Political and economic transformations in Ukraine: The view from psychiatry

Methods

My research in Ukraine was conducted primarily in an urban area in the south-central part of the country on the campus of a state-run psychiatric hospital (a research site chosen because of pre-existing local contacts). This was supplemented with additional research in the capital city of Kyiv at a rehabilitation clinic also located on the grounds of a state-run psychiatric hospital. I was allowed access to the psychiatric hospital in south-central Ukraine through my contact with the president of a non-governmental organization (NGO), which I refer to in this paper as Human Rights for Psychiatric Patients (HRPP). ¹ It was through my affiliation with this organization that I also gained access to the rehabilitation center in Kyiv. Both of these state-run psychiatric hospitals looked similar to university campuses, and both were comprised of several separate buildings laid out over very large tracts of land, which at one time were completely surrounded by forests, separate from the cities they serviced.

HRPP focuses its efforts on helping patients and their families navigate the psychiatric environment and mitigating the abuses that patients often suffer. These abuses range from forced hospitalization to the takeover of a patient’s apartment by family and nonfamily acquaintances to unequal access to legal services, to name a few. In addition to the rehabilitation clinic, HRPP manages educational programs for those with a diagnosed mental illness and their families and advocates for patients in interactions with the legal system, such as an arrest following a neighbor’s complaints, or when challenging family and relatives for property, parental, or guardianship rights. At the time of my research, the organization had 150 active members in 14 regions of Ukraine, but was based in the state-run psychiatric hospital located in the south-central part of the country. While HRPP has one psychiatrist acting as deputy, it is a patient-run organization, meaning that all members have been registered at some point at a psychiatric hospital as a patient or have family members who have been registered. I worked most closely with the president of HRPP (not the same person as the deputy), who provided much support and direction for my research. My sponsor was very happy to help with my research, as he was quite passionate about improving the lives of those with mental illness. During my time in Ukraine, I was able to observe the daily workings of the organization, from consultations with patients and families who lost housing due to their hospitalizations, to educational seminars aimed at helping social workers and mental health advocates better understand the current laws and rights of patients. HRPP has been funded by organizations such as USAID and others such as the Soros Foundation and the International Renaissance Foundation. HRPP could be understood as an organization that “fills in the cracks” where services provided by the state are insufficient.

My connection with HRPP enabled further observations and research opportunities in Kyiv. My sponsor, a former psychiatric patient turned advocate and now president of HRPP, often made trips to Kyiv for press conferences, where he would speak with news agencies about the conditions found in state-run psychiatric hospitals. It was here that I was introduced to many individuals with vested interests in mental health care reform, such as members of the Ukrainian Psychiatric Association. It was also in Kyiv that we visited another rehabilitation clinic located on the grounds of a state-run psychiatric hospital (the second hospital I mentioned previously). This rehabilitation clinic was unique in that it focused its efforts on rehabilitation through art. I was able to visit this clinic twice and conducted four interviews with social workers and staff who taught painting and ceramics to patients. It must be noted here that many mental health providers are also patients, or have been patients at one time, so the lines between patient and provider are often blurred. I also visited Kyiv for other activities; for example, in May 2009 my sponsor was invited to participate in a bioethics conference at a university and invited me to attend as well. This gave me insight into the kinds of research and topics Ukrainian researchers in the field focused on outside the psychiatric hospital.

In total, I conducted 40 semi-structured interviews (open-ended questions following a general list of topics) with psychiatrists, social workers, mental health advocates, and patients (keeping in mind that there is overlap between the categories—e.g. social workers who had been patients). ² To recruit participants, I spent several hours a week in the rehabilitation clinic at the psycho-neurological hospital in south-central Ukraine, where I casually asked patients that showed up voluntarily if I could interview them. These interviews were conducted in a large private room at the rehabilitation clinic—the majority of my observations and interviews took place in and around this rehabilitation center, or on the hospital grounds. When my sponsor had time he would take me to meet providers such as psychiatrists and social workers, from whom I could solicit interviews. His assistance was necessary, as I could not just walk into a ward by myself where most providers would be found behind locked doors. Most of my research took place in a city; however, I did have the opportunity to visit a small village and meet with a family whose son was a patient at the same psychiatric hospital in the city. This gave me insight into the challenges that patients living in rural areas face.

