
may conclude that Rokiskis MATRA
project facilitated an essential turn of
risk assessment in forensic psychiatric settings in Lithuania, because
it initiated the implementation of
structured clinical judgment instruments as an alternative to subjective
considerations.
Risk assessments might also be
seriously considered in correctional
settings. We may boast about the
Lithuanian Prison Department,
which has developed and currently
is implementing the Probation Concept. Such risk assessment instruments as HCR-20, PCL-R (Hare’s
Psychopathy Checklist – Revised),
SVR-20 (Sexual Violence Risk
assessment instrument), OASys
(Offender, Assessment System),
Static-99, SARA, SORAG and others are planned to be introduced
into the Correctional System of
Lithuania.
In summary, the handling of risk assessment tools in Lithuania shows
that the provision of modern forensic psychiatric and prison mental
health services has been started in
Lithuania and we are very hopeful
that this process will be continued
by implementing the appropriate
risk management strategies in both
forensic psychiatric and correctional
settings in order to reduce the level
of re-offenders in the Lithuanian
population.
Russian Federation
In 2007, Global Initiative on Psychiatry started a new project “Development of forensic psychiatric and
prison mental health services in
Kaliningrad Region,” also financed
by MATRA. On the basis of the experience gained during the Rokiskis
MATRA Project regarding the importance of risk assessment providing
services for offenders with mental
health problems, it was decided to
implement HCR-20 in the forensic
psychiatric and penitentiary institutions in Kaliningrad Region.
It was found that the permission for
the Russian version of HCR-20 has
already been given to some professionals working in the North-Western
> “These risk assessment tools
represent the best of objective
judgment for the future.”
>
In June 2006, two representatives of
Lithuania, Prof.Rita Žukauskienė and
the author of this article, received
the official permission to translate
into Lithuanian, edit, and print the
manual for the HCR-20, Version 2
(Webster, Douglas, Eaves, & Hart,
1997) from the Mental Health, Law
and Policy Institute of Simon Fraser
University (Canada), which holds the
copyright of the abovementioned instrument. During the next two years,
400 copies of HCR-20 Lithuanian
version was published following
the requirements described in the
official permission. The longitudinal
validation research has been conducted and in the middle of 2009, it
is anticipated that the first results of
the follow-up of forensic psychiatric
patients released from the hospital
at least 12 months ago will be gathered.
part of Russia. The leader of the
team, Dr. Oleg Ponomarev, agreed to
cooperate with GIP in such a way that
he permits GIP to publish 1000 copies of HCR-20 Russian version and
GIP covers the costs of translation
and editing and also provides trainings to specialists of Arkhangelsk
Regional Clinical Psychiatric Hospital
on the use of the instrument in daily
practice. GIP also commits to transfer 100 copies of HCR-20 Manual to
Arkhangelsk Hospital and to provide
support in training the trainers of application of HCR-20 in Russia.
Since Russia is such a large country
and the Kaliningrad specialists did
not know about developments in
Arkhangelsk where permission was
given in 1995 for developing the first
Russian language version of the
HCR-20, we may assume that there
might be other initiatives to develop
risk assessment methods that are
not yet known to us. It is possible that
these initiatives are not embraced
by the two main institutes in Russian
Federation charged with coordinating all forensic psychiatric issues:
Serbsky Institute in Moscow and
Bekhterev Institute in St.Petersburg.
We hope that this information will be
helpful in avoiding double work and
enhance cooperation among institutions at the local and international
level, particularly considering the
quite strict requirements and procedures to obtain the permission for
developing a national version of the
particular instrument.
Georgia
Unstructured clinical judgment is
the only method used to assess the
risk of forensic psychiatric patients
in Georgia. This country is lacking
psychologists, social workers and
other members of a multidisciplinary
team; therefore the report to the court
is often based on the description of
the patient’s mental state and progress of medical treatment. The current situation in the country requires
focusing mainly on coping with
trauma, psychosocial rehabilitation
of refugees and internally displaced
people, and on strategies that support the process of recovery.
On the other hand, the increasing
level of offenses (especially among
juveniles) is observed in Georgia as
an outcome of the traumatic events
of last summer. Thus, it is the right
time to address the implementation
of risk assessment instruments as a
background for development and
application of risk management
strategies.
It is our hope that these valuable risk
assessment tools, already translated
into Russian and Lithuanian, will be
further translated and used throughout the former Soviet Union. These
tools represent the best of objective judgment for the future and will
hopefully replace the unstructured
clinical judgment used in the past.
Virginija Klimukiene is the Project
Manager for GIP-Vilnius office and
her email address is
vklimukiene@gip-global.org.
July2009
13
Developing Partnerships in Forensic
Psychiatry: The Pompe Foundation as
Partner in GIP projects
Forum GGz Nijmegen is a large
organization for mental health
care in the eastern part of The
Netherlands. Part of this organization is the Pompe Foundation, which consists of a high
security forensic psychiatric
clinic with facilities for resocialization, a policlinique for
ambulant care and treatment
of forensic psychiatric patients
and a center for research and
development.
By Thieu Verhagen and
Dick Raes
At a congress in Prague in 2000,
the first author (T.V.) met a medical
sexologist from Lutz in the western
part of the Ukraine. This individual
was invited to the Pompe Foundation, gave information on the situation
of forensic psychiatry in the Ukraine
and asked for assistance to improve
the conditions in forensic psychiatry
in his country. This resulted in a visit
of a delegation of the board of the
Pompe Foundation to the Ukraine.
The Authors
Visiting
Forensic Facility
in Serbia
The youth prison in Kovel especially made a deep impression on
the visitors. Hundreds of boys were
incarcerated without any activities,
with lack of proper food and medical care and hardly any possibilities
for rehabilitation. Back in The Netherlands, the delegation succeeded
in raising philanthropic funds for a
project to improve the conditions in
this youth prison.
The result was that, after four years,
this facility had its own kitchen
where the boys were baking their
own bread, a shoe reparation workplace, a garage and several smaller
work places. The boys were trained
in these new facilities as part of
their rehabilitation.
14
MentalHealthReforms
A visit from Holland in 2007 made
clear that these changes would
be maintained. Inspired by these
results, the Pompe Foundation decided to go further on this way, but as
it appeared, getting more formalized
funding from the Dutch government
was met with too many complicated
administrative procedures. This led
to a structural cooperation between
the Pompe Foundation and GIP, the
latter with its longstanding experience with projects in Eastern Europe
and the New Independent States of
the former Soviet Union, as well as its
experience writing project proposals
to the Dutch government.
It is the intention of GIP to extend
their activities in these fields to Asia
and Africa.
A steering group was formed to lead
the project since there were many aspects of forensic psychiatry to be included: pre-trial assessment, prison
mental health, and the execution of
criminal law. In addition, the number
of projects in this field was increasing;
currently, the Pompe Foundation is
involved in three ongoing projects - in
Lithuania, Russia and Georgia. New
projects are in preparation in Serbia/
Montenegro, Bulgaria and Sri Lanka.
In this article the results so far in
the first mentioned countries will be
described.
Forensic Psychiatric Hospital Rokiskis, Lithuania
The first project involving the Pompe
Foundation started in the only psychiatric hospital in Lithuania, situated
in Rokiskis, a far away village in the
northern part of the country. It was an
old psychiatric hospital with prisonlike characteristics, comparable
with Dutch psychiatric facilities from
about 1950. Its staff was low paid, in
general poorly trained and its motivation to change not very high, with the
exception of the medical director.
Patients stayed in their rooms during the day, shared with four or five
other patients. No daily activity program was offered and their treatment
mainly consisted of medication.
The Pompe Foundation offered several trainings to different groups of
workers, including a multidisciplinary
approach to each individual patient’s
problems, patient-staff interaction
and psychopathology. Together with
local partners, the risk assessment
instrument, the HCR-20, widely used
in the West and described in the previous article, was translated into Lith-
The three-year financing of the project by the Dutch Ministry of Foreign
Affairs (the so called Matra financing,
Matra meaning Social Transformation) ended in 2007. But the activities
of the Pompe Foundation will be continued, based on a Memorandum
of Understanding between Rokiskis
Hospital and the Pompe Foundation
(“twinning”) resulting in ongoing support by the Pompe Foundation. It is
important that the progress achieved
will go on. The project has moved
Rokiskis at least 25 years ahead of
where it was; a great deal has been
achieved but still more is to be done.
It should be mentioned that apart
from the activities of the Pompe
Foundation, GIP was able to use the
opportunity to organize workshops
with members of the court and the
public prosecutor’s office.
Forensic Psychiatry in Kaliningrad (Russian Federation)
This Matra project started in 2007
and involves the three areas mentioned above. Kaliningrad is a province of the Russian Federation, but
has become an enclave, separated
from the main country. In our view,
based on earlier experiences, this
is an advantage because of the fact
that all aspects of forensic psychiatry
are centrally directed from Moscow.
Because of its more isolated position
towards Moscow, we expect to have
more cooperation with the local authorities and colleagues.
The first visit of a Pompe delegation took place in 2007 to the high
security forensic psychiatric clinic in
Chernyakovsk. The treatment of the
400 patients consists only in the application of medication, aimed at stabilizing the condition of the patients.
The average duration of the patient’s
stay in the hospital is 10 years (twice
as long as in the Pompe Clinic). They
are allowed to be in contact with their
families by mail or telephone but
never get permission to visit them.
Family members were never involved
in the treatment; patients and, especially, those admitted for political reasons as happened in the old regime,
were as a rule admitted as far away
as possible from their original place
of living. Because of the isolated
location of Kaliningrad, most of the
patients are nowadays admitted from
the Kaliningrad area. Thus, it is easier
for family members to visit the hospital and offer also better opportunities
for rehabilitation and resocialization.
