Social and

Community
Psychiatry

Towards a Critical,
Patient-Oriented
Approach

Stelios Stylianidis
Editor

123
Social and Community Psychiatry
Stelios Stylianidis
Editor

Social and Community

Psychiatry
Towards a Critical, Patient-Oriented
Approach
Editor
Stelios Stylianidis
Department of Psychology
Panteion University
Athens
Greece

The Work was first published in 2014 by TOPOS BOOKS/MOTIBO PUBLISHING SA with
the following title: Σύγχρονα θέματα κοινωνικής και κοινοτικής ψυχιατρικής: Για μια
κριτική ανθρωποκεντρική ψυχιατρική

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Foreword

Social psychiatry deals with the context that shapes mental health and mental ill-
ness. This is done on a macro level as exemplified by the work on how mental health
and mental health problems are framed within the value system of a society with the
core topic of discrimination and stigma as well as by epidemiological data like those
currently widely debated on inequality and health and mental health. The meso-
level concerns key institutions in our societies such as schools, health and social
services, housing, employment and legal situations and essentially how help for
dealing with mental health problems and disabilities is organised and delivered in a
community. The micro-level is dominated essentially by what happens between
people with core topics such as therapeutic as well as family and peer communica-
tion and support.
All these and more of our field’s fundamental issues will be dealt with in this
book. As a textbook of social psychiatry, it provides insight into its scientific and
political foundations, its core policies and practices and their evolvement to date.
All along it also addresses current dynamics and future developments of social
psychiatry.
“The future of academic psychiatry may be social” is a convincing 2013 editorial
statement in the British Journal of Psychiatry by eminent social psychiatrists and
researchers Stefan Priebe, Tom Burns and Tom Craig.
Let me take this opportunity to state my conviction that the future of all psychia-
try will be social. And let us acknowledge that much of its presence is.
While the great reforms in psychiatric services and treatment of the past decades
are far from completed, community-based, integrated service models have by and
large replaced the institutional psychiatry that had been dominant in earlier years, at
least in the Western industrial nations. Psychiatric inpatient treatment increasingly
takes place in general hospital units and is essentially restricted to the provision of
crisis intervention over a few days or weeks. While the 1960s were still dominated
by the aim of avoiding “institutionalism”, i.e. the negative consequences of long
institutional stays, nowadays these concerns are confounded by economical consid-
erations calling for ever shorter inpatient stays.
What shape acute services should ideally take and what role hospital beds and
their location might play are questions that remain at the forefront of service plan-
ners’ concerns. Nowadays, in mental health emergency situations, brief inpatient
treatment in general hospitals is considered a significant alternative, as well as

v
vi Foreword

models of acute mental health home treatment , a form of community-integrated

crisis intervention. From a scientific perspective, the minimal number of hospital
beds needed remains undetermined as are questions about effectiveness, suitability
and possible adverse effects of different community-integrated acute interventions
as well as the “dosage”, i.e. the intensity of the required community-integrated ser-
vices that are capable of preventing hospitalisations. This book describes various
specific developments for specific situation in different parts of Greece, such as day
centres, mobile health teams, ACT and home care.
Fact is, hospital stays take up only a fraction of time in patients’ lives. Psychiatric
treatment occurs essentially in the community. In the community, that is where
mental health and social care workers are busy every day to help other people – in
times of crisis as well as in situations of long-term needs for different types of assis-
tance for their life in the community in various roles.
All these activities and interactions in the community together constitute social
psychiatry: prevention, treatment, rehabilitation, the provision of assistance in
everyday real-life situations, healing and empowering people and communities
towards inclusive community life. However, there is a mismatch between the real-
life everyday efforts and the conceptual formulations of this kind of essential work.
Consequently, textbooks on social psychiatry are rare. This one is a great step. With
its comprehensive range of information, it will reach, educate and motivate different
professional groups as well as policymakers, but hopefully also activists and various
stakeholders including prominently users of services and their families and friends.
It will be welcomed as a state-of-the art textbook as well as an orientation and inspi-
ration for further developments.
Professor Stelios Stylianidis is held in highest regard in the international research,
policy as well as the mental health practice community. His experience covers
essential working fields from grassroot developments to leadership positions in
global organisations, clinical practice in different contexts as well as organisational
and policy activities on the local, national and international arena over quite some
time – times that have seen and brought on tremendous changes.
He and his co-authors address the specific situation in Greece on several levels
with relevant historical and conceptual assumptions and a variety of practice exam-
ples in different locations and situations. They also introduce topical international
developments and their implications for Greece, importantly recovery-orientation
and the actual patient and human rights situation, especially with regard to persons
with psychosocial disabilities.
Current government policies of recovery-orientation in traditionally influential
English-speaking countries follow important changes in mental healthcare over the
last decades. Deinstitutionalisation and the community support movement have
been accompanied and are intertwined with a strong family movement and a politi-
cally influential voice of users of services.
People with a lived experience of mental health problems and treatments have
been an essential force among the pioneers of the recovery movement, who have
created the concepts and a language for recovery. As authors of the groundwork for
the movement, they have developed and impacted not only alternatives but also
Foreword vii

international mental health system transformation efforts and specific models of

recovery-oriented practice.
From their work we know that much of recovery is lived outside clinical settings,
but also that important challenges concern the roles and responsibilities of mental
health professionals in supporting and assisting people with mental health problems
in their efforts towards making full use of their health and resilience and achieving
their goals in life. Self-determination and individual choice of flexible support and
opportunities, promoting empowerment and hope and assistance in situations of
calculated risk are the new indicators of the quality of services. In contrast to a defi-
cit model of mental illness, recovery-orientation includes a focus on health promo-
tion, individual strengths and resilience. A shift from demoralising prognostic
scepticism towards a rational and optimistic attitude towards recovery and broaden-
ing treatment goals beyond symptom reduction and stabilisation require specific
skills and new forms of cooperation between practitioners and service users,
between mental health workers of different backgrounds and between psychiatry
and the public. New rules for services, for example, user involvement on all levels
and person-centred organisation of care, as well as new tools for clinical collabora-
tions, for example, shared decision-making and psychiatric advance directives, are
being complemented by new proposals regarding more ethically consistent anti-
discrimination and involuntary treatment legislation, as well as participatory
approaches to evidence-based medicine and policy.
Recovery demands all our best efforts in terms of human rights, patients’ rights,
scientific and clinical responsibility and service, in the interest of those of us who
might become patients and those who have. We learn from those who are using
services, those who have used services (ex-users) and those who define themselves
through overcoming harmful experiences in the support system (survivors).
One prominent example of successful engagement of activists with a lived expe-
rience is the explicit inclusion of persons with psychosocial disabilities in the
recently widely ratified UN Convention on the Rights of Persons with Disabilities
(CRPD). The CRPD puts the force of law behind rights to non-discrimination in key
areas, including health, housing, education and employment as well as standards of
living and social, political and cultural participation (Bartlett 2012). Community-
based services are central to the implementation of the treaty’s provisions.
In many ways the first human rights treaty of the twenty-first century epitomises
the essentials of recovery. Forged between diplomats and a throng of civil society
representatives – many of them persons with disabilities as experts in their own
right, including those with psychosocial disabilities (Sabatello and Schulze 2013) –
the treaty is the product of a truly participatory process. In a corresponding logic, it
makes the consultation of its constituency – persons with disabilities and their rep-
resentative organisations, respectively – an obligation.
The reality of “nothing about us without us” seems to have arrived and is irre-
versibly here to stay: no policy development and no amendment of legislation or
elaboration of new regulations shall be undertaken without including experts in
their own right – persons with a lived experience of mental health problems and
services. The Mental Health Action Plan for Europe, the WHO Global Mental
viii Foreword

