Ne kura, ne jajc' – ampak zajc' – zdravstveno-moralistična sprenevedanja

Objavljam (gostujočo) kolumno, ki bo izšla v majski številki Kraljev ulice.

Očitno je, da v pomanjkanju streliva zoper bolj pravično regulacijo konoplje nasprotniki bolj stvarnega in manj kriminalizirajočega ravnanja, streljajo z slepimi naboji. Eden izmed teh je tudi ta, da uživanje trave povzroča shizofrenijo. Zadnji adut v rokavu, ki se izkaže za lažnega. Prvi problem pri tem je, da pravzaprav ne vemo, kaj shizofrenija je, pa tudi sama psihiatrična stroka ni enotna, ali sploh obstaja. Torej dokazujemo obstoj škodljivosti uživanja konoplje z nečim, za kar nismo gotovi, da obstaja.

Res pa je, da obstajajo duševne stiske, ali kakor bi psihiatri rekli motnje (razlika med stisko in motnjo je predvsem v tem, da stiske definiramo subjektivno, doživljajsko, medtem ko naj bi motnje bile nekaj bolj objektivnega, vendar to objektivnost definiramo glede na odklon od norme, ki pa jih postavlja določen družbeni red). Ljudem se odtrga, znorijo, težko jih razumemo in pogosto, a ne nujno, tudi sami to doživljajo kot nekaj obremenjujočega – torej kot osebno stisko.

Obstaja veliko število bolj ali manj znanstvenih raziskav, ki so hotele predvsem dokazati, da kajenje trave v pomembni meri povzroča take stiske in taka, včasih človeku samemu, pogosto pa njegovemu okolju, zoprna stanja. V teh raziskavah se je večkrat pokazalo, da obstaja povezava med dolgotrajnim uživanjem trave in dolgotrajnimi duševnimi stiskami. Vendar pa tako Evropski center za spremljanje drog in zasvojenosti z njimi (EMCDDA) kakor tudi ameriški Nacionalni inštitut za zlorabo drog (NIDA) opozarjata, da sicer te raziskave kažejo na povezavo med tema dvema fenomenoma, a ni dokazov, da je ta povezava vzročna.

Kot sicer pri dvojnih nalepka (zdravniki bi rekli diagnozah) gre namreč za splet več okoliščin in dejavnikov. Nekateri si s kajenjem trave, ali pač s pitjem alkohola oziroma z zadevanjem s kakšno drugo drogo lajšajo stisko, ki jo doživljajo. Mimogrede – vse prepovedane droge so bile v nekem zgodovinskem obdobju tudi psihiatrična zdravila – sedanja psihiatrična (antipsihotična) zdravila pa le redkokdo jemlje v rekreativne namene. Nekatere pa dolgotrajno uživanje opojnih substanc spravi v duševno stisko. Pri prvih je duševna stiska očiten vzrok za uživanje drog, torej ne posledica; pri drugih pa lahko trdimo, da ne gre nujno za vzročno zvezo, prej bi rekli, da gre za dvojno posledico kakor pa za vzrok (uživanje drog) in posledico (duševno stisko). Pogosto gre namreč za življenjski slog, življenjske dogodke, okoliščine, ki sprožijo tako intenzivno uživanje drog kakor tudi intenzivno duševno stisko.

Podobno je tudi z brezdomstvom, ki je pogosto povezano tako z enim kakor drugim. V osemdesetih letih, ko se je začela dezinstitucionalizacija – praznjenje velikih psihiatričnih ustanov, je v nekaterih državah prišlo do preplaha, da je tudi to povzročitelj brezdomstva. Glede na to, da je veliko ljudi na ulici imelo tudi duševne stiske, so sklepali, da je to učinek sočasnega praznjenja takih ustanov. Raziskave so pokazale, da temu ni tako. Za ljudi, ki so se preselili iz norišnic, so praviloma dobro poskrbeli, imelo so kam iti in streho nad glavo. Le malo jih je končalo na ulici.

Izkazalo se je, da imajo ljudje brez strehe nad glavo, bivališča duševne stiske zaradi stresnega življenja, negotovosti. Življenje na ulici, neprestano iskanje zavetja, hrane itn. lahko spravi človeka v paranojo ali pa do tega, da obupa, je do konca potrt (strokovno 'depresija'), in podobno. Velja tudi nasprotno, da lahko duševna stiska človeka požene na ulico. A tudi v tem primeru je težko reči, kaj je prej – kura ali jajc' (v času velike noči bi rekli zajc'). Izguba službe, stanovanja, ločitev ali izguba ljubljene osebe, šikaniranje v službi, ne izplačevanje plače itn. prav lahko povzroči oboje – duševno stisko in brezdomstvo – lahko hkrati ali pa zaporedoma.