The director and his staff are very
motivated for changes, but there is a
lack of skills and knowledge. A lot of
the potential of the staff is not used
because of the strict hierarchical relations in the organization and insufficient professional education.
A Dutch developmental agency (Cordaid) was willing to support a project
to improve the circumstances and
treatment in the forensic psychiatric
hospital in Quitiri. Recently, all forensic psychiatric patients from Georgia
were brought together in this hospital.
Because of the isolated situation of
the hospital, it lacks enough qualified
personnel which, in turn, is reflected
in the quality of treatment. Also in
this situation, the Pompe team has to
deal with implementing knowledge
in nurses and as well in psychiatrists
and psychologists, regarding basic
principles of psychopathology, multidisciplinary treatment, risk assessment and risk management. There
is a positive perspective on cooperation with the local professionals.
It is clear that the nursing staff needs
training on working with the patients
in a therapeutic way, methods for
planning, effectuating and evaluation
of the treatment, also in a multidisciplinary context. But also improvement of the position and involvement
in the treatment by the psychologists
is rather urgent, including the introduction of the HCR-20. Between
2007 and 2010, The Pompe team will
offer three trainings each year. Apart
from these activities, the Prison Mental Health Team of GIP succeeded
in organizing activities with penitentiary psychologists to improve mental
health care in the prison system in
Kaliningrad.
General recommendations
1. It is very important before starting
a project with real interventions to
get the trust of the local partners,
as well the people we try to work
with as the authorities that have the
final responsibilities. The Russians
especially do not trust the influence of western involvement under
the name of NGOs and MATRA.
2. It is our experience that the expectations of at least beginning trainers are too high as to what they
can achieve.
3. Administrative and logistic tasks
should be taken care of by others than the professional trainers
involved. These tasks would take
time from the work needed to meet
their primary goals.
4. Be prepared for the specific
problems concerning traffic and
transport. Local people are usually very hospitable but not aware
of the stress their driving behavior
provokes.
5. Be aware of drinking habits. Do
not be surprised when vodka
is served at breakfast or lunch.
Restrict yourself regarding this to
dinner situations.
6. Be prepared that many intended
activities will work out in a different
way. This requires improvisation
and creativity. (T.V.: “Nothing is
certain until it has happened.”)
Georgia
Georgia appeared to be one of the
countries where the departure of the
old Soviet system left the country in
a state of almost anarchy. This situation offered advantages and disadvantages. Due to total corruption in
the system of pretrial assessment,
GIP was asked to establish a new
approach to psychiatric expertise to
advise the courts. Because of the
results of a new expertise center for
pretrial assessment and a series
of seminars for the staff, GIP was
asked to assist in the arrangement of
a new centralized clinic for forensic
treatment and as well for the care of
mentally disturbed prisoners in a new
prison center.
> “The average duration of a
patient’s stay in the hospital is 10
years; they can receive mail from
family members but are unable to
visit with them.”
>
uanian, according to the regulations
and an expert of the Pompe Foundation gave training in the application of
this instrument for psychiatrists and
psychologists from Rokiskis and the
Romero University in Vilnius.
Thieu Verhagen is Head Concern
Staff, Forum GGz Nijmegen and
part-time consultant with GIP. E-mail:
t.verhagen@forumggznijmegen.
nl. BCM (Dick) Raes is Professor in
Forensic Psychiatry, member of the
board of GIP. E-mail: d.raes@wxs.nl
July2009
15
Initiating Reform in Prison Mental
Health & Forensic Psychiatry in
Serbia
In October 2007, a team of experts of Global Initiative on Psychiatry
visited Serbia for the first assessment of the situation in forensic
psychiatry and prison mental health. Several institutions were visited,
including the forensic department of the Gornja Toponica hospital in
Nis and the Central Prison Hospital in Belgrade. The report of the visit
was received positively by all parties concerned, as it offered a wide
range of possible fields of collaboration. The Dutch Embassy agreed
to finance a continuation of the assessment as well as some first
activities in this field. Within the framework of this project, a further
inventory of the situation in forensic psychiatry in Gornja Toponica
would be carried out and professional exchanges between Serbian
and Dutch forensic psychiatry professionals would be started. Also,
a second assessment visit to the Specialized Prison Hospital in Belgrade would take place followed by a first step in the direction of an
exchange of views and experiences. In addition, materials to stimulate day time activities and rehabilitation work at the forensic department of the hospital Gornja Toponica would be bought and a seminar
on forensic psychiatry and prison mental health would be organized
for all stakeholders in Serbia.
By Robert van Voren
Forensic psychiatry: visit
to Gornja Toponica
In March 2008, John Kobessen and Roland van Rooij of the
Pompe clinic in Nijmegen (The
Netherlands) visited the specialist
psychiatric hospital Bolnica Gornja
Toponica (Nis, Serbia). This hospital accommodates nearly 700
general psychiatric patients and
120 forensic patients, the latter
group of which consists of 80
men and 40 women. The assignment from GIP was to take a close
and unprejudiced look at Bolnica
Gornja Toponica’s vision, method,
patients and building, and to make
as much contact as possible with
the professionals at work. Special
attention was paid to meaningful
pastime: what current activities are
there and where do opportunities
for growth lie?
The Dutch experts were cordially
received by the general manager,
16
Dr. Milan Stanoskovic, and by
the unit managers (Dr. Snezana
Vladejic, Dr. Dragana Arandelovic,
Dr. Sanja Stanojrovic) and staff.
Everything is done optimally with
the possibilities at hand (e.g. using medication as effectively as
possible). The atmosphere is open
and there is direct contact with
the patients, who are treated with
respect and care, and at the same
time there is a balanced relationship between staff and patients.
Every effort is made to provide social safety, taking into account that
there are as few as one to six staff
members at a unit, for a maximum
population of 80 patients, residing
in 5 dormitories. There are no computers and, thus, no fast and direct
communication. Patients’ records
are still kept on paper.
One example of the involvement of
staff is the weekly group meeting
where 60 male patients are hosted
MentalHealthReforms
by 6 staff members (doctors and
therapists). This group (that has
patients in the positions of chairman and secretary) is used to let
patients react to each other, to
inform them (e.g. about treatment)
and to correct them if necessary.
Another striking example is a morning meeting that requires patients
to stand next to their neatly made
beds at 8 am and be scrutinized
by the full staff of the ground and
first floors, who point out any peculiarities (there is no privacy).
While an informal culture has
developed, there is hardly any
formal culture. No protocols exist
for incidents or hostage situations
and understaffing, nor are there
any written house rules or job descriptions. Psychotic patients and
patients with personality disorders
are mixed. (Our impression was
that on these units the psychotic
patients were the vast majority;
Visiting Gornja
Toponica
Forensic
Department
Lammers and Rob Hollander visited the Special Prison Hospital
in Belgrade. This hospital has 4
different specializations with a
total of sometimes more than 600
patients.
75% versus 25% personality disorders).
Expansion of patients’ leave has
to be requested directly at the
courthouse, upon which a judge
reacts with a simple “yes” or “no.”
However, if anything happens to
the patient while on leave (flight,
recidivism), the sole responsibility
falls on the hospital and the general manager. The consequence is
that patients have little chance of
moving out of the secured building;
and rehabilitation often consists of
nothing more than being dropped
back into society at a certain moment, at which point patients completely depend upon their (often
deficient) social network.
The largest group, the department
with compulsory treatment, is in a
building unsuitable for this population and without a good treatment
environment. In some cases,
patients stay for over 20 years in
this prison hospital. When patients
have no social network after their
treatment, the court will not release
them because they still consider
them as a danger to society. For
those patients, a normal resocialization program cannot take place
at all.
The logical consequence is a high
percentage of (risk of) recidivism
and patients returning to society in
an often highly unstable condition.
There are few social workers who
can guide patients and their social network. The travel distances
are also unfavorable; patients
living 300 km from the hospital
can often be consulted by means
of telephone only. Serbia has no
after-care and resettlement organizations.
It is true that there are activities for
forensic patients inside the building and sometimes on the hospital
grounds. An impeding factor is
that patients cannot be employed
in “real” work because it is considered by outsiders to be exploitation
of patients; however, it is this kind
of work that offers opportunities for
patients to develop themselves. It
is important to educate patients
individually in certain basic skills
(cleaning, kitchen, garden, maintenance, etc., but also basic knowledge of language, mathematics,
writing, etc.): positive experiences
create positive energy.
The second reason why there is so
much hesitation to extend patients’
movements beyond the hospital
gates is the negative public image
of (forensic) psychiatric patients.
Time and energy is invested in
making contact with society, with
some success.
Prison Mental Health: Visit
to the Specialized Prison
Hospital
In June 2008, Wendy Weijts, Theo
Compulsery
Treatment,
incl drugs
and alcohl
adiction
• around 450
patients
• around 66 patients
Acute crisis • 400 admissions per
intervention
year
pre trial
• around 50 patients
assessments
somatic
ward
Distribution
of patients
in Belgrade
Special Prison
Hospital
• around 50 patients
Within this restricted facility, the
staff was very committed to the patients; the occupational therapists
try to make the residence of those
patients a bit less miserable. One
guard is responsible for one ward
which sometimes contains more
than 120 patients and, at times
may be responsible for two or
more wards at the same time. Most
of the patients receive tranquilizing medication (most common
use is Bentazin) and have nothing
much to do other than staying in
their beds. Sometimes (in case of
severe aggression) patients get
restraint measures (special room
where the patient is tied to a bed).