Health Action Plan, the recommendations of the first trialogic task force of the
World Psychiatric Association (WPA) providing for a partnership with users of ser-
vices and their families and friends (Wallcraft et al. 2011) and the call for “user
involvement”, a “partnership approach” or participatory approach are evidences that
henceforth no significant development can be advanced without the meaningful
involvement of experts in their own right.
It is against these historic developments and future perspectives that this book
presents the breadth and depth of social psychiatric thinking and doing. The reader
will be able to understand and roam with pleasure and urgency the landscape opened
up by this essential way of looking at reality and knowing how to play a significant
role in shaping it. Readers will be motivated and ready for the promotion and imple-
mentation of social psychiatric concepts and practice for the good of psychiatry, for
medicine and for society.

Wien, Austria Michaela Amering

Bibliography
Amering M, Schmolke M (2009) Recovery in mental health. Reshaping scientific and clinical
responsibilities. Wiley-Blackwell, London
Bartlett P (2012) The United Nations convention on the rights of persons with disabilities and
mental health law. Mod Law Rev 75(5):752–778
Priebe S, Burns T, Craig TK (2013) The future of academic psychiatry may be social. Br J
Psychiatry, 202(5):319–320
Sabatello M, Schulze M (Eds) (2013) Human rights and disability advocacy. University of
Pennsylvania Press
Schulze M (2010) Understanding the convention on the rights of persons with disabilities.
Handicap International, New York. Retrieved from: http://hiproweb.org/uploads/tx_hidrtdocs/
HICRPDManual2010.pdf
Wallcraft J, Amering M, Freidin J, Davar B, Froggatt D, Jafri H, … Herrman H (2011) Partnerships
for better mental health worldwide: WPA recommendations on best practices in working with
service users and family carers. World Psychiatry 10(3):229–236
About the Book

Dr. Stylianidis and his colleagues have produced a comprehensive marriage of theoreti-
cal social psychiatry and current practice. Their analysis of the historical and conceptual
assumptions prevalent in the Greek situation and their impact on attempts to overcome
and/or make use of recent chaotic opportunities for change, carry lessons relevant for
many other parts of the world wishing to transform mental health services.

Dr. Marianne Farkas

Center for Psychiatric Rehabilitation
Boston University, USA

This book about social psychiatry and public mental health in Greece represents a
unique effort to bridge social psychiatry as a theory and as a set of applied strate-
gies. Its middle-income country perspective provides a rather innovative insight

Prof. Benedetto Saraceno,

School of Medical Sciences,
Nova University of Lisbon, Portugal

This book deals with principles of social psychiatry as applied in the current envi-
ronment that is especially critical for mental health. While awareness on mental
health has increased substantially, there are new threats to essential services due to
lack of adequate resources. The lessons of this book will be important to keep in
mind as countries and communities discuss their plan for mental health.

Dr. Shekhar Saxena

Department of Mental Health and Substance Abuse
World Health Organization, Geneva, Switzerland

ix
x About the Book

This is a book that has much to offer to readers interested in psychiatry and mental
health. It includes a comprehensive and original overview of the historical, concep-
tual, and operational aspects of social psychiatry. It critically discusses the process
of mental health reform in Greece, showing the impact of the economic crisis on the
mental health of the population in one the most affected countries in Europe. Finally,
it introduces the reader to the most recent contributions of psychiatric epidemiol-
ogy, of the recovery approach, and of global health and mental health promotion,
helping to understand why these contributions have radically changed mental health
across the world.

Dr. José Miguel Caldas de Almeida

Department of Mental Health
NOVA University of Lisbon, Portugal
Introduction

Social and community psychiatry cover wide, complex fields. Our contemporary
world requires that we re-examine those fields both from an interdisciplinary and
public health perspective.
The scope of social psychiatry ranges from understanding the impact of social
structures and experiences on the appearance, course and outcome of mental disor-
ders, through the development and evaluation of complex social interventions and
services, right up to the impact of society on the construction of mental disorders
and the responses it provides to them (Morgan and Bhugra 2010). From that view-
point we can argue that social psychiatry interacts with intercultural and community
psychiatry, taking a philosophical approach about the emergency and aetiology of
mental disorders, and intersects with a series of other scientific disciplines including
clinical psychiatry, various schools of individual and group psychotherapy, social
epidemiology, public health, sociology and anthropology. By formulating the basic
hypothesis that mental disorders like all mental phenomena cannot be seen outside
of the historical, socio-cultural and economic environment in which they emerge,
social psychiatry occupies an interim position between biomedicine, genetics, the
neurosciences, psychology and the social disciplines.
Social psychiatry has changed over time as it followed wider scientific, cultural
and policy developments in community psychiatry. According to Thornicroft and
Tansella (2001, 2010), community-based mental health services are those which
provide a full range of effective mental healthcare to a specific population and
which, in cooperation with other local bodies, train and help people with mental
disorders, so as to relieve their stress and pain.
Our key argument is that despite fears over the disappearance of both social psy-
chiatry and the special nature of psychiatry overall as a discipline for studying,
understanding and treating psychopathological phenomena, social psychiatry can
only be theorised about and implemented in practice through constant interaction
between genetics, biology, psychology and the social sciences. These disciplines
should not compete against each other or vie for importance with each other, but
ought to be factors in a common effort to understand the psychopathology of the
complex living being that is man, by taking a holistic approach to his existence.
The proclamations made by the world psychiatric community about the
biopsychosocial model of mental illness remain a lot of hot air in day-to-day clinical
practice, to the extent that emphasis is only placed on one of those aspects

xi
xii Introduction

(such as biological treatments to ease symptoms, or psychotherapy or psychosocial

interventions).
In conclusion, social psychiatry deals with the impact of the social environment
on an individual’s mental health and with how individuals facing mental problems
interact with their social environment.

