Mental Health Care Reforms in Europe: Rehabilitation and Social Inclusion of People With Mental Illness in Russia

Russia has a long-established elaborate system of social protection for vulnerable groups, including people with mental health problems. A key component of this system is the Medico-Social Expert Commission (MSEC) established under the Ministry of Health and Social Development. It acts as a gatekeeper to social protection services, including pensions, rehabilitation, and employment services. [More information about the MSEC is included in an online supplement to this column at ps.psychiatryonline.org .]

Each local MSEC branch has a critical role in determining and managing the rehabilitation of people with severe mental illness ( 1 , 2 , 3 ). The branch is responsible for assessing the level of disability of individuals with physical or mental health problems. The level of disability determines both the type and level of benefits received. MSECs decide whether an individual might benefit from rehabilitation and, if so, MSEC staff members create an Individual Rehabilitation Plan (IRP), which, subject to the consent of the client, should be implemented within 12 months. Thus MSECs play a pivotal role in providing access to rehabilitation resources, including referral to regional branches of the Federal Labor and Employment Service.

Given the critical position of MSECs, it is important to analyze their role in encouraging or impeding the social inclusion of people with mental illness. We draw on findings of a three-year research project undertaken in Sverdlovsk Oblast, an administrative region with 4.5 million people 2,000 km east of Moscow.

Collaboration with the Federal Labor and Employment Service

MSECs across Russia are obliged to collaborate with the local branch of the Federal Labor and Employment Service when making recommendations about a person's ability to work and designing IRPs. For all people with disabilities, the employment service provides legal advice on employment law, information on the scope of different occupations and the skills required to perform them, psychological counseling, and general support. If an IRP recommends a particular type or field of work, the employment center should find employment or training opportunities in that area. The client receives unemployment benefits while suitable work is sought ( 4 ).

Between 1997 and 2003 the number of people in Sverdlovsk Oblast who were registered with a disability and who applied to employment services increased by 150%. In 2003, of the 4,600 people with disabilities who made applications for assistance with finding employment, approximately 2,000 found employment. However, all those who obtained work were registered with physical disabilities, not mental health problems or intellectual disability. No one with mental health problems was able to obtain work through the employment service (personal communication, Ministry of Social Protection, Sverdlovsk Oblast, 2009).

Systemic barriers to inclusion

In the management of people with mental illness in Russia, the emphasis tends to be on the medical aspects of treatment, without adequate consideration of social and occupational rehabilitation. Employment is a low priority in the rehabilitation process, in contrast with systems in other countries where individuals may not even be able to obtain a disability pension without having first tried and failed to complete a program of rehabilitation ( 3 , 5 ).

In Russia the links between MSECs and the local employment services are weak, which creates a number of problems because of the apparent mismatch between MSEC recommendations and available employment. First, our research project in Sverdlovsk Oblast found that MSEC recommendations for work often specify a precise job, where a broader recommendation would enable the employment service to consider more options for clients. Second, many people with disabilities register with the employment services in order to obtain a job-seeking benefit, rather than to actually work. The employment services are unable to distinguish between genuine cases and others. Third, information about clients provided by MSECs to employment services is not enough for employment service staff to find job placements for people with mental illness. Fourth, employment service staff members have not been trained to work with people with mental illness. Therefore, most have a poor understanding of clients' needs and are reluctant to closely engage with them. However, the employment services lack the resources to provide such training for staff.

Another challenge is that the MSECs are unable to assess the financial situation of clients because they do not have the expertise, the human resources, or the mandate. Thus the benefits they recommend often fail to reflect clients' needs. Furthermore, poor collaboration between the health services, MSECs, and the employment services means that once disability and benefit levels are set, they rarely change. Clients can theoretically move between categories of disability as their conditions improve, but doctors often deliberately do not change the category of disability because this would reduce the size of the disability pension.

In addition, our analysis in Sverdlovsk Oblast found no strategies or incentives to improve multidisciplinary teamwork at the level of the individual client or collaboration between sectors at the level of the municipality or oblast. Because of the lack of collaboration, coordination, and effective partnering, there is a lack of continuity between services for the client.

Although the municipal social services employ social workers, they have no training or experience in supporting people with mental health problems, nor do the psychologists employed by employment services. Both the symptoms of illness and the side effects of medication may impair concentration, communication skills, and overall work performance, and staff members at employment agencies need to be aware of these issues and of clients' specific capabilities if they are to help them get back to work.

Resource constraints

Although Russian laws stipulate that a basic rehabilitation program should be available to clients free of charge, in reality such programs are limited. MSECs have too few staff to manage the existing workload, and staff members cannot spend enough time with clients to tailor their IRPs. Currently, every IRP takes an hour to prepare, but every staff member has to deal with about 20 new clients a day. Only 35% of those who should have an IRP currently have one. As a result, the IRPs that are developed are inadequate or inappropriate, and there is a huge list of clients waiting for IRPs.

The shortage of social workers in Russia, which is exacerbated by the fact that many new social work graduates seek employment in the higher-paid private sector, means that social work is severely constrained. Because of the shortages of both social workers and psychologists, MSECs are largely staffed by physicians and nurses, with a predominantly medical model. But even when they are not staffed that way, there appears to be little discussion of the clinical symptoms and abilities of clients. Consequently, information provided to the employment services is basic, often stating only that the individual presents no threat to public safety and indicating the degree to which the client must be supervised.

