Psychiatric Hospital or Poor House? Socio-economic precariousness and weak family support.
The "career" of the psychiatric patient begins before hospitalization (4), that is, within his family. With this in view, family plays an important role in the "career" of persons with mental disabilities and, by extension, in the phenomenon of social segregation resulting from the psychiatric treatment carried out in the Clinic Psychiatric Hospital. This fact makes us consider the elements of family solidarity (5) or, on the contrary, to take into account the lack of solidarity and family support, from the first signs of the disease, going on to admission in hospital and, to the discharge from hospital. More than that, we have to consider the way in which the relationships between a chronic patient, under the pressure of repeated hospitalizations over many years, and the other members of his family, change. The community centers developed in the Republic of Moldova in recent years (6) aim at giving patients access to community mental health services on the principle of multidisciplinary teams and outpatient care. Indirectly, this reform transfers a part of social responsibility of the psychiatric institution and of the system of mental health on the whole to the family of the patient. The question is to what extent such families, in their majority poor and vulnerable from a socio-economic point of view, are prepared to cope with this responsibility? In a larger context, this article is a starting point in considering the challenges facing the family involved in the treatment and psycho-social recovery of persons with a psychiatric diagnosis. Besides a precarious financial situation in some of the families of these patients, there are problems related to alcoholism or/and domestic violence. There is also a situation in which patients do not have a family or close relatives who can accept them.
A SOCIAL SEGREGATION OF PATIENTS
Members of the hospital staff confessed, under confidentiality, that they had treated in secret persons belonging to rich families. To a certain extent, even the institution is part of this mechanism of selecting patients on class criteria (according to their income) as a result of hospitalization requirements and due to the official model of patients' treatment, and also because of the negative image of such a hospital in society--a situation inherited from the time of the Soviet Union, and, also, as a result of the stigmatization of patients treated in hospital. According to some recent surveys (7), persons with psychic disorders are subject to a significant social distance: 4 of 6 points, associated with "disability", being sources of "aggression" and "danger". Treatment in the Clinic Psychiatric Hospital is often seen as a factor that affects the image and status of a person and family in the community of origin, a fact discussed by a large number of patients in their interviews.
"Even if I worked as before, they did not consider me to be a human being. Seemingly, I was ill in my head, they were mocking me. At work they laughed at me." (Female age 45) "I love Chisinau as much as you cannot imagine. You know, when you go to B (the name of the village of origin-n.a), you have such a feeling, in fact it is really like that -everybody knows you there- everybody knows that I have health problems. Even at the pub they did not want to employ me as waitress, a woman used to say: 'I cannot employ you because you have health problems!'" (Female age 38)
The fact that social groups of people are not admitted in this hospital is not evidence that people with high income may not be affected by mental diseases. This may indicate, that such people avoid hospitalization and, consequently, the social and moral deprivation. Persons with low income are treated in the Clinic Psychiatric Hospital. Families with relatively high income having a member with psychic disorders avoid hospitalization and look for an alternative treatment. To some extent, we agree on the hypothesis of "social drift" according to which mental disorders have a biological component. On the other hand, this hypothesis also implies that persons with mental health disorders are more exposed to the risk of being placed in a social class inferior to their initial one after their disease worsens and, thus, they become victims of a "downward social mobility" (8). In our research, this hypothesis is confirmed by the condition of almost half of our subjects (9), especially in those cases in which the disease did not occur/ manifested in early youth, but later on: during high school or they are already adults, when such people had various professions. The occurrence of the disease symptoms and then hospitalization had negative consequences on the social success of such people. This is a tendency which supports indirectly the meritocratic vision on psychic diseases, which are considered to be the cause of professional failure.
THE FAMILY PROFILE OF PATIENTS
There is complementarity between the poverty of persons and their families and the network of social support for such people and families (10). According to a survey (11), family connections are more precarious in the working class than in the upper middle class. The same situation has been reported in our research too.
The interviewed persons said that they had a relatively small number of family members or relatives. On the basis of the data regarding family ties of those interviewed, we have found the following: out of the total number of 53 patients, 35 live with their family of origin, old parents, out of which 25 are divorced and returned to these families after their divorce, 10 persons had never been married and are in difficulty to find a partner. Nine persons are married, out of which 3, although officially married, live alone because their spouse is has gone to work abroad. Eight persons live alone (two taking care of young children, three have children who do not live with them, and three have neither parents nor children). One person is on the point to get married. Concluding we may say that, besides their poor socio-economic situation, their vulnerable condition worsened as a result of having a small and poor family.
THE PATIENT'S FAMILY: SUPPORT OR EXCLUSION?
A psychiatrist from the Clinic Psychiatric Hospital in Chisinau, reports that during first hospitalizations, members of families or relatives accompanying persons in crisis, come to visit them, make inquiries about their health, try to find solutions to their problems, look for advice from medical staff. When hospitalizations are more frequent (more precisely, after the "third hospitalization", according to the same source), members of their families or relatives come more rarely to see the patient. Persons in crisis are taken to hospital by emergency teams, by police, or come alone to hospital. In the same way, families or relatives come more and more rarely to pick up patients when discharged from hospital. According to the same psychiatrist, there are patients who do not have money to go back home: "We give them clothes and money for their trip home. We do not have the means to send home those living in other districts. Nobody waits for them at home and members of their families are not happy to have them discharged from hospital". Patients also confirmed the same mechanism of decaying and even losing family connections after the disease had a relapse and after repeated hospitalizations. Over the years, there is less and less support and help from families, the family moves from a "centipede" position to a "centrifugal" one (12). Finally, family connections crumble and members of the family separate. In this way, the family of persons admitted in the Clinic Psychiatric Hospital becomes a place of tension, suffering, even exclusion, instead of being a resource and a place of support. Once admitted in hospital, the person acquires a social disqualifying status. Repeated hospitalization over several years consolidates his image of a chronic sick person. Family ties deteriorate, or are even broken, because the disease, with all its symptoms, influences, directly and negatively family environment. "Each person, patient or not, is not only a subject, but also a person in connection with his family, which he influences and is influenced by it. When the disease gets more complicated and lasts longer it influences the patient and his family and the other way round, in an endless and painful spiral." (13)
Before, my brother used to come to see me, he brought me food.... But now, he does not come anymore. He said: 'I am fed up with you! Go and do whatever you want ... It is not my problem'. They are fed up with me (members of the family -n.n.). From '981 keep coming to hospital. You get fed up: one and the same thing every day, every month, every year" (Female age 39)
"Do you have a family?"