Social Psychiatry and the Situation in European Countries

First, some specific data: one in four European citizens will have some sort of men-
tal health problem over the course of their lifetime (Herman et al. 2005). It’s esti-
mated that more than 27 % of adult European citizens will experience a mental
disorder every year, the most frequently occurring being stress-related disorders and
depression (Fryers et al. 2003; WHO 2010). In Europe, mental disorders are esti-
mated at 20 % of all disability, and according to the WHO by 2020 depression will
be the main cause of disability and disability-adjusted life years (DALYS) in the
developed world (WHO 2008). Despite governments, international organisations,
health policymakers, international research centres and universities having jointly
realised that the extent and scale of the mental health problem is immense, the way
in which mental health services are organised and funded in Europe varies wildly
and is far from being considered satisfactory. Given the current socioeconomic cri-
sis, which by the look of things will be long-lasting, the massive increase in social
inequalities and the increase in the vicious cycle of poverty, social exclusion, stig-
matism, self-stigmatism and the major increase in mental disorders, mental health
as a major public health problem continues to be very low on the political agenda of
EU countries, save for very few exceptions.
Implementing the WHO guidelines (2001, 2003) calling for a series of real actions
to promote and improve public mental health and defend the basic constitutional
rights of European citizens suffering from a serious mental disorder remains, to a
large degree, mere statements of principle that are far from offering the possibility of
comprehensive psychosocial interventions that meet the population’s real needs.
In addition, given the diverse economic, social and institutional crisis which is
shaking the very European venture to its core, and calling into question the viability
of the welfare state, the problem of limited resources, means and targets for psychi-
atric care systems has been raised and strongly reiterated by all stakeholders: politi-
cians, mental health professionals, family associations, users of mental health
services, local communities and local governments.
However, we find ourselves faced with a major paradox, at both global and
European levels: the few resources available for mental health are unevenly distrib-
uted, without any real evaluation and monitoring of the quality of care or the out-
come of all services provided. For example, the WHO’s Mental Health Atlas (2005)
states that Europe has the largest number of psychiatric clinics per capita in the
general population (8/10,000 residents) while 70 % of resources for mental health
are still being invested in old-style psychiatric hospitals or asylums – new commu-
nity-based institutions. Even though the differences in GDP between various
Introduction xiii

European states are not large, it is clear that mental health policy and the psychiatric
care models and culture which prevail are determined by a series of factors such as
the number of psychiatric clinics, the number of psychiatrists compared to other
mental health professionals, the number of hospitalisations on orders from the
Public Prosecutor, the revolving door phenomenon, the operation of social networks
to provide social care, the real involvement and participation of families and users
in the design and running of mental health services, and so on.
Consequently, a key issue in the current debate about mental health resources,
and about harmonising in- and outpatient models for providing psychiatric care
(what one might call a balanced care model approach), clearly highlights the impor-
tance of social and community psychiatry for the contemporary socioeconomic situ-
ation (Thornicroft and Tansella 2013). As Thornicroft and Tansella (2001) so aptly
point out, “Social care … is a vehicle for providing services. It can allow treatment
to be provided to a patient, but is not treatment in itself”. As part of this work, by
exploring different scientific and social approaches, we will attempt to show that
even today the key elements of treatments and the outcomes of different models and
schools are being inadequately monitored, assessed and evaluated.
Relatively recent European naturalistic studies such as the EPSILON Study,
ODIN Study and EuroSC and experimental studies (EQOLISE, EDEN Study, Quatro
Study) (Ruggeri and Bertani 2010) are very important pilot research attempts which
are sadly an exception despite the need to understand what is really going on, both
from the viewpoint of professionals and from the perspective of users of services
and their families.
One also needs to add to all these aforementioned problems and impasses in
older models of how services were organised, the problems of new objects of psy-
chopathology and current clinical practice, which derive from conditions of extreme
social exclusion, social insecurity, social inequalities and new forms of social pain
and day-to-day life of European citizens. The complexity of these new needs
requires innovative, inventive answers from interdisciplinary mental health teams,
which the simplistic reductionism of both the hospital-centred and biomedical mod-
els cannot provide. On the other hand, the social mandate given to mental health
professionals by the State, which is unable to support its welfare aspect, is to pro-
vide social control of those fluid, new forms of social pathologies via the systematic
logic of psychiatrising them (via changes in DSM-5) (Karavatos 2014; Kleinman
2012; Parker 2014).

Psychiatric and Mental Health: Conceptual Clarifications

It is commonly accepted both in the field of mental health and in related scientific
disciplines (philosophy, sociology, social anthropology) that there is conceptual
ambiguity, even confusion one might say, between the concepts of mental health
and psychiatry. That confusion, and the inability to demarcate the two disciplines,
has frequently affected theory and practice in social and community psychiatry and
also therapeutic work in clinical psychiatry.
xiv Introduction

Let’s take a more systematic look at the reasons for this confusion, by going on
a brief historical journey. Over the last 30 years at European and global level, an
extension and impressive transformation in the role of the initial mission and objec-
tives of public psychiatry (namely, prognosis, treatment and rehabilitation of mental
illnesses) have been observed. This expansion has benefited general mental health
policy aimed at preventing and treating all forms of psychological pain, including
non-pathological forms, while it has also attempted to modify social representations
of the general public using mental health promotion and education methods.
Thanks to that development, the initially “closed” discourse of clinical psychia-
try began to spread to all levels of social organisation (social work, education, the
workplace, trade union, associations, civic organisations, even lifestyle magazines),
but there had not been any real debate about what the boundaries, objectives and
nature of its clinical and therapeutic work were. One visible consequence of this
dissemination of “psy” discourse through all levels and networks of day-to-day life
(Stylianidis 2008), among others, was an immense mushrooming in the “psy” mar-
ket through the unthinking, unsubstantiated multiplication of hundreds of psycho-
therapeutic schools that sought to “treat the normal” and “develop everyone’s
personal skills and potential”.
In the 1880s American psychiatrists were already using the expression “mental
health” in reference to preventative actions in the urban environment, to avoid
behavioural disorders emerging in children (Ehrenberg and Lovell 2001). Thirty
years later the psychiatrist Adolf Meyer founded the American “mental health”
movement, whose key aim was to prevent psychiatric illnesses through research and
psychiatric care for mental disorders in the community.
In 1922 the French psychiatrist Edouard Toulouse (1865–1947) took the initia-
tive to set up a “mental disease prevention” clinic in Paris which combined open
structures and social services, making it the forerunner of the French psychiatric
sector, which only crystallised in the form we know it today in 1960 (Lovell,
op. cit.). Toulouse believed then that synergies between the American and French
mental health movement could trigger a radical transformation of traditional psy-
chiatry on a global scale (Ahrenfeld 1958). One can clearly understand that that
so-ambitious forecast came to naught.
There are various definitions of mental health, none of which is really satisfac-
tory. The most comprehensive definition is given by the WHO, which defines men-
tal health as “a state of well-being in which every individual realises his or her own
potential, can cope with the normal stresses of life, can work productively and fruit-
fully, and is able to make a contribution to her or his community”. The positive
dimension of mental health is stressed in WHO’s definition of health which states
that “health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity”.
The inadequacy of the definition derives from the fact that the concept of mental
health necessarily requires a value judgement: mental health means nothing except
in the context of a socio-cultural system which dominates in a given historical
period. This relativisation makes it difficult to recognise objective elements in the
definition which are universally acceptable. A brief analysis of some of the
Introduction xv

