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Mental Health Reforms

Special issue: > Forensic Psychiatry and Prison Mental Health

09
No. 2

A Global Initiative on Psychiatry publication

Contents

Editor Ellen Mercer Editorial Board Katja Assoian Elena Mozhaeva Robert van Voren Florence Baingana Margi Kirschenmann Graphic Design/ Printing BADE creatieve communicatie www.bade.nl Mental Health Reforms is a publication of Global Initiative on Psychiatry (GIP). While MHR is distributed free of charge, we are dependent on your support to sustain the journal. Contributions are therefore welcome and may be made to: ABN AMRO Bank s Gravelandseweg Branch Hilversum, The Netherlands BIC: ABNANL2A Euro account:62.07.29.074 IBAN: NL16 ABNA 0620 7290 74 USD account: 62.07.29.244 IBAN: NL82 ABNA 0620 7292 44 To request additional copies please contact: Global Initiative on Psychiatry P.O. Box 1282 1200 BG Hilversum The Netherlands Tel.: +31 35 683 8727 Fax: +31 35 683 3646 e-mail: hilversum@gip-global.org www.gip-global.org

Editorial

By Robert van Voren

Developing Prison Mental Health Services in Countries in Transition: Challenges, Constraints and Opportunities
By Dick Raes and Robert van Voren

Seven Years in Kresti Prison: A Unique Project to Develop Modern Prison Mental Health Services in St. Petersburg
By Konstantin Antsiferov, Rob Hollander and Wendy Weijts

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Risk Assessment in Post-Soviet Countries


By Virginija Klimukiene

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Developing Partnerships in Forensic Psychiatry: The Pompe Foundation as Partner in GIP projects
By Thieu Verhagen and Dick Raes

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Initiating Reform in Prison Mental Health & Forensic Psychiatry in Serbia


By Robert van Voren

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Bulgaria: A European Union Member Lagging Behind in Forensics


By Petar Marinov and Vladimir Velinov

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Mental Health Reforms


Special issue: > Forensic Psychiatry and Prison Mental Health

Convicted Juveniles in Georgia Problems and Prospects


By Lela Tsiskarishvili

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09
No. 2

From Lunatic Asylum to National Institute of Mental Health in Sri Lanka


By Dr. Neil Fernando, Marieke de Vries, and Nanthini Sivanesan

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Goals of GIP in Sri Lankas Forensic Hospital System


By Robert van Voren
A Global Initiative on Psychiatry publication

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Cover photo: Chernyakhovsk Special Psychiatric Hospital, Kaliningrad, Russia

Russian Summaries
By Elena Mozhaeva
July 2009

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Editorial

In most countries around the globe, mental health service users are stigmatized in ways that can affect their quality of life and position in society. However, for those who have a mental illness and have also com -mitted a crime, there is a double stigma: he/she is mad, and bad. Virtually everywhere these individuals receive less treatment and care than needed. Global Initiative on Psychiatry has been involved in the development of projects in the field of forensic psychiatry and prison mental health for the past eight years. In those years, we have managed to support the initiation of reform in more than half a dozen countries, mainly in Eastern Europe and the former Soviet Union, but also in Sri Lanka. In addition, there is good reason to believe that projects will be implemented in several other countries in the near future. It is difficult to get programs of this sort started; governments are often

not very interested in this group of patients they are mad and bad, arent they? and society usually does not like the idea of forensic patients reintegrating into society after their treatment has been concluded. The majority of the population believes that such people should be locked up as long as possible, preferably for the rest of their lives. Penitentiary systems are, by definition, repressive in nature, and prisoners with mental health problems are often considered to be simulators who should be dealt with in only one way: put them under such horrible living conditions that they want to go back to their regular cells as soon as possible. Part of the work of Global Initiative on Psychiatry is to convince authorities to take prison mental health and forensic psychiatry seriously. First of all, forensic psychiatric patients who have not received adequate treatment remain a threat to society, so it is in the interest of the population as a whole that good forensic psychiatric care programs are developed.

Prisoners with mental health problems badly affect the atmosphere in penitentiary facilities which may, in turn, lead to security risks. In addition, bad treatment and living conditions almost invariably lead to human rights violations, and it is the duty of each government to do everything possible to prevent such violations from taking place. We realize that our job is not an easy one; yet over the past years, we have seen many positive developments and concrete results of the work of our partners and ourselves. This issue of our journal Mental Health Reforms provides you with a kaleidoscope of such projects, dealing with a wide range of issues in diverse countries. We do not attempt to cover all that has been accomplished or is being accomplished but we do hope that this issue provides the reader with a good overview and, by doing so, convincingly argues why this work needs to be undertaken. Robert van Voren

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Developing Prison Mental Health Services in Countries in Transition: Challenges, Constraints and Opportunities
In most countries - including those that meet the criteria for democracy- the execution of criminal law, its procedures and its institutions can be characterized as a rather closed system. A closed system in this sense is regarded as a complex of interdependent organizations, regulations and facilities within society, but with few possibilities for society to have insight, control and influence concerning what is really going on within this system. At the same time, this system, including the criminal law, is usually a reflection of the attitude of governments, politicians and citizens towards crimes and criminals. Legislation in each country should be regarded as the source of protection of rights, i.e. the psychological, physical and material integrity of each individual citizen. Criminal law provides the criteria, procedures and measures for punishment of persons who violate the above-mentioned rights and integrity. The criminal law should address the criteria of proportionality and efficiency and should also safeguard the legal rights of the individuals who are confronted with the criminal law. When a person is found guilty of an offense, the aims of punishment are retaliation, as well as specific and general prevention, including probation and rehabilitation especially after prison sentences, to prevent recidivism. The closed system of the criminal law, its procedures and institutions stretches from the time the suspect is brought to a police station to his/her release from prison. This article pays attention to the prison system as part of a chain of provisions within the criminal law, the influence of the penitentiary system on prison mental health and provides examples of efforts to improve prison mental health care in countries in transition.
By Dick Raes and Robert van Voren

Prison mental health as part of a consecutive chain of provisions


Each person under suspicion of having committed an offense should be considered not guilty until an independent court has as-

sessed his guilt and pronounced a verdict. This implies that such a person should be treated accor ding human rights standards. The career of a suspect usually starts when he is brought to a police

station and possibly formally arres ted and taken into custody. There is hardly any control on the manner in which police officers deal with such individuals. Next, the investigation phase starts when evidence about the offense in question is collected.

Keys to Kresti Prison Ward

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The main part of this investigation consists of interrogation of the suspect. In many countries, the criminal investigators can interrogate the individual without his having benefit of an attorney. They will try to get a confession, sometimes using methods that are not allowed according international standards. The written report by the interrogators is not always a true representation of how a confession was achieved and is beyond control of the court. A well known error during the investigation is the so called confirmation bias: the investigators are selectively looking for information which confirms their suspicion and tend to neglect information that forms an indication of the innocence of the suspect. The public prosecutor is responsible for what takes place during the investigation phase and has to prepare the indictment for the court session. It should be stressed that the state is and remains responsible for the physical and psychological condition of the suspect. When needed, he should get the same medical/psychological care as he would if not in custody. In cases of more serious offenses, the suspect will be admitted to a pre-trial prison (or remand prison), in most countries a penitentiary facility with a very restricted regime. The time spent in a pre-trial prison should be as short as possible, depending on the time needed for preparation of the case for the court session, the seriousness of the offense and the risk that the defendant will escape and hide in order to avoid further prosecution and sentencing. During the trial, the court will interrogate the defendant, eventual witnesses and evaluate other aspects of proof, as presented by the public prosecutor. During the court session, there should be a so-called balance of power, meaning that the defendant and his lawyer have equal rights to access all material collected by the public prosecutor and the lawyer of the defendant has the right to cross examine the witnesses and to bring forward his own witnesses. In many countries, this balance of power does not exist and the public prosecutor is the most powerful party during the trial,

especially in Russia and the new independent states of the former Soviet Union. Basically the members of the court should be independent, but in many countries this might not be true (e.g. appointed selectively by the government). In case the defendant is convicted of the crime and sentenced to prison, he will be sent to a labor camp or another penitentiary facility, often far away from his place of residence. It should be clear that this chain of facilities and provisions put a heavy psychological burden on the defendants and convicted persons, especially for people who are already suffering from mental problems. They are robbed of most of their civil rights, the circumstances in the prison system are usually very poor, medical and psychological assistance is often non-existent and there is no possibility for the individual to complain about the treatment he/she receives. Many international studies have shown that the number of offenders suffering from minor or major psychiatric disorders is very high (the mad and bad). In general, this chain of regulations and facilities is very repressive; a prison sentence robs one of his/her freedom. But the circumstances within this chain add a lot of extra suffering. Prison mental health care should deal with all elements of this chain, starting at the police station. Trying to improve one element of the chain will likely raise resistance in other parts of the chain. Changing legislation is not enough. Implementation of a more humane approach in the whole chain is more important, otherwise it will remain as window-dressing.

assistance, the uncertainty about the future, including the result of the court session and ending up in a repressive prison climate, often in crowded cells without any privacy. As mentioned earlier, quite a number of offenders are already suffering from mental disorders when entering the criminal justice system. Forms of need assessment are absent. Quiet prisoners are the best prisoners. The psychological effects of imprisonment are well known: depression, self harm, suicidality and completed suicide. These conditions are increased because of bullying by guards and other prisoners, ending low on the pecking order list that exists in every prison, aggressive and sexual assault. These individuals often further experience anger without outlet because of the repressive and dehumanizing regime, isolation from their nearest and dearest, lack of contact with the outside world, poor hygienic and nutritional conditions accompanied by increased vulnerability for all kind of contagious diseases. To insure the rights and the needs of individual prisoners, the penitentiary system should develop within the system a differentiation in regimes, based on the availability and the level of medical/psychological/psychiatric/nursing care. This differentiation should be made for special groups of vulnerable prisoners: prisoners with mental disorders, with learning disabilities, adolescents, first offenders, pedophiles and other child molesters. The criminal law and its procedures should insure high quality pre-trial psychiatric assessments to make a distinction between defendants who are non- or diminished ac-

Exterior of Kresti Prison

The influence of the penitentiary system on prison mental health


People who enter the criminal justice system run the risk of being confronted with all kinds of negative psychological effects because of the way the system deals with them. Being taken away from home without the possibility of contact with their nearest family, being bullied at the police station, the stress of being interrogated in certain ways, the lack of psychological and juridical

 . Fazel & J. S Danesh, Serious mental disorders in 23000 prisoners: a systematic review of 62 surveys, Lancet 2002, 545-550

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countable for the crime for which they are indicted, based on their mental status while committing the crime. The psychiatrists and psychologists involved in such assessments should be independent expert witnesses to the court and not contribute to the investigations of the public prosecutor. When the court accepts the non- or diminished accountability, these persons should not be punished in a regular prison but referred for treatment to special forensic psychiatric hospitals.

more than twenty years. However, millions of people remained in the camps, either because they were considered to be hostile to the Soviet regime, or because their forced labor was needed for the economy. Much of the construction and industry in Siberia was developed by forced laborers and completely ending this free workforce would have ruined the country. The first description of the Gulag after Stalin was written by Anatoly Marchenko, and published in 1969. Marchenkos book showed that although the regime had softened and mortality rates in the death camps of Vorkuta and Kolyma had decreased considerably, life in the Soviet penitentiary system remained harsh and dangerous. In the 1970s, most dissidents were incarcerated in the prison of Vladimir and the camps in Mordovia, later Chistopol prison became the main prison for politicals while male political prisoners were sent to the camp complex near Perm; Mordovia was then earmarked for female political prisoners. After the death of Stalin, outright torture of political prisoners stopped. Indirectly, however, torture or maltreatment continued through inhumane living circumstances, dangerous working conditions, malnourishment and insufficient medical care. However, life for criminals was usually more difficult, and since ordinary prisoners had no ambassadors in the West, their maltreatment went much less noticed. In the mid-1980s, however, life for political prisoners also had become much more difficult and the number of deaths increased quickly. In protest against the bad living conditions, Anatoly Marchenko, then serving a term of fifteen years of camp and exile, went on hunger strike, which cost him his life in November 1986. His death triggered the release of all political prisoners in the USSR. Throughout the Soviet period, and actually up to this very day, the phenomenon of vor v zakone formed an integral part of life within the penitentiary system. Vor v zakone is best described as a separate criminal class that placed itself outside regular society and maintained its own hierarchy and laws. Vor v

