Public Rehabilitation System in 1991–2005

The Kyrgyz Republic (KR) was formed as a sovereign independent state in 1991 after the collapse of the Soviet Union. During the difficult ‘post-perestroika’ period mental health services in the KR struggled to preserve the remnants of the previous mental health system, including the centralized mental health care structure and a few rehabilitation units, such as the daycare departments and the occupational workshop located within the Republican center of mental health. The transition period for the state occurred to be a makeshift for the general medicine as well. There was a serious lack of governmental funding, and limited aid from international organizations (for instance Open Society Institute) was not helpful for the system. In 1991–2005, psychiatric hospitals were often used as shelters for patients without any family support, including those who were abandoned by their close relatives and lost their social connections, or did not have any financial means to survive. They were admitted to psychiatric hospitals to join other patients with acute psychosis to spend winter and to be fed, oftentimes being supported by the medical personnel, who shared their own limited resources with patients in the hospitals. The number of beds in the Republican center of mental health in 1991 was 846 [4], and at least half of them were occupied by chronic patients, who were hospitalized either due to fatigue of their family members to support them, or because of the aforementioned reasons.

Mental health care system reforms in the KR has caused a sharp decline in a number of beds in urban mental health centers (up to 400 in RCMH) and has tightened the selection of patients for hospitalization, although it did not reduce a total number of patients with mental disorders. Such dissociation, together with the collapse of the formerly available rehabilitation services, led to overcrowding in the rural hospitals that had provided only minimal conditions for survival of a human being. As a result, the mortality rate among patients in Chim-Korgon rural hospital, located close to Bishkek, has increased by fifty percent [4]. The decade from 1991 till 2001 was ambiguous for the mental health care specialists: on the one hand, it was characterized by the successful trials of implementing international standards (clinical protocols, shifting to ICD-10 from ICD-9, training specialists to use valid clinical scales) into the mental health care system, on the other - by active rejection of the previous system without any reanimation efforts from the relevant governmental structures. The abovementioned reasons caused a chaotic activity of several NGOs, advocating for human rights, and patients with mental disorders seemed to be an inviting target group. Unfortunately, these efforts had become easily transformed into a fight against psychiatrists, and, therefore, increased stigmatization of psychiatrists and psychiatry itself.

One of the first efforts to renew the rehabilitation services in the Kyrgyz mental health sphere was the conversion of one of the inpatient departments of the Republican center of mental health into a rehabilitation unit. Patients, mostly with the diagnosis of schizophrenia but without any psychotic symptoms were treated with cognitive-behavioral group psychotherapy. They were allowed to spend more time with their family members, and were prepared for the usual life routine. As a rehabilitation unit, this department had been functioning till 2003, and then, due to the lack of personnel reluctant to work as underpaid psychologists and psychotherapists, was retransformed into a usual unit for patients with acute psychoses. It is worth to mention that one of the rural RCMH’s units (a ward number 12) had been functioning as a rehabilitation department since the establishment of RCMH in 1963. The following quotation from the report of Mental Disability Advocacy Center shows the status of the rural rehabilitation unit # 12 in 2003:

… Rehabilitation Unit # 12, commonly known as “Ward 12”, is a barracks-style ward, located in the village of Novo-Pavlovka, on the outskirts of Bishkek. It provides accommodation to approximately 30 male patients. According to staff members, the patients at Ward 12 have either been “abandoned” by their families or in some other way have lost all other social connections… The emphasis at “Ward 12” is entirely upon providing custodial care rather than psychiatric treatment…Many of the patients stated that they were always hungry and that in the winter they were very cold…Patient rooms were crowded with beds, allowing for little room for movement and no privacy…Two large bathtubs, unconnected to any plumbing system, sat unused in one room. According the staff, these bathtubs had been the gifts of “an American.”…Despite these dire conditions, the staff members of Ward 12 – who are underpaid and largely forgotten by the authorities in the Kyrgyz mental health system – expressed a great deal of sympathy of the patients in their care… [1, p.33]

One of the most promising Ministry of Health’s efforts to revive the rehabilitation services in mental health care was introducing positions of psychologists for every department of the psychiatric hospitals. Job description of a psychologist working with patients with mental disorders includes psychosocial rehabilitation activities. The idea, so attractive in theory, in practice turned into a caricature on a Western-style psychiatric ward: an outrageously low salary does not attract highly qualified specialists; therefore the staff turnover is high, and psychologists’ positions are occupied by other specialists with rather formal attitudes to their duties.