Mental health care reform

A complete transformation of the health care system, including the mental health system, is currently underway in Ukraine. Thus far, three major issues have constituted the focus of mental health care reform for Ukrainian policymakers: 1) the transition from “institutional” to “community-based treatment;” 2) the transition from socialized to privatized or insurance-based care; 3) and the adoption of the World Health Organization’s (WHO) International Classification of Diseases (ICD-10) to diagnose and treat mental health disorders. In other words, Ukraine is trying to move away from a state hospital-based, socialized system of care to a privatized, market-based, decentralized system of health care. These reforms, however, are still in the theoretical or “testing” phase, with the exception of the ICD-10, which is already in use to varying degrees.

Currently, while there is an effort to develop community-based treatment (smaller, local clinics with treatment on an outpatient basis), such centers remain rare. Instead, mental health care is still largely the domain of the large state psychiatric hospitals, many built over a century ago. While some private, for-profit clinics do exist (not necessarily the same as community-based services), I was unable to observe or interview anyone from such a clinic, or find anyone who had found treatment in such a clinic, which likely remains unaffordable to most. Individuals instead are serviced by a particular hospital according to where they live. The constitution of Ukraine, ratified in 1996, states that health care is provided by the government free of charge (Tarantino, Chankova, Preble, Rosenfeld, & Routh, 2011, p. 23); however, in reality, many patients have to pay for services and medications due to insufficient hospital budgets. And while mental illness the world over is usually associated with differing levels of stigma and discrimination (Cohen et al., 2002), Ukraine has inherited a psychiatric system overshadowed by particularly disturbing legacies from the Soviet Union, where psychiatric diagnoses and confinement were used as forms of political repression (Korolenko & Kensin, 2002; Lindy & Lifton, 2001; Ougrin, Gluzman, & Dratcu, 2006; Van Voren, 2002).

The transformations found in mental health care are part of a more general neoliberal trend taking place in Ukraine, in which historically centralized state institutions, such as fuel and energy, industry, transportation, and construction, are dismantled and privatized (Elborgh-Woytek & Lewis, 2002, p. 8). Privatization in Ukraine is a condition of funding from the International Monitory Fund (IMF) which “began in earnest only in 1995 and picked up considerably in 2000” (Elborgh-Woytek & Lewis, 2002, p.2). Such reforms have been initiated both from within and from outside of Ukraine; many changes are related to funding allocated by organizations such as the U.S. Agency for International Development (USAID), the WHO, and U.S. federal funding that aims to “strengthen civil society” (UNDEF, 2012). Funds from these organizations are being allocated to non-governmental organizations (NGOs) to promote change and reform from within. For example, Ukraine entered into an agreement with the United Nations Development Programme (UNDP) for assistance in meeting the Millennium Development Goals, and the UNDP has supported national priorities relating to democratization in Ukraine in two major areas: institutional reforms to promote human rights and human rights-based approaches, as well as civil society empowerment and participation in decision making (UNDP, 2006, p. 9).

Like many other newly independent nations around the world, Ukraine engaged in Structural Adjustment Programs (SAPs) (also known as austerity measures) to receive funding from the International Monetary Fund (IMF) and World Bank. These programs reflected neoliberal policies and assumptions that promoted a particular set of requirements countries had to meet in order to receive funding, such as reducing state funding for health care, education, and other social services, privatization of government-owned enterprises, opening up their economy to foreign investment and so forth. The move to community-based mental health care and the adoption of insurance-based care are more directly related to neoliberal reform, as both will help cut social service expenditures through the privatization and decentralization of the health care system. The core logic of neoliberal reforms demands that governments “cut social service expenditures, decrease industry protection [and] privatize state-owned enterprises” (Shefner, 2008, p. 24); both of these aim to reduce state intervention while increasing competition and investment, in order to stimulate economic growth. Additionally, neoliberalism explicitly promotes what is called “developed capitalism” along with its assumed sociopolitical concomitants such as individual civil and political rights and democratic institutions (Liu, 2003, p. 2). Policies reflecting the neoliberal agenda in Ukraine often promote “civil society and development” models (Phillips, 2005a, p. 502) and “strategies to instill initiative, independence, and Western-style individualism” (Phillips, 2005a, p. 254), in addition to privatization.