prevailing definitions shows that the same criteria systematically crop up again and
again: there are definitions based on the absence of mental illness, on identifying
mental health with normalcy, or even vague states of “well-being” deriving from a
balanced personality or from problem-free adjustment and integration to the social
world. Psychiatry is a scientific discipline dealing with the treatment of mental dis-
orders, but mental health is a discipline relating to the psychosocial well-being of
individuals and communities. Consequently, the twin ideas of illness/treatment are
not sufficient for or capable of incorporating the aspect of social pain, exclusion and
vulnerability which are characteristic of millions of individuals on the planet, irre-
spective of the presence or absence of specific mental disorders.
Consequently, such a reading raises major epistemological difficulties. The first
difficulty is associated with the nature of psychopathology, since the term “disease”
on its own is a source of confusion about the special nature of psychiatry to the
extent that it applies too across the rest of medicine. The second difficulty is that the
field of psychopathology, and the wider field of mental disorders, has become
exceptionally complicated, as evidenced by the successive, constantly expanding
classification systems that encompass the ever-increasing number of new patholo-
gies, which are published by the WHO (ICD) and IPA (DSM). The third difficulty
derives from the diversity and relativity of mental illnesses, which are widely known
thanks to the contribution of phenomenology, psychoanalysis and ethnopsychiatry.
Thus, defining mental health by reference to normalcy and problem-free adjustment
criteria remains exceptionally fluid and fragile. Besides, the well-documented con-
cerns expressed by Georges Canguilhem (Le normal et le pathologique 1972) and a
series of other philosophers have made it legitimate for us to ask the question “what
is normal?” To render the definition clear, do we need to adapt ourselves to a statisti-
cal model or a simplifying model? Both one and the other conflict with ordinary
observation and the logic of a “neutral” evaluator.
In contrast to these approaches, references to purely subjective criteria, i.e. the
subjective condition and experience of “well-being”, the way in which we perceive
our self image personal balance and happiness, quite self-evidently are not firm
scientific criteria, especially if one espouses Popperian logic.
In the context of this book, it is necessary to examine this paradoxical condition
about the fluidity of definitions of mental health from three viewpoints. Firstly, as
a field of special activities for promoting mental health and educating others about
it, which is something constantly evolving and developing. Secondly, as a body of
new knowledge, especially in relation to new forms of social pain and new social
pathologies (new forms of depression, new forms of addiction, new forms of grief,
new forms of “antisocial” behaviour) (Ehrenberg 2008, 2010). Thirdly, mental
health can be understood as a set of historically defined ways in which psychologi-
cal pain can be expressed. By examining these three viewpoints together, we can
better formulate a definition for mental health, both from the results of new prac-
tices (deinstitutionalisation and care in the community, the recovery movement, the
movement of users of mental health services and their families, new forms of
empowerment and advocacy) and from a fresh reading of its dynamic
representations.
xvi Introduction

In conclusion one might say that this brief overview of mental health definitions
has revealed that these three perspectives refer to three intervention rationales. First,
mental health can be viewed as a part of what it means to be human and the need to
promote health. Second, mental health can be viewed a forum within which pain is
expressed, whose social and cultural elements must be integrated. Third, mental
health can be viewed as a way for individuals to address diversity, life events and
different social, environmental and individual factors (Patel et al. 2006) utilising a
dynamic life plan and searching for a new equilibrium.
As Benedetto Saraceno so succinctly puts it (2014, p. 181), “being involved in
mental health means being involved with situations of pain which frequently include
diagnosed illnesses, which in most cases, are characterised by physical and mental
vulnerability, humiliation, poverty, social marginalisation, and exclusion from
access to basic rights. Being involved in mental health also means being involved
with pain and illness, with individuals and groups, with psychological, physical and
social aspects, not only with human bodies but also with emotions and feelings,
resources, opportunities and violations of rights”.

Maroussi, Greece Stelios Stylianidis

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Contents

Part I Social Psychiatry

1 A Brief Historical Overview of Madness

in Social Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Stelios Stylianidis
2 Philosophical and Sociological Foundations
of Social Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Stelios Stylianidis
3 Psychiatric Epidemiology and Its Applications
in Social Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Lily Evangelia Peppou and Stelios Stylianidis
4 Global Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Michail Lavdas, Stelios Stylianidis,
and Christina Mamaloudi
5 Psychiatric Reform in Greece . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Panagiotis Chondros and Stelios Stylianidis
6 The Contribution of Psychoanalytical Thinking
and Practice to Social Community Psychiatry . . . . . . . . . . . . . . . . . . . 93
Michael A. Petrou

Part II Applications of Social Psychiatry

7 Promoting Mental Health: From Theory

To Best Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Stelios Stylianidis, Pepi Belekou,
Lily Evangelia Peppou, and Athina Vakalopoulou
8 Social Suffering and Mental Health in Metropolitan
Athens: A Qualitative Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Stelios Stylianidis, Athina Vakalopoulou,
and Lily Evangelia Peppou

xix
xx Contents

9 The Recovery Model and Modern Psychiatric

Care: Conceptual Perspective, Critical Approach
and Practical Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Stelios Stylianidis, Michail Lavdas, Kalomira Markou,
and Pepi Belekou
10 Mobile Mental Health Units on the Islands:
The Experience of Cyclades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Stelios Stylianidis, Stella Pantelidou, Antonios Poulios,
Michail Lavdas, and Nikos Lamnidis
11 Community Child Psychiatry: The Example
of Mobile Mental Health Units in the NE
and Western Cyclades. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Stella Pantelidou, Vicky Antonopoulou, Antonios Poulios,
Jenny Soumaki, and Stelios Stylianidis
12 A Modern-Day Community Daycare Centre
in Operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Stelios Stylianidis and Dimitris Trivellas
13 Assertive Community Treatment: Home Intervention for People
with Severe and Enduring Mental Health Problems:
Designing the Greek Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Alex Krokidas, Xenia Varvaressou, and Stelios Stylianidis
14 Brief Psychotherapy in a Community Framework . . . . . . . . . . . . . . . 277
Marina Skourteli and Stelios Stylianidis
15 Community Mental Healthcare for Migrants . . . . . . . . . . . . . . . . . . . 309
Nikos Gionakis and Stelios Stylianidis
16 Modern Technologies and Applications
and Community Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Orestis Giotakos
17 Assessment and Management of Domestic Violence
Cases Within a Community Mental Health Services
Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Stella Pantelidou, Athina Vakalopoulou,
and Stelios Stylianidis
18 Sexuality of Patients with Serious Psychiatric Disorders
in Psychosocial Rehabilitation Units . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Stelios Stylianidis, Pepi Belecou, and Stelios Farsaliotis

