Mental health policy and practice across Europe: an overview

16 Mental health policy and practice
coping stratagems were non-medical in nature, involving the Church and local
authorities. A mental health care system presupposes a multidisciplinary
approach to psychiatric illness, and makes the assumptions that (a) admission
to a psychiatric facility is therapeutic rather than custodial, and (b) that effective
psychopharmaceuticals or convincing physical therapies exist for assistance in
community care. Although today biopsychosocial models of care, which
involve many disciplines, are in vogue, historically the triumph of the doctor
over the priest in the treatment of mental illness entailed, essentially, the
triumph of the medical model (Shorter 1997: 1–22).
The history of mental health care within the territories that became the EU
may therefore be divided into three periods. Period I, dating from the early
nineteenth century to the mid-twentieth, represents the epoch of institutional
mental health care, as a district-level network of mental hospitals was constructed
across Europe, and spas and private sanatoriums became the elective
sites of care for ‘nervous’ illnesses among the middle and upper classes.
Period II, from the end of the Second World War to the 1970s, represents the
beginning of systematic community mental health systems, in the form of
extensive private-practice psychiatry, the advent of effective psychoactive
medications, and the establishment of day care and outpatient clinics in
most psychiatric hospitals. This period really represents the first wave of
community-based care.
Period III, dating from the ‘long-term programme’ in 1970 of the WHO
Regional Office for Europe to the present (Freeman et al. 1985: 5), represents a
systematic expansion of vertical care, in the form of sectorization and deinstitutionalization,
as well as horizontal care, in the form of the continent-wide
expansion of the comprehensive community-care patterns that had begun after
the Second World War.
Period I: the era of the asylum
The legacy of this initial period in the modern history of psychiatric care was
the institutional impulse (Porter and Wright 2003). It represented a cultural,
political and social reflex that made admission to a mental hospital the benchmark
of quality mental health care. Undoubtedly, in a situation where community
mental health care was non-existent for the majority of people, hospital
admission did represent an appropriate treatment for major illness, all the
more so in the absence of effective psychopharmaceuticals. Yet as a legacy to
an era that possesses pharmacologic alternatives, the institutional reflex is
inappropriate, chaining mental health care to giant structures of brick and
mortar.
A bit of perspective is useful here, however. It has become fashionable to
deplore the ‘confinement’ of psychiatric patients in mental hospitals and to
demand community care. But one recalls that, in the context of the history of
psychiatry, the early therapeutic asylums were a decided step forward in view of
the often terrible conditions that these individuals encountered in the ‘community’.
In Denmark, for example, as late as 1840, the mentally ill were locked
up in wooden cages in the villages or chained in stalls; 142 such cages were