Unraveling the Threads

Georgia's journey in mental health care started with traditional spiritual practices. Over time, the country embraced medical knowledge from both Eastern and Western traditions. However, during Soviet rule in the 19th century, because of the heavily medicalized and institutionalized mental health system, psychiatric hospitals overcrowded and there was a shortage of resources. After the Soviet Union collapsed in 1991, Georgia began significant healthcare reforms with the move towards deinstitutionalization and community-based care, but this transition has been slow, and people who really needed support, left without it. Later, in the 1990s, basic healthcare services were being restored, and further reforms in the early 2000s aimed to modernize the system again. The goal was the same, to move away from the Soviet-era model and establish patient-focused services. Despite these efforts during different times, the system still faces challenges now: like funding shortages, a lack of professionals, and ongoing stigma.

Even with initiatives such as the setting up of a Public Monitoring Council and the adoption in 2006 of new laws on psychiatric care, Georgia faced difficulties in delivering effective mental health treatment, which was demonstrated by poorly reported statistics for social care residents, so it is unknown how widespread the issue was. In 2008, the World Health Organization conducted a study on the state of mental health care in Georgia, also revealing significant shortcomings in the system. The study found that family doctors in Georgia hadn't sufficient training and qualification to address mental health issues. However there was a notable increase in their numbers from 100 in 2004 to 1500. Furthermore, mental health services were limited to a one day treatment facility and 19 out-patient clinics mainly in Tbilisi.

During this time, Tinatin was a patient in mental health hospitals where she experienced severe living conditions, especially for women, ranging from hygiene issues to food shortages. She mentioned that there was no chance to get any fruit, or food with vitamins, during those years. Tinatin described hospitals where medication was the main treatment method, and due to low salaries and a shortage of staff, psychologists were unable to conduct sessions for each patients. One of the most serious issues for beneficiaries was their lack of awareness of their rights, which made it impossible for them to advocate for themselves.

The Public Monitoring Council under the Office of the Public Defender checked living conditions, freedom restrictions, and involuntary measures in psychiatric institutions. However, many people lacked representation and there was not enough legal help for those admitted involuntarily. Such conditions making it more difficult for them to obtain appropriate mental health care and legal protection.

In 2011, Georgia embarked on mental health reforms aimed at enhancing services, accessibility, and reducing stigma. Initiatives such as the Mental Health Strategy and Action Plan 2015-2020 were introduced, supported by funding, training, and advocacy from NGOs and international bodies. A 2018 review of mental health services in Georgia revealed a significant gap between registered cases (102,977) and actual users (49,789), showing that 50% of people avoided seeking help due to stigma and access issues. To address this, funding increased by 11.5 million GEL from 2017 to 2020, with a focus on community outpatient and mobile team services to improve access for everyone.

In 2023, a milestone was reached in the mental health sector in Georgia: the adoption of the term "peer supporter". This crucial step came as part of Georgia's 2022-2030 mental health strategy, after training sessions designed for individuals, who were engaged or interested in various activities. Lali Tsuleiskiri, Head of the psycho-social rehabilitation department at the National Center for Mental Health and Drug-Addiction prevention, was one of the first to offer jobs to patients inside the center and tried to help them with socialization. Now, she highlights the importance of the peer support service and gives several reasons for this.

According to her, before, patients served as equal instructors, with the main goal of assisting social workers in encouraging beneficiaries to seek treatment. However, the shift to peer support has expanded their roles significantly. Their responsibilities include active listening, providing encouragement, and participating in team reviews as well as following to ethical guidelines. Also, key attributes of a peer include motivation, relevant skills, and a collaborative mindset. Tsuleiskiri believes that peers play a crucial role in holistic care, especially their assistance to empower beneficiaries and their families throughout the healing journey.

Tinatin listens to current patients' stories and challenges during her regular visits as a peer supporter, giving them an opportunity to openly discuss their issues and emotions. Her personal experience allows her to empathize with their challenges, share her own, and provide helpful advice based on her journey. 

Challenges and Opportunities

A 2020 study conducted from March to August established 16 outpatient and 14 mobile mental health services across various regions in Georgia. Research was made by the Petre Shotadze Tbilisi Medical Academy, supported by the Alliance for Better Mental Health Research Team and Bread for the World's "For Health, Care, and Social Rights" program, which revealed several challenges faced by these outpatient services. One of them was, that referral mechanisms weren’t working well because they mostly depended on verbal advice. Also, Clinics with knowledgeable staff were better at running social programs, that show how crucial staff expertise is for supporting patients. Sadly, there were still too few skilled social workers and limited community programs, which made it tough for patients to become independent and integrate into society.

Furthermore, according to "Mental Health Services Deinstitutionalization: International Experience and Georgian Context" by Zavradashvili (2021), over 40% of hospital beds are occupied by patients who do not require psychiatric care but have no other options. Georgia is struggling with a severe shortage of psychiatrists, having only about half the number found in other European countries. This leaves a shortfall of at least 250 psychiatrists. The analysis shows a clear need for better referral systems and more qualified social workers and community activities. Improving these areas is essential for making Georgia’s outpatient mental health services more effective.

The Rustavi Mental Health Center in Georgia has made significant progress in integrating peer assistance into its mental health services. Giorgi Matiashvili, the center’s Community Services Multidisciplinary Teams Coordinator, shared an update on the project's progress and the challenges faced. He mentioned that the center now has two peer supporters who joined the mobile teams in January 2024 after a two-month internship. These peer supporters are fully involved with the teams, taking part in meetings, helping with intervention planning, and making visits both on their own and with other team members. Even though they’ve only recently started, their involvement has already led to some positive changes.

Matiashvili highlights the importance of including peer support in mental health services, pointing to Georgia's mental health strategy for 2022 to 2030. This strategy aims to create job opportunities for people who have used mental health services. The Ministry of Health is tasked with rolling out the peer support program by the end of 2024. While there’s been some progress, there are still challenges. He notes that training peer support workers is a key part of the effort, with about 10-12 people having been trained with help from both international and local organizations. However, he also mentions that the exact plans from the Ministry of Health for moving forward aren’t yet clear.

From Patient to Peer

Tinatin started her internship at the Rustavi Mental Health Center after completing her peer supporter training through the "Support of Peer Work in Georgia" project, which was implemented jointly by the Czech NGO "Centre for Mental Health Care Development" and the Georgian Union "Partnership for Equal Rights" with support from the Czech-UNDP Challenge Fund. She joined the Community Services Multidisciplinary Team in Rustavi and gained valuable experience. This opportunity allowed her to learn from experienced professionals and effectively engage with patients dealing with mental health issues. Working at the center gave Tinatin firsthand experience assisting people dealing with a variety of mental health issues.

Later, Tinatin secured a part-time position at The Evidence Based Practice Center, Georgia's leading community-based mental health center, established in Tbilisi in 2012. This center maintains regular contact with approximately 200 clients per week, offering services such as medication distribution, counseling, and monitoring client adherence to treatment plans. Having been a patient at this center for two years and continuing to be one, Tinatin received support from other peer supporters. Initially, Tinatin assisted patients through the Mobile Team, working alongside others, and now operates independently. This team caters to clients who are unable or unwilling to access outpatient services and require intensive treatment.

In her role, Tinatin goes beyond just offering practical help. She also organizes city excursions and different activities to encourage patients to socialize. From her internship to her current position as a part-time peer supporter, she has developed a deep understanding of mental health care and meaning of her personal experience as both a patient and a supporter, that gives her a unique perspective on the challenges people face. Tinatin joins the team of psychiatrists and social workers daily to discuss various patient cases and is involved in the process as a full-fledged member.