"I had two families. Now I'm alone.
"What about your brother who lives close by?"
"Ah, my godfather! But, now he got fed up with me too! To go after me coming to Costiujeni. Now he says:' Look I am fed up with you'(..) That sister of mine from Chisinau, she is fed up with me as she says! She may still come, but I don't know for how long, she told me:' if you get to hospital again I won't come any more. My feet hurt to come to see you. I study in Chisinau, I work ...' There have been years! Since they take the pains to come to see me. I used to work for 2-3 months, but again and again I go to hospital! (Male age 53)
On the other hand, hospitalization emphasizes their feeling of personal and professional failure. Only a few of them can resume their work when they go out of hospital. Institutionalization in a psychiatric hospital results in people losing their place of work, a painful experience, amplified by disconnecting the relationships with those close to them. In other words, hospitalization leads to a process of social degradation for people who have already a fragile status. This "burden" increases in time, and parents to such people grow old (the majority of patients who got a divorce come back to their families of origin and live together with their parents in poverty), and cannot take care of them, parents themselves need to be taken care of: "I have always been a nurse to him.
From now on, I am completely down. What can I do with him? What am I to do with him?" (mother of a 28 year old patient). Patients' brothers and sisters have their own families and have their "own problems". Some relatives dream, as a last solution, to find a kind of care home where they can place them and "forget" about their children forever, although they are grown ups: "I wanted to take him to a care home, but it is said that there is not such a place. Before, it seems to have been such a place in Cocieri, there was also another one I do not know where--you can leave him there forever." (mother of a 39 year old patient).
This phenomenon of social segregation as a result of the psychiatric treatment, partly invisible, is in a direct connection with the "social capital" (14) of persons with a psychiatric diagnosis and with the quality of the family support in a social context, where psychiatric patients are strongly stigmatized. Patients from a poor environment, interviewed in this study, speak about various instances when they encountered lack of solidarity (or a low level of solidarity) from their families. They often feel abandoned in hospital. Several members of such families admit that they are motivated by the "invalidity allowance" given to psychiatric patients after hospitalization.
The reforms implemented in the mental health system starting from 2012 onwards (15), especially those for developing community mental health centers, will influence the mechanism of social segregation of psychiatric treatment, creating a new perspective in psychiatric treatment, which will help inclusion in community and society of persons affected by mental diseases (16).
No matter how "advantageous" hospitalization is regarding food, shelter and care, it has no social function, it provides only a temporary solution for a limited period of time. Patients admit that they are permanently on the move from their home to such units as "what is the use of the treatment, if I go home and come back again?!" (Female, age 32). Such a person remains confronted with the same problems which, to a certain extent, are the cause of their crisis. "Treatment is of no use. They give us a pill which gives us sleepiness! That's all. And nothing changes in fact, yes, something has to be changed! (Female, age 59). "I might find a permanent place of work and ... those who have gone from home should come back home (he refers to his wife and son who are working in Italy-n.a.) and maybe this condition of mine ... will be radically changed" (Male age 46).
It is the reform that has this social responsibility regarding persons with psychiatric diagnosis, a responsibility which may be much more important than all the other components in the recovery of a chronic patient. It needs a lot of work to change attitudes and perceptions towards persons with mental disabilities in communities (consequently, this could solve a number of problems related to unemployment and social status and income; lack of social support etc.), to include in their families persons already excluded or those who, although live under the same roof with the other members of the family, are not accepted, are not taken care of and have no connections with their family. It is also important to prevent, in nuce, weakening and breaking the relationships with family in case s of persons diagnosed with psychic diseases. A large mobilization of social services could change these requirements into resources, which may accelerate a major change in the health system in the Republic of Moldova.
ACKNOWLEDGEMENTS AND DISCLOSURES
The authors state that they are no declared conflicts of interest regarding this paper.
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(8.) We refer to the biographies of those 25 divorced patients out of the total number of 53 interviewed persons.
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(14.) Government Decision No 1025 from 28.12.2012 regarding the National Program for mental health care for 2012-2016. The Order of the Ministry of Health No 610 from 24.05.2013 regarding the development of mental health services on the level of the community and integration of primary medical care for 2013-2016.
(15.) Gauchet M, Swain G. (1980). La Pratique de l'esprit humain. L'Institution asilaire et la revolution democratique. Paris: Editions Gallimard.
Aurelia BORZIN -Ph.D. Student, Faculty of Philosophy and Social-Political Sciences "Alexandru loan Cuza" University, Iasi, Romania
Aurelia BORZIN, Ph.D. Student, Faculty of Philosophy and Social-Political Sciences "Alexandru Ioan Cuza" University, No. 11 Carol I Bd., Iasi, Romania, email@example.com
Submission: 28 Nov 2017
Acceptance: 15 jan 2018
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|Title Annotation:||Multidisciplinary contributions|
|Publication:||Bulletin of Integrative Psychiatry|
|Date:||Jun 1, 2018|
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