Mental health policy and practice across Europe: an overview

A lack of historical continuity
Historical development of mental health services 27
In retrospect, it is puzzling that the momentum of history has had so little heft.
Normally, one expects that patterns laid down in the eighteenth or nineteenth
centuries will continue to resonate in some form even into the twenty-first. Yet
in mental health care this seems not to be the case. With the exception of such
singularities as the thriving of home boarding in Belgium, an inheritance of the
colony of Gheel (EOHSP 2000a: 48–9), few of the regularities of the nineteenth
century have survived into the twenty-first.
• The uniformity of the former Austro-Hungarian Empire has dissolved on the
threshold of the twenty-first century. Austria continues to have high rates of
asylum care with little provision for community mental health. Hungary
shows the opposite pattern.
• Today, many east European countries have a large surplus of clinical beds,
many of them unneeded and an inheritance of the Soviet emphasis on ‘more
is better’. ‘What countries from the eastern parts of Europe have in common’,
comments one observer, ‘is not so much ancient history and traditions as
their shared recent past. Essentially, the political division of postwar Europe
interfered with the historical course that each respective country had been
following earlier’ (Tomov 2001: 22). Classically, some of these lands, such as
Bohemia, offered well-ordered asylum care; others did not.
• Countries in which the private and voluntary sectors once excelled, such as
Britain and the Netherlands, have now gone over to statist national health
and social insurance services in which non-state players have little to
say about mental health. (The growing voice of psychiatric consumers
might be seen as a qualification to this statement, yet voluntary charitable
organizations, as such, have receded in importance.)
• Countries that once constituted Europe’s rearguard in mental health care, such
as Portugal, are now in the vanguard – as a result of political realignments.
Truly, the momentum of the past seems today to count for little. The reason,
of course, has to do with the vast political discontinuities introduced after the
Second World War, as Europe became divided into a Soviet camp in the East and
a welfare state camp in the West (a camp more recently embracing Spain and
Portugal). Both effaced traditional patterns, ensuring that the history of mental
health care would be, essentially, a history of the past 50 years.
From history to policy
This historical analysis closes with a present-day observation. A WHO report
noted that ‘The concept of what constitutes mental illness varies amongst
cultures based on local beliefs and practices’ (WHO 2002: 28). In other
words, policy-makers need to craft programmes based on the national illness
representations of the population; otherwise the services will be shunned.
If we wish to integrate mental health services into primary care, it is
important to get around these fears. ‘There still appears to be a division between
so-called “physical” and “mental” health’ write Üstün and Jenkins, who believe