Ne gre torej za vprašanje, kaj je bilo prej – ali kura ali jajc'. Življenje je včasih zapleteno in ga je težko razplesti. Zadeve se ciklajo in se v krogu ojačujejo. Gre bolj za moralistični preskok (zajc'!), zamenjavo dela za celoto. Moraliziramo o uživanju drog, zasvojenosti, duševni 'bolezni' ali brezdomstvu, pri tem pa ne pogledamo globje. Morda predvsem zato, da nam ni treba česa narediti ali celo spremeniti. Dekriminalizacija, dezinstitucionalizacija, aktivno sprejemanje drugačnosti in vključevanje ljudi v družbeno življenje terja od nas veliko več poguma, sprememb in bistveno večje skoke v prihodnost. 

Dichotomies in beliefs on residents' resettlement (an analysis of Macedonian centres for social work response)

Beliefs about residents’ resettlement significantly shape the action of the providers and other stakeholders in the resettlement. They provide motivation (or lack of it) for change and simultaneously inform decisions on how resettlement will take place (or will not).

The centres for social work were asked, in an impromptu survey conducted in the summer of 2017 by MoLSP, for their opinion on ability for their residents in Demir Kapija to live outside the institution and for suggestions about what kind of care they would need. A third of the response was positive – that there are possibilities for extra-institutional care; a third was negative and a third did not answer. The response was made hastily and was not based on the characteristics of residents; it was arbitrary and indicates the attitude of a particular centre or worker of the centre who was answering rather than real possibilities for either support or capabilities of a resident to live outside of the institution. The main determinant of the response was therefore, the orientation of the centres.

Some did not answer, some were answering negatively. Most frequently, the negative statements were general: [the resident] “needs to stay in the institutions, there are no conditions for integration”. Some were oriented on potential of the residents and some on lack of services in the community (a peculiar answer, but very indicative was: “the resident is considered to be well adapted to the institution and there is no need to resettle”). 

A certain group of the centres (or practitioners) answered predominantly positively that there is a way to resettle. Mostly they suggested group homes (24 out of 60 suggestions) and ‘organised living with support’ (26/60) of which considerable number (10/60) of responses was that they would need 24 hours health care. The rest (9/60) were suggesting foster care placement and one was just generally considered able to be resettled. In regard to foster care two centres (for 7/9 cases) had written that there was no potential to live in a group home and the centre had applied for foster care. If ‘potential’ is meant for the residents, these two centres consider foster care as more potent way of caring.[1]

This response does not indicate the intensity of need of the resident nor the need or availability of support outside the institutions but the orientation of centres for social work. There is a clear division of the centres for social work that are pro deinstitutionalisation and those who are against it (i.e. do not see a possibility of resettlement).[2] This division is marked also geographically. It seems that Skopje and southern centres for social work see more possibilities for resettlement, and in northern areas, regardless the West and East, do not see these possibilities, while the centres for social work in central part of the country are undecided and silent. The intra-regional variations between individual centres for social work are very similar to the results of the analysis of geographical distribution of residents with the same centres for social work that stand out of the picture in their attitude. This division, in a way, reflects the division between the declarative orientation on deinstitutionalisation and actual reservation that are present both in politics and in the culture. Some centres for social work express their willingness to participate in the process while some share the doubt that this is possible.

In the response of centres for social work, we can discern the usual professional (and lay) beliefs about resettlements. Some support them and some obstruct. In the table on the next page, we elaborate such beliefs in more detail. Most of the beliefs that obstruct resettlement accede to deinstitutionalisation and resettlements in principle, but pose reservation about its scope. Mainly they express reservations on the ability of people to live outside, are dismissive of residents’ rights to live outside and point to a relative but permanent necessity of institutions. Like all myths, they contain a piece of truth to arrive to false conclusions. On the other hand, we have the beliefs that promote resettlements. This may be seen as utopian, far beyond existing reality. Yet, this utopia, as has been demonstrated many times is doable, it is what Basaglia (1981, 1987) termed ‘practical utopia’. These views are ethically consistent and support affirmative action, while the former prevent action, change, improvement and are ethically highly questionable.