Neoliberal reforms of the mental health care system are seen by many in Ukraine as problematic, however, because they force people to restructure their health-seeking behaviors and to call into question their relationships to the state, their community, and their families as well as their morals, values, and identities. These reforms also include the Westernization of diagnostic criteria and diagnoses that encourage Ukrainians to continue to frame mental health problems as biomedical in nature. Also known as medicalization, this process often disregards environmental and societal forces acting on individuals and communities, shaping their experience with health and illness. While this reform is not directly linked to IMF and World Bank austerity measures, it does fall in line with market reforms, since the Westernization of diagnoses and diagnostic categories or the “globalization of the American Psyche” (Watters, 2010) means the continued medicalization of mental illness in Ukraine and hence the opportunity for pharmaceutical companies to enter new markets.

Medicalization is not a new process to Ukraine. Mental illness, disability (Phillips, 2011), childbirth, and pregnancy (Rivkin-Fish, 2005) were all heavily medicalized during the Soviet period. Today, however, medicalization in Ukraine is increasingly framed through “global mental health” approaches and the use of human rights discourse. Often these are used to combat the abuse of the mentally ill or disabled (Patel, Kleinman, & Saraceno, 2012), which is widespread in many contexts, and certainly in Ukraine. As Laurence Kirmayer has argued, the global mental health movement and the use of human rights discourse and the values associated with both “may have a liberating effect by creating new options for people limited by illness or untenable social situations, but it also creates ethical conundrums” (2012, p. 108). These ethical conundrums are rooted in the “global hegemony of psychiatric knowledge” (Kirmayer, 2012, p. 108), most of which originates from European and American notions of individualism and autonomy and is being exported around the world. In Ukraine, these ethical conundrums include dilemmas regarding the proper and humane diagnosis and treatment of the mentally ill as well as the problematic nature of reforms when the structural and ideological frameworks to make such reforms possible are missing; an issue I will elaborate on later in this paper. It is important to note that human rights discourse is used by NGOs in Ukraine as a way of challenging “abuses of psychiatric power” (Kirmayer, 2012, p. 99). While there are documented cases of human rights abuses in Ukraine, such as wrongful confinement in psychiatric hospitals, other abuses, such as discrimination and mistreatment, especially by health care workers or families and neighbors, are being interpreted as human rights abuses. In this light, the language of human rights is used as a strategy for the weak and vulnerable to gain support to challenge the status quo, a way to speak back to power in social and political struggles (Kirmayer, 2012, p. 101). There is another conundrum here, however: neoliberal reforms work to de-emphasize economic and social rights, and hence undercut the promotion of health as a human right.

Biomedicine and mental health

While Soviet diagnostic and treatment methods for mental illness and those promoted under neoliberal reforms share certain characteristics—both privilege psychobiological theories and pharmaceutical treatment methods—there are, of course, important differences between these models. The Soviet state emphasized collective economic rights, whereas neoliberalism promotes individual political rights and freedoms (Lambelet, 1989, p. 76). In the mental health setting one example which illustrates the tension between these ideals is the Soviet promotion of “work therapy,” in which patients learned viable trades such as woodworking or sewing, and sold their products with the profits returning to the hospital. Training patients in this fashion and allowing them to sell their products as a form of therapy is no longer meant to be practiced in Ukraine; the “reformed” mental health system claims this type of therapy infringes on the human rights of psychiatric patients. The valorization of the collective over the individual arguably also allowed for particular uses of psychiatry as a form of social control, as in the infamous diagnosis of numerous dissidents with schizophrenia and their commitment to psychological “re-education” (Lambelet, 1989, pp. 72–75) . Finally, the Soviet system was characterized by a highly paternalistic relationship between psychiatrists and their patients, with psychiatry enjoying “almost unrestricted autonomy in its power to treat patients, and psychiatrists…display[ing] very little self-assertive or fractious spirit” (Joravsky, 1989, p. 419).

The major differences between the Soviet system and the one being adopted in Ukraine today, as well as the points of overlap, have real implications for the transition of the mental health system in terms of service delivery, diagnosis, and treatment. For example, transitioning from a hospital-based system (i.e. large state psychiatric hospitals) to community-based care (small hospitals or clinics in local communities) has meant cutting the number of psychiatric hospital beds each ward offers and redirecting that money (where each bed equals a particular amount of funding) from these hospitals to clinics within local villages or cities. However, for a variety of reasons, including a lack of basic infrastructure such as transportation, or physical structures such as clinics and hospitals within local villages or cities, as well as—it is rumored—the corruption of local officials, care for the mentally ill is often seen as simply disappearing along with the funds. This has created a contradiction: on the one hand, the reformers suggest that it is “inhumane” for patients to be crammed into large state psychiatric hospitals, while on the other, “local” community-based care options do not exist, leaving patients without access to medications and families unable to care for them at home either physically or mentally.