Within a prison system, this is an
accepted measure, even in western countries. The main problem is
that, when in restraints, the patient
is actually under the observation
of another patient. In our opinion,
this is not an acceptable situation;
patients should be accompanied
by a professional.
At this moment, five out of seven
wards (hallways) are renovated.
The hallway is a 50 meter corridor
with cells on the side housing 6 to
10 patients each. Most of the time
patients are in the corridor or in
their beds. Every ward is closed
by a fence with the guard sitting in
a small room in front of that fence.
This is the only way to enter the
ward. The guard has absolutely no
view of the cells or at the end of the
corridor. When a patient is required
for some reason (medication, visitors, etc) the guard will shout the
person’s name through the fence.
In the morning, the doctors and
nurses visit the patients on the ward
mostly for the purpose of checking
to see if anyone is having too many
side effects from the prescribed
medication. We hope to redesign
the wards to a more therapeutic
level which also considers safety
issues.
Over the past two years, Global
Initiative has become involved
in forensic psychiatry and prison
mental health in Serbia, and although much needs to be done, a
positive working relationship and a
sincere desire to change has been
the cornerstone of our work. As
a result of our collaboration with
Serbian partners, a major proposal
has been submitted for funding
to the Dutch Ministry of Foreign
Affairs. The project will offer the
opportunity of laying the groundwork for a contemporary chain of
forensic psychiatric services. The
project enjoys the support of all
parties involved, both at the governmental and local level. It will
create a model that changes the
system of forensic psychiatric services from a purely custodial one
to a service directed at treating,
curing and safely re-integrating the
mentally disturbed offender. At the
same time, it provides a treatment
model that adequately addresses
the mental health needs of the
prison population.
Robert van Voren is the Chief
Executive of Global Initiative on
Psychiatry. His email address is
rvvoren@gip-global.org
July2009
17
Bulgaria: A European Union Member
Lagging Behind in Forensics
Bulgarian forensic psychiatry
has its roots in the beginning
of 20th century with the leading
Bulgarian and European books
of Vladov, Danadjiev and Schipkowensky. An in-patient university clinic was created in the
second half of the century for
complex expert assessments,
requiring more experience and
complex psychiatric and psychological investigations.
By Petar Marinov and Vladimir
Velinov
During the last two decades, several
alarming tendencies in Bulgarian
forensic work have emerged. The
quality of expert work has decreased
while corruption increased, including among some psychiatrists. The
Forensic Psychiatry Clinic made a
series of proposals to the Dean of
Medical Faculty in Sofia, the Rector
of the Medical University in Sofia
and the Minister of Justice for the improvement of the quality of forensic
work, the continuing education and
promoting an inter-institutional body
for control in forensic psychiatric
practice. No measures were accepted and the passivity remained
the main institutional behavior. This
situation became more and more
chaotic.
Through the efforts of the Clinic, the
specialty of forensic psychiatry was
introduced in 2001 as required by
the EU rules for basic medical specialties. This step decisively created
new opportunities for professional
growth in experience of specialists
in the area. However, Bulgarian legislation annihilates this opportunity.
There is no differentiation of levels of
competence in forensic psychiatric
practice. Every specialist in psychiatry has the right to prepare forensic
assessments and reports and is ac-
18
cepted as equally competent by the
judicial system. There are no ideas
for stimulation and requirements for
continuing education and improvement of forensic work. The system
even introduced discriminative agerelated exclusion criterion in forensic
work, although it is a freelance profession.
On the other hand, the organization of the specialization in forensic
psychiatry in the only place – the
Clinic of Forensic Psychiatry and
Psychology in Sofia - is financed
on the general rule of the number of
patients per month. This rule forced
the Clinic to accept more and more
general psychiatric patients and has
limited the time for forensic work to
only around 20%. The State Specialized Hospital of Neurology and
Psychiatry “St. Naum” fired many of
the professionals in clinical psychology; there is currently only one clinical psychologist, who is responsible
for 200 neurological and psychiatric
beds. Judicial institutions are not
discussing other possibilities for
funding forensic work although it is
essential for the survival of forensic
education and practice.
Other negative tendencies have
appeared in recent years. Some
MentalHealthReforms
Lovech Prison
Hospital
academic psychiatrists expressed
their personal and unexplained
negativism towards the Clinic. The
main point was the opinion that the
clinic should be moved into the
prison system. The culmination of
these ideas was the organized voting in the Department of Psychiatry,
under the leadership of the Head of
the Department and also National
Consultant in Psychiatry Prof. Vihra
Milanova, MD, PHD. The final decision was that there is no need for the
Clinic of Forensic Psychiatry, and no
need for the Senior Educator (Associated Professor) to lead the Clinic.
The main argument of Prof. Milanova
was that “every specialist in psychiatry is equally competent to prepare complex forensic assessments
and reports and every professor in
psychiatry is competent to conduct
education in that area.” These ideas
were accepted by a small majority,
but it caused highly destructive effects on the specialization in forensic
psychiatry and fatal consequences
for the existence of the Clinic of Forensic Psychiatry and Psychology.
Gradually the personnel of the clinic
were reduced to only one forensic
psychiatrist, which was detrimental
to the possibilities of organizing forensic assessments and education
in the field. All interested judicial and
academic institutions were informed
without response; a typical reaction
for the systems in Bulgaria.
Using SWOT analysis several aspects could be described:
1.Strengths. In Bulgaria, the educational system and specialty in
forensic psychiatry was established. There are several residents in this specialty who were
on their way to being promoted
to specialists. A good number
of judges and prosecutors in
Bulgaria acknowledge the need
for the specialty and for the Forensic Psychiatry and Psychology
Clinic.
2.Weaknesses. There is an extremely low number of specialists
in forensic psychiatry and a very
low level of inter-institutional collaboration as well as interest in
the institutions to help the future
of forensic expertise.
3.Opportunities. One of the main
opportunities is the potential involvement of professionals and
experts from EU countries in
advising Bulgaria on the future
of forensic psychiatry. Another
opportunity is the potential of involvement in the monitoring of the
judicial system in Bulgaria. The
third opportunity is the preparation of professional teams in forensic psychiatry and justice who
can prepare a National program
for development of forensic psychiatry and forensic psychology
in collaboration with EU experts.
Another opportunity is the preparation of a new law on forensic
psychiatry and forensic psychology.
4.Threats. The principle threat is
the resistance of some social
groups who are against forensic
psychiatry and the judicial system
as a whole. Another risk is that EU
countries could view the problem
as an “internal” Bulgarian issue
and neglect the importance of
forensic sciences and their academic and practical development
in the judicial system in Bulgaria.
Promoting ideas about the replacement of the clinic by prisons
could change the basic concept
of forensic assessment in all of
the phases of investigation and
could be contradictory to its independence.
Dr. Petar Marinov, MD, PhD is Past
President of Bulgarian Psychiatric
Association. Prof. Vladimir Velinov
is professor emeritus of forensic
psychiatry in Sofia. They can be
reached at petmarinov@abv.bg and
v.velinov@gmail.com
Response from GIP
Global Initiative has been involved in
mental health care development in
Bulgaria for almost fifteen years. In
the mid-1990s, it started its involvement by assisting in the training of
mental health care personnel, concentrating on the younger generation
of future psychiatric leaders. It developed a publication program with the
Bulgarian Psychiatric Association, in
the course of which a dozen books
and manuals were published, and
sponsored the annual meetings
of the Bulgarian Psychiatric Association. Subsequently, it set up a
Day Care Center in Sofia, assisted
in the development of the Bulgarian
Institute of Human Relations as part
of the New Bulgarian University,
developed training programs for various specialists, helped organize an
ENMESH Conference in Sofia and,
in 2001, set up a Regional Office in
the Bulgarian capital, responsible for
projects in South Eastern Europe. In
2005, in partnership with the Stability
Pact, GIP commenced a project for
development of a consecutive chain
of community mental health care services in Blagoevgrad, which is used
as a pilot for the rest of the country.
Currently the GIP-Sofia office is involved in developing community services in the Sofia suburb of Slatina.
In 2004, GIP supported the Social
Activities and Practices Institute to
make an assessment of the psychiatric, psychological and social services provided to prisoners and staff
in the places of imprisonment. The
report was published in the Prison
Affairs, (XXXVIII, book3/2004) and
since then remains the only national
research done on mental health in the
prison. The research evaluated both
the satisfaction with the general health
services and mental health care in
particular and the stress related complaints of the prison staff. The report
concludes that there is a lack of an
integral conception about the treatment of prisoners with special needs
(training of the personnel, programs,
care, etc.). The report considers the
under-funding of the system and the
lack of autonomy of the prison medical staff as main structural reasons for
the observed shortcomings within the
prison health care.
Except for this report, GIP has not
been active in the field of forensic
and prison mental health services
in Bulgaria. GIP has assessed the
situation with the goal of seeing how
and where Global Initiative could be
of assistance. GIP has been active
in the field of forensic psychiatry and
prison mental health for quite a few
years and in a growing number of
countries. It is hoped that this experience and expertise might make a
difference in Bulgarian forensic and
prison psychiatry.