The starting point: conditions in penitentiary institutions in the NIS at the end of the 20th century
The history of the Soviet Union of the twentieth century is one of bloodshed, terror and mass detention of large segments of society, starting with the revolutions of the Russian Empire in 1917, a vicious civil war with mass arrests, and followed by the State terror unleashed by Stalin in 1924. By 1941, onetenth of the population was incarcerated in a vast Gulag of camps scattered all across the country, but predominantly in the endless stretches of forests, tundras and deserts of Siberia and Central Asia. Millions of citizens were murdered by execution or hard labor in forced labor projects. During the Second World War, millions of Soviet citizens again perished as a result of acts of war, the Nazi-German killing machine and the unrelenting meat grinder of the NKVD. The next phase of history saw a new wave of terror that sent millions of so-called collaborators to the camps. And shortly before the death of Josif Stalin, another wave of terror was under preparation. The Doctors Plot, allegedly a plan of Jewish doctors to kill Stalin, was, in reality, concocted by the NKVD in order to make mass arrests, in particular of people of Jewish background. In 1953-1955, millions of prisoners were set free, and many of the Gulag camps were abandoned. NKVD director Lavrenti Beria was executed as were many of his accomplices, and successor Nikita Khrushchev publicly denounced the terror that his predecessor had unleashed against his nation for

zakone was a potent force within the penitentiary system; they maintained a strict regime and determined to a large degree the quality of life in a cell or barrack: who slept where and with whom, who got the best food and other privileges. The fact that they maintained strict discipline made them an ally of the administration, and often their force was used as a means to keep discipline, the way the Nazis made use of kapos. Even though these were hardened criminals with severe punishments for those who broke their laws, they also had a romantic air surrounding them. Their attitude of untouchability was enhanced by the many tattoos on their bodies, indicating their crime history and various preferences, from sexual to political. Although the power of the vor v zakone is not as strong as it was in Stalin times, they currently remain a force to be reckoned with, and their relationship with the administration is a combination of respect, fear and collaboration.

The history of the Soviet Union >

Probably the best description of Stalins regime of terror is Conquest, R., The Great Terror, Pimlico, UK., 1992, a revised edition of his original book with the same title published in 1968. 3 Marchenko, Anatoly,  My Testimony, Pall Mall Press, London 1969.
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Another important aspect of the penitentiary system in the (ex-) USSR worth mentioning is that of transit prisons. Camp memoirs are full of horrendous stories about life in these prisons. Prisoners were sometimes for weeks and even months na etap, in transit, and moved from one transit prison to the next. The prisons were often huge holding tanks with large communal cells where dozens of prisoners are locked up together, often under the rule of the vor v zakone and where living conditions are such that by the time prisoners reached their final destination they are exhausted and in bad health. Putting a prisoner on a lengthy etap could and was used as a form of punishment, and a very effective one indeed. It is this penitentiary system that formed part of the heritage of the Soviet Union when the country collapsed in 1991 and fell apart into

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in the 20th Century is one of bloodshed, terror and mass detentions of large segments of society.

fifteen separate countries. The way the countries dealt with this heritage differed from one country to the other, but without exception they all still suffer from the Soviet past.

It was an alcoholic representative for human rights of President Putin in North-West Russia who opened the doors to Kresti prison for us. He had recently been to the psychiatric department of Kresti prison in St. Petersburg, the largest pre-trial prison in Europe that at that time held close to 12,000 prisoners. He had left in shock, and from conversations it was clear that his indignation was sincere, the situation in the psychiatric department of Kresti prison had really touched him. And there was reason enough for that. About three hundred fifty psychiatric patients were cramped together in small moist cells, where water was running down the walls, ventilation was absent and where in winter it was too cold and in summer too hot. Sometimes more than nine persons were locked up in one cell of two by three meters, sometimes with only six bunks. That meant sleeping in turns and twenty-three hours behind locked doors, with the only relaxation being one hour airing in a small courtyard that only offered a view to the sky. The stench was unbearable, food outright disgusting, prisoners were seriously neglected and when a psychosis would result in too strong reactions, the prisoner concerned would be isolated and tied to a rusty metal bed frame because medicine was unavailable. Our conversations with the prison director went unexpectedly smoothly; he had the impossible task of running an overcrowded prison without sufficient support from Moscow, and, at the same time, trying to humanize conditions. All support was welcome, he said, and he accepted it with open arms. The task ahead seemed to be an impossible one. It was very clear that the psychiatric department needed a thorough reconstruction. In addition, staff was insufficient, medicine almost never available and the space made it completely impossible to create any therapeutic environment. What

In the end, we managed to find a way out of this dilemma, and after almost four years of struggling we could see our temporary success: the reconstruction of the psychiatric department had been finished and the new unit could be opened. True miracles had happened. What before had been a dark, moist cave now had been transformed into a prison department that could also have fit in a prison in Western Europe. The architects had succeeded bringing in much more daylight, as a result of which the central part looked much nicer. The cells were dry, well heated, and the number of beds had been reduced to maximally four per cell. On top of that, fitness equipment had been placed in the department, as well as table tennis and other games; a revolutionary development in a prison system that hadnt changed since the beginning of the twentieth century. For several months, the staff of the department carried out a daytime program for the psychiatric patients like nowhere else in Russia. Prisoners were taken out of the cell in small groups, played table tennis, exercised on the fitness equipment or played chess at the tables in the center court between the cells. A truly humane department had been created within a terribly repressive prison system. It seemed our project had finally succeeded. Unfortunately, Russia wound up increasingly in dictatorial waters which had immediate consequences for the Kresti project. The projects main goal was to bring about attitudinal change, exactly in the opposite direction than that of current Russian politics. We strived to humanize the system, to help the penitentiary system start dealing with prisoners with mental health problems as human beings, to see them first as patients, and only after that as prisoners. However, the system continued to view the person as a criminal, someone who needed to

Kresti Prison Psychiatric Ward Before and After Renovation


 he best books on T the subject are Baldaev, D.S., Tatuirovki Zaklyuchennykh, Limbus Press, St Petersburg, 2001, and Lambert, Alex, Russian Prison Tattoos, Schiffer Publishers, Altgen PA, 2003 5 See for instance  Appelbaum, Anne, Gulag A History, Penguin, London, 2003, pp.261-270, and Solzhenitsyn, Aleksandr, The Gulag Archipelago I, Harper & Row, New York, 1973 6 An extensive de scription of the transit camps and their effect on the prisoners psychological and physical state can be found in the chapter The Pots of the Gulag Archipelago in A. Solzhenitsyns The Gulag Archipelago I.
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be taught a lesson. The ill prisoner was preferably seen as being a simulator; with the worst simulator being the prisoner who pretended he had a mental illness. He was dealt with double harshly, and was often locked up under even more inhumane circumstances than the rest. Change in leadership of the penitentiary system in St. Petersburg endangered the project even more. It was probably a combination of orders from Moscow to straighten things out and the natural reaction of a leader in such a repressive organization to create fear through a temporary reign of terror and to show who is boss. Using a conflict with one of the prisoners as a pretext, the prison administration took the fitness equipment away and stopped the day program, allegedly because an aggressive patient had made all this impossible. But after a while the day program resumed; this cycle repeated many times.

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Case study: changing attitudes within a resisting system (Russia)

followed were years of negotiating, sometimes without any result. Even when the funds were released, we couldnt do anything because every step forward was blocked until we delivered. Delivering meant to pay bribes and when we refused, the project came to a standstill

The projects main goal was > to bring about attitudinal change, exactly opposite of current Russian politics.

This was our dilemma. Is it at all possible to hope that Russia will become more humane, or do we have to accept that a democratic Russia has for the time being become a fata morgana again? The article by Konstantin Antsiferov, Rob Hollander and Wendy Weijts follows with some additional details on this project.

places of detention. Clearly, since independence, the Lithuanian prison system made enormous progress in shedding the Soviet past and strives to reach European standards as soon as possible. At the same time, it is also clear that much work still needs to be done and that prisoners with mental health problems are no less stigmatized in the prison system than in society at large and that extra efforts are needed to change that situation. In spite of assurances that new premises will be built, the prison psychiatric department is still housed in the pre-trial investigation prison in Vilnius (Lukiskes prison). Symbolically, the psychiatric department has the worst possible accommodation in this facility - in a wing of the pre-trial prison but under much worse conditions than the pre-trial prison facility itself or the rest of the prison hospital. The cells are damp without any ventilation, housing four to five prisoners in one cell. The department has sufficient medication available, but the quality of services provided is questionable. The perimeter is surrounded by five fences and walls, with prison dogs running around between the first fence and the actual prison building, creating an eerie atmosphere with their constant barking. It is hard to explain why a European Union country such as Lithuania has no interest in improving prison mental health services and ending such unacceptable conditions in a prison located less than 500 meters from the Lithuanian parliament building. Protests and complaints, including by a WHO delegation in 2005, have not led to any results. Persons with mental illness are no

priority, and neither are imprisoned criminals; those who are a combination are double stigmatized, and suffer the consequences.

Case study: when desire exceeds the possibilities (Georgia)


Georgia also inherited a Soviet penitentiary system, housed in dilapidated buildings with some of the most inhumane living conditions we had seen over the years. In no way could a therapeutic atmosphere be established in the existing premises, the professional level of the few available staff was excruciatingly low and the conditions were so bad that, in our view, only one solution was possible: close the department down and start a new one somewhere else, under better conditions. We had been asked by the Georgian Ministry of Health to reform forensic psychiatric services in the country after a corruption scandal had resulted in the dismissal of all forensic psychiatrists by the Minister; yet the Ministrys understanding of the scope of their request was minimal. We were facing not only low professional standards, corruption, lack of professionals and bad living conditions, but also the absence of collaboration between the Ministries of Health and Justice and complete lack of coordination within the ministries themselves. What we had, however, were very enthusiastic and reform-minded officials, including actively involved deputy ministers and young mental health professionals. The ministers and their deputies also were young, which resulted in an interesting combination of lack of experience in governance, a quick grasp of the needs due to first-class Western education, and a drive to change things overnight. However, there clearly was no chance of a quick solution to the immense problems. We decided that the only way to help Georgia structurally and sustainably was by dealing with the issue in an allencompassing manner, tackling the whole chain of services. Georgia became the only country where we managed to take this global approach. An inter-Ministerial committee was established, that met on a regular basis, involved all stakehold-

Case study: indifference as the main obstacle (Lithuania)


Lithuanians are a proud people, proud of their history and also proud of their constant resistance to foreign oppressors. In Soviet times, it was a Lithuanian underground publication that was published uninterruptedly until the collapse of the regime; the Lithuanians were the first to declare themselves independent in 1990, and managed to hold on in spite of strong pressure, an economic blockade and military action by then-President Gorbachev. In order to prevent a storming of the parliamentary building, officials placed huge concrete fortifications around the building - a portion of which is still visible in the form of a monument. In 2004, Lithuania joined NATO and the European Union. It was truly a milestone in the history of the nation, marking a definite reintegration into Europe and ending the fear of future Russian domination; yet, at the same time, it also marked the end to many of the reform processes. After accession to the European Union, the developments in the country slowed down and eventually came to a standstill. Typical The penitentiary system in Lithu- Psychiatric ania was inherited from the Soviet Prison Cell Union as an outdated network of prisons and labor colonies, and a workforce that had been educated as a Soviet militarized machinery to keep prisoners locked up and out of society. In the late 1990s, many young people joined the penitentiary service and questioned many of the approaches. These young people had enlightened minds educated in post-Soviet Lithuania with additional trainings abroad. They started introducing new services such as those for prisoners with alcohol and substance abuse, and humanized life in many of the