Part III Evaluation

19 Evaluation of Social Psychiatry Services . . . . . . . . . . . . . . . . . . . . . . . 389

Stelios Stylianidis, Petros Skapinakis,
Venetsanos Mavreas, and Michael Lavdas
Contents xxi

20 Implications of the Socioeconomic Crisis for Staff in Community PSR

Units: The Case of an NGO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Stelios Stylianidis, Klimis Navridis, and Anna Christopoulou
21 Staff Evaluation and Presentation of Organisational
Culture in Mental Health Structures . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Stelios Stylianidis, Meni Koutsosimou, Nikos Symeonidis,
Panagiotis Chondros, and Giorgos Chadoulis

Part IV Empowering and Rights in Mental Health

22 User and Family Participation in Mental Health Services . . . . . . . . . 437

Panagiotis Chondros, Stelios Stylianidis, and Michael Lavdas
23 Involuntary Hospitalisation: Legislative Framework,
Epidemiology and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Stelios Stylianidis, Lily Evangelia Peppou,
Nektarios Drakonakis, and Emilia Panagou
24 The Impact of the Economic Crisis in Greece:
Epidemiological Perspective and Community Implications . . . . . . . . 469
Marina Economou, Lily Evangelia Peppou, Kyriakos Souliotis,
and Stelios Stylianidis
25 Afterword: The Economic Crisis and Mental Health . . . . . . . . . . . . . 485
Stelios Stylianidis, Panagiotis Chondros,
and Michael Lavdas
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
 Part I
Social Psychiatry
A Brief Historical Overview of Madness
in Social Psychiatry 1
Stelios Stylianidis

Abstract
The definition of madness and how it has been dealt with in different historical
periods establish the social, cultural and institutional foundations for the emergence
of psychiatry as a separate scientific discipline and the development and establish-
ment of the schools of social and community psychiatry. This chapter examines the
historical background of psychiatry and mental health from the viewpoint of the
change in the social and scientific handling of madness and the interplay of wider
cultural and social processes. This historical development begins in antiquity, con-
tinues with the emergence of asylums and the examination of “nervous disorders”
in the Victorian age through the development of measures to promote mental health
taken between WWI and WWII and the wider mental health movements which
emerged in both Europe and the USA and came to fruition in the modern age and
concludes with us highlighting contemporary issues, conflicts and concerns.

1.1 Introduction

This chapter focuses our attention on the development of the discipline of

psychiatry and of mental health from the age of asylums (1800–1900) to the
modern day.

Tomorrow, during the visit, when you try to communicate with those people without any diction-
ary, remember and realise that you are superior is only one regard: Strength.
F. Basaglia (1963)
(From the Manifesto of the French Surrealist painters to the Asylum Directors, 1923)

S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 3

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_1
4 S. Stylianidis

By examining its historical development from the vantage point of a twenty-first-

century observer, it is impressive to see how the field of mental health has developed
via institutions, new psychiatric care structures, professionals and users of services.
For example, in 1890, only a very small number of professionals could call them-
selves psychotherapists in the USA (VandenBos et al. 1992). Today, even applying
stricter criteria and in the same country, a minimum of 100,000 professionals are
now considered to be highly specialised psychotherapists, and using wider criteria,
more than 250,000 psychotherapists and mental health counsellors meet the needs
of the US population.
In addition, the mental health sector has improved in terms of quality: the range
of treatment options has expanded impressively from institution- and asylum-based
care to the “traitement moral” of the nineteenth century to a wide diversity of psy-
chological and pharmacological interventions which have become available over
the last decade. Likewise, the number of related scientific disciplines has grown too
at a rapid pace, frequently via harsh struggles with one school of psychotherapy
vying for pole position against another. Today, the field of mental health does not
only include psychiatrists, psychologists and psychoanalysts but also psychothera-
pists from various schools and creeds, nurses, social workers, speech therapists,
logopedists, mental health counsellors, as well as priests, and GPs with special
training in psychosomatic conditions.
The growth of the mental health sector is also tied – in a quite complex way –
with cultural and social mechanisms and with the development of the scientific
disciplines of psychiatry and psychology. On the one hand, it reflects wider cultural
processes at play such as individualisation, the appearance of social management
and the psychiatrisation of social phenomena.
Via the general, brief historical overview we provide, we attempt to show the
turning points in the social and scientific handling of madness and how this ties into
wider mental health movements which emerged in both Europe and the USA. This
historical development commences with the emergence of asylums and an examina-
tion of “nervous disorders” in the Victorian age, goes on to examine the growth in
measures to promote mental health between WWI and WWI and ends with a short
analysis of contemporary tensions in the field of psychiatry.

1.2 From Antiquity to the Emergence of Asylums (Fifth

Century BC to 1800)

Deviant forms of behaviour, which we nowadays associate with mental disorders,

were examined in detail by Hippocrates (460–377 BC), Asclepius, Galen (130–200
BC) and Aristotle (384–322 BC) in antiquity. Findings brought to light during
archaeological excavations provide firm evidence of this: skulls with holes drilled
into them, clearly in an attempt to free the diseased person of the spirit which pos-
sessed him (Kaprinis et al. 2009).
Later when the Byzantine Empire was at its peak, under the influence of Arabic
culture, methods for dealing with mental disorders which were more humane came
1 A Brief Historical Overview of Madness in Social Psychiatry 5

to the fore, involving protecting the rights of the mentally disturbed and avoiding
non-beneficial forced periods of hospitalisation; in fact the ways in which health
and mental health services were organised could be characterised as forerunners of
current mobile mental health units (Stylianidis et al. 2007). Reliable historical
sources note that medicine in Byzantium was strongly influenced by the advances
made in the Classical period and the Hippocratic approach. Byzantine doctors,
many of whom were also men of the cloth (bishops, metropolitans, etc.), studied in
Athens, and their medical practice placed particular emphasis on caring for the
mentally disturbed. It is worth noting that closed care facilities in Byzantium (poor-
houses) had features of modern-day milieu therapy and included industrial therapy
as well. In contrast to the medieval West, the “psychiatric culture” of Byzantium
drew a clear distinction between perceptions and practices of demonic possession
and mental illness.
Under the Ottoman Empire, various foundations were set up which served more
as places for treatment and rehabilitation and less so as places of imprisonment
(Ploumpidis and Evans 1993).