The main problems of Sofia Prison
include:
• Purely a medical approach;
• Lack of multi-disciplinary teamwork
and resocialization programs;
• Lack of psychiatric knowledge of
staff, especially guards and nurses need an education program on
mental health problems;
• Lack of psychiatrists. Each prison
has vacancies for psychiatrists
because of the low salaries;
• Attitudinal problems of staff towards patients, e.g. not being able
to see the inmates as patients;
• Stress and burnout among the
staff. The staff works in shifts of 24
hours with a three-day intervals,
and the other three days are used
for other part-time jobs to supplement the salaries;
• Acquisition of medication. Generic
medication is too expensive;
• Increase of inmates with HIV/
AIDS;
• Inmates with a drug and/or alcohol
problems;
• The general quality of care in the
prison is low.
July2009
19
The Prison mental health department in Sofia prison is part of the
internal diseases unit and has a
small capacity for patients with mental health problems. About 5% of the
inmates in the Bulgarian prison system are identified with mental health
problems and/or addiction problems. This 5% is under supervision
of a psychiatrist. Suspected mental
health problems are registered.
Evidence from many countries consistently shows that the prevalence
of mental health problems amongst
prisoners is significantly higher than
amongst the general population.
This is especially true for personality
disorders, substance abuse, depression and psychotic disorders. Prevalence rates among female prisoners
are higher in many countries. Most
probably, the estimated 5% prevalence in the Bulgarian prison system
indicates that there are serious flaws
in the (mental) health assessment
system. According to legislation,
inmates can attain services outside
the prison if they need proper care
or wish to have a second opinion.
Each inmate has the right of access
to any medical services but has to
pay for them himself.
Lovech prison hospital connected to Sofia prison receives inmates
with mental health problems who
are transferred from the Sofia prison.
About 200 patients are treated here
annually. According to the “Regulation for medical service in prisons,”
people who are considered by a
court decision to be unaccountable
are sent to Lovech psychiatric hospital for compulsory treatment. HIV/
AIDS has a small prevalence and
the Sofia prison keeps a record on
the persons who are infected. Persons living with HIV/AIDS can attain
the services anonymously and their
medical status is confidential. Within
the prison, VCT - Voluntary Committee Testing - tests the inmates who
want to be tested. In case a person
needs medical assistance, access
to the hospital is provided; all persons with contagious infections are
treated in state programs in nearby
hospitals. Prisoners dependent on
20
and cardio-vascular problems. Up
to now psychological care is mainly for prisoners and not for staff.
“After working 15 years in
>prison,
the staff develops a variety of problems, such as serious neuroses, stress, insomnia,
headache, and cardio-vascular
problems.”
>
Sofia prison with 2,100 inmates
has only 4 psychologists. In cases
where alcohol, psychological or
physical problems are detected, the
psychiatrist and general practitioner
develop a treatment program for the
prisoner’s stay in prison.
drugs have access to methadone
therapy. Psychiatrists receive training on how to supply the methadone
program.
Keys to Lovech
Prison Hospital
MentalHealthReforms
The possibilities of improving the
circumstances were discussed with
our Bulgarian colleagues and a
number of items were listed:
•T
here should be a broader therapeutic approach, and not only a
medical approach. In Bulgaria, too
much stress is currently put on the
medical aspect.
•T
he department should develop
operative multi-disciplinary teamwork, with each team consisting of
a general practitioner, psychiatrist,
social worker, nurses and the psychologists.
• Rehabilitation programs should be
developed.
•E
ducation and acceptance programs should be developed for
prison staff, as well as for inmates
and their families, in order to increase tolerance for inmates in
general and inmates with mental
health problems in particular.
• Intervention and support programs
should be developed for the staff.
Work in prison is a hard job and
in many respects the staff has to
deal with the same situation as the
inmates. After working 15 years in
prison, the staff develops a variety
of problems, such as serious neuroses, stress, insomnia, headache,
According to one of the main psychiatrists in the hospital, Dr. Neshkov, the prison hospital encounters
the following problems:
• Burnout problems of the staff; there
is neither attention to this issue nor
prevention of burnout.
• Bad material conditions related
to inconvenient accommodation
(leakage); construction of the
current building for the hospital
started in 1982 but could only be
put to use in 2005.
• Bad and outdated equipment
(PC’s, EEG); new computers and
x-ray were requested from the Ministry of Justice.
• Hospitals were forced to buy more
expensive medication because
some pharmaceuticals companies
stopped the production.
• Provision of treatment exclusively
according to the biological model;
no other treatment methods are
practiced, nor (day) activities or
work therapy is provided.
• There is very little tolerance of staff
and guards towards the patients.
The Forensic Department of
the University Hospital, Sofia
operates on the basis of private
payments of clients needing a forensic psychiatric assessment. The
forensic psychiatric assessment
unit does not provide any treatment.
Forensic psychiatric assessment is
carried out in criminal cases, civil
right cases and civil law cases. In
criminal cases, the forensic psychiatric assessment takes place during
the period of investigation of the
crime. Assessment and prosecution
are, however, closely interrelated.
Other categories of people making
use of forensic psychiatric assessment are patients who have a court
sentence and are being treated
in a forensic psychiatric ward of a
general mental hospital or in the
prison hospital, as well as persons
suspected of serious mental health
problems. Every six months, a forensic psychiatric patient in Bulgaria
is reassessed. If a patient refuses to
be assessed, he/she is sent to compulsory observation in the closed
forensic mental health unit.
According to our colleagues in
Bulgaria, outpatient care should be
dealt with in relation to forensic psychiatric treatment in Bulgaria:
•C
are homes for reintegration
• Developing and implementing
resocialization activities as part of
forensic treatment (not of the assessment procedures)
Typical Patient
Cell
A proposal for the development of
outpatient care was submitted several times to the Ministry of Health;
each time the proposal was rejected.
The main problem regarding outpatient care is that it is not covered by
health insurance. The system is not
transparent in assigning patients to
facilities. Some patients are referred
to Lovech, some to general mental
health hospitals, some to prisons
with a mental health unit.
Recommendations and
Suggestions:
GIP has visited the facilities in Bulgaria and studied the materials and
reports of other organizations in
order to devise a list of recommendations for the future involvement of GIP
in the fields of prison mental health
and forensic psychiatry in Bulgaria.
In our view, the GIP approach should
be a gradual and systemic one, allowing us to start with a number of
small initiatives in order to test the
water, develop relationships with the
Bulgarian colleagues and modify our
common understanding of the situation in order to come to an adequate
response to the existing need.
The key problems facing forensic
psychiatry and prison mental health
in Bulgaria seem to concentrate on
> “A proposal for development
of outpatient care was submitted
to the Ministry of Health several
times; each time it was rejected.”
the following issues:
•A
bsence of a clear continuity of
care within the system, as well as
of a clear profiling of the various
institutions involved;
• Insufficient care programs, in particular the absence of multi-disciplinary teamwork, lack of psychosocial rehabilitation programs and
possibilities for the resocialization
of forensic psychiatric patients;
• Inhumane and denigrating living conditions for patients in the
forensic departments of Lovech
psychiatric hospital;
• No vision on how the system of care
should be developed in Bulgaria.
First of all, we feel that it would be very
helpful to organize a working conference with the Ministries of Justice,
Health, and Labor and Social Policy,
as well as with other stakeholders
such as professionals, universities
and professional associations, in
order to discuss how a consecutive
chain of prison mental health and forensic psychiatric services could be
developed in Bulgaria. It is essential
that, rather sooner than later, a task
force be established with representatives of the three ministries that take
responsibility for this field. The ultimate goal of such a working conference would be to establish the basis
for a task force with representatives
of the three ministries to work with
GIP on these issues in the years to
come and to share the responsibility
for doing so. The basis for such a future involvement should be an agreement with the prison department of
the Ministry of Justice, in which the
partnership should be outlined.
In addition, we feel it would be very
helpful if ongoing links could be
established between Bulgarian professionals and Dutch counterparts,
in order to discuss modern forensic
psychiatric practice and to make
use of each others’ experience. In
the course of these exchanges,
more specific areas of collaboration
could be identified, such as the development of modern treatment programs, psycho-social rehabilitation
programs, the use of risk assessment instruments and, eventually,
the development of a computerized
patient data registration system.
Finally, in our view it would be good if
a small selected group of Bulgarian
professionals in the fields of prison
mental health and forensic psychiat-
ric treatment could visit Dutch facilities in order to initiate an exchange
of experiences. This should lead to
support of the prison mental health
professionals in developing modern
treatment programs, as well as the
development of aggression management training. Also, it would be
very helpful if a program could be
developed to assist the prison system in developing more adequate
psychological support programs for
their staff.
It is of specific importance that adequate attention be given to the issue
of stress and burnout among the
personnel of the Sofia prison and
other institutions. It would be very
helpful if specific programs could
be developed in this area.
In our view, absolute priority should
be given to changing the living and
treatment conditions in the forensic
department of Lovech psychiatric
hospital. We have serious questions
about the quality of the medical personnel and feel that the “treatment”
provided borders on torture and has
no therapeutic value whatsoever.
We would strongly recommend
closing the department altogether
and setting up a new one closer to
or in Sofia, where a better quality of
staff could be attracted. It seems
to us that it is a waste of money to
reconstruct the current building,
but even the construction of a new
one would not alter the situation
fundamentally. Within several years
the same conditions would prevail.
Also, we wonder whether the envisaged community mental health programs now prepared at this hospital
will make any sense, both because
of their location (on the premises of
the hospital) and because of the low
quality of the hospital management.
After studying the situation in Bulgaria, we believe that a large contingency of forensic patients and
prisoners with mental health problems are not identified as such. The
numbers of persons in the facilities
visited suggest that a much larger
population has needs that are currently not identified and, therefore,
unmet. We would very much recommend developing an assessment
within the Bulgarian prison, mental
health and social care system to find
these “missing” persons.
