Reforming forensic psychiatry and prison mental health in the former Soviet Union

Over the past 2 years the Global Initiative on Psychiatry has developed a wide range of initiatives in the fields of prison mental health and forensic psychiatry in Eastern Europe and the former Soviet Union. Both areas, until recently, were either ignored or deliberately avoided. This is not coincidental. The prison systems in the former Eastern bloc are in essence military organisations with a strict hierarchy and a rather tarnished past. Although some reform programmes in this field were implemented or started during the past decade (e.g. by Prison Reform International and the London Institute for Prison Studies), none of these projects has involved mental health services within the penitentiary system. A society that often limits itself to locking away those who have committed crimes or are suspected of having committed them, and pays only little attention to the physical and emotional well-being of those imprisoned, does not see the mental health of these persons as a priority. Equally unimportant seems to be the mental health of those who guard the prisoners and who are under constant stress. Forensic psychiatry in Eastern Europe, and in particular in the former Soviet Union, was closely and directly involved in the systematic use of psychiatry for political purposes by declaring political and religious dissidents mentally ill (Bloch & Reddaway, 1977, 1984; van Voren, 1989). Also, in principle, the same school of thought that of the Serbsky Institute for Forensic and General Psychiatry in Moscow is still predominant. Even in the Baltic countries, now members of the European Union, forensic psychiatric practice still follows the precepts of the Institute, and part of the training is provided by its associates. The fact that the sector is secretive, influential and actively dominated by the Serbsky Institute has deterred mental health reformers from tackling this issue. Another reason why forensic psychiatry has been avoided as a field of operation is corruption. No other branch of psychiatry is as open to corruption as forensic psychiatry. It is public knowledge that some powerful criminals buy their way into ‘non-responsibility’, and hence several years in a mental institution, rather than be sentenced to long prison terms. It is very difficult to provide hard evidence of this corruption. All parties involved (both the criminals and those who provide the false diagnoses, as well as those who allow this corruption to continue) have strong interests that the system is left untouched. However, from confidential sources we even know in some countries the prices that criminals pay for a false diagnosis. In June 2004, the Georgian Minister of Health Dr Vladimir Chipashvili dismissed all forensic psychiatrists in the country after a public scandal over a case of corruption, in which a criminal had allegedly escaped a long prison term by being diagnosed as mentally ill. The more one pays, the lighter the regimen and the shorter the ‘treatment’. Tackling forensic psychiatry means trying to end this corruption and in the light of the amount of money it entails this is not without risk. One of the collaborators of Global Initiative, the Director of the Forensic Expert Bureau in Georgia, Mr Levan Samkharauli, was assassinated on 21 May 2005 only hours after his return from The Netherlands. Although not all the evidence has been disclosed, it is almost certain that his murder was politically motivated. However, some changes might be made in prison mental health as this is viewed as an issue for prison rather than psychiatric authorities. However, even here extreme caution is required.

Over the past 2 years the Global Initiative on Psychiatry has developed a wide range of initiatives in the fields of prison mental health and forensic psychiatry in Eastern Europe and the former Soviet Union.Both areas, until recently, were either ignored or deliberately avoided.This is not coincidental.The prison systems in the former Eastern bloc are in essence military organisations with a strict hierarchy and a rather tarnished past.Although some reform programmes in this field were implemented or started during the past decade (e.g. by Prison Reform International and the London Institute for Prison Studies), none of these projects has involved mental health services within the penitentiary system.A society that often limits itself to locking away those who have committed crimes or are suspected of having committed them, and pays only little attention to the physical and emotional well-being of those imprisoned, does not see the mental health of these persons as a priority.Equally unimportant seems to be the mental health of those who guard the prisoners and who are under constant stress.
Forensic psychiatry in Eastern Europe, and in particular in the former Soviet Union, was closely and directly involved in the systematic use of psychiatry for political purposes by declaring political and religious dissidents mentally ill (Bloch & Reddaway, 1977, 1984;van Voren, 1989).Also, in principle, the same school of thoughtthat of the Serbsky Institute for Forensic and General Psychiatry in Moscow -is still predominant.Even in the Baltic countries, now members of the European Union, forensic psychiatric practice still follows the precepts of the Institute, and part of the training is provided by its associates.The fact that the sector is secretive, influential and actively dominated by the Serbsky Institute has deterred mental health reformers from tackling this issue.Another reason why forensic psychiatry has been avoided as a field of operation is corruption.No other branch of psychiatry is as open to corruption as forensic psychiatry.It is public knowledge that some powerful criminals buy their way into 'non-responsibility', and hence several years in a mental institution, rather than be sentenced to long prison terms.It is very difficult to provide hard evidence of this corruption.All parties involved (both the criminals and those who provide the false diagnoses, as well as those who allow this corrup-tion to continue) have strong interests that the system is left untouched.However, from confidential sources we even know in some countries the prices that criminals pay for a false diagnosis.In June 2004, the Georgian Minister of Health Dr Vladimir Chipashvili dismissed all forensic psychiatrists in the country after a public scandal over a case of corruption, in which a criminal had allegedly escaped a long prison term by being diagnosed as mentally ill.The more one pays, the lighter the regimen and the shorter the 'treatment'.Tackling forensic psychiatry means trying to end this corruption and in the light of the amount of money it entails this is not without risk.One of the collaborators of Global Initiative, the Director of the Forensic Expert Bureau in Georgia, Mr Levan Samkharauli, was assassinated on 21 May 2005 only hours after his return from The Netherlands.Although not all the evidence has been disclosed, it is almost certain that his murder was politically motivated.
However, some changes might be made in prison mental health as this is viewed as an issue for prison rather than psychiatric authorities.However, even here extreme caution is required.

