The International Journal of Psychosocial Rehabilitation

Psychosocial Rehabilitation in Slovenia

(A Brief Report)

 

 

Vesna Švab, MD, PhD
vesna.svab@psih-klinika.si

Assistant Professor

University Psychiatric Hospital Ljubljana, Slovenia



Citation:
Švab, S.   (2005). Psychosocial Rehabilition in Slovenia
.
   International Journal of Psychosocial Rehabilitation. 
10 (1)

 

Contact:
 Vesna Švab, Psihiatrična klinika Ljubljana, Studenec 48, 1260 Ljubljana, Slovenija

 Nace Kovač, director of home, ŠENT Slovenian Association for Mental Health, nace.kovac@sent-si.org


Abstract
Development of psychiatric rehabilitation in psychiatric hospitals and of psychosocial rehabilitation in non-governement associations in Slovenia are described regarding historical and societal experience. Main obstacles to further development of community rehabilitation are searched for. Basic recommendation is to strenghten anti-stigmatization movement and to improve education in the field of mental health.

Key words:
Psychosocial rehabilitation -  history - stigmatization



Introduction
Slovenia is a Central European country with a population of two million. At the end of the 19th century it was part of the Austro-Hungarian monarchy, in the 20th century it joined with the Serbs and Croats to create a kingdom and also made up part of the communist bloc after World War II in the Federal Republic of Yugoslavia. As the northern and most developed part of former Yugoslavia Slovenia its gained independence in 1991 with a referendum, following  a ten-day war with the Yugoslav army that had then started to disintegrate. The religion is predominantly Catholic (70%). Some 100,000 people from former Yugoslav republics still live in Slovenia. The country’s GNP per capita was USD 10,400 in 2003, which is lower than most »old« European countries but better than most 'new' ones.

While
Slovenia was previously engaged in a communistic regime all the time it still tried to achieve developed European social models. It had a relatively well-developed network of public health and social services. With democratic reforms and the removal of the planned economy myths about the firmness of the public network and citizens’ social security started to collapse. The former social policy proved to be too expensive and counterproductive for the country due to the lack of support for private initiatives, non-profit voluntary organisations and civil society. People with mental illnesses were predominantly institutionalised, treatment and care were government regulated and separated from other illnesses. The mental health system used to work relatively well due to the fact that institutions and outpatient clinics were widely available to everybody in need. Deinstitutionalisation and community care only held academic and experimental significance and were chiefly influenced by the British model.

The social democratic government also tried to implement the Scandinavian model of social care involving strong public services and the influence of user organisations.
The challenge of deinstitutionalisation was resisted by the firm stand of Slovenian psychiatrists also due to the experience of the Nazis’ criminal euthanasia of psychiatric patients from a Slovenian psychiatric hospital during World War II. The work and education of psychiatrists was guided by the permanent warning that psychiatric patients require special safeguarding and protection which influenced the strengthening of institutional forms of care. There was no tradition of voluntarism and people then had to struggle for their own economic survival. The cultural perception of mental illness is still determined by a mixture of distancing, fear and pity. After criticism of psychiatric institutions (Gofman, 1968, Wing and Brown, 1970), European psychiatry was reformed in terms of the quality of hospital care and treatment (Curson et al., 1992) followed by community treatment and social care. Despite the rapid and – in comparison with the rest of Europe – early shrinkage of hospital capacities and hospitalisation days, attempts prevailed to maintain care and treatment within institutions such as social asylums and homes for the elderly. Simultaneously, a wide network of psychiatric outpatient clinics developed in the 1970s but without establishing any other complementary services. These should be linked with general practice and thus located as close as possible to patients' homes.

Hospitals have been renovated and provided with a greater number of staff, however it is still incomparable with that somatic hospitals. Chronic patients were de-hospitalised and moved to asylums, old peoples’ homes and to their families. The majority of the hospital population of 20 years ago was quickly discharged, mainly with very little preparation and due to economic pressure. In
Slovenia’s main psychiatric hospital (University Psychiatric Hospital Ljubljana; hereafter: PH) there are only about 2% of long-term hospitalised patients. The number of admissions to the central Slovenian psychiatric hospital has been increasing rapidly while hospitalisations themselves have become shorter, chiefly as a result of the further rapid reduction of the number of psychiatric beds (by 22%) seen in recent years.

 

Figure 1. Hospital beds and admissions in the central Slovenian psychiatric hospital

 

The need for planning post-discharge care was increasing and therefore hospital staff were  gradually undergoing training in the planning of treatment and care with patients, as well as in evaluations of their social functioning, work with family members and teaching daily and social skills. Special care has been dedicated to changing attitudes to patients and to implement the values of partnership and empowerment.

It was up until the middle of the last decade that our mental health care system managed relatively well the problems of homelessness, imprisonment of psychiatric patients, poor accessibility of care and suitable housing. Nevertheless, it was becoming increasingly apparent that institutionalised care was posing an obstacle to the recovery of people with a mental illness. Users’ movements and protests supported by a few social care experts after 1982 sought to make this fact public. At this time the civil movement first organised a campaign for abolition of the biggest social institution in the country, in which patients had been living in unbearable conditions. Apart from calls for the total deinstitutionalisation of psychiatry and particularly the abandonment of psychiatric-social asylums, the campaign was the beginning of ‘normal’ socialising for the most severely disabled psychiatric patients. A group of dedicated social workers appealed for patients' employment, independent living and empowerment. Yet nothing much happened in this area in the following decade. The psychiatric profession persisted in protecting its patients and recent deinstitutionalisation after witnessing the deficient care of patients in Gorizia and Trieste, the two centres of Italian deinstitutionalisation, only one hundred kilometres from the centre of Slovenia.

