A mission to promote disability rights in Slovakia

When psychologist Daniel Holland, PhD, traveled all the way to Slovakia to learn about programs for people with disabilities, it was partly a personal mission. A University of Arkansas at Little Rock professor, Holland is the son of two parents with disabilities.

In fact, he was an advocate for improving disability rights long before he was a psychologist. His mother was an interdisciplinary psychologist and social worker who encouraged him to become professionally involved in mental health and disability issues.

"One of the people who influenced me most also ended up being the person closest to me with a progressive neurological disability," says Holland. "That's part of the reason for my involvement in disability rights and research related to disability issues."

That perspective took Holland to Slovakia, where he spent five months in 2002 on a Fulbright scholarship studying how grassroots community health programs and nongovernmental organizations (NGOs) promote disability policies in a region where few services exist for people with disabilities.

Now back in the states, Holland is continuing where his Fulbright ended, studying Slovak NGOs to learn how they can influence disability rights policy--knowledge he hopes to share with the international disability rights community to encourage them to give needed resources to the region. The former member of APA's Committee on Disability Issues in Psychology recently applied for a fellowship through the Eastern European Studies Center at the Woodrow Wilson International Center to study the most effective ways that disability rights groups can influence policy in the region.

His personal understanding of what it means to have family members with disabilities drives his international scope.

"Being the son of someone with a disability shaped the way I approach the profession, the way I invest myself in psychology and what I do with it," he says. "And I want to make disability issues particularly relevant for large groups of people to consider."

The state of Slovakian mental health

Holland began his research in Martin, a rural town of 40,000 people in central Slovakia, where he taught at Comenius University's Jessenius School of Medicine.

There he found a society struggling economically since gaining independence from the former Soviet Union in 1989.

While he taught health psychology to medical students at the school, he had a secondary purpose: to research how grassroots NGOs influence disability rights policy in a developing country. Much like an anthropologist, he conducted open-ended interviews with leaders of grassroots organizations and presented his findings in a report at the end of his Fulbright.

"I was interested in how grassroots groups function in a transitional government," Holland explains. "We know how to create policy in the United States. But how do disability rights get promoted when you are writing up a new constitution? When you only have a fledgling civil society?"

Holland's interdisciplinary approach--combining psychology and anthropology in his research--is a critical step psychology must take to help abroad, others say.

"If we are concerned about the well-being of people in different parts of the world, we must understand that mental heath is not always viewed as it is in the West," says Arancha Garcia del Soto, PhD, director of refugee initiatives at the University of Pennsylvania's Solomon Asch Center for Study of Ethnopolitical Conflict, a center founded by Martin E.P. Seligman, PhD, when he was APA president.

Holland was a fellow in 2003 at the center's 10-week summer institute for international scholars conducting interdisciplinary research. There, del Soto noted Holland's "openness, genuine interest and willingness to learn reciprocally from others--assets in international work," she says.

What the grassroots leaders told Holland about Slovak health care is sobering. Slovakia's state-sponsored medical system lacks consistent leadership. Though some members of the country's factious, multiparty parliament support community-based health-care systems like some of those in the United States and Western Europe, many politicians who support the country's communist roots endorse highly centralized and institutionalized government-run health care, Holland says.

Regardless of various political philosophies, a strong biomedical model is currently the norm throughout the health-care systems of Eastern Europe, Holland adds. Unlike the United States, whose federal and state governments account for 44 percent of total health-care spending, Slovakia's government accounts for about 90 percent of that country's official health-care spending.

"The good part is that the system covers most citizens," Holland explains. "The bad part is that it has awful institutionalization of people with severe disabilities with almost no state-funded, community-based, independent living alternatives."

That institutionalization is part of the reason the World Health Organization describes mental health care in Slovakia as "insufficient and backward."

For example, some mental institutions confine patients with mental illnesses such as schizophrenia by placing small cages over the patients' beds.

"Some of the units I visited were that way--they had no sense of an independent living model or of assisting people to re-enter the community," Holland says. "People with neurological disabilities--people like my mother--were being warehoused in often impoverished conditions. Seeing that kind of institutionalization brought to the fore what the NGOs' mission is. They really are fighting for the lives of people with disabilities there."

Complicating matters further, the Slovak health system has a thriving gray market. Though health care is socialized, doctors still expect people to pay out-of-pocket and under the table for services, Holland says.

"You are expected to bring a tip, and the size of that tip determines how long you wait, and the quality of services you receive," he says. "And people with disabilities in Slovakia are often among the poorest."

Moreover, most medical professionals lack the training to understand the relationship between mental and physical health. Slovakia's national health insurance policy does not allow clinical psychologists to work with psychiatrists or nurses in outpatient facilities.

What's worse, legislative gridlock slows chances of passing laws providing better health care for people with disabilities, he explains.

Exchanging ideas with NGOs

Such political holdups make the work of local grassroots advocacy groups critical, Holland says. While in Slovakia, he met with leaders of various groups and watched them operate, researching how they survive in an often unwelcome political climate and on miniscule budgets.

It isn't easy. Most Slovak NGOs depend on the Slovak government for funding, making it difficult for them to criticize government policies. Some, like the Slovak Humanitarian Council, which provides practical community-based services like psychological therapy or nursing care for people with disabilities, shy away from lobbying the government for policy change. Others, like the Alliance of Organizations of Disabled People in Slovakia, take a different tack. It influences Slovak health policy by encouraging citizens with disabilities to run for parliament, Holland says.

Either way, success is possible, Holland says. For example, the nongovernmental Center for Independent Living established a pilot program with taxi drivers in Bratislava, the Slovak capital, in which cabbies receive subsidies for picking up people with disabilities, whom many drivers previously ignored.

Yet NGOs need more international support, Holland says. He says grassroots cooperatives for people with psychological disabilities could work well in Slovakia. In these programs, people with disabilities own the co-op, control the resources and learn vocational skills to use in permanent employment.

Holland seeks money to help Slovaks learn about these programs. He also keeps close ties with Slovak NGOs like the Alliance and hopes to call attention to the problems there by continuing his interdisciplinary, international work. In fact, Holland aims to return to Eastern Europe--possibly through a follow-up Fulbright Senior Specialist Fellowship--to conduct further research. If anything, he says, the direct experience of the Fulbright gave him the necessary perspective to do this work.

"Sometimes it's quite lonely as the only psychologist marching around rural Slovakia, but I believe psychology has relevance to those issues," he says. "It's the mantra I stick to: If I think in flexible, interdisciplinary, cross-cultural terms, I know I can ultimately help others."