Treating the Symptom vs. Targeting the Illness

Author: Iva Ruicheva

The recently broadcast BBC documentary Bulgaria’s Abandoned Children led to a huge public outcry – and it should have. The story it revealed was powerful, intense – at times even too intense to watch. What made it even more powerful and dramatic was that it is happening not to children somewhere far away, in a conflict-torn African country, but in Europe – within the new boundaries of the rich, elite-like EU. And not to orphans, but to children who actually do have families and living parents! The shock of all this, naturally, could not allow any normal human being to remain uninvolved – the response was as powerful and as instantaneous as a flood gate. And not only in the UK, where the documentary was broadcast, but also in Bulgaria itself.

The news about the film and the story it reveals spread nationwide with the speed of the Internet (even though, until this moment, it has not been showed on Bulgarian TV) and produced mass public reaction – an emotional mix of shock, anger and deep sorrow, but also one of determination for change. Within a couple of days a number of civil groups, NGO’s, think-tanks, etc., signed petitions, organized public protests, united themselves in a unified body and demanded, among other things, immediate action towards the resolution of the case of Mogilino. Since then a number of things have already taken place – different experts and committees have been sent to assess the situation in the home and to look at possible solutions; critical funding was secured for food, clothes, immediate medical attention, etc., but most importantly securing funding for a thorough, expert, overall medical and psychological assessment of each and every individual child, is now well on the way.

An unexpected positive aftermath of the event was that it brought under the light a large number of NGO’s, charities and civil groups, which have been actively (and often successfully) working in the field and trying to improve the life of children in a variety of institutions. The latest developments made it obvious that the inner potential and resources for change, in the form of crucial organizations, professionals and experts, is there. The problem seems to be, as often is the case in the field of social sciences, that most of the agents are fighting their own small battles, often creating a small miracle at a time, but all in such isolation and solitude which hampers cooperation, transfer of best-practice experience, and, what is most important, the creation of a more united front for picking up the bigger battle.

The recent outcry, both national and international, gave them a public voice and, hopefully, opened a place for dialogue and negotiation of change of practice with the various government institutions. Signs of this are already becoming visible – meetings were held with several government representatives, such as Labour and Social Policy Minister Emilia Maslarova, European Integration Minister Gergana Grancharova, Justice Minister Miglena Tacheva, leading to the latest decision to close the home altogether and to transfer the 65 children with mental and physical disabilities to alternative care-institutions and facilities. The public response and determination has gone far beyond this specific case, though. A number of social initiatives are already on the way, both in Bulgaria and in the UK, including open debates, round tables of experts, professional discussion meetings, all of which aiming to induce a coherent policy change, formulating a list of the most urgent cases in the country and practice implementation on a case-to-case basis.

The next steps to follow should involve raising public awareness about mental and physical disabilities, in order to de-stigmatize such children and to facilitate their socialization into the general community. An overall more positive acceptance in the society (accompanied by the provision of the right services) will naturally have a positively reinforcing effect on some families with such children, making it both psychologically and practically easier for them to look after their children in their homes. And this leads us to the hottest and most controversial topic, raised by this case – the debate between the feasibility of care for children in institutions vs. families.

Among all the reactions and outcry, one voice sounded the loudest and got the biggest public resonance – de-institutionalization! At the end of it almost an automatic link was developed between the two, much like poison – antidote – childcare institutions – de-institutionalization. This link is now so strong that even raising the question about the power of de-institutionalization as a feasible alternative raises doubts in the motivation of those who dare ask it, if not in their interest in the welfare of the children, which, in itself, is an interesting (and universal) phenomenon. It is an amazing fact that the dangers and shortfalls of de-institutionalization of care have already been widely recognized and explored when related to other population groups, such as the mentally ill or the elderly, but the same question is almost universally avoided when it comes down to children. And here the case with the Bulgarian Mogilino becomes even further complicated, because when it comes to countries of central and eastern Europe the pressure to de-institutionalize becomes even stronger and more uncompromising. This is linked, to a large extend, to the still existing shadow cast by the political past of the region, which was characterized by dominant, centralized state. In such context, therefore, de-institutionalization can easily be seen as a sign of a positive change away from the old structuralism, a sign of a state “modernity”, much like privatisation was seen some more than a decade ago. Because, even though social values have always played important role in it, historically the oscillation between institutionalization and de-institutionalization of care has always served various political interests and/or societal shifts.