Robert van Voren
July2009
21
>
Convicted Juveniles in Georgia
Problems and Prospects
The Georgian Center for
Psychosocial and Medical Rehabilitation of Torture
Victims (GCRT) is a non-profit,
non-governmental organization
that is trying to meet the needs
of traumatized communities
and offer relevant assistance.
The Center provides multidisciplinary, professional mental
and medical health services
as well as legal counseling to
victims of torture, inhuman
or degrading treatment and
organized violence in Georgia.
GCRT is also active in the field
of juvenile justice and provision of psychosocial services
to young offenders serving
a prison term. Below we will
briefly describe this particular
direction of GCRT’s work.
By Lela Tsiskarishvili
Problem Statement
Youth delinquency and violence
are issues of major concern in
Georgia, due to the absence of
a comprehensive state strategy
on the prevention of youth delinquency. In addition, there is a lack
of early detection and intervention
programs resulting in the finding of
criminal responsibility of youth and
adolescents between 14-18 years
old and are behind prison bars.
This is aggravated by the facts that
often the sentences adolescents
receive are not appropriate for the
crimes committed (e.g. 4 years of
imprisonment for a minor theft, 8
years of imprisonment for robbery,
etc); the investigation process is full
of violations; and society is intolerant towards youth in conflict with
the law. All of the above contributes
to the exclusion and marginalization
22
Digomi center
for forensic
psychiatric
assessment
MentalHealthReforms
of the young offenders. Thus, it is
extremely important that a psychodevelopmental framework for convicted juveniles be established.
Avchala Correctional Facility is the
place where all convicted male
juveniles serve their prison terms.
The facility is overcrowded – it
houses 160 juveniles; the number
of staff serving the boys is 70, with
5 of these in the social unit. Juveniles sleep in barracks of 25 – having very little privacy and personal
space. The facility has a school,
however attendance is not obligatory; due to overcrowding, one of
the classrooms is used as a dormitory. There is no structured leisure,
sports or informal educational activities in place. Youngsters know
very little about their rights and
responsibilities within the facility.
In 2006, GCRT started working
in the juvenile correctional facility.
Three of our psychologists are running psycho-developmental groups
and are conducting individual
psychotherapeutic sessions. The
group meetings take place twice
a week, individual psychotherapy
takes place once a week. Below we
will try to illustrate the psycho-social
portrait of juveniles, outline the
main areas of concern and briefly
describe the main focus of our intervention. It should also be underlined
that GCRT currently is the only organization providing such services.
This is certainly not sufficient; every
single adolescent in custody should
have access to psychosocial services aimed at their personal growth
and development. Also each one of
them should have a chance to reintegrate with society.
Who they are
ate environment – aggression is
punishable; whereas sensitivity or
sincerity may be dangerous and
harmful. This inability to identify or
express emotions and feelings has
the tendency to manifest either in
self-destructive behavior, or isolation, indifference and apathy.
> “The absence of positive rein-
forcement from adults contributes
to the formation of a criminally
inclined belief system among
convicted juveniles.”
>
The majority of juveniles serving a
sentence in the facility come from
families with relatively poor socioeconomic background. Many of
them have incomplete families;
some are living with grandparents or
relatives. Many of the adolescents
have either witnessed violence in
childhood, or have become victims
of violence (domestic, peers, etc.).
Adolescents also lack a loving and
caring attitude from their parents.
In many cases, their upbringing is
strict – where physical abuse, humiliation and punishment are part
of the family culture. On the other
hand, some are “victims” of over
controlling and hyper protective
parents; thus, by the age of 13-14,
juveniles may try to revolt against the
parents. Either way the attachments
within the families and the immediate environment are disturbed and
dysfunctional – this, in turn, creates
fertile soil for delinquency.
Their perception of the world beyond the prison bars is very hostile
and unwelcoming – they blame the
environment for their misfortunes
and are not able to take responsibility for the crimes committed.
Although, once again, it should be
emphasized that the inadequacy
of prison terms in comparison with
the committed crimes reinforces
the feeling of injustice and negative
attitude towards the environment.
Many of the crimes committed are
related to underlying behavioral
problems; however, this is not taken
into consideration during investigation or court hearings.
What they feel
Many of these kids have a diffused
Self Concept – the self is not differentiated, it is merged with the
surrounding environment – the juveniles think, behave and live in the
same way as their important others.
In many cases, these important
others are their peers or adults with
strong criminal mentality where they
romanticize and idealize criminal
mentality and rigid social dispositions and attitudes prevail. They
believe that the world belongs to
the perpetrators.
Many of the adolescents have low
self esteem manifested through a
high level of anxiety, feelings of victimization, which, on the one hand,
is hyper compensated through
negligent or aggressive attitude
and behavior. On the other hand,
the low self esteem indicates a
psychological “invalidization” – the
self is perceived as incompetent
and incapable, while the sense
of future (which implies planning,
aspirations, etc.) is foreshortened.
These youngsters also lack understanding about their personal
traits and resources; they are often emotionally illiterate, i.e., they
have difficulties in differentiating
and identifying their own or others emotions. Apart from this, they
have the tendency to suppress
their emotions. This is conditioned
by the dominance of the immedi-
How we work
The aims of the intervention are:
• Creating the atmosphere of
basic trust - these adolescents
experience problems with trusting others. They perceive the
surrounding world as hostile and
Lela
Tsiskarishvili
unwelcoming. In order to ensure
success of the intervention, it is
crucial to create the space where
the adolescents can feel free and
confident in expressing their feelings and thoughts.
• Bringing in the overall frame and
structure - the space and time of
these juveniles is unstructured.
The rules are imposed externally
and are oppressive in nature.
Thus, during group work, it is vital to establish some internalized
rules to contribute to formation of
the self-structure and an internal
framework.
• Working on the “self-concept” overcoming destructive beliefs
about one’s self and the surrounding world. As previously
mentioned, these juveniles perceive themselves as incompetent
and incapable; thus, dealing with
self-esteem and helping them in
discovering and identifying their
resources is extremely important
for the success of the intervention.
• Acquiring skills of emotional
literacy and their congruent expression - this is directly related
to managing anger and aggression and overcoming the negative
behavior patterns. In this regard,
developing communication skills
in juveniles is also important.
• Working on the value system – the
absence of positive reinforcement
from the side of adults contributes
to the formation of a criminally
inclined belief system among
convicted juveniles. Intervention
is aimed at changing these dispositions.
• Realizing and becoming aware of
the genesis of each crime, taking
responsibility for the committed
crime.
•P
lanning the future - preparation
for the future integration into the
society after leaving the facility
Problems and barriers
• After reaching the age of 18, juveniles are transferred to adult prisons, which seriously damages the
results achieved during the psychosocial work and devastates
the prospects of reintegration.
• Ad hoc presence of outsiders
in the group meetings – the
space where the meetings take
place is not completely isolated;
sometimes the staff of the facility
decides to attend the meetings,
which creates great tension and
July2009
23
What is accomplished
After 3 years of working in the
facility, GCRT had gained trust
from among the inmates and administration as well. The facility’s
employees feel the responsibility
and advise newcomers to sign up
for group or individual treatment.
The involvement of the juveniles
is quite high. They have new
ideas and topics for discussions,
they have become more active
not only within the facility but are
eager to communicate with the
outside world.
Upon their request, GCRT organizes meetings with public
figures, facilitates various film
screenings, helps the boys
participate in various literary
contests and organizes sports
events in the facility. Through
these activities, the boys receive
positive reinforcement and gain
understanding of the importance
of education, work, civil activity,
success, etc. This also results
in a decrease of hostility towards
the surrounding world. It is noteworthy that as the juveniles partly
realize their personal responsibility for the committed crimes, they
have a critical attitude towards
their past. Through inclusion of
sports contests and different
types of competitions, they successfully manage to channel
their destructive impulses into a
positive framework. GCRT in collaboration with Ilia Chavchavadze
State University set up an enamel
studio for juvenile convicts. ICSU
developed a special 6 month
certified course and for the first
time, 30 juveniles have a possibility to go through comprehensive
vocational training.
24
What is planned
After three years of work in the
facility GCRT in cooperation with
Global Initiative on Psychiatry
(Hilversum and Tbilisi offices),
Union “Saphari,” the Department
of Prisons, Ministry of Education,
and the Ombudsman’s office developed a project “Ensuring access to sustainable development
of juvenile convicts through an
issue based intersectoral cooperation.” The project is funded by
the European Union. The overall
objectives of the project are:
1. to maximally improve the conditions of the most vulnerable,
marginalized and disadvantaged youth in Georgia – juvenile convicts serving prison
terms in the juvenile correctional facility,
2. to ensure their access to education and development,
3. to guarantee their well being,
4. to promote their re-socialization and re-integration through
a structured dialogue between
the civil society and state
actors, capacity building of
these sectors on implementing coordinated actions and
through introduction of new
instruments/initiatives into the
system of juvenile justice.
We aim to do this by adapting
the best European practices of
the juvenile detention system and
MentalHealthReforms
> “GCRT has gained the trust of
the administration of the facility as
well as of the juvenile inmates. ”
>
each time the psychologists
have to delicately tackle this
issue.
• Often new juveniles express
the desire to participate in the
group which sometimes damages the dynamics of the process; on the other hand, it is not
possible to turn away newcomers who want to participate in
the group.
• In more general terms, it is very
difficult to sustain the achievements of the work, because of
the scarcity of external positive
reinforcement.
introducing these practices in the
context of juvenile correctional facility, through trainings of staff, provision of screening, risk assessment
instruments, preparing the basis for
introduction of needs based educational and day programs. This will
lead to a more strategic approach
on delivering services to juveniles
in detention. Implementation of the
project will be advised by Global
Initiative on Psychiatry (Hilversum)
and Dutch Juvenile Facility Harreveld.