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ers including the deputy ministers of health and justice and discussed all the issues collectively. After some compromises, many decisions were taken during these meetings. In the course of four years, we managed to agree to develop a new pre-trial assessment center in Tbilisi, built with Georgian money and according to European standards, the result of collaboration between Dutch and Georgian architects. With a delay of half a year due to the August Russian-Georgian war, we now expect the center to open before the end of 2009. Also, renovations started at a newly established central forensic psychiatric facility in Qutiri, and in spite of the war, reconstructions are continuing, again with Georgian funds. And, last but not least, an agreement was reached to open a new prison mental health department in the newly built prison in Gldani just outside Tbilisi, and hopefully also this department will be opened in 2009. Trainings were organized for doctors, nurses, social workers and other personnel, including the guards. A permanent link was established between a Dutch forensic psychiatric hospital and the hospital in Qutiri, and an agreement was reached with the Georgian government that GIP will provide intellectual support, while all construction and material needs will be financed by the Georgian government. Until now, they have stuck to their word. A true professional exchange has developed with the Georgians; implementation of the projects is based on real partnership.

top-down, but are even more difficult than the opposite: changes from bottom-up. Basically, efforts to bring about change should be aimed at all levels of a society but will meet a lot of resistance. For example, it is amazing that the expansion of the European Union to include countries in Eastern Europe neglects human rights related to the fate of prisoners in these countries. Obviously these have a very low priority. Nevertheless, NGOs try to find likeminded partners in these countries to create ways (and money) to work from the bottom of the penitentiary system to bridgeheads higher in the hierarchy. As described above, these efforts are not always successful and these changes take a lot of time, because experience shows that changes only can be achieved in very small steps forward.

Lukiskis Prison, Vilnius, Lithuania

plicable in each different country. Preferably this preparation should be carried out together with local partners who want to participate as change agents. During this preparation, attention should be paid to possible changes in each part of the chain that has been described above. Support of the project by the ministries involved is very important in the sense that the bureaucracy takes his own responsibility in the process of change. Unfortunately, the regimes in these countries are not as stable as we would like for implementing the projects and their sustainability. Dick Raes is Professor in Forensic Psychiatry, member of the board of GIP and his email is: d.raes@wxs. nl. Robert van Voren is Chief Executive of Global Initiative on Psychiatry. His email address is rvvoren@gipglobal.org. . Editors Note: For further background (and fascinating reading), please note the attached information of a new book by Robert Van Voren:

Conclusion what lessons can be learned


It is our view that each project concerning the improvement of prison mental health requires extensive preparation to make the project ap-

Prison mental health as a mirror of society: what is achievable in the coming years?
The criminal law, its procedures and institutions, constitutes a closed system within the wider system of society, including politicians, bureaucrats and citizens. To start with the penitentiary system, the way the director deals with his staff will be reflected in other layers of his organization, to end up with the attitude of the guards toward the prisoners. Where democracy is lacking, there are hardly any possibilities of influencing the existing system. Eventual changes should be implemented

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Seven Years in Kresti Prison: A Unique Project to Develop Modern Prison Mental Health Services in St. Petersburg
As mentioned in the previous article, in 2002, a unique cooperation started between Dutch and Russian professionals working in the prison system. The goal of this project was to improve the care for mentally disturbed prisoners in the Kresti-prison St. Petersburg NW region Russian Federation. Because of the uniqueness of this project, we would like to make a few additions from our own experiences. By Konstantin Antsiferov, Rob Hollander and Wendy Weijts

Activities for Prisoners in Kresti Prison Psychiatric Ward. Photo taken by Theo Lammers

The Kresti prison, built in 1827, is one of the largest prisons in Europe. At the banks of the river Neva, the prison was originally built for 950 prisoners. During our first visit, 12,000 prisoners were held in Kresti, and by the time our project started, still approximately 7400 prisoners were detained. In the Kresti, there are several wards housing prisoners with HIV/AIDS (1200), prisoners with tuberculosis (700) and prisoners with severe psychiatric disorders (270). We would like to point out here that the renovation of the prison ward, our first priority, was accomplished mostly through the work of the convicted prisoners. They constructed two types of cells within the ward. One type of cell was built for patients in an acute psychiatric phase and hosted two prisoners. The other type of cell was for stabilized patients and hosted four prisoners. The light green walls, the windows, the clean environment and the equipment for activities made the total metamorphose complete. The new psychiatric department now

meets the international construction standards for prison mental health. The daily activities introduced have been mentioned previously; those activities were planned to create a sense of purpose into the lives of the mentally disordered detainees. Through offering them regular and meaningful activities in their lives, their self-esteem would be raised. It is also important to note that these activities create some ideal moments for observation - observations that lead to very useful insights and can be used in the assessment of behavior and possibilities of treatment of the (individual) patient. In the past seven years, we spoke about this subject with many of our Russian colleagues. Many times these talks seemed as useless as the daily lives that the patients have to endure. But, in the end, there were some success stories to be told: daily programs for patients were introduced and frequently the patients are now undertaking more meaningful activities with each other. As we have recently been told, this is a unique development

in the Russian prison system. It is hard to determine if and how all attitudes will be changed because of this project. In the Russian prison system, the convicted prisoners (sanitary) play a very important role. The authorities consider them as personnel for the prison and they are employed in many different jobs. Not only do they do the cleaning, cooking and maintenance work, often they are also responsible for the security within the prison. Once we visited a prison with only eight guards who were responsible for 2000 inmates. In reality, this is not manageable for the guards, so special prisoners are assisting those guards in different ways. The system where convicted prisoners take care of other prisoners is highly undesirable but a harsh reality due to a lack of money for the prison authorities. In the Kresti, the sanitary assist the doctor in his/her consultation with patients on the psychiatric prison ward. The sanitary are also responsible for discipline amongst the

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The Kresti prison annually receives more than 3500 prisoners. It is impossible for the psychologist to see all new prisoners so we introduced a screening instrument to detect psychiatric problems at an early stage. In a pilot setting, we have trained some junior inspectors in using the questionnaire with newly arriving prisoners. The outcome of the screening can be an indication that the new prisoner needs consultation of the psychologist. The prison authorities found this screening instrument

Recommendations
Working in the Russian prison system is often a matter of patience, improvising skills and good personal relationships with important key holders. During this project, many of the key holders changed. One example is that the Kresti got a new director who was not as enthusiastic as the former one. This resulted in a temporary withdrawal of the day program and recreational facilities. It took a considerable amount of time for him to agree and support the project, especially the

Instruction Manual for Kresti Prison Psychiatric Ward. Photo taken by Theo Lammers

> >

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patients with mental disorders. Despite our effort to establish a fixed team of guards who are trained to deal with mentally ill prisoners, we did not succeed in this. In the end, we chose to develop an instruction manual for the sanitary that work in the psychiatric ward and discussed the selection criteria of those sanitary with the prison director. This manual was printed on big key-shaped plastic cards. The symbolism of these keys is to open doors and gave a small entrance to the psyche. The keys gave short instructions about how to deal with inmates with psychiatric problems. For example: how can one manage his attitude when a prisoner is anxious or depressed. The keys may result in attitude changes of the sanitary on the psychiatric department and give some sustainability.

effective and efficient and support implementation. During the project we tried to introduce the subject prison mental health in the Russian system. We visited the Pushkin Institute that is responsible for training prison staff throughout the Russian prison system in order to establish some sort of collaboration. Unfortunately, this was an unfulfilled goal.

> It is impossible for the


psychologist to see each of the 3500 patients who come to Kresti each year.

day program. We had some nice conversations and peppered discussions. Sometimes it felt like two steps forward and one step back. However, every visit ended with a toast of vodka and the words: to our friendship. In order to implement new methods, those methods must be adapted to the Russian situation. The first reaction from the authorities is often a negative one indicating that they cannot implement new methods; but when we insisted, their opinions changed completely. We also needed to be flexible in our approach; many times, we encountered changes within our program and had to keep from being frustrated while adapting to the new situation. After seven years of work within the Kresti, we developed some unique relationships and accomplished many of our goals. This was not possible without the support of many. We are very thankful for that. Konstantin Antsiferov is the GIP representative in St. Petersburg and his email address is Antsiferov@inbox.ru. Wendy Weijts and Rob Hollander work in the Dutch prison mental health service and are active in many of GIPs projects. They can be reached at: roberthollander1999@yahoo.com and wweijts@yahoo.com.

July2009

11

Risk Assessment in Post-Soviet Countries


By Virginija Klimukiene
A risk assessment is a statement on the likelihood that a certain undesirable event will take place in the future.1 Risk assessment is a routine practice in the field of forensic psychiatry: every 6 months, the court receives the reports from the hospital and must make decisions, based on these reports, as to either prolong the present compulsory treatment measures or to change them into lighter or stricter ones. In most of the post-Soviet countries, the court will release a forensic psychiatric patient from the hospital only when it is obvious that the mental state of the patient has changed; in other words, when his/her risk of reoffending is significantly reduced. However, one could argue that the changes in mental state and the reduction of risk to reoffend is not the same. These factors depend on the approach to Mental Health we take as a baseline: a biological approach emphasizes the medical treatment of mental disorder as a keystone to prevent criminal behavior in the future. A bio-psycho-social approach to Mental Health takes into consideration all biological, social and psychological factors, which determine (future) offenses, therefore a reduction of risk will be related to both medical treatment and resocialization, i.e. management of all risk factors. Post-Soviet countries gained their independence 15-18 years ago and have taken their unique way of development. However, the neighboring countries often take rather similar steps and speed in development. Taking into consideration the lack of the precise knowledge about the situation of risk assessment in every particular Post-Soviet country, the author presumes to group the countries and present one state from each group: the Baltic States in this article will be represented by Lithuania; Russian Federation, Republic of Belarus and Ukraine will be represented by the Russian Fed-

The Author Presenting on HCR-20

eration; and Caucasian and Central Asian countries by Georgia.

vational conditions and prolongation or end of hospitalization. In Lithuania, as in most Post-Soviet countries, risk is mainly assessed on the basis of so-called unstructured clinical judgment approach, which implies, that the clinician is, as it were, his own risk assessment tool (M.Philipse, 2005). It means that the final conclusion is determined subjectively (and often implicitly) by each individual clinician. The above mentioned project has revealed a deep need to develop Lithuanian versions of world-widely recognized and used risk assessment tools. HCR-20 Violence Risk Assessment Scheme 2nd version (developed in 1997) was chosen from a long list of instruments, because it is designed to assess the risk of people who have some Mental Health disturbances. In addition, it is quite easy to understand and apply. HCR-20 represents the structured clinical judgement approach rather then actuarial one; it does not require a long validation process and the creation of local norms; and it also impacted the decision to pilot the risk assessment in Lithuanian forensic psychiatric setting on the basis of this instrument.

Lithuania
In 2004 2007, GIP implemented a project titled Reorganizing forensic psychiatric services in Lithuania financed by MATRA (hereinafter Rokiskis MATRA Project). This project aimed to develop a contemporary system of forensic psychiatric service delivery in the Republic of Lithuania that adequately provides care to this specific group of patients and protects society from the criminally insane. The provision of adequate care to forensic psychiatric patients and protection of society from the criminally insane is directly related to the assessment of risk to offend in the future, because of the following: 1. R  isk assessment helps to ascertain the main factors contributing to the criminal behavior of the particular patient; 2. I t serves as a background for the development of individual plans of treatment and risk management; 3.  It enables the evaluation of the effectiveness of measures taken during the treatment; 4. I t helps in reporting to the court regarding the changes of obser-

 .W.G.Philipse. PreM dicting Criminal Recidivism. Empirical studies and clinical practice in forensic psychiatry. Printed in The Netherlands by Febodruk, Enschede, 2005.

