Mental health policy and practice across Europe: an overview

Historical development of mental health services 29
effectively delivered in settings that do not necessarily announce themselves
as psychiatric clinics or community mental health services, but as centres for
physical therapy with a focus upon the central nervous system.
Nor is this organic-sounding labelling necessarily a deceit: in North America,
pain clinics that offer physical therapy also supply psychoactive medications
and counselling. There is no reason why this highly effective package should be
denied to Europeans.
Our current concepts of mental health rely heavily on the acknowledgement
of psychogenicity: that the patient, in fact, has a mental disorder rather than a
nervous one. In the absence of such acknowledgement, patients refuse to seek
psychiatric treatment, and the facilities sit idle. After half a century of psychodynamic
psychotherapy in North America and western Europe, the doctrine of
psychogenicity has a certain following. Psychiatry and mental health care do
not need to hide their lights. The situation elsewhere may be different, however.
And in the absence of this kind of acknowledgement, policy-makers who wish
to deliver representationally congruent care will seek to give the consumers
what they want.
Notes
* The author wishes to thank Professor Marijke Gijswijt-Hofstra for some helpful
editorial suggestions.
1 The standard history of social insurance (Köhler et al. 1982) contains very little on
mental health. A compact overview of the issue appears in Elster (1923: 932–42).
2 According to Ville Lehtinen, a mental health specialist in Finland, there are still about
6000 psychiatric beds in Finland, but almost all are in the psychiatry divisions of
general hospitals rather than in state asylums. In a 1991 reform, several older asylums
were simply declared to be psychiatric annexes of nearby general hospitals, an issue of
definition rather than a fundamental change (personal communication). There are
apparently still two state psychiatric hospitals in operation in Finland (see Table 2.1,
note 1).
3 Psychogeriatric beds in the Netherlands have climbed from 8680 in 1980 to 26,332
in 1996, while asylum beds have scarcely declined and psychiatric beds in general
hospitals have dropped by 19 per cent (Mangen 1985; Wiersma 1991: 198–9; Schene
and Faber 2001: 76, Table 1).
4 A promising initiative was the conference in Germany in 2000 on the occasion of the
25th anniversary of the German ‘Psychiatrie Enquete’ that helped launch reform in
that country. Yet the comparative data presented there are limited to nine countries,
and treatment issues are not covered (Becker and Vázquez-Barquero 2001).
5 See for example Power et al. 1997. It goes without saying that a majority of suicide
victims do have a psychiatric illness; yet the minority without seems significant
enough to impair the usefulness of the suicide rate as a cross-national indicator of
‘mental health’. A sudden change in the suicide rate within a country, of course, raises
questions about care.
6 It is recommended that WHO’s in some ways exemplary gathering of cross-national
mental health data be augmented by the work of an independent commission
or information-gathering body that is more sensitive to context. Such a commission
would consist of observers sensitive to cross-national differences in the context
of care, rather than merely in such quantitative variables such as the number of