This particular project is part of the
larger juvenile justice reform process
that is taking place in Georgia. We
hope that the project will allow translation and implementation of policy
changes in the Juvenile Correctional
Facility and will help to rehabilitate
the lives of boys in detention.
Digomi center
for forensic
psychiatric
assessment
Lela Tsiskarishvili is Executive Director for the The Georgian Center
for Psychosocial and Medical Rehabilitation of Torture Victims, 0179
V. Anjaparidze st 9, Tbilisi, Georgia
www.gcrt.ge. Her email address is
ltsiskarishvili@gcrt.ge.
From Lunatic Asylum to
National Institute of Mental Health
in Sri Lanka
By Dr. Neil Fernando, Marieke de
Vries, and Nanthini Sivanesan
Lunatic asylums in Ceylon (Sri
Lanka) are best described as
overcrowded, dirty, violent human
warehouses. The conditions on the
male forensic ward at the National
Institute of Mental Health (NIMH),
Angoda in Sri Lanka are basically
the same as an asylum at the end
of the 1800s.
‘Modern’ psychiatry in Sri Lanka
began in the mid 1800’s during the
British colonial period and revolved
around mental hospitals. The Leper
Asylum in Hendala, founded through
private benevolence in the Dutch
period, saw, under the British, the
first known hospitalization of mental
cases (‘lunatics’). In the early years
of colonization, the mentally ill were
incarcerated in jails among criminals. Their disturbed behavior and
screams during the night became a
major burden and, thus, they were
transferred to the Leper Asylum.
It was very clear that there was a
necessity to separate ‘lunatics’ from
criminals as well as from lepers. So
around 1847, the first mental asylum
was opened at Borella, a district in
Colombo.
The Borella asylum struggled from
the start with major challenges:
•overcrowding (particularly in the
female division of the asylum)
•separation of violent patients and
problems transferring them from
asylum to jail and from jail to asylum
•poor sanitation and drainage systems
•insufficient meals to feed a patient
• clothing and bedding.
Another problem was the advanced
state of ‘lunacy’ in an individual by
the time they were admitted, after
having tried to cure the mentally
ill with native remedies and devil
dancing. The British tried to ban
Psychiatric
Prisoners in Sri
Lanka
these remedies and local medicine. Gradually the use of sedatives
found its way into the service due to,
perhaps, the availability of opium in
Asia and cannabis in India.
There were hints of advances in
these early years, even with the obstacles faced by any reformers. The
first form of Occupational Therapy
(OT) was provided for patients in the
form of employment in the Borella
asylum. This was introduced as a
treatment as was recreation therapy,
exercise and amusements. In addition, at a similar time, the first patient
classifying system was introduced:
quiet and harmless versus excitable
and violence, clean versus dirty, etc.
but there was no follow up. Record
keeping consisted of recording admission, discharge and death. And
circa 1890 were the first reports of
inflicted violence on patients.
Around 1885, a second asylum was
built at Cinnamon Gardens, Colombo, to relieve the overcrowded
asylum of Borella and later, in 1917,
the foundation was laid for the ‘lunatic’ asylum at Angoda, about 6
miles from Colombo. Both asylums
met the same problems as the
Borella asylum, especially in the
overcrowded conditions. Angoda
could accommodate up to 1800
patients and there were times when
it housed over 4000 patients.
Sri Lanka is still dealing with the 139
year old Lunacy Ordinance, altered
to a Mental Disease Act in 1957 and
revised in 1983 as the Mental Health
Act. A few amendments were added
although it still focuses on risk, is
devoid of an ethical heart and gives
room for misconceptions of violence
and mental illness and not enough
possibility of patients’ rights. Last
year, a recommendation was made
for a new legislative framework but
this was rejected by government.
Eight years after the construction
began, the new Angoda asylum was
completed. In 1957, the Mulleriyawa
Mental Hospital was opened with
an ‘open door policy.’ Until about
1940, Angoda was a custodial facility which offered minimal treatment.
By then important developments in
mental health care began to reach
Ceylon which suffered from a lack of
trained staff and facilities limiting the
effectiveness of these treatments.
While attempts were made to provide modern treatment for patients,
broken machines with no spare
July2009
25
However from the 1950’s, things
started to improve with psychiatrists
returning to Sri Lanka following their
training in Great Britain, introduction
of ECT and psychotherapy, occupational therapy and anti-psychotic
medication.
This all leads us to mental health
care in Sri Lanka today. It has been
estimated that 400,000 Sri Lankans
currently suffer from serious mental
illnesses and 10% of the population
in the country is thought to suffer
from common mental health problems. In 2005, more than 90% of the
country’s mental health resources
were concentrated in three big mental hospitals in the Colombo area
but Angoda is the only one housing
a forensic psychiatric ward.
Many improvements have taken
place at Angoda Mental Hospital,
presently called the National Institute of Mental Health. Some of these
developments are: the training of
medical staff in psychiatric rehabilitation, development of a mother and
baby unit, learning disability unit,
intensive care unit, adolescent unit
and improvements on policies and
procedures, quality of service, area
for families, repainting and refurnishing and more. Even though it seems
that with all these improvements
that have taken place in the last few
years, the forensic ward has been a
gulag, a forgotten ward. Housed on
the first floor of one of the old threestory blocks without any alterations
or improvements, you might think
yourself placed in an asylum 100
years ago. Patients at the forensic
ward are in custody because of a
wide variety of crimes and violations
while being mentally ill or retarded.
They are locked up, most often in
an overcrowded ward, which can
house 70 patients but often houses
twice that number. There is no such
thing as refusing a patient who has
been sent by the Magistrate Court;
they simply have to be admitted
since there is no other forensic psychiatric facility in the country. But
these patients are easily forgotten
and, at times, even disappearing in
the legal system which is not properly reviewing their status within the
prescribed 6 months for evaluation.
The overcrowding of the ward means
a shortage of beds, mattresses
26
and floor mats, plates, cups, and
clothes and, above all, insufficient
sanitary facilities. Five toilets, of
which two are out of order, and one
small shower tap without any private
space around it to serve them all.
Men and boys, with severe mental
conditions, are living together in one
area. There are no possibilities of
compartmentalisation or seclusion.
If a disturbed patient has to be removed from the group, he has to be
taken out to a less secured area in
the midst of staff, other patients and
even visitors. There is no staff on
duty during the night, so no control
of unwanted or disruptive behavior.
> “It is exciting to see the
eagerness of the team of health
workers.”
able and when working alone are at
great risk. The result is they cluster
together in the staff room avoiding
any individual contact with patients.
Other essential aspects of good
service, like record keeping and
care planning are not happening. Of
course, there are no computer facilities, telephone, fax, printer, personal
security/alarming system available.
Therapy in the hospital is mostly of a
biological nature, meaning that only
psycho-pharmaceutical medication
is available. Inactivity of patients
in the forensic ward due to sedation and lack of daytime activities
undermine their physical condition
and speed up the hospitalization
process causing them often to show
premature degeneration as a result.
Visitors are rare; since NIMH has
the only forensic psychiatric facility in Sri Lanka, patients come from
all over the island and almost live
in complete separation from their
relatives and communities. Above
all, these patients can not leave the
ward, there is no secured garden
area and no means to feel the soil
under their feet.
In general, nurses and other staff
working in a mental hospital or forensic ward do not do so by choice.
They are appointed by the government without consideration of their
own preference and no special training in psychiatric illnesses or forensic services. Nurses are young, with
little experience and can feel vulner-
MentalHealthReforms
>
parts and a lack of proper medication often defeated these attempts.
In 2008, at the invitation of the World
Health Organization (WHO), Global
Initiative on Psychiatry (GIP) carried out two assessment visits to Sri
Lanka. In January 2009, a follow up
visit was organized and a team from
GIP and two forensic psychiatric experts from the Pompe Foundation in
Nijmegen, the Netherlands, carried
out an assessment visit to NIMH
forensic department. This resulted
in a proposal for the development
of the existing forensic psychiatric
service to one that would be humane, therapeutic, affordable and
sustainable. Since then the forensic
ward at NIMH is high on the agenda
of Dr. Jayan Mendis, director of
NIMH and consultant psychiatrist,
who is very much in favor of change
and improvements of mental health
services.
Typical
Psychiatric Cell
in Sri Lanka
Since that time, small changes have
taken place and small improvements are being made. Finally this
ward was given the attention so desperately needed and it was exciting
to see the eagerness of the team
of health workers on this ward and
how ready they are to be involved in
this change for the benefit of all their
patients. This is the beginning of
something new for forensic services
in Sri Lanka.
(Historical Source: The History of
Mental Health Care in Sri Lanka by
James Carpenter, 1988)
Dr. Neil Fernando is a Consultant
Psychiatrist; Marieke de Vries is a
Mental Health Project Manager,
and Nanthini Sivanesan is a Mental
Health Trainer VSO volunteer. They
can be reached at
nanthiniuk@yahoo.co.uk
Goals of GIP in Sri Lanka’s
Forensic Hospital System
In 2008 and early 2009, GIP visited
Sri Lanka three times to obtain an
overview of developments in mental
health in the country with particular
regard to community mental health
and deinstitutionalization as well as
forensic psychiatry and prison mental health.