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In June 2006, two representatives of Lithuania, Prof.Rita ukauskien and the author of this article, received the official permission to translate into Lithuanian, edit, and print the manual for the HCR-20, Version 2 (Webster, Douglas, Eaves, & Hart, 1997) from the Mental Health, Law and Policy Institute of Simon Fraser University (Canada), which holds the copyright of the abovementioned instrument. During the next two years, 400 copies of HCR-20 Lithuanian version was published following the requirements described in the official permission. The longitudinal validation research has been conducted and in the middle of 2009, it is anticipated that the first results of the follow-up of forensic psychiatric patients released from the hospital at least 12 months ago will be gathered. In May 2007, three groups of 20 professionals each from Rokiskis forensic psychiatric hospital were trained on risk assessment and application of HCR-20 in practice. Participants of these trainings had different educational backgrounds: including psychiatrists, psychologists, social workers, occupational therapists and nurses. Rokiskis MATRA Project had a fundamental impact on creating multidisciplinary team work in Rokiskis hospital and trainings on HCR-20 were designed to teach ways that this instrument could be handled by all team members (one of the indirect tasks of HCR-20 is to structure the meetings of multidisciplinary teams). Thus we may conclude that Rokiskis MATRA project facilitated an essential turn of risk assessment in forensic psychiatric settings in Lithuania, because it initiated the implementation of structured clinical judgment instruments as an alternative to subjective considerations. Risk assessments might also be seriously considered in correctional settings. We may boast about the Lithuanian Prison Department, which has developed and currently is implementing the Probation Concept. Such risk assessment instruments as HCR-20, PCL-R (Hares Psychopathy Checklist Revised), SVR-20 (Sexual Violence Risk assessment instrument), OASys (Offender, Assessment System), Static-99, SARA, SORAG and others are planned to be introduced

into the Correctional System of Lithuania. In summary, the handling of risk assessment tools in Lithuania shows that the provision of modern forensic psychiatric and prison mental health services has been started in Lithuania and we are very hopeful that this process will be continued by implementing the appropriate risk management strategies in both forensic psychiatric and correctional settings in order to reduce the level of re-offenders in the Lithuanian population.

Russian Federation
In 2007, Global Initiative on Psychiatry started a new project Development of forensic psychiatric and prison mental health services in Kaliningrad Region, also financed by MATRA. On the basis of the experience gained during the Rokiskis MATRA Project regarding the importance of risk assessment providing services for offenders with mental health problems, it was decided to implement HCR-20 in the forensic psychiatric and penitentiary institutions in Kaliningrad Region. It was found that the permission for the Russian version of HCR-20 has already been given to some professionals working in the North-Western

Arkhangelsk where permission was given in 1995 for developing the first Russian language version of the HCR-20, we may assume that there might be other initiatives to develop risk assessment methods that are not yet known to us. It is possible that these initiatives are not embraced by the two main institutes in Russian Federation charged with coordinating all forensic psychiatric issues: Serbsky Institute in Moscow and Bekhterev Institute in St.Petersburg. We hope that this information will be helpful in avoiding double work and enhance cooperation among institutions at the local and international level, particularly considering the quite strict requirements and procedures to obtain the permission for developing a national version of the particular instrument.

Georgia
Unstructured clinical judgment is the only method used to assess the risk of forensic psychiatric patients in Georgia. This country is lacking psychologists, social workers and other members of a multidisciplinary team; therefore the report to the court is often based on the description of the patients mental state and progress of medical treatment. The current situation in the country requires focusing mainly on coping with trauma, psychosocial rehabilitation of refugees and internally displaced people, and on strategies that support the process of recovery. On the other hand, the increasing level of offenses (especially among juveniles) is observed in Georgia as an outcome of the traumatic events of last summer. Thus, it is the right time to address the implementation of risk assessment instruments as a background for development and application of risk management strategies. It is our hope that these valuable risk assessment tools, already translated into Russian and Lithuanian, will be further translated and used throughout the former Soviet Union. These tools represent the best of objective judgment for the future and will hopefully replace the unstructured clinical judgment used in the past. Virginija Klimukiene is the Project Manager for GIP-Vilnius office and her email address is vklimukiene@gip-global.org.

> These risk assessment tools


part of Russia. The leader of the team, Dr. Oleg Ponomarev, agreed to cooperate with GIP in such a way that he permits GIP to publish 1000 copies of HCR-20 Russian version and GIP covers the costs of translation and editing and also provides trainings to specialists of Arkhangelsk Regional Clinical Psychiatric Hospital on the use of the instrument in daily practice. GIP also commits to transfer 100 copies of HCR-20 Manual to Arkhangelsk Hospital and to provide support in training the trainers of application of HCR-20 in Russia. Since Russia is such a large country and the Kaliningrad specialists did not know about developments in

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represent the best of objective judgment for the future.

July2009

13

Developing Partnerships in Forensic Psychiatry: The Pompe Foundation as Partner in GIP projects
Forum GGz Nijmegen is a large organization for mental health care in the eastern part of The Netherlands. Part of this organization is the Pompe Foundation, which consists of a high security forensic psychiatric clinic with facilities for resocialization, a policlinique for ambulant care and treatment of forensic psychiatric patients and a center for research and development. By Thieu Verhagen and Dick Raes
At a congress in Prague in 2000, the first author (T.V.) met a medical sexologist from Lutz in the western part of the Ukraine. This individual was invited to the Pompe Foundation, gave information on the situation of forensic psychiatry in the Ukraine and asked for assistance to improve the conditions in forensic psychiatry in his country. This resulted in a visit of a delegation of the board of the Pompe Foundation to the Ukraine. The youth prison in Kovel especially made a deep impression on the visitors. Hundreds of boys were incarcerated without any activities, with lack of proper food and medical care and hardly any possibilities for rehabilitation. Back in The Netherlands, the delegation succeeded in raising philanthropic funds for a project to improve the conditions in this youth prison. The result was that, after four years, this facility had its own kitchen where the boys were baking their own bread, a shoe reparation workplace, a garage and several smaller work places. The boys were trained in these new facilities as part of their rehabilitation. The Authors Visiting Forensic Facility in Serbia A visit from Holland in 2007 made clear that these changes would be maintained. Inspired by these results, the Pompe Foundation decided to go further on this way, but as it appeared, getting more formalized funding from the Dutch government was met with too many complicated administrative procedures. This led to a structural cooperation between the Pompe Foundation and GIP, the latter with its longstanding experience with projects in Eastern Europe and the New Independent States of the former Soviet Union, as well as its experience writing project proposals to the Dutch government. It is the intention of GIP to extend their activities in these fields to Asia and Africa. A steering group was formed to lead the project since there were many aspects of forensic psychiatry to be included: pre-trial assessment, prison mental health, and the execution of criminal law. In addition, the number of projects in this field was increasing; currently, the Pompe Foundation is involved in three ongoing projects - in Lithuania, Russia and Georgia. New projects are in preparation in Serbia/ Montenegro, Bulgaria and Sri Lanka. In this article the results so far in the first mentioned countries will be described.

Forensic Psychiatric Hospital Rokiskis, Lithuania


The first project involving the Pompe Foundation started in the only psychiatric hospital in Lithuania, situated in Rokiskis, a far away village in the northern part of the country. It was an old psychiatric hospital with prisonlike characteristics, comparable with Dutch psychiatric facilities from about 1950. Its staff was low paid, in general poorly trained and its motivation to change not very high, with the exception of the medical director. Patients stayed in their rooms during the day, shared with four or five other patients. No daily activity program was offered and their treatment mainly consisted of medication. The Pompe Foundation offered several trainings to different groups of workers, including a multidisciplinary approach to each individual patients problems, patient-staff interaction and psychopathology. Together with local partners, the risk assessment instrument, the HCR-20, widely used in the West and described in the previous article, was translated into Lith-

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uanian, according to the regulations and an expert of the Pompe Foundation gave training in the application of this instrument for psychiatrists and psychologists from Rokiskis and the Romero University in Vilnius. The three-year financing of the project by the Dutch Ministry of Foreign Affairs (the so called Matra financing, Matra meaning Social Transformation) ended in 2007. But the activities of the Pompe Foundation will be continued, based on a Memorandum of Understanding between Rokiskis Hospital and the Pompe Foundation (twinning) resulting in ongoing support by the Pompe Foundation. It is important that the progress achieved will go on. The project has moved Rokiskis at least 25 years ahead of where it was; a great deal has been achieved but still more is to be done. It should be mentioned that apart from the activities of the Pompe Foundation, GIP was able to use the opportunity to organize workshops with members of the court and the public prosecutors office.

as possible from their original place of living. Because of the isolated location of Kaliningrad, most of the patients are nowadays admitted from the Kaliningrad area. Thus, it is easier for family members to visit the hospital and offer also better opportunities for rehabilitation and resocialization. The director and his staff are very motivated for changes, but there is a lack of skills and knowledge. A lot of the potential of the staff is not used because of the strict hierarchical relations in the organization and insufficient professional education. It is clear that the nursing staff needs training on working with the patients in a therapeutic way, methods for planning, effectuating and evaluation of the treatment, also in a multidisciplinary context. But also improvement of the position and involvement in the treatment by the psychologists is rather urgent, including the introduction of the HCR-20. Between 2007 and 2010, The Pompe team will offer three trainings each year. Apart from these activities, the Prison Mental Health Team of GIP succeeded in organizing activities with penitentiary psychologists to improve mental health care in the prison system in Kaliningrad.

A Dutch developmental agency (Cordaid) was willing to support a project to improve the circumstances and treatment in the forensic psychiatric hospital in Quitiri. Recently, all forensic psychiatric patients from Georgia were brought together in this hospital. Because of the isolated situation of the hospital, it lacks enough qualified personnel which, in turn, is reflected in the quality of treatment. Also in this situation, the Pompe team has to deal with implementing knowledge in nurses and as well in psychiatrists and psychologists, regarding basic principles of psychopathology, multidisciplinary treatment, risk assessment and risk management. There is a positive perspective on cooperation with the local professionals.

General recommendations
1.  It is very important before starting a project with real interventions to get the trust of the local partners, as well the people we try to work with as the authorities that have the final responsibilities. The Russians especially do not trust the influence of western involvement under the name of NGOs and MATRA. 2.  It is our experience that the expectations of at least beginning trainers are too high as to what they can achieve. 3.  Administrative and logistic tasks should be taken care of by others than the professional trainers involved. These tasks would take time from the work needed to meet their primary goals. 4.  Be prepared for the specific problems concerning traffic and transport. Local people are usually very hospitable but not aware of the stress their driving behavior provokes. 5.  Be aware of drinking habits. Do not be surprised when vodka is served at breakfast or lunch. Restrict yourself regarding this to dinner situations. 6.  Be prepared that many intended activities will work out in a different way. This requires improvisation and creativity. (T.V.: Nothing is certain until it has happened.) Thieu Verhagen is Head Concern Staff, Forum GGz Nijmegen and part-time consultant with GIP. E-mail: t.verhagen@forumggznijmegen. nl. BCM (Dick) Raes is Professor in Forensic Psychiatry, member of the board of GIP. E-mail: d.raes@wxs.nl

Forensic Psychiatry in Kaliningrad (Russian Federation)


This Matra project started in 2007 and involves the three areas mentioned above. Kaliningrad is a province of the Russian Federation, but has become an enclave, separated from the main country. In our view, based on earlier experiences, this is an advantage because of the fact that all aspects of forensic psychiatry are centrally directed from Moscow. Because of its more isolated position towards Moscow, we expect to have more cooperation with the local authorities and colleagues. The first visit of a Pompe delegation took place in 2007 to the high security forensic psychiatric clinic in Chernyakovsk. The treatment of the 400 patients consists only in the application of medication, aimed at stabilizing the condition of the patients. The average duration of the patients stay in the hospital is 10 years (twice as long as in the Pompe Clinic). They are allowed to be in contact with their families by mail or telephone but never get permission to visit them. Family members were never involved in the treatment; patients and, especially, those admitted for political reasons as happened in the old regime, were as a rule admitted as far away

Georgia
Georgia appeared to be one of the countries where the departure of the old Soviet system left the country in a state of almost anarchy. This situation offered advantages and disadvantages. Due to total corruption in the system of pretrial assessment, GIP was asked to establish a new approach to psychiatric expertise to advise the courts. Because of the results of a new expertise center for pretrial assessment and a series of seminars for the staff, GIP was asked to assist in the arrangement of a new centralized clinic for forensic treatment and as well for the care of mentally disturbed prisoners in a new prison center.

