Mental health policy and practice across Europe: an overview

18 Mental health policy and practice
urban psychiatric clinics – first proposed by Wilhelm Griesinger (1868), professor
of psychiatry in Berlin – that had by the turn of the century blossomed in a
number of cities. Intended for acute cases, urban clinics usually had fewer than
100 beds and were suitable for short-stay patients, who would either recover or
be transferred to a large asylum. Many university psychiatric hospitals also functioned
as short-stay clinics in this sense (Sérieux 1903: 22–4, 31–3, 675–86). In
practice, however, these urban boutique clinics were not always kept small: for
example, around the year 1900 the one in Frankfurt had 300 beds.
The final exception was the existence of community organizations for postdischarge
care, almost always organized by private charities and foundations.
These were not to be found universally, yet existed in enough large cities to
make a difference. In France, the first Oeuvre de patronage pour les aliénés convalescents
was founded in Paris in 1843. In England, the Mental Aftercare Association
was established in London in 1869 (Bennett 1991: 323). Among the 15
such foundations in existence in Germany by 1900, the first was founded in
Wiesbaden in 1829, the others dating to the 1870s and 1880s (Sérieux 1903:
650). In Italy, a society to help reintegrate ‘the poor insane’ discharged from
the (otherwise very) progressive asylum at Reggio-Emilia, was set up in 1874
(Sérieux 1903: 671–4).
In addition, although the state mental hospital remained the dominant public
institution in the asylum era, it was not the only one. Relatively early, general
hospitals began admitting mentally ill patients into psychiatry divisions. After
the Second World War, the shift from asylum to general hospital was to take on
positive, progressive overtones – the tip of the lance of ‘de-asylumization’, to
coin a phrase. Yet this was not always so. In Hungary, for instance, the psychiatry
‘annexes’ of general hospitals were initially conceived as dumping grounds
for chronic patients who presumably had no access to the psychiatric treatments
and psychotherapy that the state asylums had on offer. Towards 1900,
there were only four state asylums in Hungary (with 2300 patients), but 12
general hospital annexes with more than 100 patients apiece, in addition to
numerous other smaller psychiatry wards in general hospitals, housing a total of
over 5000 patients. In subsequent years, these general hospital units came to
admit acute cases of all kinds, not just chronic patients dumped from the progressive
asylums; and they also eventually acquired psychiatrists as directors
(Pandy 1908: 439–40; Nyiro 1968: 77–8). Yet the Hungarian case is a reminder
that the general hospital link in the vertical referral chain has not always been a
forward-looking one.
Before the Second World War, the best example of integrated mental health
care was found not in the public sector but in the private: the whole world of spa
therapy and private sanatoriums for the middle classes and the wealthy (Shorter
1990). It is often forgotten that in the past, generally the well-to-do in Europe
received their health care in private clinics, and above all in spas. It was a not
so well-kept secret that the prime clientele for spa therapy (aside from the tuberculars
in such dedicated settings as Davos) were the ‘nervous’ patients, a
euphemism for psychiatry patients (Shorter 1997: 119–28). For example, the
water-cure clinic in Boppard am Rhein, ostensibly a refuge for patients with
aching joints seeking the healing waters, was in fact, primarily, a psychiatric
facility. Admission statistics on 1185 patients between 1883 and 1888 show that