During the visits, the teams met with
a wide range of key actors in the
field of mental health, with a number
of NGOs working in mental health
and related areas, as well as with a
number of government officials from
the Ministries of Health and Social
Welfare. The teams also visited two
psychiatric hospitals in the Colombo
district, one in the Gampaha district
north of Colombo, the psychiatric university clinic, the child mental health
department and the prison, as well as
the prison hospital in Colombo that
holds a prison mental health department. The 2009 visit focused mainly
on the existing forensic psychiatric
and prison mental health services,
meetings with Sri Lankan colleagues
and collecting information that should
lead to a plan for the development of
a forensic psychiatric department
at Angoda hospital that would be
humane, therapeutic, affordable and
sustainable, as well as a plan how to
take things further.
With the Dutch experts and the
director and staff of Angoda psychiatric hospital, it was agreed that
a project should develop in phases,
which would allow those involved
to reflect every time on what was
accomplished, what issues were
solved or omitted and to decide
whether the next phase could be
implemented. At the same time, budgetary restraints (both because of
lack of local funds and the difficulty
of raising outside funding) call for a
step-by-step approach, allowing us
to make visible each time what has
been accomplished.
Phase 1 (approximately 10 months)
addresses the need to change the
physical environment for the patients.
Instead of being locked in one big
cage on the first floor of the building
and little possibilities for getting out, it
was decided that the top floor would
be renovated so that the patients
would be moved temporarily while
the first floor was being renovated,
replacing the sanitation, create separate toilets and bathrooms, and compartmentalize the first floor to make
a division into separate categories of
patients possible. This is essential,
because at this stage all categories
are together: adolescent, adult,
psychotics, mentally handicapped,
persons undergoing forensic assessment (and thus possibly mentally
healthy), etc. Separation is essential
both for therapeutic and safety purposes, in particular because supervision during the night is minimal
and in no way can one now control
what is happening behind the bars.
A staircase should be constructed
allowing patients to go from the first
floor to the garden which would be
prepared exclusively for their use. In
the end, the first floor would be for
sleeping and the top floor for recreation and rehabilitation.
Phase 2 relates to the training of personnel. Currently, the staff, including
the consultant psychiatrist in charge
of the department for the past five
years, has no specific training in forensic psychiatry and rehabilitation,
On-the-job training would be provided by Dutch experts from the Pompe
clinic and a vision will be formulated,
along with Sri Lankan professionals,
that would be the basis for therapeutic work in the department.
Phase 3 would see the introduction
of risk assessment tools, allowing
the staff to assess whether or not the
person is ready for a return to society
and whether a patient poses any
danger to his environment and him/
herself. An electronic system should
be developed, allowing the department to have a full overview of both
the forensic psychiatric population
and the individual patient’s medical
and legal history. Finally, a commission would be formed to look at
Sri Lankan legislation to see how
changes in legislation could be proposed that would better enshrine the
rights of the patients, prevent patients
“disappearing” in the system (which
happens repeatedly) and makes
sure that only real forensic patients
are held in the forensic department.
Phase 4 would focus on the assessment of the patients’ mental health.
The ground floor of the forensic building could be vacated and turned
into a separate forensic psychiatric
assessment center, separating those
who undergo forensic psychiatric
assessment from persons being
treated for their mental illness. Staff
would be trained in forensic assessment (having in mind the prevention
of unjust admission of non-forensic
patients).
Phase 5 would include the development of five departments in other
towns on the island for treatment at
a low security level. This means that
the current department in Angoda
would be used exclusively for medium and high security patients. This
will also help to separate light cases
from severely disturbed and dangerous patients, who are now locked up
together in one cage.
In March of 2009, a meeting was held
with the relevant Sri Lankan staff,
including forensic psychiatrists, the
director of NIMH, nurses, occupational therapists, and training and occupational therapist volunteers. This
meeting was the result of the January
2009 visit of GIP, followed by a written
report with recommendations. This
was the first time multidisciplinary
forensic teams at NIMH had come
together to discuss future plans. This
meeting is the first of many planned
to monitor the progress and set priorities in light of the budgetary realities.
All are enthusiastic and optimistic that
these new steps will greatly improve
the treatment of patients and the lives
of the staff.
Robert van Voren
July2009
27
Russian Summaries
By Elena Mozhaeva
От редакции
Роберт ван Ворен
В большинстве стран мира потребители
служб психического здоровья страдают
от стигматизации, а люди с психическими
расстройствами, совершившие деяния,
считающиеся в обществе преступными, страдают
вдвойне: их объявляют и сумасшедшими, и
порочными. На практике в местах заключения
они почти всегда оказываются лишены
адекватного лечения и помощи. В последние
восемь лет Глобальная инициатива в психиатрии
(ГИП) занимается проектами в области судебной
психиатрии в Восточной Европе и бывшем
СССР. Эти программы трудно ''запустить'':
правительства обычно не интересуются этой
категорией пациентов, а общество мало
привлекает идея их возвращения в обычную
жизнь по завершении лечения. Большая часть
населения считает, что их следует навсегда
посадить за решетку, а в системе наказания их
зачастую принимают за симулянтов, к которым
следует применять максимально жесткие меры
наказания.
ГИП пытается убедить власти в том, что
пенитенциарная и судебная психиатрия
–дело серьезное. Ведь если такие пациенты
не получают адекватной помощи, они будут
представлять опасность для общества, так что
в интересах общества обеспечить им хорошую
программу лечения. Настоящий выпуск Mental
Health Reform дает представление о проектах
ГИП в области пенитенциарной и судебной
психиатрии в самых разных странах.
Kresti Prison
under
construction
Развитие пенитенциарных служб
психического здоровья в странах с
переходной экономикой
Б.К.М. Раас и Роберт ван Ворен
В большинстве стран исполнение уголовного
законодательства, уголовная процедура
и заведения для исполнения наказания
представляют собой довольно закрытую систему.
Эта репрессивная система является тяжким
психологическим испытанием для подсудимых
и заключенных, особенно для лиц, страдающих
психическими расстройствами. Психологические
эффекты в условиях изоляции от общества и
агрессивной внутренней среды хорошо известны:
это депрессия, нанесение самоповреждений,
суицидальность. Длительное заключение
порождает апатию, ''синдром госпитализма'',
т.е. неспособность функционировать в
нормальном обществе, потерю независимости
и деперсонализацию. В целях обеспечения
прав заключенных важно разработать внутри
системы более дифференцированные режимы
медицинской, психологической, психиатрической
и сестринской помощи с выделением особо
уязвимых групп: психически больных, умственно
отсталых, подростков, лиц, впервые нарушивших
закон, педофилов и пр. На примере проектов в
трех странах (Россия, Литва, Грузия) описываются
подходы и конкретные результаты гуманизации
системы, в частности, по отношению к
заключенным, страдающим психическими
расстройствами.
Семь лет в тюрьме Кресты: уникальный
проект модернизации психиатрического
отделения в Санкт-Петербурге
Константин Анциферов, Роб Холландер и Венди
Вейтс
Данный проект сотрудничества голландских и
российских специалистов начался в 2002 году.
Его целью было улучшение оказания помощи
лицам с психическими расстройствами в тюрьме
Кресты. Он предполагал изменение архитектуры
28
MentalHealthReforms
отделений для пациентов-заключенных: создание
двух типов камер - двухместных для острых
пациентов и четырехместных для пациентов в
фазе стабилизации; выделение пространства
для разнообразных видов деятельности;
обучение специалистов, внедрение скрининговых
инструментов, позволяющих выявлять
психические расстройства на ранней стадии.
На настоящий момент данный проект остается
уникальным в российской тюремной системе.
Проблема оценки рисков в пост-советских
странах
Вирджиния Климукиене
В западных странах оценка рисков является
рутинной практикой судебной психиатрии и
основой для принятия судебных решений о
прекращении принудительного лечения лиц,
совершивших общественно опасные действия и
признанных судом невменяемыми или частично
вменяемыми. В пост-советских странах оценка
потенциальной опасности пациентов строится в
основном на неструктурированном клиническом
суждении специалистов, т.е. их субъективном
мнении. Автор описывает первые попытки
использования в Литве и России HCR-20, который
может стать в будущем важным инструментом
для оценки рисков.
Развитие партнерства в судебной психиатрии:
Организация ''Помпе'' как партнер в проектах
ГИП
Тьё Верхаген и проф. Б.К.М. Раас
Расположенная в восточной части Нидерландов
организация ‘’Помпе’’ включает в себя судебнопсихиатрическую больницу со строгим режимом
безопасности и соответствующими службами
Trainings on
HCR-20
реабилитации, поликлинику для оказания
амбулаторной помощи и лечения судебнопсихиатрических пациентов, и центр научных
исследований и развития. ‘’Помпе’’ участвует в
трех проектах ГИП – в Литве, России и Грузии,
и готовится к участию в проектах в Сербии/
Черногории, Болгарии и Шри Ланке. Главным
образом, это проекты, связанные с работой
судебно-психиатрических больниц. На основании
своего опыта авторы сформулировали ряд
рекомендаций. В частности, они указывают
на большое значение доверия со стороны
местных партнеров, важность разделения
профессиональных и административных задач,
необходимость избегать завышенных ожиданий, а
также способность импровизировать и находить
неординарные решения.