The fact that Bulgaria has one of the highest rates of institutionalized children is certainly a problem that requires attention. But de-institutionalization can serve its purpose meaningfully only when there are appropriate structures in place, ready to pick up the newly created responsibilities. And this has been deemed a challenging task even to states that are much wealthier and better functioning than Bulgaria, such as the US or the UK. A common problem to all cases of de-institutionalization is a phenomenon often referred to as “trans-institutionalization”, under which people that would otherwise be in various care institutions get referred to other facilities, such as juvenile prisons, nursing homes, mental hospitals, etc. Another important danger, linked to de-institutionalization, is the huge number of people that “fall” through the system, due to insufficient resources, facilities to accommodate their needs or even a centralized body responsible for the assessment and targeting of these needs. Thus children, and people in general, are often left in no-man’s-land, caught between foster care, community services, government agencies, and not being the primary responsibility of any one in particular (good example for this is the fact that between 30% and 50% of the homeless in the US are mentally ill).

On the other hand, the most wide-spread alternative to institutional care – foster care – also comes with a number of negative side-effects, such as the lack of continuity, the overall less stable structure it offers and the fact that it most often offers a temporary, short-term solution and thus all the children that have no “option of reunification” are constantly moved from one foster home to another, until with age they fall out of the childcare services altogether. The full extent of the consequences of foster care on children has not been properly studied – there have been only a few longitudinal studies on the topic, thus making it far from clear what the potential benefits or shortfalls are. Very little is known about important dangers of foster care, such as neglect or abuse, as while institutions have been heavily scrutinized on the matter, the relevant research in the context of foster care is extremely scarce – a fact that once again points to the general biased attitude to institutions. A bias which is even more confusing, when one takes into account the fact that there are a number of other contexts (and cultures) in which institutional, highly regulated care outside of the family of origin/adoptive family is actually praised and seen as a virtue society aspires to. Such an example is the case of boarding schools, where children often as young as 4-5, are readily taken away from the loving, nurturing environments of their homes, despite the constant evidence of the negative effect this has on their emotional development and sense of well-being in later life.

Not denying our responsibility about what has gone so powerfully wrong in Mogilino, but rather the opposite – in an attempt to understand the real extent of our role in this – we should acknowledge the fact that, unfortunately, the case of Mogilino is not a unique, isolated case that happens only in economically poorer and socio-politically more vulnerable states as Bulgaria. The US, for example, is a champion of such scandal-inducing horror stories. This is most probably because care institutions across borders and contexts have a lot more in common, than generally presumed – most probably this is what accounts to their universally bad name. By and large, institutions are often turned into self-fulfilling prophecies, where, on the one hand, they are given a number of responsibilities and a large range of services to cover, but, on the other, little power in decision making processes and little resources to work with (i.e., underfunded, understaffed, etc.). At the same time all negative patterns and failed practices are not properly assessed and responsibly addressed, but the outcome is most often placed down to the universally low-paid staff, the specific home, etc., thus cleaning our hands from the need of honest reflection and from our involvement in their practical sabotage. Maybe rather than burning the institutions on the stake they should be seen for what they really are – not as intrinsically good or evil – and properly assessed for their inside potential and resourcefulness*.

And last, but not least, we should carefully and honestly examine the existing alternatives to institutions, before deciding we want to oppose them. Is the notion of existing loving, supportive family for these children a reflection of reality or simply a good intention and positive thinking? The high rates of rape, violence & general abuse that happen inside families are well recorded and universally recognized – what would that rate be with extremely vulnerable children, kept behind locked doors, with limited resources for proper professional supervision – be it governmental or non?

Foster care has universally low record with ethnic minorities – how will that affect the actual prospects of the vast majority of Roma and other minority groups children in Bulgarian institutions? All these concerns fail to demystify the idea of the family setting as the perfect one for the raising of (all) children – it is the most “natural” one. But often when things are presumed “natural” they are rendered to be therefore unquestionable – let us dare to ask the right questions, when it comes to taking the decision about the life of our children. The successful problem resolution always consists of two basic phases – admitting there is a problem (the evidence is irrefutable) and committing to really making a change, and not just to a skin deep procedure. The above mentioned questions should be carefully examined before the government agencies, as main responsible policy bodies, and the different public groups, as main drivers of change, set on a well-intended path of change, whose side effects might prove not entirely negligible. Because not knowing what exactly we are moving towards, but only keeping our eyes fixed on what we are trying to run away from, might easily make us run around in circles.

Iva Ruicheva works at the Adult Mental Health Unit of Chelsea & Kensington Hospital and as a private Applied Behavior Analysis (ABA) therapist to children with autism. She has a psychology degree from the “St. Kliment Ohridski” University in Sofia, Bulgaria and has studied Women’s Studies at the University of Oxford. Previously she has worked as a Research Fellow at Oxford University within the research areas of Family, Community and Intergenerational Relationships, and Health and Social Care.

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