Mental health policy and practice across Europe: an overview

20 Mental health policy and practice
Serbia, Romania and Yugoslavia. During the 1920s and 1930s, France and
Sweden adopted similar legislation. 1 Certain kinds of spa and sanatorium therapy
also were included after the First World War so the integration of mental
health care into social insurance systems was well underway before the Second
World War.
Period II: the rise of mental health systems
The key theme of the post-war years is the gradual inclusion of mental health
within social insurance plans and the welfare state. In terms of mental hospitals,
the 1950s and 1960s were eras of growth. All the countries in the then European
Community, except the United Kingdom and Ireland, had a higher number of
mental health beds in 1970 compared to 1950 (Mangen 1985: 21–2, Table 1.2).
By 1971, a quarter of the mental hospitals in the WHO European Region had
more than a thousand beds. ‘Impersonal custodial regimes, lack of privacy and
of . . . stimuli leads to apathy and the aggravation of symptoms’ noted a WHO
report (1975: 37). However, the great turnabout was soon in coming. The 1970s
saw the beginning of deinstitutionalization: there is no country where the
number of beds failed to decline between 1970 and 1979 (Mangen 1985: 21–2,
Table 1.2).
This gathering deinstitutionalization took place under the aegis of the integration
of psychiatric care, meaning the erasure of the firewall between asylum
and the community. In 1948, the National Health Service (NHS) in the United
Kingdom made the first move in this erasure by taking over responsibility for
asylums from the local authorities. As Charles Webster noted, ‘The NHS marked
the end of a 25-year campaign to end separate administration of mental health
services . . . ‘Integration’ was seen as the key to modernization and to the development
of services freed from the taint of the Poor Law and lunacy code’ (1991:
104). One bears in mind that the great ‘bins’, as the English mental hospitals
were known, had already begun the process of opening up to the outside. As
examples of isolated initiatives of this kind, the Maudsley Hospital in London
began admitting psychiatric patients in 1923, and accepted male and female
outpatients (on alternate days) while the Mental Treatment Act in 1930 had
introduced voluntary treatment (Bennett 1991: 324–5).
It remained for the Mental Health Act of 1959 to enshrine deinstitutionalization
in the United Kingdom, emphasizing community care. The Hospital Plan
for England and Wales, promulgated by the Ministry of Health in 1961, called
for a big decrease in asylum beds and a corresponding increase in psychiatry
beds in general hospitals together with day hospitals and community services.
As an American visitor commented in 1965 on the British mental hospitals he
had visited, ‘Personal liberty is actively promoted. Closed wards and locked
doors appear to be at an irreducible minimum. Patients wear their own clothes,
are encouraged to visit outside and to have visitors. Good relations with the
surrounding community are fostered’ (Furman 1965: 2). Thus, the British
experience gives us the flavour of gathering reform.
By the mid-1960s five patterns of organizing local mental health services had
evolved in western Europe, as identified by Sylvan Furman (1965: 4–5):