The consequences of conflict between the psychiatric and social movements are still apparent and manifest themselves in extremely incompatible education programmes on mental health at the Medical and Social Work faculties and particularly in the negligible or even absent co-operation between the relevant professions. A change was brought about by the establishment of some non-governmental organisations in the mental health field which, aware of the evidently unsatisfied needs for rehabilitation of the mentally ill, tried to stimulate co-operation and contacts between social and health services, particularly those concerned with psychiatry. General practice joined the debate on the possibilities of mutual activities with some caution due to understaffing (1,800 patients per general physician). In 1992, the non-profit organisation ŠENT started to prepare multidisciplinary programmes for day-centres, vocational rehabilitation and group homes, which proved to satisfy certain needs of their users (Švab et al., 2003). Rehabilitation activity was also developed in parallel organisations operating across the territory of Slovenia. ŠENT developed educational programmes for work in the rehabilitation field, which were joined by social workers, occupational therapists, medical nurses and some general practice physicians and parallel tailored but essentially equal educational groups for patients and their families. In following years, these education programmes were launched in the central psychiatric hospital and transferred to some other regional psychiatric hospitals. The first textbook on psychosocial rehabilitation (Svab et al., 2004) was at least partly based on the Boston model of psychosocial rehabilitation (Anthony et al., 2002) and intended for all members of multidisciplinary work groups, including patients and their families. Parallel to that, users, family members and care-takers were joining in within the framework of different non-profit organisations, and have thus gained some political power in the last few years. While the family members are striving for the better quality and accessibility of care as well as timely intervention in critical situations, users' initiatives centre on the fight for a better social and economic status and a critique of psychiatric institutions.

The rights of psychiatric patients were regulated by the health law which provided the basis for involuntary hospitalisation. This law has been overruled by the Constitutional Court and at this point in time Slovenia has no legislation on mental health. The situation has been resolved by other legislative acts and by the decision of the Constitutional Court on obligatory co-decision of advocates about involuntary admission. In the last ten years the mental health law has remained an unfinished project. The fact that we have no law on protection of patients’ rights in hospitals, upon admission and in the fields of treatment and rehabilitation enables at least the concealed abuse of psychiatric patients because of the lack of information about their rights. There is a report by the European Commission (Mental Disability Advocacy Centre, 2003:54) on the existence of a few cage beds in Slovenian hospitals and a few other complaints. Such concern is understandable due to the lack of professional monitoring and weak NGO influence on quality standards The abuse of psychiatric patients is more obvious when it comes to their low employment levels, lack of supported employment, housing opportunities, low incomes and regarding the paternalistic attitudes of psychiatric and social workers which, to our knowledge, is no different than in other countries.

Conclusion
The rehabilitation programmes outside the hospitals are solely financed by the social care system and through donations. Slovenian health care policy does not reveal any intention to support the implementation of rehabilitation programmes in the home setting, while in hospitals these are only carried out to a very limited extent due to the short hospitalisation periods. Attempts to connect hospital care, to facilitate the evaluation of patients’ needs, health condition and functioning, with public and private organisations that perform rehabilitation in the community are still in a preliminary stage. The dissociation of health-care, social and private rehabilitation services represents the main obstacle to the implementation of co-ordinated and individually adjusted programmes. Attempted integration agreements such as those discussed at the Conference on Rehabilitation and Community Care (2002), and the Conference on Education in the Field of Mental Health (2004), although relatively well accepted, have remained overlooked in the planning of health care. The main reason for this indifference seems to be attributable to discrimination against patients with mental disorders. Therefore, our main efforts are directed towards destigmatisation. It is necessary to reduce the stigma associated with large institutions, encourage the decriminalisation of psychiatry, i.e. draw a dividing line between the forensic and other lines of psychiatry, and offer education for increasing the power and influence of the users of rehabilitation services. However, as pointed out by patients themselves, in order to achieve this it is necessary to improve their weak social status and poor living conditions, which are the biggest obstacles to their actual integration.


References

Anthony W, Cohen M, Farkas M, and Gagne C. Psychiatric Rehabilitation. Boston: Center for Psychiatric Rehabilitation 2002.

Curson DA, Pantelis C, Ward J and Barnes TR. Institutionalism and schizophrenia 30 years on. Clinical poverty and the social environment in three British mental hospitals in 1960 compared with a fourth in 1990. The British Journal of Psychiatry 1992; 160: 230-241.
Goffman E. Asylums. Harmondsworth 1968. Penguin.

Švab V (ed). Psihosocialna rehabilitacija. Ljubljana: Šent - Slovensko združenje za duševno zdravje 2004.

Švab V, Tomori M, Zalar B, Ziherl S, Dernovšek MZ, Tavčar R. Community rehabilitation service for patients with severe psychotic disorders:the Slovene experience. Int. J. Soc. Psychiatry 2002; 48 (2):156-160.

Wing JK, Brown BW. Institutionalism and schizophrenia. Cambridge University Press. Cambridge 1970.





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