The average duration of a >

>

patients stay in the hospital is 10 years; they can receive mail from family members but are unable to visit with them.

July2009

15

Initiating Reform in Prison Mental Health & Forensic Psychiatry in Serbia


In October 2007, a team of experts of Global Initiative on Psychiatry visited Serbia for the first assessment of the situation in forensic psychiatry and prison mental health. Several institutions were visited, including the forensic department of the Gornja Toponica hospital in Nis and the Central Prison Hospital in Belgrade. The report of the visit was received positively by all parties concerned, as it offered a wide range of possible fields of collaboration. The Dutch Embassy agreed to finance a continuation of the assessment as well as some first activities in this field. Within the framework of this project, a further inventory of the situation in forensic psychiatry in Gornja Toponica would be carried out and professional exchanges between Serbian and Dutch forensic psychiatry professionals would be started. Also, a second assessment visit to the Specialized Prison Hospital in Belgrade would take place followed by a first step in the direction of an exchange of views and experiences. In addition, materials to stimulate day time activities and rehabilitation work at the forensic department of the hospital Gornja Toponica would be bought and a seminar on forensic psychiatry and prison mental health would be organized for all stakeholders in Serbia. By Robert van Voren

Forensic psychiatry: visit to Gornja Toponica


In March 2008, John Kobessen and Roland van Rooij of the Pompe clinic in Nijmegen (The Netherlands) visited the specialist psychiatric hospital Bolnica Gornja Toponica (Nis, Serbia). This hospital accommodates nearly 700 general psychiatric patients and 120 forensic patients, the latter group of which consists of 80 men and 40 women. The assignment from GIP was to take a close and unprejudiced look at Bolnica Gornja Toponicas vision, method, patients and building, and to make as much contact as possible with the professionals at work. Special attention was paid to meaningful pastime: what current activities are there and where do opportunities for growth lie? The Dutch experts were cordially received by the general manager,

Dr. Milan Stanoskovic, and by the unit managers (Dr. Snezana Vladejic, Dr. Dragana Arandelovic, Dr. Sanja Stanojrovic) and staff. Everything is done optimally with the possibilities at hand (e.g. using medication as effectively as possible). The atmosphere is open and there is direct contact with the patients, who are treated with respect and care, and at the same time there is a balanced relationship between staff and patients. Every effort is made to provide social safety, taking into account that there are as few as one to six staff members at a unit, for a maximum population of 80 patients, residing in 5 dormitories. There are no computers and, thus, no fast and direct communication. Patients records are still kept on paper. One example of the involvement of staff is the weekly group meeting where 60 male patients are hosted

by 6 staff members (doctors and therapists). This group (that has patients in the positions of chairman and secretary) is used to let patients react to each other, to inform them (e.g. about treatment) and to correct them if necessary. Another striking example is a morning meeting that requires patients to stand next to their neatly made beds at 8 am and be scrutinized by the full staff of the ground and first floors, who point out any peculiarities (there is no privacy). While an informal culture has developed, there is hardly any formal culture. No protocols exist for incidents or hostage situations and understaffing, nor are there any written house rules or job descriptions. Psychotic patients and patients with personality disorders are mixed. (Our impression was that on these units the psychotic patients were the vast majority;

Visiting Gornja Toponica Forensic Department

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75% versus 25% personality disorders). Expansion of patients leave has to be requested directly at the courthouse, upon which a judge reacts with a simple yes or no. However, if anything happens to the patient while on leave (flight, recidivism), the sole responsibility falls on the hospital and the general manager. The consequence is that patients have little chance of moving out of the secured building; and rehabilitation often consists of nothing more than being dropped back into society at a certain moment, at which point patients completely depend upon their (often deficient) social network. The logical consequence is a high percentage of (risk of) recidivism and patients returning to society in an often highly unstable condition. There are few social workers who can guide patients and their social network. The travel distances are also unfavorable; patients living 300 km from the hospital can often be consulted by means of telephone only. Serbia has no after-care and resettlement organizations. It is true that there are activities for forensic patients inside the building and sometimes on the hospital grounds. An impeding factor is that patients cannot be employed in real work because it is considered by outsiders to be exploitation of patients; however, it is this kind of work that offers opportunities for patients to develop themselves. It is important to educate patients individually in certain basic skills (cleaning, kitchen, garden, maintenance, etc., but also basic knowledge of language, mathematics, writing, etc.): positive experiences create positive energy. The second reason why there is so much hesitation to extend patients movements beyond the hospital gates is the negative public image of (forensic) psychiatric patients. Time and energy is invested in making contact with society, with some success.

Lammers and Rob Hollander visited the Special Prison Hospital in Belgrade. This hospital has 4 different specializations with a total of sometimes more than 600 patients. The largest group, the department with compulsory treatment, is in a building unsuitable for this population and without a good treatment environment. In some cases, patients stay for over 20 years in this prison hospital. When patients have no social network after their treatment, the court will not release them because they still consider them as a danger to society. For those patients, a normal resocialization program cannot take place at all.

this is not an acceptable situation; patients should be accompanied by a professional. At this moment, five out of seven wards (hallways) are renovated. The hallway is a 50 meter corridor with cells on the side housing 6 to 10 patients each. Most of the time patients are in the corridor or in their beds. Every ward is closed by a fence with the guard sitting in a small room in front of that fence. This is the only way to enter the ward. The guard has absolutely no view of the cells or at the end of the corridor. When a patient is required for some reason (medication, visitors, etc) the guard will shout the persons name through the fence. In the morning, the doctors and nurses visit the patients on the ward mostly for the purpose of checking to see if anyone is having too many side effects from the prescribed medication. We hope to redesign the wards to a more therapeutic level which also considers safety issues. Over the past two years, Global Initiative has become involved in forensic psychiatry and prison mental health in Serbia, and although much needs to be done, a positive working relationship and a sincere desire to change has been the cornerstone of our work. As a result of our collaboration with Serbian partners, a major proposal has been submitted for funding to the Dutch Ministry of Foreign Affairs. The project will offer the opportunity of laying the groundwork for a contemporary chain of forensic psychiatric services. The project enjoys the support of all parties involved, both at the governmental and local level. It will create a model that changes the system of forensic psychiatric services from a purely custodial one to a service directed at treating, curing and safely re-integrating the mentally disturbed offender. At the same time, it provides a treatment model that adequately addresses the mental health needs of the prison population. Robert van Voren is the Chief Executive of Global Initiative on Psychiatry. His email address is rvvoren@gip-global.org

Compulsery Treatment, incl drugs and alcohl adiction

 around 450 patients

Acute crisis  400 admissions per intervention year

 around 66 patients

pre trial  around 50 patients assessments

somatic ward

 around 50 patients

Distribution of patients in Belgrade Special Prison Hospital

Prison Mental Health: Visit to the Specialized Prison Hospital


In June 2008, Wendy Weijts, Theo

Within this restricted facility, the staff was very committed to the patients; the occupational therapists try to make the residence of those patients a bit less miserable. One guard is responsible for one ward which sometimes contains more than 120 patients and, at times may be responsible for two or more wards at the same time. Most of the patients receive tranquilizing medication (most common use is Bentazin) and have nothing much to do other than staying in their beds. Sometimes (in case of severe aggression) patients get restraint measures (special room where the patient is tied to a bed). Within a prison system, this is an accepted measure, even in western countries. The main problem is that, when in restraints, the patient is actually under the observation of another patient. In our opinion,

July2009

17

Bulgaria: A European Union Member Lagging Behind in Forensics


Bulgarian forensic psychiatry has its roots in the beginning of 20th century with the leading Bulgarian and European books of Vladov, Danadjiev and Schipkowensky. An in-patient university clinic was created in the second half of the century for complex expert assessments, requiring more experience and complex psychiatric and psychological investigations.
By Petar Marinov and Vladimir Velinov

During the last two decades, several alarming tendencies in Bulgarian forensic work have emerged. The quality of expert work has decreased while corruption increased, including among some psychiatrists. The Forensic Psychiatry Clinic made a series of proposals to the Dean of Medical Faculty in Sofia, the Rector of the Medical University in Sofia and the Minister of Justice for the improvement of the quality of forensic work, the continuing education and promoting an inter-institutional body for control in forensic psychiatric practice. No measures were accepted and the passivity remained the main institutional behavior. This situation became more and more chaotic. Through the efforts of the Clinic, the specialty of forensic psychiatry was introduced in 2001 as required by the EU rules for basic medical specialties. This step decisively created new opportunities for professional growth in experience of specialists in the area. However, Bulgarian legislation annihilates this opportunity. There is no differentiation of levels of competence in forensic psychiatric practice. Every specialist in psychiatry has the right to prepare forensic assessments and reports and is ac-

cepted as equally competent by the judicial system. There are no ideas for stimulation and requirements for continuing education and improvement of forensic work. The system even introduced discriminative agerelated exclusion criterion in forensic work, although it is a freelance profession. On the other hand, the organization of the specialization in forensic psychiatry in the only place the Clinic of Forensic Psychiatry and Psychology in Sofia - is financed on the general rule of the number of patients per month. This rule forced the Clinic to accept more and more general psychiatric patients and has limited the time for forensic work to only around 20%. The State Specialized Hospital of Neurology and Psychiatry St. Naum fired many of the professionals in clinical psychology; there is currently only one clinical psychologist, who is responsible for 200 neurological and psychiatric beds. Judicial institutions are not discussing other possibilities for funding forensic work although it is essential for the survival of forensic education and practice. Other negative tendencies have appeared in recent years. Some

Lovech Prison Hospital

academic psychiatrists expressed their personal and unexplained negativism towards the Clinic. The main point was the opinion that the clinic should be moved into the prison system. The culmination of these ideas was the organized voting in the Department of Psychiatry, under the leadership of the Head of the Department and also National Consultant in Psychiatry Prof. Vihra Milanova, MD, PHD. The final decision was that there is no need for the Clinic of Forensic Psychiatry, and no need for the Senior Educator (Associated Professor) to lead the Clinic. The main argument of Prof. Milanova was that every specialist in psychiatry is equally competent to prepare complex forensic assessments and reports and every professor in psychiatry is competent to conduct education in that area. These ideas were accepted by a small majority, but it caused highly destructive effects on the specialization in forensic psychiatry and fatal consequences for the existence of the Clinic of Forensic Psychiatry and Psychology. Gradually the personnel of the clinic were reduced to only one forensic psychiatrist, which was detrimental to the possibilities of organizing forensic assessments and education in the field. All interested judicial and