1.3 The Emergence of Asylums and the “Traitement Moral”

(1800–1900)

Before asylums were set up, there was no organised system for treating deviant
behaviour. In the Middle Ages in the West, people considered to be mentally ill who
exhibited strange or dangerous forms of behaviour were cared for by their families
or the community, and only rarely were they locked up in special, separate homes
like the “dolhuysjes” of Holland (Abma 2004).
The first known asylum for the chronically ill was founded in Valencia in 1409.
Asylums then spread rapidly through Spain and other European countries. The vast
majority of these institutions were under the aegis of the Catholic Church and only
provided asylum-style care (Foucault 1961a).
Then in the mid-seventeenth century, as more people began moving to cities and
farmers began abandoning the countryside en masse for large European urban cen-
tres, city authorities had to urgently impose rules for preserving social order and
cohesion. The monumental work of the philosopher Michel Foucault and his gen-
eral contribution to our understanding of the “great confinement” has been a guiding
force in tracing instances of social exclusion of diversity throughout that historical
period, which is a matter explored in more detail in the next chapter.
The Hôpital Général was founded in Paris in 1656, designed to lock up the
unemployed, the poor and anyone who deviated from the model of productivity
and rationalism and constituted a threat to the preservation of the social order. The
shared dogma of that time in Western Europe was that “normal” people act ratio-
nally, respect social order and accept the economic ideal of productivity. Those
who did not comply were deemed “mad” and “affected” (aliénés) and had to be
locked up in major institutions. The goal of locking them up was to educate these
individuals through forced labour and religious practices, in the belief that these
6 S. Stylianidis

“immoral” individuals would be able to internalise the moral rules being forced
on them.
During the eighteenth century, doctors in various European countries, influenced
by the ideas of the Enlightenment, confirmed that as a disease “madness” could be
treated. In England, William Battie published the Treaties of Madness in 1758,
thereby announcing that psychiatry was both a science and a form of treatment.
Some decades later, doctors like William Tuke in England, Philippe Pinel in France,
Johann Reil in Germany and Vincenzo Chiarugi in Italy developed theories and
hypotheses about the organic aetiology of madness. In the same vein, the American
doctor Benjamin Rush wrote in 1812: “The cause of madness is seated primarily in
the blood vessels of the brain, and it depends upon the same kind of morbid and
irregular actions that constitute other arterial diseases”. These biological views
about the causes of madness had almost no therapeutic value. It is no coincidence
that the first treatment methods were based on social and psychosocial principles
rather than medical ones. The forms of treatment/care which developed consisted of
an intensive, detailed system of discipline aimed at “reinstilling” morality into the
mental life of patients. For that reason, the mentally ill were confined to separate
institutions in their countries, which were specialised in the “traitement moral”. The
first of these was the Retreat Institution in York, founded in 1796 by William Tuke.
In France, Philippe Pinel in his work Traité médico-philosophique sur l’aliénation
mentale, ou la manie (translated under the English title of the Treatise on Insanity)
focused on the psychological core of the “traitement moral”. The patient had to
place himself under the imposing prestige of an individual “who through his physi-
cal and moral properties is able to exert an invincible impact on the patient and
change his perverse chain of ideas”. In other words, by “liberating” the mad from
their chains, the “traitement moral” was imposed on them as a mixed system of
persuasion and effect, focused on the moral prestige of the doctor, all of which took
place within a well-organised institution.
However, because the “traitement moral” was not medically substantiated, it was
also invested in by other professionals. For example, philosophers, judges, priests
and even “charitable volunteers” preached that they too could do just as well and be
as effective in implementing the “traitement moral”. In the end, the “traitement
moral” was considered to be an ineffective method, as had initially been suspected,
and in 1880, it was abandoned as a form of treatment.
As far as the development of psychiatry itself is concerned, in the first half of the
nineteenth century, psychological interpretations dominated the understanding of
mental phenomena, especially in Germany, where two schools of thought, the
Psychiker and the Somatiker schools, were in conflict. However from 1850 onwards,
an organic approach to the pathogenesis of mental illnesses began to prevail. One
example of this is the German professor Wilhelm Griesinger, who argued in one of
his works in 1845 in a quite dogmatic manner that “mental illnesses are diseases of
the brain”, a view supported by the boost given to medical research by the discovery
of the syphilis bacteria at that time. Likewise the work of Morel in France and
Maudsley in England contributed to the purely biological orientation of research
into psychiatry (Abma 2004, p. 98).
1 A Brief Historical Overview of Madness in Social Psychiatry 7

However, at the end of the nineteenth century, both the psychological and bio-
logical approach experienced a crisis, to the extent that no theory could adequately
explain the pathogenesis of mental illnesses. However, the immense contribution of
the German psychiatrist, Emil Kraepelin (1856–1926), appeared to show a way out
of the crisis. Successive editions of his work on dementia praecox, as schizophrenia
used to be called, and his important development of a system for classifying mental
illnesses, based on tens of clinical observations of patients in psychiatric institu-
tions, meant that Kraepelin exerted a major influence on the shape of psychiatric
nosography and therapeutic practice.
In short, through the culture of “curability” which prevailed in the nineteenth
century in Western countries, asylums which had been used to lock up the insane
gradually began to transform into treatment institutions, hosting an increasingly
growing number of patients. However, treatment in the context of an asylum did not
also go hand in hand with corresponding developments in psychiatric theory.
Theoretically speaking, the focus was on rational and scientific explanations of men-
tal phenomena, but the dominant theoretical references and forms of treatment still
derived from the Enlightenment tradition. Towards the end of the nineteenth century,
the golden age of psychiatry appeared to be reaching the end of its own delusion. At
a therapeutic level, the “traitement moral” was considered a failed method to the
extent that those few patients who were able to abandon the asylum returned to it,
thereby bolstering the “revolving door” phenomenon so well known to us all today.