Transitioning to private insurance-based care is still in the planning and testing phases. A pilot program was tested in four Ukrainian cities – Dnipropetrovsk, Donetsk, Vinnytska, and Kyiv (Tarantino et al., 2011, p. 22), but was “temporarily interrupted after the winter 2014 political crisis” (World Bank, 2015, p. 6). The new Health Minister recently proposed a bill to extend the pilot project to other regions in Ukraine. Additionally, the World Bank in 2015 approved “an 18 year loan of $215 million to support health sector reform” (Kiev Post, 2015, n.p.). The overall goals of this program include reducing the number of empty beds in state psychiatric hospitals, strengthening the role of primary health care providers (PHC), allowing private sector health services to compete for funding from the public sector, and introducing mandatory social health insurance (Tarantino et al., 2011, p. 22). The expected outcome of these programs is to “change the budgetary model of the health system to a social insurance model” (Tarantino et al., 2011, p. 22).

In my research and interviews with psychiatrists, social workers, advocates, and patients I noted varying tensions rooted in diverse vested interests. For example, community groups and patients would like a reformed and more humane mental health system with greater access to quality medications, greater focus on social work, and more monitoring of patients. Many bureaucrats and neoliberal economists (mental health reformers) would like to defund public services and promote privatization, while psychiatric professionals would like better treatment of patients, more funding to hospitals, and higher pay. In the following sections I detail these tensions and vested interests.

Patients

While neoliberalism is heavily driven by the push to erode “communitarian” reliance on the state, it might, in fact, be pushing people into new forms of communitarian reliance on traditional belief systems, healers, and social relationships. From the perspective of the patients I interviewed, the key tensions revolved around therapy, quality medications, and better living conditions.

In addition to pharma-therapy (medications), the state-run hospital also promotes psychotherapy, art therapy, and work therapy (such as planting vegetables and flowers, weeding and general upkeep of the hospital grounds). The patients are also encouraged to learn crafts, such as stuffing mattresses and woodworking; however, they are not allowed to sell their products because of new laws that prohibit the psychiatric hospital from this type of activity. Aside from care found in the state-run psychiatric hospitals, there is a folk medical system that works alongside and separately from the state-run psychiatric hospitals. For example, Sarah Phillips (2004, pp. 25–26) has argued that women folk healers (babki) in rural western Ukraine “carry out gendered performances that accord them a measure of prestige and power; complement and replace the system of state medicine; act as psychotherapists; and specialize in psychosocial ailments to simultaneously heal persons and communities.” Babki also perform a kind of informal psychotherapy by spending extended periods of time with patients, talking at length about their understandings of the problems faced, and about their past, present, and future (Phillips, 2004). This kind of psychotherapy might “allow the patient to re-connect with disturbing or traumatic events from the past and to reflect on the possible causes for his or her physical or emotional ailments” (Phillips, 2004, p. 28).

Although babki are still important, and are perhaps the only truly available “community mental health providers,” most professionals dismiss their utility. The HRPP president describes different categories of patients and their interactions with both medical systems thus:

There are those that come voluntarily, those that are being brought, and those that have lost all hope after going through babushki [grandmothers] and dedushki [grandfathers], “Shamans” and “Witches” … different churches and things like that, and nothing works for any of them and after all that—they go to the doctor.

“Human rights” and the role of NGOs

The landscape of the mental health system is changing, and NGOs have a large role to play in the new system. NGOs, often described as an element of civil society, are thought to be central to the liberalization and democratization of the country. HRPP is a local, patient-run NGO whose goal is to promote human rights for psychiatric patients as well as help patients and their families navigate through stigma and abuse. The role they play in the lives of patients and families across all of Ukraine is significant. Also, HRPP, as well as other professional associations, such as the Ukrainian Psychiatric Association, are the leading voices in critiquing the current state of mental health affairs through participation in venues where they speak out on injustices and promote reforms.

