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Collaborative Learning from Mental Health System Reform in Russia: Introduction to Special Issue
I. Y. Gurovich & A. H. Neufeldt, Co-Editors
The articles of this issue of the IJDCR have their origin in a 10-year series of projects jointly led by the Moscow Research Institute of Psychiatry (MRIP) and the Community Rehabilitation & Disability Studies Program (CRDS), University of Calgary. Their focus was to introduce community-based mental health services principles, concepts and techniques into Russia's psychiatric services system that was at an early stage of reform when the projects began. These projects contributed to seminal reforms and became a rich source of mutual learning about not only different approaches to organizing and providing mental health services, but also about the way in which political, cultural and economic philosophies influence their development and implementation.
To date, most publications on ensuing changes have been in the Russian language, the most recent a book summarizing current mental health service innovations in Russia and Canada (Gurovich & Neufeldt, in press). But, large-scale change such as that in Russia's mental health system, is of much broader interest. Consequently, it was decided that a selection of chapters of broad interest from the book would also be published in English. The articles in this issue, then, are mostly the English equivalent of their Russian language counterpart. In only one or two instances was it felt useful to reframe the text so as to better inform an international audience.
To understand the context, a few comments on similarities and differences in shape and orientation of Canada and Russia's mental health services are in order. Historically, the beginnings of both are similar to those in other countries of Western Europe and North America. The earliest residential facilities for people with mental disorders had confinement as the main objective, and little in the way of treatment until reforms were introduced in the late 19th and early 20th centuries. Over time, though, these services were shaped in different directions by the political and economic orientation unique to each country. In Russia, the emphasis was on central planning not only of the economy but also of human services, with a commonly held view that citizens are best served when a core of well-educated experts at a central level, using a scientific approach, determine the best knowledge for meeting population needs, and a central government then transforms such knowledge into implementation policies and guidelines for service providers throughout Russia. In contrast, Canada's context is that of a 'market economy', a decentralized system of government, and a view that services are best planned when they involve a mix of local citizenry with government and expert specialists.
Such differences are reflected in 20th century development of services for people with mental disorders. In Russia this took the form of having central specialized psychiatric research institutes (e.g. MRIP) charged with determining the best, scientifically based treatment approaches, and disseminating these to clusters of treatment specialists housed in large psychiatric hospitals organized to serve geographic catchment areas. This approach had its early successes. For instance, by the late 1920s Russia had widely implemented a concept of 'dispensaries' (out patient clinics) linked to psychiatric hospitals to make psychiatric consultation more accessible, an innovation not matched in North America until considerably later. This hospital-dispensary system remained relatively intact until the latter part of the 20th century when it became apparent that reforms were needed in mental health services to address new and changing public and economic realities. Russian psychiatry began cutting bed capacities in 1990, and in 1995 began the process of developing a 'poli-professional' team approach as well as changing from a primarily biological to bio-psycho-social model of treatment.
In Canada, the idea of geographic catchment areas for organizing services had early nascent forms, but it did not become a serious principle for organizing mental health and other services until the 1950s. And, while large psychiatric hospitals were the dominant source of specialized treatment during the early 20th century, by the mid-1960s these were largely discredited and being replaced by regional psychiatric centers and inpatient units in general hospitals along with outpatient clinics, follow up services and a growing number of community-based services led by consumer and other non-governmental organizations (NGOs). Where a bio-medical model of mental disorder had predominated, this was rapidly replaced by a bio-psycho-social model that contributed to development of an increasingly complex array of community-based services.
It was within this context that the current partnership emerged. The MRIP interest was for Russia to benefit from Canada's considerable experience with community-based mental health services. Given the CRDS location, this translated into the Calgary region's experience in the Alberta context, though effort was also made to provide a broader perspective. Conversely, the CRDS interest was to learn how ideas oriented around consumer participation, a recovery model, and a dispersed variety of community-based services would be transformed in a different cultural, political and economic context as a way of providing a feed-back learning loop for Canadian (more specifically, Calgary's) services systems.
While ten years is a fairly long time for projects to be funded, and a reasonable time frame for social innovators to experiment with basic new ideas, it is short for change to take place in large social systems. Large-scale change takes one to two generations. It will take another decade or more before a definitive analysis can be made of the outcomes from these initiatives. Hence, the articles that follow must be seen as reflecting what has been learned in the exciting early phases of reform where new philosophies and service models have been introduced, are still formative and in various stages of adoption.
Co-Editors:
Isaac Gurovich, MD, PhD, Professor
Deputy Director of Moscow Research Institute of Psychiatry
Head of the Department of Outpatient Psychiatry and Mental Health Services Organization
Moscow, Russia
Email: isaac.gurovich@gmail.com
Aldred H. Neufeldt, Professor and Director
Community Rehabilitation & Disability Studies Program
University of Calgary
Canada
Email: aneufeld@ucalgary.ca
Acknowledgements
The Editors gratefully acknowledge the financial and moral support of the Canadian International Development Agency (CIDA), some of it in collaboration with the Gorbachov Foundation, and some of it as part of a larger Canada-Russia Disability Program involving a broader array of partners in Russia and Canada. An overview of these projects and partners involved can be found at the following URL: www.crds.org/regional/russia/index.html
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