1.4 Nervous System Diseases and Victorian Era Illnesses

(1870–1920)

In addition to the emergence of large institutions, treatments and theories concern-

ing serious psychiatric disorders (madness) at the end of the nineteenth century,
another form of mental illness also emerged, milder forms of mental disorders,
more paroxysmal and not so chronic, with symptoms and vexations such as fatigue,
a general sense of weakness, mental instability and a feeling of impending collapse.
These “nervous disorders” were introduced, along with madness, as a new class of
mental problems. This development not only defined the expansion of the field of
psychiatry into what we nowadays call mental health but also highlighted a new
professional group within that discipline, called neurologists.
Victorian era illnesses, primarily characterised by symptoms of fatigue and
weakness, without any determinate organic foundation, had already been described
in various forms in the seventeenth and eighteenth centuries. During those periods,
these illnesses were dealt with using a variety of treatments, including mesmerism
and “animal magnetism”. The fluidity of these symptoms led to them being lumped
together in as “neurasthenias”, meaning weaknesses of the nerves. For example, one
can mention the American doctor, George M. Beard, who described the illness in
depth in his book entitled American Nervousness (1881). Neurasthenia was a “use-
ful” diagnostic term, because it medicalised a series of mental symptoms while also
releasing mental illnesses from the stigma of madness.
8 S. Stylianidis

In that way, from the mid-1800s to the historically recent full segregation of the
disciplines of psychiatry and neurology (which took place in the 1970s and 1980s
in Europe), neurology developed as a new medical specialisation which backed up
its therapeutic approach in medical terms, generating remarkable results both con-
cerning conditions of the nervous system and mental disorders in general. In addi-
tion to criticising the asylum system as anti-therapeutic and ineffective, neurologists
also proposed that Victorian era illnesses be treated in private clinics and university
clinics using treatment methods which included everything from hypnosis and sug-
gestion to exhortations towards moral improvement, travel and rest at specially
designed sanatoria.
The underlying theory on which these practices rested was the belief that condi-
tions of the nervous system could be treated through some form of physical treat-
ment. With that in mind, S. Weir Mitchell, a famous neurologist of the period, stated
that You treat the body and in some way you find that the mind is also treated
(Zakzanis et al. 1998).
The counterweight to the causes of neurasthenia and hysteria, which date from
the eighteenth century, focuses not on the nervous system but on mental functions.
In Europe, the roots of these diseases were thought to rest in the individual uncon-
scious, in the form of unchecked base urges: it was therefore thought that these
urges could be suppressed through hypnosis or free association. Hypnotism was
used and developed by the famous French neurologist Jean-Martin Charcot at Paris’
Pitié-Salpêtrière Hospital, where Freud (1856–1939) himself studied, and was an
important turning point in the process of discovering unconscious functions and the
role of sexual drives in the emergence of neuroses and more generally in establish-
ing psychoanalytic theory and practice.
The introduction of the concept of neurasthenia, which we examined above,
made a decisive contribution to a clear dividing line between the two types of men-
tal disorders, madness and nervousness, and a dividing line between psychiatrists on
the one hand and neurologists and all other types of psychotherapists on the other,
as professionals.
However, because psychiatrists believed they were losing ground and their clini-
cal practice would be limited to work in large institutions, they attempted to bridge
the gap between madness and neurasthenia by introducing the concept of preven-
tion. This concept brought major changes to the world of mental health, based as it
was on the assumption that the failure of the traitement moral for madness was due
to the fact that serious psychiatric disorders had already become chronic as a devel-
opment of non-treatable forms of neurosis.
So, in the name of prevention, a methodology for timely diagnosis and treatment
of neuroses in the community could be applied. Through this development, the
boundaries between academic discipline and the practice of psychiatry and neurol-
ogy became blurred and fluid. The emergence of psychiatrists from asylums also
contributed to a new area of specialisation developing, that of psychiatric social
work, which in effect, if practised by a psychiatrist, was the forerunner of profes-
sional social psychiatry. The psychiatrist, Adolf Meyer, who studied medicine in
Switzerland, migrated to the USA in 1892, where he played a leading role in setting
1 A Brief Historical Overview of Madness in Social Psychiatry 9

up the movement for community mental healthcare, as part of his work at the
New York State Psychiatric Institute. His working hypothesis was that psychiatric
disorders were a manifestation of an unhealthy life and ineffectual adjustment by
the individual to his social environment. However, we need to take a critical stance
towards that innovation for its time, to the extent that it proposed not just individual
treatment but a complex web of precautionary mental health and social control mea-
sures for all forms of deviant behaviour, such as sexual perversions, rape and violent
criminal behaviour.
On the initiative of a former patient, Clifford Whittingham Beers, who suffered
from bipolar disorder, the first social mental health association was set up on the
advice of Meyer in 1908, and the national mental health committee followed in
1909 (Reisman 1991). However, what is of interest is the different types of interven-
tions that fell under the “mental health” umbrella. The prevention principle expanded
the field of mental health, to incorporate not just patients with mental and nervous
conditions but also all persons who were at risk. What Meyer wrote in 1930 is illus-
trative indeed of this point: mental health as a prevention philosophy is an ideal,
and a guiding principle in work, in the context of daily life, where possible, before
the ‘normal’ and pathological diverge. It is worth noting at this point that the con-
flict between treatment/prevention and social control which runs through the field of
psychiatry to this day was already present in a movement which was progressive for
its time in the USA, the social mental health movement (Castel 1981). From that
point in history on, the path opened up for full medicalisation of social deviance, as
shown by the works of Foucault and Basaglia (Foucault 1961b; Basaglia 1963). In
the USA in particular, we can see a synergy between psychiatrists, churches and
social workers, to expand the role of the discipline of psychiatry, to include not just
treatment of serious psychiatric disorders and also to promote “proper” adjustment
and mental care for “normality”.

1.5 The Mental Health Movement (1914–1960)

Both the therapeutic impulse and the wish to more effectively manage mental disor-
ders led to a truly impressive growth in the field of mental health, in the interwar
years and especially so after WWII. The painful experiences of WWI played a deci-
sive role in this change. For the first time in the history of psychiatry, psychiatrists
were directly involved in military activities. Their efforts were complemented by
clinical psychologists who developed a new diagnostic tool, which was more objec-
tive and rational compared to the past: psychological tests. For the general public,
during the 1920s and 1930s, any basic knowledge about psychology had to do with
psychoanalysis. At the same time, social policymakers viewed both psychoanalysis
and its main competitor at that time, behaviourialism, as important pillars in their
attempt to regulate normal and deviant behaviour.
With the outbreak of WWI in 1914, new destructive technologies emerged on the
battle field (Binneveld 1997). These new technologies also led to the emergence of
new mental disorders, such as hysterical blindness, paralytic crises, terrors,
10 S. Stylianidis