In the early days of HRPP, which was created in 1998, the goal was simply to help supply medications and to employ experienced epilepsy specialists (their office was located at a psychiatric and psycho-neurological hospital and for this reason their work encompassed epilepsy). Soon afterwards the organization began educating patients and families about their legal rights. Patients and their families can now seek legal and medical help through HRPP. The organization responds to violations of human rights within psychiatric hospitals all over Ukraine, in addition to organizing press conferences to let the public know about issues in psychiatric hospitals. The organization is now focusing its efforts on “social work” and creating a “social work network,” a discipline that has only very recently been introduced into Ukraine. HRPP believes that using social workers as a way to understand the real-time needs of patients and their families will help to build the appropriate support and appropriately direct resources into the community. HRPP, in addition to training and incorporating social work into psychiatry, is also pushing the government for more monitoring of patients. As Phillips (2005a) notes with respect to civil society and women’s social activism in Ukraine, HRPP is also “struggling to stop up the gaps in the postsocialist state’s crumbling social service infrastructure” (p. 493). To quote the HRPP president:

These days, in order to protect our rights, we create our own team of human rights activists. They will study at the International Helsinki Foundation of the Protection of Human Rights … Our goal is to form a sufficient amount of human rights activists out of our patients that will be able to protect the rights of the patients in Ukraine. (Panashuk, 2008) ⁴

If we look more closely, the use of human rights language itself registers a cultural shift. Human rights language (originating largely from the West and often attached to neoliberal discourse and reforms) emphasizes civil and individual liberties and political freedoms, whereas socialism under Soviet rule particularly emphasized economic rights, such as the right to work (Lambelet, 1989, p. 76). However, HRPP faces a huge task: while the organization is protecting the rights of individuals by advocating in the court room, hospitals and in the villages, they are sometimes met with resistance, even by the very family members of the patients that they are trying to help, especially when the outcome favors the individual, but not the family, such as in a property dispute.

While HRPP is working to “fill in the gaps,” the president of HRPP is very concerned with how the reforms are actually playing out for practitioners and patients. For example, he states that “every year the IMF gives lots of money to Ukraine,” yet he doesn’t feel like he has that money. He is frustrated with the lack of funding that is available and the difficulties and challenges he must face to get what little funding there is. He is also frustrated with the implementation of these reforms, specifically the push for community mental health; he states that “the number of beds should directly correlate with the development of social [net]work, not just outpatient care, but it’s not happening.”

Psychiatric professionals/mental health reformers

Advocates of mental health reform whom I met in Ukraine, including members of the Ukrainian Psychiatric Association, have been pushing the government for more outpatient services. They are concerned with not only the current state of affairs regarding funding for state-run psychiatric hospitals, but also the wellbeing of patients, many of whom spend much time as inpatients living in the state-run hospitals. They would like to see patients return to society and live at home instead of state-run psychiatric hospitals or at “psychiatric boarding schools” called internaty.

Internaty differ from state-run hospitals in that they are strictly specialized residence institutions for citizens with disabilities (Phillips, 2011, p. 61). Internaty are separated into four categories, “those for the elderly and disabled; for the disabled only; for ‘veterans of work’ with especially long and revered work histories; and for persons diagnosed with psychoneurological problems” (Phillips, 2011, p. 61). Once a disabled child reaches age 16–18, he or she will be transferred to an internaty for adults (Phillips, 2011, p. 61). Internaty are “total institutions” intended as a “permanent residence” for those who require constant practical and medical assistance. Under the Soviet system, such care was framed as a right and optimal for quality of life (Phillips, 2011, p. 62). However, they have also been compared to “prisons and labor camps” (Phillips, 2011, p. 62). Several patients whom I interviewed spent part of their time living between internaty and the state-run psychiatric hospital. For example, one patient explained that she had a home as a child but it was taken by neighbors—not an uncommon situation according to the patients I interviewed and happens when they are placed in a psychiatric hospital. She described how she had been living on and off in an internaty for most of her life and prefers living there because she can see her children—as opposed to when she is hospitalized. While she did not liken them to prison or labor camps, others described them as “homeless shelters,” or “adult orphanages.” This raises the question of whether the actual implementation of deinstitutionalization in Ukraine would result in the kinds of social consequences—increases in homeless and prison populations—familiar from the U.S. and other settings (Yankovskyy, 2005).