All these challenges mean that despite the comprehensive legal framework and defined procedures, there is little practical implementation of IRPs. Even though employment plays a critical role in rehabilitation and reintegration of people with mental health needs into society, no legal framework either regulates the relationship of the mental health services and MSECs with employers or explicitly facilitates employment for people with mental illness.

Cultural norms

A widespread stigma about mental illness remains among employers and employees. Both groups fear engaging with people who have mental health problems. This is by no means unique to Russia: helping individuals with mental health problems to return to or remain at work is now a major policy goal in many western European countries ( 6 ). However, few actions to promote return to work have been undertaken in Russia. No education programs exist to allay fears or to support employers and their employees about issues related to mental illness. The employment services collaborate with 170 educational institutions that provide training for unemployed people, but no attempts have been made by MSECs or the employment services to provide information to employers or their employees about mental illness.

Russian employment law is complex and stipulates that each person who applies to the employment service for an unemployment benefit should be actively seeking work. Also, according to current regulations, MSECs should not disclose the medical diagnosis of a client but only recommend areas of suitable work. However, the mental hospital stamp on the MSEC form that clients present to the employment services acts almost like a brand. Because employment service staff members are not trained to deal with people who have mental illness, these clients are often inadequately served.

Evidence from elsewhere in Europe suggests that supported employment—in which an individual obtains a job in the open labor market and receives ongoing support to help cope with the stresses and challenges of the work environment—can be much more effective than sheltered employment in helping individuals return to work ( 7 ). In Sverdlovsk Oblast it is clear that the system of sheltered employment, including workshops in psychiatric hospitals, fails to act as a conduit to jobs on the open labor market. Employers remain wary of employing anyone with a mental disability who has had an IRP.

Incentives for employers

Historically a number of incentives have been used to encourage the employment of people with disabilities across Europe, but none have distinguished between physical disabilities and mental health problems or intellectual disability. Federal law in Russia stipulates that in any enterprise 3% of the workforce should be registered disabled or the employer will be fined. In 2002, in Sverdlovsk Oblast 1,540 persons with registered disabilities found work through this quota system, compared with 273 in 1997; however, few of the job placements went to people with mental health problems. Not surprisingly, many employers have opted to pay the meager fine of 2,000 rubles ($70) that the law prescribes rather than employ people with disabilities. In 2003 the Sverdlovsk Oblast government collected fines amounting to two million rubles ($70,000). This revenue has been allocated to rehabilitation and sheltered work placements for people with physical disabilities but not to services for people with mental illness.

In addition, financial support was formerly offered to employers to help with the costs of employing persons with disabilities. In 2001 this support covered 50% of salary costs, but such support has not led to any increase in the employment of people with mental health problems ( 7 ).

The situation has been made worse by the global recession, because a tightening job market means that employers are less interested in employing people with a history of mental health problems. They perceive the incentives as being far too weak. In addition, many people referred by MSECs to employment services are, for a variety of reasons, unwilling to work. Reasons include physical and psychological health problems, lack of training, poor motivation, and low salaries. Furthermore, employers can terminate contracts if an employee is placed on long-term sick leave. Consequently, many people with disabilities worry about what might happen if they are unable to hold onto their jobs, given the lack of flexibility in the benefits system, and the potential risk of not regaining all the benefits they once had. There are also disincentives for people who have an IRP. Their meager disability pensions are their only source of income. Ironically, successful rehabilitation could mean that they lose their pension but have no prospect of a job.

There are also financial disincentives to reducing the number of people living in internats (large social care institutions). Residents continue to receive their disability benefits as inpatients, but a large proportion is deducted by the internats as "hotel" costs. It is also in the hospitals' interest to retain as many clients as possible, because high occupancy levels safeguard their funding stream ( 8 , 9 ).

Ultimately MSECs have acted as obstacles to social inclusion, even though they were established to help people with mental disorders obtain disability benefits and rehabilitation services. However, we found that this situation is not unique to Sverdlovsk Oblast or even to Russia. Disability assessment systems exist across Europe, and the lack of intersectoral liaison is a problem in many of them ( 10 ). There is a pressing need for continuing efforts to promote social inclusion across Europe. However, the deeply vertical health structures, an intensely bureaucratic legacy that discourages intersectoral liaison, and the financial disincentives to change, all combine to make social inclusion particularly challenging in Russia.

Major overhaul required

The MSEC approach needs a systematic overhaul to ensure closer liaison between psychiatric teams and employment services, with the MSECs acting as channels of communication rather than obstacles to it. This is a huge challenge, beset by stigma, lack of understanding, and diminishing employment opportunities in an economic downturn. As in other countries, change is likely to happen only incrementally, but actions might be taken in the near future that do not require radical societal or economic change and that would take steps toward encouraging cooperation and collaboration between the MSECs, employment services, and medical services. At the most basic level, these actions include establishing mechanisms for an exchange of information and regular dialogue. Ultimately, as in other countries and other areas of policy making, it is importantwhen justifying additional investment for reform to identify the many personal and economic long-term benefits that can arise when more individuals are able to live and work independently in the community.

Acknowledgments and disclosures

This work was funded by the United Kingdom Department for International Development as part of a collaborative project on adult mental health care reform in Sverdlovsk Oblast.

The authors report no competing interests.