Mental Healthcare Reforms in Post-Soviet Russia : Negotiating new ideas and values

This thesis provides insights into the process of mental healthcare reform in postSoviet Russia. The reforms started in Russia in the early 1990s, following the collapse of the Soviet Union. They were triggered by a desire to conform to international standards for patients’ rights within a mental healthcare system that had previously been sharply criticized for ineffectiveness and political abuse. In this study, the development of Russia’s mental health policy is considered in its social and historical context and with reference to the World Health Organization’s guiding principles. The thesis provides a historical review of Soviet psychiatry in order to gain a greater sense of the significance of mental healthcare reforms in post-Soviet Russia. The thesis focuses on policy issues such as patients’ rights, deinstitutionalization, service users’ inclusion and participation, and the prevention of stigmatization. These internationally recognized principles have provided the basis for the development of mental health policy in many countries, and could be deemed central to the analysis of the reforms in Russia. Methodologically the study is based on interpretive policy analysis (Yanow 2000), which focuses on the meanings that policies have for a broad range of policy-relevant publics. This research started from the premise that the meanings that different interpretive communities attach to mental health policy are important for its development and implementation. In this thesis, policymakers, the media, mental healthcare staff, and the relatives of people with mental illness are considered key interpretive communities. Each study (article) provides insights into how policy principles were interpreted by a particular interpretive community. For the conceptual basis, I drew on social constructionist theory, which claims that discourses (such as those on mental healthcare reform) are tied to the cultural, social and political contexts of the particular society. I also used the concept of path dependency to analyse whether and how the Soviet background has influenced mental healthcare development. The research aimed to answer the following questions. What kinds of similarities and differences appear in different interpretive communities’ interpretations of the new mental health policy principles, and how do these interpretations relate to either support for or opposition to mental healthcare reforms? How do different interpretive communities see the role of various actors (such as policymakers, the mass media, state institutions, non-governmental organizations, service users and their caregivers) in the reforms? How are interpretations of mental health policy constructed in terms of distinctions from and links to the Soviet historical background? The study methods were qualitative, consisting of qualitative content analysis and thematic analysis. The research material included mental health policy documents, mass media texts from selected newspapers, and interviews with mental health professionals and family caregivers of people with mental disabilities. The results of the study revealed that the policy discussion on patients’ rights and the reorganization of mental healthcare was a significant advance over the Soviet past. However, the policy documents did not pay attention to the issues of stigmatization or users’ empowerment. The media response to the new policies was largely ambivalent. Support for patients’ rights was accompanied by fears about the detrimental effects of the liberalization of psychiatry on public safety. The research revealed that negative media responses to the reforms preceded the policy programme for deinstitutionalization, creating an unfavourable climate for its implementation. There were also multiple gaps between policy planning and practice in Russia. The way the policy was introduced by the government and represented by the mass media contributed to a distrust of the reforms among citizens affected by the policy. Deinstitutionalization met with little support from professionals or family caregivers. The professionals criticized the new policies and were suspicious of reform, arguing for the preservation of the existing system. They perceived psychiatric institutions as a means for the social control and protection of people with mental illness and their families. Simultaneously, caregivers were strongly concerned about the high risk of losing the support they received from existing services. In sum, the results of this study demonstrate that transferring mental health policy ideas across national boundaries is a complex process. This underlines the importance of seeking balance between internationally driven initiatives and the readiness and willingness of the receiving country to accept the proposed changes.