The Law « On Psychiatric Aid and Citizens’ rights » , which was considered to be another step to improve mental health rehabilitation, was adopted in 1999 by KR Jogorku Kenesh session [1, p. 3]. One of its basic components was reforming outpatient assistance to people with mental disorders. The Report of Mental Disability Advocacy Center from April 2004 demonstrated that the Law has being implemented ineffectively due to the variety of reasons; the first rate belongs to the negligence of psychiatry from the Kyrgyz Ministry of Health. In 2000, the government launched its national program called “Mental Health of the Population of the Kyrgyz Republic in 2001–2010”. The program anticipated a shift from institutionally based mental health care to more localized community-based services, aiming at bringing mental health care to individuals in their local communities. Due to the lack of funding, the implementation of the program was suspended. Currently, the next national program is being developed with prospective funding from the World Bank.

Thus, despite the occasional administrative efforts, and microscopic financial investments, rehabilitation of patients with mental disorders in the Kyrgyz Republic by the end of 2005 could be described as an active destruction of the old system without a construction of anything new instead. Patients with mental disorders and their families became the primary victims of these social upheavals. They did not feel any beneficial effect of innovations, and also were significantly affected by the destruction of the old, imperfect, but still running rehabilitation structure. In the academic sphere, the period from 1991 till 2005 was characterized by a variety of publications, criticizing different imperfections of mental health care system, including poor conditions of accommodation in RCMH, and nasty quality services in rural hospitals. Numerous suggestions to reform and improve mental health, including rehabilitation services, were too general (“to renew…,” “to strengthen…,” “to reform…”) and could not be effectively used due to the basic lack of funding.

Support of Patients with Mental Disorders by the Family, Clan, and Community

It is important to notice that rehabilitation has never been limited by the functioning of imperfect governmental structures. Family support, asymmetrical towards Kyrgyz men and Kyrgyz women, has always been an important dimension of rehabilitation of patients with mental disorders. Traditional Kyrgyz community is characterized by historically inherited tribal structure; it takes care of persons belonging to the “family” (ui-bolo) in its broadest sense. In accordance with a strict hierarchy, all roles and responsibilities in a traditional Kyrgyz family are clearly defined. Junior family members respect and unquestioningly obey their seniors; women, though being more independent compared to other Central Asian wives, obey men of the clan. The older men cannot be called by their first names. Due to the primate of a father’s figure, family members are expecting the first child to be a boy, and the youngest daughter-in-law (kelin) lives with her husband (the youngest son in a family) in her parents’ in-law house and does all the housework. Numerous relatives gather for the big holidays (toi) on different occasions. Taking part in family activities, especially devoted to the sad events (serious illness of a family member or death) is considered to be absolutely necessary for everybody who has even an indirect relationship to the family. Helping country-men (Jergesh) is beyond any doubts and it serves as a good explanation for all the actions, committed ‘in the name of family’. Tribal structure of the Kyrgyz community partly explains the extremely widespread nepotism: if one of the members of the clan ‘becomes a boss’, then his/her responsibility is to help the less fortunate brethren. Thus, in one particular state agency or in a local NGO one can meet a real “family enterprise,” where all key positions are occupied by close relatives or members of the same clan.

Attitudes towards a relative with a mental disorder are determined by several factors. Among them are:

  1. 1.

    Place of birth and settlement. In rural areas, especially in the north of the Kyrgyz Republic, for example, in Talas and Issyk-Kul oblasts, traditional beliefs have much greater power than modern Islam. Spirits of ancestors are perceived as a part of reality. People talking to invisible entities are defined as gifted, spiritual and respected members of a community. Therefore, some patients with verbal hallucinations, might not only preserve their previous social status, but also acquire specific prestige in a Kyrgyz community as future – tellers (kez-achyk), shamans (kuuchu), and healers.

  2. 2.

    Gender differences. Men in Kyrgyz community, due to its patriarchic structure, are supported much more than women. In case the head of the clan becomes ill, all recourses of a family are devoted to his treatment and rehabilitation.

  3. 3.

    Position in a family hierarchy. The higher it is, the more attention is attracted to support a family member and to maintain his/her authority. Reported cases of Alzheimer’s disease are extremely rare in rural areas of the Kyrgyz Republic not due to the low morbidity rate but because of a great respect seniors receive from the other family members. A patient with Alzheimer’s disease not only remains in the family, but is surrounded by intensive care and attention up to his/her death [2].

  4. 4.