There are two main reasons why mental health reformers are pushing for more outpatient care, or even community mental health centers (CMHC) in Ukraine. First, is the idea that these reforms are partly a reaction to Soviet injustice performed through psychiatry. Second, these reforms satisfy the neoliberal agenda to defund public sector services and privatize health care. As such, funding sources are central to the move to CMHC. For example, during Soviet times, the effectiveness of the health care system (along with the allocation of funding) was measured by the number of “beds” and “physicians”—a focus that some believe sacrificed quality for quantity and encouraged lengthy hospitalizations (Lekhan, Rudiy, & Nolte, 2004, p. 15). This meant that the majority of the health care budget went towards inpatient care—up to 80%, with 15% spent on outpatient care and 5% for primary health care (Lekhan et al., 2004, pp. 14–15). With the independence of Ukraine in 1991, mental health reformers were particularly interested in combating this trend towards “more beds equals more money” and instead have been pushing for more outpatient services, which in theory would mean that funding would not be contingent upon “beds.” Instead, funding would shift towards social programs and local (community) public and private clinics, where private clinics would be competing for funding alongside public clinics. This vision is contingent upon the transition to mandatory health insurance, which would help rearrange funding sources for patients and hospitals.

While the transition to community-based care in Ukraine has not yet begun, such reforms are widely perceived as potentially improving the quality of care for those who seek help at state-funded psychiatric hospitals. For this reason, the mental health care providers I worked with generally supported such reforms; however many had their reservations as to how these reforms would actually work. Moreover, general reforms in health care (such as the “law on psychiatric patients”) are perceived by practitioners as having positive effects, evidenced in part by the view of the head of a psychiatric hospital who noted that since the fall of the Soviet Union more people are turning towards psychiatry as opposed to folk medicine and the use of a babka or shaman, or no treatment at all. The head of a women’s inpatient ward, located on the campus of the state-run psychiatric hospital, described how she has much more freedom to speak with patients about everyday issues such as the side effect of medications. Such topics were frowned upon before Ukraine’s independence, which could be attributed to cultural norms such as the emphasis on “overcoming pain or weakness,” a kind of “stoicism,” in addition to “not complaining.”

Prior to 1991 it was particularly difficult for people with disabilities living in rural areas to access services or to receive compensation. A disability specialist described how, during Soviet times, “invalids” (a term used for people with many types of disabilities, including mental illness) living on collective farms would receive no compensation or help; they were not even considered for disability status. A social worker and former patient from the rehabilitation center in Kyiv added that there was a policy to deny anyone on collective farms passports (the only acceptable form of identification so that one could travel within and outside of the country), which was intended to prevent these workers from leaving the country or the collective farm. Therefore, before 1991 it would have been extremely difficult for a collective farm worker to receive a disability status and the benefits that follow. However, after 1991 this all changed; everyone, regardless of their position, could receive the status of disability if needed. Depending on the level of disability, this status could include monthly payments (a living stipend), free medications, and bus passes for example.

However, reforms for those with disability status are not without problems. Sarah Phillips (2011) describes the tension between empowerment narratives which promote individual independence and self-sufficiency among the disabled in Ukraine, and the lack of state and community-based supports that are needed to make these ideals a reality. As a result, the idea of “independent living” remains for the most part an unattainable reality.

While many practitioners feel that health care reforms more generally are having positive effects, these same practitioners feel that the country is not ready to transition to community-based services. The head of the psychiatric hospital and the head psychiatrist of a women’s inpatient ward, both felt that Ukrainians were not “mentally ready,” and that a wider change in people’s attitudes towards psychiatry must happen first. This points to how the overall transition from the Soviet system to a post-socialist, or even neoliberal arrangement, requires a remaking of cultural orientations as much as structural and policy changes. This reluctance by the hospital staff to transition to outpatient care stems from their opinion that the population in general does not know what to do with family, friends, or neighbors who have a mental illness, and even if they do, they usually do not have the resources to help. They are especially concerned about the abuse of mentally ill patients they observed at the hands of family members, neighbors, police, and the state, as well as problems patients have in accessing quality medications and the lack of infrastructure that would make community-based care possible. As a result, the hospital staff I interviewed often took a paternalistic attitude towards their patients. In other words, if we (psychiatrists or hospitals) don’t take care of them (the patients) no one will—because society at large lacks the compassion, understanding, or financial ability to do so. In Romania, a similar situation has led practitioners to create new labels and venues for moral judgments. Jack Friedman (2009) writes that psychiatrists have created a new category of people called “social cases,” deemed unable to survive outside of the institution because of poverty and a nonexistent welfare system. Instead of releasing these “social cases” back onto the streets, they are allowed to stay on at the hospitals as patients. Stillo (2011), writing about a tuberculosis sanatorium, also in Romania, says that political and economic transitions and austerity measures are forcing the medical sector to address social problems such as homelessness and unemployment, leading doctors to resist discharging patients who are without economic and social support. This paternalistic attitude by psychiatrists towards their patients was also noted by Polubinskaya (2000), who states that this attitude needs to move towards partnership between providers and patients. While this concept of partnership is not a condition of neoliberalism—it could be argued that they do have an elective affinity—“patients as active agents in their care” resonates well with other neoliberal agendas mentioned earlier such as: “strategies to instill initiative, independence, and Western-style individualism” (Phillips, 2005b, p. 254). At the same time “patients as active agents in their care” is problematic because of the lack of structural and ideological frameworks and as a result falls under the “ethical conundrums” (Kirmayer, 2012, p. 108) described earlier.