Table 9: Beliefs that obstruct and promote resettlement

Topic	Beliefs that obstruct resettlements	Comment	Beliefs that promote resettlement
caring nature of institutions	Residents are taken care of and they would not be taken care of in the community	This belief implies that there are some aspects of care that can be performed in the institution, which for care institutions is not the case.	There is nothing that is provided in an institution that cannot be provided in community settings.
‘special needs’	Institutions’ residents have special needs that can be taken care of only in special places.	Wrong. In fact, their needs are neglected due to institutionalisation and disablist ideologies.	People with disabilities or in distress have the same needs as anyone; they need special attention and additional support in satisfying them. Needs can be taken care of in the community settings in the best way.
necessity of institution	“Some people will always need institutional care”.	This belief accedes to the imperative of DI but relativises its scope. It is true that some people need more support.	all people have the right to live in the community regardless the intensity of disability. Some people need, however intensive support to do so.
skimming	More able residents have priority in resettlement, less able are bound to stay in institutions.	This is a ‘natural’ observation, seemingly self-evident. It is false, however, on ethical and practical count. It is discriminative and causes arrest of the DI process.	Residents who have intense support needs have to have special attention and be in the second to the first echelon of the resettlements.
independent living	People with disabilities cannot live independently.	This observation is based on misconception that ‘independent living’ means either living alone or being able to take care of daily living activities by oneself.	Living independently is available to anybody if provided necessary support to make decisions and enact them. Right of choice and to make decision are the basic human faculty that has to be enabled to everybody.
need for preparation	In order to live in the community residents have to undergo thorough preparation to learn the skills of living in the community.[3]	It is true that preparation is needed. However, it should not take too long and should not be directed primarily to the residents’ abilities, but similarly to ordinary life focused on the new arrangements.	Resident should be included and involved in the preparations of their new abode from the very start. They should be main creators of the new environment. Reluctant residents should be encouraged by the visits and outings.
Intermediary structures.	Group homes are seen as deinstitutionalisation, the main if not the sole means of resettlement.	It is true that GH are an efficient way of resettling residents for institutions, however, it is not the final destination and should be considered as transitory solution and temporary abode.	For real inclusion and independent living another ‘technology’ is needed that is more personalised and that allows care provision where somebody lives – i.e. at his or her home (personal planning, assistance, home help etc.).
right and DUTIES ideology	Residents (or people with disabilities in general) have to have their rights acknowledged, but they must also acknowledge their duties.	This self-evident truth is uttered with intention to diminish the importance of rights, of which the residents were deprived.	Unconditional conception of the right to live in the community and will to enact all the human rights derogated by the institution. Reading of people’s desires and wants as the expression of rights.
‘medical’ model	People are in the institutions because of their defects that need to be treated.	It is true that some residents have a medical condition, but the main reasons why they are in an institution are that they deviate from the norm and because there is not enough support available outside.	The deficit in experienced distress is social and not personal. We need to create possibilities for people to live with people and the community; society has to learn how to live with these extraordinary people and not the other way around.

Claimer: This blog is intended as a part of Situation Analysis and Assessment/ Evaluation Report of Implementation of National Strategy on Deinstitutionalisation 2008–2018, which will be soon presented to the public within the EU framework project Technical assistance support for the deinstitutionalization process in social sector. For this blog, Vlado Krstovski is considered to be co-author.

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[1] Generally speaking, it is usually considered quite the opposite – that group homes have more potential for more intensive care. Nevertheless, in principle it is not the matter of the form of care used but how intense we make any form. Both foster families and group homes can be of low or high intensity – in group homes apart from special equipment it is a question on number and skills of the staff, in foster families it is a question of training and expertise of the fosterers (specialised) and of the amount of external support to the family.

[2] It is difficult to speculate what absence of response indicates. Does it indicate that these centres for social work do not know what is possible, or they do not dare to say – they relegate the responsibility to the MoLSP who asked the question – or they are not decided whether moving residents out is a good idea.

[3] One of the recommendations of the Ombudsman is to continue the process of deinstitutionalization by including mandatory preparatory phase period for the users. This recommendation is coming after ‘one user in the process of deinstitutionalization was transferred to a community care centre, and he could not adjust to the new conditions and was returned into the special institutions’.