Начало реформы пенитенциарной и судебной
психиатрии в Сербии
Роберт ван Ворен
В последние два года (с 2007) ГИП активно
изучала положение дел и проблемы в судебной
и пенитенциарной психиатрии в Сербии. За
этот период удалось сформировать позитивные
рабочие взаимоотношения с сербской
стороной, и сейчас, хотя многое предстоит
сделать, присутствует главное – желание
изменить существующий порядок и условия
оказания помощи в судебно-психиатрических
больницах и в специализированных отделениях
пенитенциарных учреждений. В результате
сотрудничества подготовлена и направлена в
МИД Нидерландов заявка на финансирование
проекта. Проект позволит заложить основу
современной цепочки судебно-психиатрических
служб. Его поддерживают власти - как на уровне
правительства, так и на местах. Предполагается,
July2009
29
что в результате проекта появится новая модель
системы судебно-психиатрических служб: от
обычного помещения за решетку – к службе,
ориентированной на лечение, выздоровление и
безопасную реинтеграцию психически больного
правонарушителя в общество. Планируется также
создать модель лечения, которая удовлетворит
потребности психического здоровья в тюремной
популяции.
Болгария: страна-член Евросоюза отстает в
области судебной психиатрии
Петар Маринов и Владимир Велинов
Болгарская судебная психиатрия возникла
в начале ХХ века, а первая судебнопсихиатрическая клиника для проведения
сложных экспертиз появилась во второй
половине ХХ века. В последние двадцать лет
в этой дисциплине проявились тревожные
тенденции: снизилось качество экспертиз
и усилилась коррупция, в том числе, среди
психиатров. В соответствии с требованиями
Европейского Союза, судебная психиатрия
с 2001 года существует как отдельная
медицинская специальность, но пока еще в
Болгарии любой психиатр имеет право проводить
экспертизы и писать заключения, которые
принимаются судебной системой как абсолютно
компетентные. Никто не думает о повышении
профессионального уровня и совершенствовании
судебно-психиатрической деятельности.
Существующий принцип финансирования
клиники – по количеству пациентов в месяц –
вынуждает руководителей принимать больше
обычных психически больных, а на судебнопсихиатрическую работу отводить лишь около
30
MentalHealthReforms
20% времени. В клинике остался всего один
судебный психиатр.
Ответ ГИП
ГИП работает в Болгарии почти пятнадцать лет.
За это время были выполнены самые разные
проекты по развитию служб психического
здоровья. После изучения ситуации в
судебной и пенитенциарной психиатрии
эксперты ГИП отмечают, среди прочего,
сугубо медицинский подход (биологическая
модель), отсутствие бригадных форм работы
и программ ресоциализации, низкий уровень
профессионализма среднего персонала,
нехватку психиатров, отношение к пациентам
в первую очередь как к преступникам, стресс
и выгорание у работников, общее низкое
качество помощи. В этой связи ГИП предлагает
сконцентрировать усилия в судебной психиатрии
на обеспечении преемственности помощи внутри
системы, разработке программ реабилитации и
ресоциализации, развертывании бригадных форм
работы, создании гуманных и не унижающих
человеческое достоинство условий пребывания и
лечения в судебно-психиатрических отделениях и
больницах, и разработке перспективы развития в
области судебной и пенитенциарной психиатрии.
Осужденные подростки в Грузии: проблемы и
перспективы
Лела Цискаришвили
Подростковая делинквентность и применение
насилия – серьезная проблема в Грузии. В
условиях отсутствия комплексной стратегии
по профилактике подростковой преступности,
Russian and
Lithuanian Versions
of HCR-20
раннему выявлению проблемных случаев
и применению интервенций, подростки и
молодые люди в возрасте 14-18 лет попадают
сразу за решетку. О своих результатах
исследования и работы с данной популяцией
сообщает Грузинский центр психосоциальной
и медицинской реабилитации пострадавших
от пыток (ГЦПМР). Согласно данным Центра,
большинство делинквентов – выходцы из
довольно бедных, часто неполных, семей. Многие
в детстве сталкивались с семейным насилием
и страдали от жестокого обращения. Есть
среди них и жертвы родительской гиперопеки,
которые в возрасте 13-14 лет ''восстали''
против своих родителей. У многих подростков
снижена самооценка, а высокий уровень
тревожности компенсируется агрессивностью.
За три года работы ГЦПМР удалось установить
доверительные отношения как с заключенными,
так и с администрацией учреждений для
делинквентных подростков. Ведется работа по
внедрению разнообразных программ занятости,
обеспечению возможностей продолжения
учебы и обретению профессии, использованию
инструментов оценки рисков, развитию
ресоциализации и реинтеграции, и модернизации
системы подросткового правосудия в целом.
Шри Ланка: от приюта для сумасшедших к Национальному институту психического
здоровья
Нейл Фернандо, Марике де Фрис и Нантини
Сиванесан
В настоящее время в Шри Ланке около 400.000
человек страдают тяжелыми психическими
заболеваниями, и примерно 10% населения
сталкивается в жизни с обычными проблемами
психического здоровья. В 2005 году более
90% ресурсов в сфере психического здоровья
сосредоточено в трех больших психиатрических
больницах в районе Коломбо, а единственное
судебно-психиатрическое отделение расположено
в психиатрической больнице Ангода. В этой
больнице в последние годы произошли
крупные изменения, и теперь она получила
статус Национального института психического
здоровья. На фоне активной работы по развитию
реабилитационного направления в общей
психиатрии, создания специализированных
отделений матери и ребенка, умственной
отсталости, интенсивной помощи, подросткового
и т.д., судебно-психиатрическое отделение
продолжало оставаться заброшенным
гулагом. Пациенты закрыты на ключ в одной
переполненной клетке, рассчитанной на
70 человек, но фактически там находится
в два раза больше людей самых разных
возрастов. Процедура регулярного пересмотра
необходимости продолжения лечения (раз в
шесть месяцев) не соблюдается. В отделении не
хватает коек, матрацев и даже циновок на пол; из
пяти имеющихся туалетов два не работают, есть
один на всех душ без душевой кабины. Лечение в
основном биологическое – таблетки. Отсутствие
программ занятости подрывает физическое
The photo
shows a
department
in the Special
Psychiatric
Hospital in
Chernyakhovsk
состояние пациентов и способствует развитию
синдрома госпитализма. Посетители бывают
редко. Возможностей для прогулок на свежем
воздухе нет – пациенты постоянно находятся в
отделении. Представители ГИП в 2008 дважды
выезжали в Шри Ланку с целью изучения
ситуации в судебно-психиатрическом отделении.
Цели ГИП в судебно-психиатрической
больнице в Шри Ланке
По итогам исследования ситуации в судебнопсихиатрическом отделении больницы
Ангода ГИП планирует проект, состоящий из
нескольких фаз. Фаза 1 (примерно 10 месяцев)
предполагает изменение физической среды
пребывания пациентов: изменение архитектуры
здания, улучшение санитарно-гигиенических
условий, разделение популяции пациентов на
специфические группы (подростки, умственно
отсталые, пациенты в психозе, лица, проходящие
экспертизу), оборудование выхода на
прогулочную площадку, создание возможностей
для реабилитации. Фаза 2 касается подготовки
персонала с участием голландских специалистов.
Фаза 3 – внедрение в практику работы
инструментов оценки рисков. Фаза 4 – оценка
состояния психического здоровья пациентов,
создание центра судебно-психиатрической
экспертизы. Фаза 5 – создание в других городах
страны пяти лечебных отделений с облегченным
режимом безопасности. Отделение в больнице
Ангода будет впоследствии использоваться лишь
для пациентов, которые нуждаются в усиленном
или строгом режиме безопасности.
July2009
31
Other themes addressed by Global Initiative on Psychiatry to be covered in future
issues of Mental Health Reforms:
• Child and Adolescent Mental Health
• User Involvement in Mental Health Services
• Community Mental Health Care
• Substance Abuse Prevention
• Mental Health and Human Rights
• UN Convention on Disabilities and Its Implications
for Mental Health
Global Initiative on Psychiatry
Global Initiative on Psychiatry (GIP) is an international not-for-profit organization for the promotion of humane, ethical and effective mental health
care worldwide.
GIP is registered in Hilversum, The Netherlands, and works closely with
its network of regional centers in Lithuania, Bulgaria and Georgia 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 has also begun working in other regions of the
world. 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
Dutch Assessment Team at Pre-Trial Prison in
Kaliningrad, Russia
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)
P.O. Box 1282
1200 BG Hilversum
The Netherlands
Tel.: +31 35 683 8727
Fax: +31 35 683 3646
e-mail: hilversum@gip-global.org
www.gip-global.org
GIP-Tbilisi
49A Kipshidze Str.,
Tbilisi 0162, Georgia
Tel.: +995 32 235 314 / +995 32 214 006
Fax: +995 32 214 008
e-mail: tbilisi@gip-global.org
www.gip-global.org
GIP-Sofia
1 Maliovitsa str.
Sofia 1000, Bulgaria
Tel.: +359 2 987 7875
Fax: +359 2 980 9368
e-mail: sofia@gip-global.org
www.gip-global.org
GIP-Vilnius
M.K. Oginskio g. 3
LT-10219 Vilnius, Lithuania
Tel.: +370 5 271 5760 / +370 5 271 5762
Fax: +370 5 271 5761
e-mail: vilnius@gip-global.org
www.gip-global.org / www.gip-vilnius.lt
GIP’s General Board
Robin Jacoby, Chair (UK)
Jaap van der Haar, Secretary/
Treasurer (NL)
John Bowis (UK)
Nicoleta Candea (RO)
Melvyn Freeman (ZA)
Mahesan Ganesan (LK)
Clemens Huitink (NL)
Rolf Hüllinghorst (DE)
Lars Jacobssen (SE)
Joseph Mbatia (TZ)
Dainius Puras (LT)
Dick Raes (NL)
Simon Surguladze (GE)
Peter Tyrer (UK)
Conny Westgeest (NL)
Mental
HealthReforms