    Female hierarchy. When a Kyrgyz woman experiences a mental disorder, the attitudes towards her are determined by her social status in a family. The older women in rural places are usually surrounded by support and care; kelins (daughters in law) are expected to fulfill their duties in that whatsoever, their disorders are often denied, and if a kelyn is a “bad wife” her husband has right to divorce. There were observed a plenty of cases when a family of a girl abandoned her due to her mental disorder, explaining this abandonment as “she is not good enough to marry anyone.” It is not a rare case when a female patient has been spending several years in rural hospital, waiting for her family to allow her to come back home.

Overall, cases of mental disorders in rural areas of the Kyrgyz Republic are either diagnosed late, or not diagnosed at all. Those men with mental disorders, who were treated in one of local mental health centers, are highly supported by the other members of their families, and this support is effective in many cases, even though some dimensions of such support are perceived as quite brutal. For instance, according to the widely distributed beliefs, a “normal” man should be married. Bride kidnapping has become widespread just after the collapse of the Soviet Union due to the lack of finance in a lot of families of potential grooms. In a case of a bride kidnapping, a groom is not obliged to pay ransom (kalym) for the bride. Bride kidnapping is still very popular in rural areas of the Kyrgyz Republic, although it is considered to be a criminal act according to KR law system and is punished by up to three years of imprisonment. Due to this practice, a person with a mental disorder might maintain an image of a ‘normal life’, even at the expense of his wife and her relatives.

Community-Based Rehabilitation Service

Mental Disability Advocacy Center after its inspection of the KR mental health services in 2004 concluded that: “… mental health care practitioners in KR are faced with an emergent and particularly critical situation. They bear the responsibility of devising and implementing an appropriate remedy in the most cost-effective and exigent means possible” [1, 44]. The “most cost – effective and exigent means possible” for the KR mental health practitioners means, above all, the use of existing resources in the country, including the support that is provided to patients with mental disorders by the clan’s members. One of the possible solutions of this problem has become an implementation of the adopted WHO guidelines [5] for community- based culturally-sensitive mental health care services.

Model of integrated community-based multidisciplinary psychosocial support has been functioning in the Kyrgyz Republic since December 2006 [3, p.35]. The main goal of this model is to reduce the frequency and duration of hospitalization, and integration of persons experiencing mental disorders in the society. Multidisciplinary teams consist of a social worker, medical nurse, psychologist and psychiatrist. Apart from psychoeducation and family counseling, functions of a multidisciplinary team include correction of treatment and even hospitalization of a patient when it is strongly required due to the conditions, listed in the Law « On Psychiatric Aid and Citizens’ rights » . Psychiatrist as a member of the multidisciplinary team creates a therapeutic plan, which includes both short-term and long-term goals. The long-term goals encompass integration a patient into society (or family in a broad meaning of the word). Psychologist as a member of the multidisciplinary team explores family relationships if a family allows him/her to do so. Despite the fact that all members of the multidisciplinary team usually belong to the same ethnic group and, in many cases, to the same clan, establishment of compliance between mental health care specialist and family of a patient is still not an easy way to go. Mental health care specialists in KR are stigmatized even more than patients with mental disorders, and families perceive official mental health services as the worst way to get help.

Another branch of the development of mental health rehabilitation in KR is a growing number of family-based NGOs, created by the relatives of patients with mental disorders. One of the most successful ones is “Hand-in-Hand” NGO, which works with autistic kids. A few non-governmental organizations launched a number of rehabilitation centers, where patients with PTSD receive relevant rehabilitation treatments, including therapies from psychiatrists and psychologists who have been trained in working with PTSD patients after Osh events in 2010.

Conclusion

Overall, the status of mental health rehabilitation in the Kyrgyz Republic, being clearly defined in official documents, is vague in reality. The official rehabilitation units are in the process of disappearing, and activities of the multidisciplinary teams highly depend on external sponsors, such as Open Society Foundation and World Bank. It appears that family-based NGOs involving mental health specialists, personally interested in reintegration of patients with mental disorders in society, might serve as groundwork for a new set of a culturally-sensitive out-patient and community-based rehabilitation system.

Although the mental health system in the Kyrgyz Republic is extremely short of funds, it should not serve as an excuse to stop efforts to create a sustainable rehabilitation system, relatively independent of external donors. In the process of writing this paper the author has encountered numerous Ego-defenses (such as active denial, rationalization of the existing problems and devaluation of the NGO movement) presented by colleagues working in the Republican Center of Mental Health. Recent past of mental health rehabilitation in KR, as well as in other countries of the former Soviet Union, was painful, full of unpleasant and unsightly events. Readiness to analyze the past, awareness of the present as well as taking responsibility for what has happened and what is happening seems to be a factor for future sustainable development of mental health rehabilitation in the Kyrgyz Republic.