One psychiatrist suggested that the need for a change in attitude towards patients is understood but difficult for psychiatrists to follow, especially older ones. She reported that in Soviet times, the doctors and the patients’ relatives would make the decision whether the patient was institutionalized or not; the patient was never involved in the decision. Now, however, “we think of the patient-doctor relationship as a partnership, but it took time for me and my colleagues to realize this.” The views of current mental health care providers are therefore significant as they highlight how the tension of transition from the Soviet system to neoliberal models is registered at the practical level of service provisions. Their own paternalistic orientation echoes that of the Soviet system, and their reflections on the lack of “mental readiness” of Ukrainians highlights how sociocultural dynamics remain largely embedded in an earlier era of psychiatry.

Currently, deinstitutionalization has not actually occurred in Ukraine, and exists only in theory, although I was told that funding has been decreasing to the state-run psychiatric hospitals. The realization of a community health model will pose significant issues for Ukraine. For example, as has been the case in the U.S., the majority of the mental health budgets are spent on “emergency stabilization” (Yankovskyy, 2005). This is a result of the inadequacies of the separate delivery systems that are necessary for community mental health. In other words, the psychiatric hospital is “one-stop shopping,” whereas community mental health means that patients have to search out separate organizations for help with medications, housing, transportation, food, clothing, and so forth. A side effect in the U.S. of the complicated nature of these services is that many individuals do without and only come into contact with services when there is a crisis, often brought in by law enforcement. This is not to argue that the state-run psychiatric hospitals provide better conditions, however it does not appear that either option is an adequate solution right now.

Conclusion

Neoliberalism is the latest philosophy shaping the world and providing justification for change and reform. I argue that the reform of the mental health system in Ukraine is more than just structural and economic reform; it also requires physical, cultural, and ideological restructuring. Patients and providers alike are required to reorder their entire meaningful worlds (Verdery, 1996, p. 35). They are being “forced to bear the ‘external shocks’ of a global system in crisis” (Nash, 2005, p. 2), and are “expressing the pain of a system out of joint” (Kirmayer, 2006, p. 138). However, I argue that the reforms proposed in Ukraine highlight the tensions inherent in both the Soviet and neoliberal systems and contain elements that overlap. These tensions have been viewed through the reconfiguration of the psy-ences (Raikhel & Bemme, 2016), particularly psychiatry and the call for global mental health. I argue however that the reconfiguration does not look much different from the perspective of the individual because of the similarities of the Soviet and neoliberal systems. Under both systems, biomedicine and discourses of science and particular ideological constructions of the individual and his/her relationship to the state or society have been used to legitimize the political-economic arrangement. Additionally, my findings suggest that neoliberal reforms of the mental health system are still largely at the stage of discourse and discussion and so the changes they may promote have not yet fully occurred. Therefore paying attention to the nuances and overlapping dynamics between the two highlights how political economies and power structures shape health and illness. In this respect, the impact of neoliberal-style reforms may not be so very different from those of the Soviet system they are supposedly replacing; this suggests deeper underlying similarities that are present in both systems. Ukraine, however, has been in the process of nation building for some time and is struggling to find a common voice and identity. Recent conflicts such as “Euromaidan,” as well as fighting in eastern Ukraine highlight the differing visions for the future of Ukraine. These tensions have been and continue to be felt in the mental health system.