Human rights
Reports by the Council of Europe and other international and national bodies leave no doubt that human rights in prisons and psychiatric hospitals are frequently abused.The aim of Global Initiative is to bring about fundamental change within these institutions, to limit the occurrence of abuse and to put in place mechanisms that allow victims to seek help.
In the case of prison mental health, our approach is twofold.First, our work is aimed at ensuring that individuals with mental health problems receive adequate mental healthcare, are removed from the prison system as soon as possible when it becomes clear that the mental health problem is long term, and are returned to prison when the problem has been dealt with effectively.Second, we want to introduce the concept of mental health within the entire prison service, ensuring the staff take the mental health of the prison population into consideration in daily practice and in establishing rules van Voren Reforming forensic psychiatry in the former Soviet Union and regulations.Of equal importance, we want to address the mental health of prison staff themselves.The constant pressure and stress in this particular workplace affects the resilience of personnel and violent behaviour can result.
A fundamental change is needed from a basically penitentiary system towards a therapeutic environment in which the criminally insane can be treated.Currently, the system is primarily targeted at locking up criminals with mental illness and keeping them separate from society.There is a lack of therapeutic vision and therapeutic environment, personnel lack adequate training and there is no programme of rehabilitation or assisting patients to prepare for their return into society.
It is clear that human rights violations in such institutions are not uncommon and that there is no mechanism for impartial handling of complaints.It is our goal to change the image of the inmates from that of prisoners to patients and establish a therapeutic environment.

Policy issues
Global Initiative works with the clear and fundamental understanding that reform in mental health systems, whether in general mental health or in specialised sectors such as the penitentiary system or the criminal justice system, is only possible and viable if those working in these systems agree to reform.However good a plan and however justified an intervention might be, without overall support from those responsible for these services there is no chance that such interventions will lead to sustainable success.
Based on extensive experience of the mental healthcare systems in Central and Eastern Europe and the new independent states built up over a period of 25 years, Global Initiative is aware that resistance to reform is deeply rooted and often seems insurmountable.This resistance is often caused by a combination of fear of change (What will a changed environment do to my career?) and distrust of the need for change (Our system is quite OK and certainly not worse, we know best and who are you to criticise us, etc.).This means that a very careful, sensitive approach is needed to build a sense of partnership.
However inhumane the living conditions and however evident human rights abuses, it is important to find a common ground to allow the other side sufficient confidence to acknowledge with time that reform might be beneficial.However, this policy of building bridges must leave some room for criticism.However, any criticism must be sensitive and shared with the partners as a basis for discussion on how to implement change.It is this policy that is particularly important when working in such sensitive areas as forensic psychiatry and prison mental health.We frequently operate without involving the press but we also believe that this approach is not harmed by the activities of those who voice their criticism openly, such as Amnesty International and the Mental Disability Advocacy Center, with whom we maintain good working relations.Both are complementary means for change.

Lithuania
Here, the situation is more promising, in part because Lithuania has joined the European Union and reform is mandatory.There is a forensic psychiatric project in Rokiskis Hospital, targeted at reorganising forensic psychiatric services.Also, good working relationships have been established with the prison system.This has lead to a regular exchange of delegations of prison officials and authorities (including ministers and their deputies), site visits and, eventually, to an agreement to develop a long-term plan to improve prison mental health services and psychological care for prison personnel.

