Legal and cultural aspects of involuntary psychiatric treatment regulation in post-totalitarian milieu : the bulgarian perspective

Background: The impact of totalitarian legacy on present changes in legal regulation of mental health care and the interplay between legal and cultural factors in involuntary psychiatric treatment in post-totalitarian states have not been systematically analyzed, neither worked through. Objectives: To assess the characteristics of the legal system and social practices concerning involuntary psychiatric treatment in Bulgaria from historical perspective, parallel with the legal developments in other European countries. Methods: Review of relevant research and historical sources, cultural reference framework, and legal norms. Results: Cultural and legal developments are far from being parallel. Totalitarian legacy in the area of patients' rights and coercion in psychiatric treatment is coped with in a milieu of transitional rules where the basic challenges concern more cultural aspects rather than legislative ones. While legal changes in non-Soviet post-totalitarian states nowadays could be best described as normalization (illustrated with Bulgarian legal traditions as an example), the major cultural shift concerning health care impacts novel concepts, e.g. autonomy vs. paternalism, and high tolerance to insecurity vs. fatalism, which mobilize defences and provoke confusion. Conclusions: Culture, and de-culturation in times of transition for that matter, is the limiting factor for practical implementation of law, and contributes to the discrepancy between written law and applicable law. Problematic issues subject to current changing legislation, such as informed consent, legal competence, disability, guardianship, and compulsory placement and treatment, could be understood and resolved if viewed in the context of a changing culture.