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academic institutions were informed without response; a typical reaction for the systems in Bulgaria. Using SWOT analysis several aspects could be described: 1.  Strengths. In Bulgaria, the educational system and specialty in forensic psychiatry was established. There are several residents in this specialty who were on their way to being promoted to specialists. A good number of judges and prosecutors in Bulgaria acknowledge the need for the specialty and for the Forensic Psychiatry and Psychology Clinic. 2.  Weaknesses. There is an extremely low number of specialists in forensic psychiatry and a very low level of inter-institutional collaboration as well as interest in the institutions to help the future

of forensic expertise. 3.  Opportunities. One of the main opportunities is the potential involvement of professionals and experts from EU countries in advising Bulgaria on the future of forensic psychiatry. Another opportunity is the potential of involvement in the monitoring of the judicial system in Bulgaria. The third opportunity is the preparation of professional teams in forensic psychiatry and justice who can prepare a National program for development of forensic psychiatry and forensic psychology in collaboration with EU experts. Another opportunity is the preparation of a new law on forensic psychiatry and forensic psychology. 4.  Threats. The principle threat is the resistance of some social groups who are against forensic

psychiatry and the judicial system as a whole. Another risk is that EU countries could view the problem as an internal Bulgarian issue and neglect the importance of forensic sciences and their academic and practical development in the judicial system in Bulgaria. Promoting ideas about the replacement of the clinic by prisons could change the basic concept of forensic assessment in all of the phases of investigation and could be contradictory to its independence. Dr. Petar Marinov, MD, PhD is Past President of Bulgarian Psychiatric Association. Prof. Vladimir Velinov is professor emeritus of forensic psychiatry in Sofia. They can be reached at petmarinov@abv.bg and v.velinov@gmail.com

Response from GIP


Global Initiative has been involved in mental health care development in Bulgaria for almost fifteen years. In the mid-1990s, it started its involvement by assisting in the training of mental health care personnel, concentrating on the younger generation of future psychiatric leaders. It developed a publication program with the Bulgarian Psychiatric Association, in the course of which a dozen books and manuals were published, and sponsored the annual meetings of the Bulgarian Psychiatric Association. Subsequently, it set up a Day Care Center in Sofia, assisted in the development of the Bulgarian Institute of Human Relations as part of the New Bulgarian University, developed training programs for various specialists, helped organize an ENMESH Conference in Sofia and, in 2001, set up a Regional Office in the Bulgarian capital, responsible for projects in South Eastern Europe. In 2005, in partnership with the Stability Pact, GIP commenced a project for development of a consecutive chain of community mental health care services in Blagoevgrad, which is used as a pilot for the rest of the country. Currently the GIP-Sofia office is involved in developing community services in the Sofia suburb of Slatina. In 2004, GIP supported the Social Activities and Practices Institute to make an assessment of the psychiatric, psychological and social services provided to prisoners and staff in the places of imprisonment. The report was published in the Prison Affairs, (XXXVIII, book3/2004) and since then remains the only national research done on mental health in the prison. The research evaluated both the satisfaction with the general health services and mental health care in particular and the stress related complaints of the prison staff. The report concludes that there is a lack of an integral conception about the treatment of prisoners with special needs (training of the personnel, programs, care, etc.). The report considers the under-funding of the system and the lack of autonomy of the prison medical staff as main structural reasons for the observed shortcomings within the prison health care. Except for this report, GIP has not been active in the field of forensic and prison mental health services in Bulgaria. GIP has assessed the situation with the goal of seeing how and where Global Initiative could be of assistance. GIP has been active in the field of forensic psychiatry and prison mental health for quite a few years and in a growing number of countries. It is hoped that this experience and expertise might make a difference in Bulgarian forensic and prison psychiatry. The main problems of Sofia Prison include:  Purely a medical approach;  Lack of multi-disciplinary teamwork and resocialization programs;  Lack of psychiatric knowledge of staff, especially guards and nurses need an education program on mental health problems;  Lack of psychiatrists. Each prison has vacancies for psychiatrists because of the low salaries;  Attitudinal problems of staff towards patients, e.g. not being able to see the inmates as patients;  Stress and burnout among the staff. The staff works in shifts of 24 hours with a three-day intervals, and the other three days are used for other part-time jobs to supplement the salaries;  Acquisition of medication. Generic medication is too expensive;  Increase of inmates with HIV/ AIDS;  Inmates with a drug and/or alcohol problems;  The general quality of care in the prison is low.

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Sofia prison with 2,100 inmates has only 4 psychologists. In cases where alcohol, psychological or physical problems are detected, the psychiatrist and general practitioner develop a treatment program for the prisoners stay in prison. The Prison mental health department in Sofia prison is part of the internal diseases unit and has a small capacity for patients with mental health problems. About 5% of the inmates in the Bulgarian prison system are identified with mental health problems and/or addiction problems. This 5% is under supervision of a psychiatrist. Suspected mental health problems are registered. Evidence from many countries consistently shows that the prevalence of mental health problems amongst prisoners is significantly higher than amongst the general population. This is especially true for personality disorders, substance abuse, depression and psychotic disorders. Prevalence rates among female prisoners are higher in many countries. Most probably, the estimated 5% prevalence in the Bulgarian prison system indicates that there are serious flaws in the (mental) health assessment system. According to legislation, inmates can attain services outside the prison if they need proper care or wish to have a second opinion. Each inmate has the right of access to any medical services but has to pay for them himself. Lovech prison hospital connected to Sofia prison receives inmates with mental health problems who are transferred from the Sofia prison. About 200 patients are treated here annually. According to the Regulation for medical service in prisons, people who are considered by a court decision to be unaccountable are sent to Lovech psychiatric hospital for compulsory treatment. HIV/ AIDS has a small prevalence and the Sofia prison keeps a record on the persons who are infected. Persons living with HIV/AIDS can attain the services anonymously and their medical status is confidential. Within the prison, VCT - Voluntary Committee Testing - tests the inmates who want to be tested. In case a person needs medical assistance, access to the hospital is provided; all persons with contagious infections are treated in state programs in nearby hospitals. Prisoners dependent on

After working 15 years in > prison, the staff develops a variety of problems, such as serious neuroses, stress, insomnia, headache, and cardio-vascular problems.

and cardio-vascular problems. Up to now psychological care is mainly for prisoners and not for staff. According to one of the main psychiatrists in the hospital, Dr. Neshkov, the prison hospital encounters the following problems:  Burnout problems of the staff; there is neither attention to this issue nor prevention of burnout.  Bad material conditions related to inconvenient accommodation (leakage); construction of the current building for the hospital started in 1982 but could only be put to use in 2005.  Bad and outdated equipment (PCs, EEG); new computers and x-ray were requested from the Ministry of Justice.  Hospitals were forced to buy more expensive medication because some pharmaceuticals companies stopped the production.  Provision of treatment exclusively according to the biological model; no other treatment methods are practiced, nor (day) activities or work therapy is provided.  There is very little tolerance of staff and guards towards the patients. The Forensic Department of the University Hospital, Sofia operates on the basis of private payments of clients needing a forensic psychiatric assessment. The forensic psychiatric assessment unit does not provide any treatment. Forensic psychiatric assessment is carried out in criminal cases, civil right cases and civil law cases. In criminal cases, the forensic psychiatric assessment takes place during the period of investigation of the crime. Assessment and prosecution are, however, closely interrelated. Other categories of people making use of forensic psychiatric assessment are patients who have a court sentence and are being treated in a forensic psychiatric ward of a general mental hospital or in the prison hospital, as well as persons suspected of serious mental health problems. Every six months, a forensic psychiatric patient in Bulgaria is reassessed. If a patient refuses to be assessed, he/she is sent to compulsory observation in the closed forensic mental health unit. According to our colleagues in Bulgaria, outpatient care should be

drugs have access to methadone therapy. Psychiatrists receive training on how to supply the methadone program. The possibilities of improving the circumstances were discussed with our Bulgarian colleagues and a number of items were listed: T  here should be a broader therapeutic approach, and not only a medical approach. In Bulgaria, too much stress is currently put on the medical aspect. T  he department should develop operative multi-disciplinary teamwork, with each team consisting of a general practitioner, psychiatrist, social worker, nurses and the psychologists.  Rehabilitation programs should be developed. E  ducation and acceptance programs should be developed for prison staff, as well as for inmates and their families, in order to increase tolerance for inmates in general and inmates with mental health problems in particular.  Intervention and support programs should be developed for the staff. Work in prison is a hard job and in many respects the staff has to deal with the same situation as the inmates. After working 15 years in prison, the staff develops a variety of problems, such as serious neuroses, stress, insomnia, headache,

Keys to Lovech Prison Hospital

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dealt with in relation to forensic psychiatric treatment in Bulgaria: C  are homes for reintegration  Developing and implementing resocialization activities as part of forensic treatment (not of the assessment procedures)

the following issues: A  bsence of a clear continuity of care within the system, as well as of a clear profiling of the various institutions involved; I nsufficient care programs, in particular the absence of multi-disciplinary teamwork, lack of psychosocial rehabilitation programs and possibilities for the resocialization of forensic psychiatric patients; I nhumane and denigrating living conditions for patients in the forensic departments of Lovech psychiatric hospital;  No vision on how the system of care should be developed in Bulgaria. First of all, we feel that it would be very helpful to organize a working conference with the Ministries of Justice, Health, and Labor and Social Policy, as well as with other stakeholders such as professionals, universities and professional associations, in order to discuss how a consecutive chain of prison mental health and forensic psychiatric services could be developed in Bulgaria. It is essential that, rather sooner than later, a task force be established with representatives of the three ministries that take responsibility for this field. The ultimate goal of such a working conference would be to establish the basis for a task force with representatives of the three ministries to work with GIP on these issues in the years to come and to share the responsibility for doing so. The basis for such a future involvement should be an agreement with the prison department of the Ministry of Justice, in which the partnership should be outlined. In addition, we feel it would be very helpful if ongoing links could be established between Bulgarian professionals and Dutch counterparts, in order to discuss modern forensic psychiatric practice and to make use of each others experience. In the course of these exchanges, more specific areas of collaboration could be identified, such as the development of modern treatment programs, psycho-social rehabilitation programs, the use of risk assessment instruments and, eventually, the development of a computerized patient data registration system. Finally, in our view it would be good if a small selected group of Bulgarian professionals in the fields of prison mental health and forensic psychiat-

ric treatment could visit Dutch facilities in order to initiate an exchange of experiences. This should lead to support of the prison mental health professionals in developing modern treatment programs, as well as the development of aggression management training. Also, it would be very helpful if a program could be developed to assist the prison system in developing more adequate psychological support programs for their staff. It is of specific importance that adequate attention be given to the issue of stress and burnout among the personnel of the Sofia prison and other institutions. It would be very helpful if specific programs could be developed in this area. In our view, absolute priority should be given to changing the living and treatment conditions in the forensic department of Lovech psychiatric hospital. We have serious questions about the quality of the medical personnel and feel that the treatment provided borders on torture and has no therapeutic value whatsoever. We would strongly recommend closing the department altogether and setting up a new one closer to or in Sofia, where a better quality of staff could be attracted. It seems to us that it is a waste of money to reconstruct the current building, but even the construction of a new one would not alter the situation fundamentally. Within several years the same conditions would prevail. Also, we wonder whether the envisaged community mental health programs now prepared at this hospital will make any sense, both because of their location (on the premises of the hospital) and because of the low quality of the hospital management. After studying the situation in Bulgaria, we believe that a large contingency of forensic patients and prisoners with mental health problems are not identified as such. The numbers of persons in the facilities visited suggest that a much larger population has needs that are currently not identified and, therefore, unmet. We would very much recommend developing an assessment within the Bulgarian prison, mental health and social care system to find these missing persons. Robert van Voren

Typical Patient Cell

A proposal for the development of outpatient care was submitted several times to the Ministry of Health; each time the proposal was rejected. The main problem regarding outpatient care is that it is not covered by health insurance. The system is not transparent in assigning patients to facilities. Some patients are referred to Lovech, some to general mental health hospitals, some to prisons with a mental health unit.

Recommendations and Suggestions:


GIP has visited the facilities in Bulgaria and studied the materials and reports of other organizations in order to devise a list of recommendations for the future involvement of GIP in the fields of prison mental health and forensic psychiatry in Bulgaria. In our view, the GIP approach should be a gradual and systemic one, allowing us to start with a number of small initiatives in order to test the water, develop relationships with the Bulgarian colleagues and modify our common understanding of the situation in order to come to an adequate response to the existing need. The key problems facing forensic psychiatry and prison mental health in Bulgaria seem to concentrate on

A proposal for development >

>

of outpatient care was submitted to the Ministry of Health several times; each time it was rejected.