Georgia
In June 2004, Global Initiative was asked by the Minister of Health to organise training in forensic psychiatry for a group of young Georgian psychiatrists.Eventually, these would form the core of a new forensic psychiatric committee in Georgia to: (a) assess forensic psychiatric services in Georgia and draw up a plan for their reorganisation; and (b) assess current prison mental healthcare services and to draw up a proposal for organisation.
In August 2004, a delegation of Dutch experts in forensic psychiatry visited Georgia for a first assessment of the situation and to draw up a plan of action.A followup visit in January 2005 resulted in an agreement with van Voren Reforming forensic psychiatry in the former Soviet Union both the Ministries of Justice and Health to set up an inter-ministerial committee to develop a long-term plan for both forensic psychiatry and prison mental health services.The committee includes deputy ministers from both ministries, a member of the law committee of the Georgian Parliament, the director of the National Forensics Bureau and a number of foreign experts.Since January 2005, the committee has met three times with Dutch experts, and progress is being made, albeit slowly.

Legal issues
In many reports on the penitentiary and forensic psychiatric systems in the former Soviet Union serious shortcomings have been identified in the legal process leading to a court ruling and, later, to a decision to continue treatment or discharge an individual.For instance, it has been frequently reported that a court ruling has been made when the person concerned and/or his legal representative has been absent.This situation also applies to review boards.Indeed, individuals have been denied access to their files and an advocate to plead their case.
It is our view, that it is important to examine the current laws and regulations, as well as the procedures followed, as they regularly seem to be incompatible or even contradictory.Recommendations should be made on how the system can be improved, and one or more countries should be identified where the environment is suitable for implementation of necessary changes.One of the recommendations could be to establish special courts that only deal with cases involving alleged mental illness, and to develop a specialty in criminal justice that deals specifically with issues involving full or partial unaccountability.Currently, the former Soviet republics have in practice a system with only two options: either one is accountable and should thus stand trial; or one is unaccountable and should thus be sent to a forensic psychiatric hospital for compulsory treatment.Decisions are currently made by judges who have no training or expertise in this field.
Another issue is that both in prisons and forensic psychiatric institutions the flow of individuals through the system is in many ways faulty.In the prison system (e.g.Kresti), once individuals are found to have mental health problems they are either placed in the regular prison system after their sentence is pronounced or are moved to the forensic psychiatric system when declared unaccountable.However, both the process leading to inaccountability and the transfer to a forensic psychiatric institution after sentencing are extremely timeconsuming owing to administrative procedures and the fact that communication between the two systems is far from smooth.For example, in Lithuania individuals enter the forensic system either via the prison system (and some of them have bribed their way into the forensic system, thereby causing a lot of security problems as they are perfectly healthy and maintain the criminal hierarchy, vor v zakone) or directly via police stations (vor v zakone, literally translated as 'thief within the law' is the hierarchical system that criminals developed in the Soviet period, with their own laws, punishments and rules and regulations.The criminals used this mechanism to maintain order within the Gulag and to settle disputes among themselves.On one hand it made them completely independent from Soviet authority, on the other, the Soviet authorities used it as a tool to keep the prisoners under control, and as a way to use the criminals to keep control over the political prisoners.However, when a person is declared unaccountable the expert commission also decides on the severity of the regime under which treatment should take place, thereby taking away a very important tool in developing a therapeutic plan for the person concerned.These are issues that need careful scrutiny, and work on improving rules and regulations, administrative procedures, instructions and possibly even laws is highly topical.In the cases of both Kresti and Rokiskis this work will be done, but it is important that the issues are raised to a level higher than the two MATRA projects.

Declaration of interest
None.
During 2002 and 2003, with financial support of the Open Society Institute, a project was developed to upgrade psychiatric services in the Kresti Prison in St Petersburg.Extensive contact with GUIN (Chief Directorate of the prison system) and the Ministry of Justice led to the development of a project that the Maatschappelijke Transformatie -social transformation (MATRA) programme of the Dutch Ministry of Foreign Affairs agreed to finance.Now, 3 years later, reconstruction of the psychiatric department is being finalised and training of specially selected staff is under way.The need to pay attention to mental health issues in a prison setting has been accepted by the relevant Russian authorities.In 2003, the Open Society Institute decided to support the development of a project proposal aimed at reorganising forensic psychiatric services in Lithuania (see below), which was also funded by the Dutch Ministry of Foreign Affairs and commenced officially in June 2004.During the same month, the Ministry of Health of Georgia requested Global Initiative to assist in reforming both forensic psychiatry and prison mental health services.