Comment by Emi Baruch:
A few days ago, the attacker of the meteorologists from Murgash Peak, Stoyan Stoyanov, was placed by a court decision for home treatment in the psychiatric hospital "St. Ivan Rilski", left the clinic voluntarily and was returned by two police officers.
These are the latest news on the case of the "naked man from the mountain", who in a visibly inadequate state at dawn on March 9 beat up Rumyana and Georgi Zlatanovi and entered all news broadcasts.
Will this latest episode make us come face to face with some of the systemic problems of psychiatric care as part of healthcare, as part of the social system, as part of medical education, as an element of judicial practice, as a reflection of negative public attitudes and political priorities… Hardly.
This can happen to any of us
We only talk about psychiatric care and the condition of patients when an "attractive plot" comes to the attention of the media. But a few days pass and the flow of news erases the topic from public attention. Other serious topics appear - such as the death of a child due to the poor condition of the roads, such as the abuse of defenseless animals or the delay of an ambulance, which led to the fatal end of a patient...
Behind the public attitude "this guy is crazy, what are we going to do with him, he will be crazy for the rest of his life!" stands the non-acceptance of this disease, the stigma and the refusal to admit that this can happen to any of us.
Bulgarian society is ashamed of its mentally ill people. This is part of the national culture.
"Two-thirds of the aggression of the mentally ill is a product not so much of the disease itself, but of the combination of the disease and the environment," explains Assoc. Prof. Dr. Vladimir Velinov - specialist in psychiatry, expert witness at the Sofia City Court and head of the Forensic Psychiatry Program.
"The world is currently very uncertain. We live with the feeling of a lack of rules, a lack of rights, a lack of rule of law, a breakdown. And we tend to ignore everything that adds additional anxiety, and these are precisely people with severe mental disorders. It is as if as a society we cannot bear it", says Valentina Hristakeva, director of the Global Initiative in Psychiatry Foundation - Sofia.
The psychiatric system is isolated, it sees the person in his worst state, when he is in crisis. He remains invisible until the next crisis. What happens in the meantime? How does this person live, who supports him, where does he recover? This picture is out of the hospital's field of vision. This is where the connection between psychiatry and the social system, which is tasked with finding solutions for the lives of people with mental disorders outside the clinic, breaks.
One of the major reasons for the poor outpatient treatment, according to Dr. Velinov, is the elimination of the dispensary system, which included mandatory meetings between the patient and his treatment team. Some time ago, even patients living in hard-to-reach areas were visited by the doctor and nurse, who periodically went by ambulance to examine the patients on site. "Because these people need permanent, continuous monitoring. And this should be state policy," says the psychiatrist. State policy, however, is different.
There is no hint of concern anywhere. The mentally ill are not in the field of view of politicians. They are not active voters, often they do not have relatives or loved ones to stand behind them. The mentally ill are not represented. They do not have national advocates.
Valentina Hristakeva manages enterprises that employ people with severe mental disorders. They work, contribute to the socio-economic growth of the country, pay taxes and social security contributions. This is a working practice worldwide. Such are the results in Bulgaria. Those who have started work do not fall into crises, they can recover so that they can live with dignity and when there is care and support, the results are visible. GIP-Sofia is also a provider of social services.
"The municipality has a leading role in this process", says Valentina Hristakeva. "It should start a procedure with the Ministry of Labor and Social Policy to request funding for this activity. When the municipality argues the need to open these services, this should be included in the funding for the next calendar year. The activity is funded by the state and delegated to our management organization."
But this is difficult to do. Because of the stigma, because of negative public attitudes, because of the unpopular target group that is not politically "interesting".
"Last year, a map of social services was adopted, but we don't see our target group being well represented in the municipalities. We see family-type accommodation centers, sheltered housing. As if this is the maximum for people from this community - to be segregated, to be separated, to be accommodated somewhere. (...) "Take them!", that's what we are most often told. "Take them, accommodate them and take care of them". However, if it can't be in the center of Sofia, if it can be somewhere in the suburbs, if it can't be in the suburbs, because people live there too, it shouldn't be next to a school, it shouldn't be next to anything. "That's more or less the expectation," says Hristakieva.