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Convicted Juveniles in Georgia Problems and Prospects


The Georgian Center for Psychosocial and Medical Rehabilitation of Torture Victims (GCRT) is a non-profit, non-governmental organization that is trying to meet the needs of traumatized communities and offer relevant assistance. The Center provides multidisciplinary, professional mental and medical health services as well as legal counseling to victims of torture, inhuman or degrading treatment and organized violence in Georgia. GCRT is also active in the field of juvenile justice and provision of psychosocial services to young offenders serving a prison term. Below we will briefly describe this particular direction of GCRTs work. By Lela Tsiskarishvili

Problem Statement
Youth delinquency and violence are issues of major concern in Georgia, due to the absence of a comprehensive state strategy on the prevention of youth delinquency. In addition, there is a lack of early detection and intervention programs resulting in the finding of criminal responsibility of youth and adolescents between 14-18 years old and are behind prison bars. This is aggravated by the facts that often the sentences adolescents receive are not appropriate for the crimes committed (e.g. 4 years of imprisonment for a minor theft, 8 years of imprisonment for robbery, etc); the investigation process is full of violations; and society is intolerant towards youth in conflict with the law. All of the above contributes to the exclusion and marginalization

Digomi center for forensic psychiatric assessment

of the young offenders. Thus, it is extremely important that a psychodevelopmental framework for convicted juveniles be established. Avchala Correctional Facility is the place where all convicted male juveniles serve their prison terms. The facility is overcrowded it houses 160 juveniles; the number of staff serving the boys is 70, with 5 of these in the social unit. Juveniles sleep in barracks of 25 having very little privacy and personal space. The facility has a school, however attendance is not obligatory; due to overcrowding, one of the classrooms is used as a dormitory. There is no structured leisure, sports or informal educational activities in place. Youngsters know very little about their rights and responsibilities within the facility.

In 2006, GCRT started working in the juvenile correctional facility. Three of our psychologists are running psycho-developmental groups and are conducting individual psychotherapeutic sessions. The group meetings take place twice a week, individual psychotherapy takes place once a week. Below we will try to illustrate the psycho-social portrait of juveniles, outline the main areas of concern and briefly describe the main focus of our intervention. It should also be underlined that GCRT currently is the only organization providing such services. This is certainly not sufficient; every single adolescent in custody should have access to psychosocial services aimed at their personal growth and development. Also each one of them should have a chance to reintegrate with society.

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Who they are


The majority of juveniles serving a sentence in the facility come from families with relatively poor socioeconomic background. Many of them have incomplete families; some are living with grandparents or relatives. Many of the adolescents have either witnessed violence in childhood, or have become victims of violence (domestic, peers, etc.). Adolescents also lack a loving and caring attitude from their parents. In many cases, their upbringing is strict where physical abuse, humiliation and punishment are part of the family culture. On the other hand, some are victims of over controlling and hyper protective parents; thus, by the age of 13-14, juveniles may try to revolt against the parents. Either way the attachments within the families and the immediate environment are disturbed and dysfunctional this, in turn, creates fertile soil for delinquency.

ate environment aggression is punishable; whereas sensitivity or sincerity may be dangerous and harmful. This inability to identify or express emotions and feelings has the tendency to manifest either in self-destructive behavior, or isolation, indifference and apathy.

The absence of positive rein>

What they feel


Many of these kids have a diffused Self Concept the self is not differentiated, it is merged with the surrounding environment the juveniles think, behave and live in the same way as their important others. In many cases, these important others are their peers or adults with strong criminal mentality where they romanticize and idealize criminal mentality and rigid social dispositions and attitudes prevail. They believe that the world belongs to the perpetrators. Many of the adolescents have low self esteem manifested through a high level of anxiety, feelings of victimization, which, on the one hand, is hyper compensated through negligent or aggressive attitude and behavior. On the other hand, the low self esteem indicates a psychological invalidization the self is perceived as incompetent and incapable, while the sense of future (which implies planning, aspirations, etc.) is foreshortened. These youngsters also lack understanding about their personal traits and resources; they are often emotionally illiterate, i.e., they have difficulties in differentiating and identifying their own or others emotions. Apart from this, they have the tendency to suppress their emotions. This is conditioned by the dominance of the immedi-

Their perception of the world beyond the prison bars is very hostile and unwelcoming they blame the environment for their misfortunes and are not able to take responsibility for the crimes committed. Although, once again, it should be emphasized that the inadequacy of prison terms in comparison with the committed crimes reinforces the feeling of injustice and negative attitude towards the environment. Many of the crimes committed are related to underlying behavioral problems; however, this is not taken into consideration during investigation or court hearings.

How we work
The aims of the intervention are:  Creating the atmosphere of basic trust - these adolescents experience problems with trusting others. They perceive the surrounding world as hostile and Lela Tsiskarishvili

>

forcement from adults contributes to the formation of a criminally inclined belief system among convicted juveniles.

unwelcoming. In order to ensure success of the intervention, it is crucial to create the space where the adolescents can feel free and confident in expressing their feelings and thoughts.  Bringing in the overall frame and structure - the space and time of these juveniles is unstructured. The rules are imposed externally and are oppressive in nature. Thus, during group work, it is vital to establish some internalized rules to contribute to formation of the self-structure and an internal framework.  Working on the self-concept overcoming destructive beliefs about ones self and the surrounding world. As previously mentioned, these juveniles perceive themselves as incompetent and incapable; thus, dealing with self-esteem and helping them in discovering and identifying their resources is extremely important for the success of the intervention.  Acquiring skills of emotional literacy and their congruent expression - this is directly related to managing anger and aggression and overcoming the negative behavior patterns. In this regard, developing communication skills in juveniles is also important.  Working on the value system the absence of positive reinforcement from the side of adults contributes to the formation of a criminally inclined belief system among convicted juveniles. Intervention is aimed at changing these dispositions.  Realizing and becoming aware of the genesis of each crime, taking responsibility for the committed crime. P  lanning the future - preparation for the future integration into the society after leaving the facility

Problems and barriers


 After reaching the age of 18, juve niles are transferred to adult prisons, which seriously damages the results achieved during the psychosocial work and devastates the prospects of reintegration.  Ad hoc presence of outsiders in the group meetings the space where the meetings take place is not completely isolated; sometimes the staff of the facility decides to attend the meetings, which creates great tension and

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What is accomplished
After 3 years of working in the facility, GCRT had gained trust from among the inmates and administration as well. The facilitys employees feel the responsibility and advise newcomers to sign up for group or individual treatment. The involvement of the juveniles is quite high. They have new ideas and topics for discussions, they have become more active not only within the facility but are eager to communicate with the outside world. Upon their request, GCRT organizes meetings with public figures, facilitates various film screenings, helps the boys participate in various literary contests and organizes sports events in the facility. Through these activities, the boys receive positive reinforcement and gain understanding of the importance of education, work, civil activity, success, etc. This also results in a decrease of hostility towards the surrounding world. It is noteworthy that as the juveniles partly realize their personal responsibility for the committed crimes, they have a critical attitude towards their past. Through inclusion of sports contests and different types of competitions, they successfully manage to channel their destructive impulses into a positive framework. GCRT in collaboration with Ilia Chavchavadze State University set up an enamel studio for juvenile convicts. ICSU developed a special 6 month certified course and for the first time, 30 juveniles have a possibility to go through comprehensive vocational training.

introducing these practices in the context of juvenile correctional facility, through trainings of staff, provision of screening, risk assessment instruments, preparing the basis for introduction of needs based educational and day programs. This will lead to a more strategic approach on delivering services to juveniles in detention. Implementation of the project will be advised by Global Initiative on Psychiatry (Hilversum) and Dutch Juvenile Facility Harreveld. This particular project is part of the larger juvenile justice reform process that is taking place in Georgia. We hope that the project will allow translation and implementation of policy changes in the Juvenile Correctional Facility and will help to rehabilitate the lives of boys in detention. Lela Tsiskarishvili is Executive Director for the The Georgian Center for Psychosocial and Medical Rehabilitation of Torture Victims, 0179 V. Anjaparidze st 9, Tbilisi, Georgia www.gcrt.ge. Her email address is ltsiskarishvili@gcrt.ge.

We aim to do this by adapting the best European practices of the juvenile detention system and

Digomi center for forensic psychiatric assessment

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each time the psychologists have to delicately tackle this issue.  Often new juveniles express the desire to participate in the group which sometimes damages the dynamics of the process; on the other hand, it is not possible to turn away newcomers who want to participate in the group.  In more general terms, it is very difficult to sustain the achievements of the work, because of the scarcity of external positive reinforcement.

What is planned
After three years of work in the facility GCRT in cooperation with Global Initiative on Psychiatry (Hilversum and Tbilisi offices), Union Saphari, the Department of Prisons, Ministry of Education, and the Ombudsmans office developed a project Ensuring access to sustainable development of juvenile convicts through an issue based intersectoral cooperation. The project is funded by the European Union. The overall objectives of the project are: 1.  to maximally improve the conditions of the most vulnerable, marginalized and disadvantaged youth in Georgia juvenile convicts serving prison terms in the juvenile correctional facility, 2.  to ensure their access to education and development, 3.  to guarantee their well being, 4.  to promote their re-socialization and re-integration through a structured dialogue between the civil society and state actors, capacity building of these sectors on implementing coordinated actions and through introduction of new instruments/initiatives into the system of juvenile justice.

GCRT has gained the trust of >

the administration of the facility as well as of the juvenile inmates.

From Lunatic Asylum to National Institute of Mental Health in Sri Lanka


By Dr. Neil Fernando, Marieke de Vries, and Nanthini Sivanesan Lunatic asylums in Ceylon (Sri Lanka) are best described as overcrowded, dirty, violent human warehouses. The conditions on the male forensic ward at the National Institute of Mental Health (NIMH), Angoda in Sri Lanka are basically the same as an asylum at the end of the 1800s. Modern psychiatry in Sri Lanka began in the mid 1800s during the British colonial period and revolved around mental hospitals. The Leper Asylum in Hendala, founded through private benevolence in the Dutch period, saw, under the British, the first known hospitalization of mental cases (lunatics). In the early years of colonization, the mentally ill were incarcerated in jails among criminals. Their disturbed behavior and screams during the night became a major burden and, thus, they were transferred to the Leper Asylum. It was very clear that there was a necessity to separate lunatics from criminals as well as from lepers. So around 1847, the first mental asylum was opened at Borella, a district in Colombo. The Borella asylum struggled from the start with major challenges:  overcrowding (particularly in the female division of the asylum)  separation of violent patients and problems transferring them from asylum to jail and from jail to asylum  poor sanitation and drainage systems  insufficient meals to feed a patient clothing and bedding. Another problem was the advanced state of lunacy in an individual by the time they were admitted, after having tried to cure the mentally ill with native remedies and devil dancing. The British tried to ban

Psychiatric Prisoners in Sri Lanka

these remedies and local medicine. Gradually the use of sedatives found its way into the service due to, perhaps, the availability of opium in Asia and cannabis in India. There were hints of advances in these early years, even with the obstacles faced by any reformers. The first form of Occupational Therapy (OT) was provided for patients in the form of employment in the Borella asylum. This was introduced as a treatment as was recreation therapy, exercise and amusements. In addition, at a similar time, the first patient classifying system was introduced: quiet and harmless versus excitable and violence, clean versus dirty, etc. but there was no follow up. Record keeping consisted of recording admission, discharge and death. And circa 1890 were the first reports of inflicted violence on patients. Around 1885, a second asylum was built at Cinnamon Gardens, Colombo, to relieve the overcrowded asylum of Borella and later, in 1917, the foundation was laid for the lunatic asylum at Angoda, about 6 miles from Colombo. Both asylums met the same problems as the Borella asylum, especially in the

overcrowded conditions. Angoda could accommodate up to 1800 patients and there were times when it housed over 4000 patients. Sri Lanka is still dealing with the 139 year old Lunacy Ordinance, altered to a Mental Disease Act in 1957 and revised in 1983 as the Mental Health Act. A few amendments were added although it still focuses on risk, is devoid of an ethical heart and gives room for misconceptions of violence and mental illness and not enough possibility of patients rights. Last year, a recommendation was made for a new legislative framework but this was rejected by government. Eight years after the construction began, the new Angoda asylum was completed. In 1957, the Mulleriyawa Mental Hospital was opened with an open door policy. Until about 1940, Angoda was a custodial facility which offered minimal treatment. By then important developments in mental health care began to reach Ceylon which suffered from a lack of trained staff and facilities limiting the effectiveness of these treatments. While attempts were made to provide modern treatment for patients, broken machines with no spare