She adds that the Ministry of Labor and Social Policy is the only one that recognizes the need for such services anyway - unlike the Ministry of Health, in which, according to her, there is no figure who is interested in this topic, no competent professional who would advocate for the care of the mentally ill.
The lack of competence, leadership, literacy regarding good international practices, as well as the lack of respect for the profession on the part of society finds expression in the anecdote: psychiatry is not a profession, but a diagnosis. This contains both the misunderstanding and the underestimation of the work of psychiatrists. In the literal and figurative sense of the word.
There is no money - act!
Psychiatry is not among the desired specialties by students. The state does not allocate money. The hospitals are municipal. The pay is miserable and the conditions correspond to the pay. This directly affects the training of medical and clinical psychology professionals.
"In clinical psychological practice, we work with methodologies that were standardized in the 1970s. This is shameful", says Georgi Kirilov, a professor of clinical and counseling psychology at Sofia University "St. Kliment Ohridski”. And he continues: "When colleagues come to work and ask the hospital to provide them with newer methodologies, they laugh at them and tell them: we don't have the money to pay your salaries, to repair the roof that leaks over the patients, and you want us to give you money for tests. You have these tests - work with them."
The problem with the training of professionals is also reflected in the work of experts. For their expert work, for which they are criminally liable (imprisonment of up to 5 years for a false conclusion or incorrect defense), they receive less than 30 leva per hour - nearly three times less than the fees in private practice. Thus, in the court proceedings, either the "Mohicans" - dedicated to the profession, or the poorly prepared, remain, which has a negative impact on the quality of the expertise. Competent clinical psychologists work for a while and leave.
Georgi Kirilov is an expert at the Sofia Court of Appeal, a supervisor in the field in which he works, and has a doctoral degree in clinical psychology. Since 2008, together with Assoc. Prof. Velinov, they have been regularly making proposals for the creation of a register of experts and a register of the expertise that these experts defend. "This will immediately provide information about the quality of the experts, and will also be useful for training future staff. Because the requirement for experts to maintain their professional qualifications is only formal. There is no body that can force me to improve my professional qualifications, nor is there any body that can question me whether this is so. Here is the closed mechanism. For years I have been proposing to the National Institute of Justice to create a unit that would be responsible for the qualification and subsequent attestation of the professional competence of experts, but there is no such interest. The state is not interested in this."
There is no mandatory discipline of forensic psychiatry in the legal education of magistrates, Assoc. Prof. Velinov continues the topic. "Well, how can prosecutors, investigators, judges understand what is happening when they encounter such cases."
Thus we arrive at one of the saddest findings, which all three of our interlocutors share: the abuse of patients' rights, marginalization, rejection. Because stigma necessarily leads to rejection.
Bad practices are provoked not only by someone neglecting the fact that mentally ill people have rights, but also by the lack of the tools to provide adequate care for this person.
There is not enough staff, there is not enough security in the workplace, there are no procedures to protect this person at the moment. There is no external support, nor public understanding of what is happening in psychiatry, explains Valya Khristakeva.
And according to Assoc. Prof. Velinov, the total problem is that there is no desire among young specialists to go to psychiatry. Because - in addition to the miserable conditions - there they will communicate with patients who are surprising, incomprehensible, sometimes frightening, and the professional, especially in the first years of his adaptation, wonders where he has ended up, says the psychiatrist.
Valya Hristakieva emphasizes that the low salaries of those working in psychiatric units are a terribly important topic. But the conditions in which "the sick are treated are also shocking - this is an absolute fact. And it is important that the topic be addressed in an adequate way. But this is by no means enough. Raising salaries will not change the quality. And it seems that this is all we are talking about - about psychiatrists and their salaries. And there is not a single word about those who live 15-20 years locked in this place."
A victim of their own mental illness
We are deeply unenlightened people in terms of mental health and we do not have high emotional intelligence as a society.
We are not civilized enough and we do not accept that the person who suffers is a victim of their own mental illness.
But does anyone teach children empathy, compassion?