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parts and a lack of proper medication often defeated these attempts. However from the 1950s, things started to improve with psychiatrists returning to Sri Lanka following their training in Great Britain, introduction of ECT and psychotherapy, occupational therapy and anti-psychotic medication. This all leads us to mental health care in Sri Lanka today. It has been estimated that 400,000 Sri Lankans currently suffer from serious mental illnesses and 10% of the population in the country is thought to suffer from common mental health problems. In 2005, more than 90% of the countrys mental health resources were concentrated in three big mental hospitals in the Colombo area but Angoda is the only one housing a forensic psychiatric ward. Many improvements have taken place at Angoda Mental Hospital, presently called the National Institute of Mental Health. Some of these developments are: the training of medical staff in psychiatric rehabilitation, development of a mother and baby unit, learning disability unit, intensive care unit, adolescent unit and improvements on policies and procedures, quality of service, area for families, repainting and refurnishing and more. Even though it seems that with all these improvements that have taken place in the last few years, the forensic ward has been a gulag, a forgotten ward. Housed on the first floor of one of the old threestory blocks without any alterations or improvements, you might think yourself placed in an asylum 100 years ago. Patients at the forensic ward are in custody because of a wide variety of crimes and violations while being mentally ill or retarded. They are locked up, most often in an overcrowded ward, which can house 70 patients but often houses twice that number. There is no such thing as refusing a patient who has been sent by the Magistrate Court; they simply have to be admitted since there is no other forensic psychiatric facility in the country. But these patients are easily forgotten and, at times, even disappearing in the legal system which is not properly reviewing their status within the prescribed 6 months for evaluation. The overcrowding of the ward means a shortage of beds, mattresses

able and when working alone are at great risk. The result is they cluster together in the staff room avoiding any individual contact with patients. Other essential aspects of good service, like record keeping and care planning are not happening. Of course, there are no computer facilities, telephone, fax, printer, personal security/alarming system available. In 2008, at the invitation of the World Health Organization (WHO), Global Initiative on Psychiatry (GIP) carried out two assessment visits to Sri Lanka. In January 2009, a follow up visit was organized and a team from GIP and two forensic psychiatric experts from the Pompe Foundation in Nijmegen, the Netherlands, carried out an assessment visit to NIMH forensic department. This resulted in a proposal for the development of the existing forensic psychiatric service to one that would be humane, therapeutic, affordable and sustainable. Since then the forensic ward at NIMH is high on the agenda of Dr. Jayan Mendis, director of NIMH and consultant psychiatrist, who is very much in favor of change and improvements of mental health services. Since that time, small changes have taken place and small improvements are being made. Finally this ward was given the attention so desperately needed and it was exciting to see the eagerness of the team of health workers on this ward and how ready they are to be involved in this change for the benefit of all their patients. This is the beginning of something new for forensic services in Sri Lanka. (Historical Source: The History of Mental Health Care in Sri Lanka by James Carpenter, 1988) Dr. Neil Fernando is a Consultant Psychiatrist; Marieke de Vries is a Mental Health Project Manager, and Nanthini Sivanesan is a Mental Health Trainer VSO volunteer. They can be reached at nanthiniuk@yahoo.co.uk

Therapy in the hospital is mostly of a biological nature, meaning that only psycho-pharmaceutical medication is available. Inactivity of patients in the forensic ward due to sedation and lack of daytime activities undermine their physical condition and speed up the hospitalization process causing them often to show premature degeneration as a result. Visitors are rare; since NIMH has the only forensic psychiatric facility in Sri Lanka, patients come from all over the island and almost live in complete separation from their relatives and communities. Above all, these patients can not leave the ward, there is no secured garden area and no means to feel the soil under their feet. In general, nurses and other staff working in a mental hospital or forensic ward do not do so by choice. They are appointed by the government without consideration of their own preference and no special training in psychiatric illnesses or forensic services. Nurses are young, with little experience and can feel vulner-

Typical Psychiatric Cell in Sri Lanka

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and floor mats, plates, cups, and clothes and, above all, insufficient sanitary facilities. Five toilets, of which two are out of order, and one small shower tap without any private space around it to serve them all. Men and boys, with severe mental conditions, are living together in one area. There are no possibilities of compartmentalisation or seclusion. If a disturbed patient has to be removed from the group, he has to be taken out to a less secured area in the midst of staff, other patients and even visitors. There is no staff on duty during the night, so no control of unwanted or disruptive behavior.

It is exciting to see the >

eagerness of the team of health workers.

Goals of GIP in Sri Lankas Forensic Hospital System


In 2008 and early 2009, GIP visited Sri Lanka three times to obtain an overview of developments in mental health in the country with particular regard to community mental health and deinstitutionalization as well as forensic psychiatry and prison mental health. During the visits, the teams met with a wide range of key actors in the field of mental health, with a number of NGOs working in mental health and related areas, as well as with a number of government officials from the Ministries of Health and Social Welfare. The teams also visited two psychiatric hospitals in the Colombo district, one in the Gampaha district north of Colombo, the psychiatric university clinic, the child mental health department and the prison, as well as the prison hospital in Colombo that holds a prison mental health department. The 2009 visit focused mainly on the existing forensic psychiatric and prison mental health services, meetings with Sri Lankan colleagues and collecting information that should lead to a plan for the development of a forensic psychiatric department at Angoda hospital that would be humane, therapeutic, affordable and sustainable, as well as a plan how to take things further. With the Dutch experts and the director and staff of Angoda psychiatric hospital, it was agreed that a project should develop in phases, which would allow those involved to reflect every time on what was accomplished, what issues were solved or omitted and to decide whether the next phase could be implemented. At the same time, budgetary restraints (both because of lack of local funds and the difficulty of raising outside funding) call for a step-by-step approach, allowing us to make visible each time what has been accomplished. Phase 1 (approximately 10 months) addresses the need to change the physical environment for the patients. Instead of being locked in one big cage on the first floor of the building and little possibilities for getting out, it was decided that the top floor would be renovated so that the patients would be moved temporarily while the first floor was being renovated, replacing the sanitation, create separate toilets and bathrooms, and compartmentalize the first floor to make a division into separate categories of patients possible. This is essential, because at this stage all categories are together: adolescent, adult, psychotics, mentally handicapped, persons undergoing forensic assessment (and thus possibly mentally healthy), etc. Separation is essential both for therapeutic and safety purposes, in particular because supervision during the night is minimal and in no way can one now control what is happening behind the bars. A staircase should be constructed allowing patients to go from the first floor to the garden which would be prepared exclusively for their use. In the end, the first floor would be for sleeping and the top floor for recreation and rehabilitation. Phase 2 relates to the training of personnel. Currently, the staff, including the consultant psychiatrist in charge of the department for the past five years, has no specific training in forensic psychiatry and rehabilitation, On-the-job training would be provided by Dutch experts from the Pompe clinic and a vision will be formulated, along with Sri Lankan professionals, that would be the basis for therapeutic work in the department. Phase 3 would see the introduction of risk assessment tools, allowing the staff to assess whether or not the person is ready for a return to society and whether a patient poses any danger to his environment and him/ herself. An electronic system should be developed, allowing the department to have a full overview of both the forensic psychiatric population and the individual patients medical and legal history. Finally, a commission would be formed to look at Sri Lankan legislation to see how changes in legislation could be proposed that would better enshrine the rights of the patients, prevent patients disappearing in the system (which happens repeatedly) and makes sure that only real forensic patients are held in the forensic department. Phase 4 would focus on the assessment of the patients mental health. The ground floor of the forensic building could be vacated and turned into a separate forensic psychiatric assessment center, separating those who undergo forensic psychiatric assessment from persons being treated for their mental illness. Staff would be trained in forensic assessment (having in mind the prevention of unjust admission of non-forensic patients). Phase 5 would include the development of five departments in other towns on the island for treatment at a low security level. This means that the current department in Angoda would be used exclusively for medium and high security patients. This will also help to separate light cases from severely disturbed and dangerous patients, who are now locked up together in one cage. In March of 2009, a meeting was held with the relevant Sri Lankan staff, including forensic psychiatrists, the director of NIMH, nurses, occupational therapists, and training and occupational therapist volunteers. This meeting was the result of the January 2009 visit of GIP, followed by a written report with recommendations. This was the first time multidisciplinary forensic teams at NIMH had come together to discuss future plans. This meeting is the first of many planned to monitor the progress and set priorities in light of the budgetary realities. All are enthusiastic and optimistic that these new steps will greatly improve the treatment of patients and the lives of the staff. Robert van Voren

July2009

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Russian Summaries

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July2009

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The photo shows a department in the Special Psychiatric Hospital in Chernyakhovsk

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July2009

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Other themes addressed by Global Initiative on Psychiatry to be covered in future issues of Mental Health Reforms:

Child and Adolescent Mental Health Community Mental Health Care Mental Health and Human Rights

User Involvement in Mental Health Services Substance Abuse Prevention  UN Convention on Disabilities and Its Implications for Mental Health

Global Initiative on Psychiatry


Global Initiative on Psychiatry (GIP) is an international not-for-profit organization for the promotion of humane, ethical and effective mental health care worldwide. GIP is registered in Hilversum, The Netherlands, and works closely with its network of regional centers in Lithuania, Bulgaria and Georgia and a country office in Tajikistan, as well as with numerous NGOs, governmental and international organizations. In addition to being a major contributor to improved mental health care systems in Central and Eastern Europe and the Newly Independent States (CCEE/NIS), GIP has also begun working in other regions of the world. In all regions our goal is to empower people and help build improved and sustainable mental health services that are not dependent on continued external support.

Photography
Dutch Assessment Team at Pre-Trial Prison in Kaliningrad, Russia The photographs in this issue were taken by the staff of GIP, authors of the articles, or other parties. The individuals portrayed were aware that their photographs might be published.

GIP-Hilversum (International Office) P.O. Box 1282 1200 BG Hilversum The Netherlands Tel.: +31 35 683 8727 Fax: +31 35 683 3646 e-mail: hilversum@gip-global.org www.gip-global.org GIP-Sofia 1 Maliovitsa str. Sofia 1000, Bulgaria Tel.: +359 2 987 7875 Fax: +359 2 980 9368 e-mail: sofia@gip-global.org www.gip-global.org

GIP-Tbilisi 49A Kipshidze Str., Tbilisi 0162, Georgia Tel.: +995 32 235 314 / +995 32 214 006 Fax: +995 32 214 008 e-mail: tbilisi@gip-global.org www.gip-global.org

GIPs General Board


Robin Jacoby, Chair (UK) Jaap van der Haar, Secretary/ Treasurer (NL) John Bowis (UK) Nicoleta Candea (RO) Melvyn Freeman (ZA) Mahesan Ganesan (LK) Clemens Huitink (NL) Rolf Hllinghorst (DE) Lars Jacobssen (SE) Joseph Mbatia (TZ) Dainius Puras (LT) Dick Raes (NL) Simon Surguladze (GE) Peter Tyrer (UK) Conny Westgeest (NL)

GIP-Vilnius M.K. Oginskio g. 3 LT-10219 Vilnius, Lithuania Tel.: +370 5 271 5760 / +370 5 271 5762 Fax: +370 5 271 5761 e-mail: vilnius@gip-global.org www.gip-global.org / www.gip-vilnius.lt

Mental Health Reforms