exhaustion and total disorientation. In 1916, the British psychiatrist Myers coined
the phrase “shell shock” to describe persistent symptoms which were initially attrib-
uted to shell explosions. Those symptoms (inability to reason, disturbed sleep pat-
terns, hyperactivity, verbal diarrhoea, loss of self-control) were initially attributed to
physical causes (the explosions) affecting soldiers serving in the artillery and if they
emerged in other soldiers were thought to be neurotic reactions of individuals
exposed to traumatic situations.
New clinical data forced traditional military psychiatrists to move beyond classic
treatment methods being used at that time (military drills, electroshock treatment,
isolation, cold showers, imaginary surgical procedures, “drowning” treatment) and
to implement new psychiatric and psychotherapeutic methods. Military neuroses
offered new material for observation and stressed the already well-known relation-
ship between mental disorders and everyday living conditions.
From the 1920s onwards, psychological interpretations of human behaviour
attracted increasingly more popular attention (Burnham 1988). The populist new
psychology manuals which began to be published, A. G. Tansley’s The New
Psychology and Its Relation to Life (1920), exerted a particular influence, while a
series of articles in the press made the key elements of Freudian theory widely
known, and to a large extent it was adopted by the general public as a new cultural
phenomenon. With the rise of Nazism in Germany in the 1930s, in particular, a
whole generation of European psychoanalysts migrated to the USA resulting in
psychoanalysis becoming the dominant theoretical orientation of psychiatry up
until the end of the 1960s.
WWII marked the emergence of a large range of innovations and the development
of the field of mental health, due to the fact that the war embroiled a large number of
healthcare professionals in various ways of diagnosing and treating military men. At
the same time, the social reorientation of psychiatry, both in terms of its theoretical
prospects and preventative and therapeutic interventions, led to the creation of social
structures providing psychiatric care. It is worth pointing out that the war made it
easier for a large number of clinical psychologists to actively participate in various
mental health activities. Moreover, the psychological needs of the military and the
rest of the population during WWII meant that not only were then-current psychiatric
and psychological treatments more widely disseminated, but so too did psychologi-
cal ideas and techniques between common currencies among military personnel. The
mass production of self-help books relating to self-management of one’s emotions in
times of crisis allows us to better understand the current massive growth (especially
in the English language literature) of populist self-help for specific psychiatric disor-
ders and the multiplication of the number of manuals available on personal growth
and how healthy individuals can improve their skills. Effective adaptation to the envi-
ronment and the ability to manage difficult social and psychological techniques
became the new goal for clinicians in the field. For example, we can cite Carl Rogers,
who was the clinical psychologist who exerted a decisive influence on counselling
for mental health issues in America and who defined clinical psychology as the tech-
nique and the art of applying psychological principles to the individual’s problems to
achieve a more satisfactory degree of adjustment.
1 A Brief Historical Overview of Madness in Social Psychiatry 11

Against this backdrop of an expanding mental health sector, it should be noted

that the National Committee for Mental Health in the USA adopted an action plan
in the 1960s. It foresaw the establishment of numerous mental health centres in all
States, to bolster social cohesion and stability. That plan was given legal substance
under the presidency of John F. Kennedy when the Mental Health Act was enacted
in 1963.
While psychotherapists from various schools and trends were constantly expand-
ing their activities in the provision of mental health services in the community, psy-
chiatrists in psychiatric hospitals were attempting to find therapeutically effective
approaches to the psychosocial rehabilitation of serious psychiatric disorders, and in
particular schizophrenia. The majority of psychiatrists relying on their belief that the
fits in grand mal epileptic crises were biological competitors of schizophrenia
attempted to apply that principle to the treatment of schizophrenic patients using
artificially induced insulin comas and electroconvulsive therapy (ECB). These shock
treatments appeared to suppress certain symptoms, but no one – not even at that
time – could ignore the serious and sometimes long-term side effects they caused.
At the same time, a more extreme and irreversible form of medical intervention
entered the psychiatric realm: prefrontal lobotomies. This method was developed in
1935 by the Portuguese neurosurgeon, Egas Moniz, who won the 1949 Nobel Prize
for Medicine for inventing it. These developments were complemented by the dis-
covery of chlorpromazine in 1952, by the Frenchmen Delay and Deniker, at Paris’
Sainte-Anne Hospital, which was a historical turning point as the first effective
antipsychotic treatment. Despite the fact that neuroleptics were discovered by acci-
dent (chlorpromazine was initially used as an anaesthetic) and at that time there was
no scientific evidence to support the precise biological action of psychoactive sub-
stances, this discovery caught the interest of both medical research and the pharma-
ceutical industry. These changes, plus the publication of the first edition of the DSM
by the American Psychiatric Association, radically altered the general public’s
image of psychiatry, calling into doubt phenomenology and psychodynamic prac-
tice in clinical treatment which had dominated up until that point.
However, it is worth noting that both psychoanalysts and the representatives of
other psychotherapeutic schools at that time (person-centred treatment and the coun-
selling of C. Rogers, all post-psychoanalytic therapies, such as behaviourialism) sup-
ported the importance of the psychological pathogenesis of mental disorders,
compared to the biological reductionism of emerging biological psychiatry, and that
psychotherapies should be provided in a social context and ought to be scientifically
backed up and should not be based on moral and philosophical approaches.

1.6 Radicalism: From Psychiatry to the Deinstitutionalism

Movement (1960–1980)

The 1960s and 1970s were a period of radical upheavals both in sociopolitical terms
and in the mental health sector. On the one hand, Western societies gradually showed
an increasing interest in mental health and improving care for sufferers, which was
12 S. Stylianidis

accompanied by the “personal growth” movement as we already mentioned. On the

other hand, influenced by radical ideologies (Marxist ideology, demands for social
and political liberation, the emergence of the concept of the subjective and social
integration of diversity, social liberation movements like feminism, the gay move-
ment, etc.), various social collectives transformed the basic assumptions of tradi-
tional psychiatry and psychology into a key question. Institutional/asylum-based
psychiatry and culture underwent intense, subversive criticism because of the social
control they exerted and because of the suppression and stigmatism of mental
patients, who were now viewed as the victims of a social injustice. From this ideo-
logical viewpoint, mental illnesses were considered by certain authors and mental
health professionals to be a myth which disguised social deviance and gave a pseu-
doscientific legitimacy to the suppressive power and violence of asylums. As a
result, alternative theories and interpretations of mental illness were developed,
such as antipsychiatry and the Italian deinstitutionalisation movement (these two
ought not to be confused though) which formed a mass social movement which
contested the institutional and neo-institutional culture and the dominance of the
biomedical model’s culture. The theoretical views of these movements which con-
tested traditional approaches, and their practical consequences on changing tradi-
tional psychiatric care, will be explored in more detail in Chap. 3 of this book. Here
we will limit ourselves to pointing out certain illustrative views from the protago-
nists of this theoretical and social challenge to the role of psychiatry.
First, Thomas Szasz (1976) published The Myth of Mental Illness where he
argued that most mental disorders are an expression of problems, exclusions and
conflicts in social life and are not due to a chemical imbalance in the brain or some
other type or organic aetiology. Consequently, biological, surgical or pharmaceuti-
cal treatments were a fraud, and covered over the real problem, both for mental
health professionals and the general public. While Szasz was developing his theo-
retical views in the USA, in Europe, alternative therapies were being developed for
psychotic and neurotic patients, such as group therapy, systemic family psycho-
therapy and a myriad of other psychotherapeutic techniques which, although lack-
ing in serious scientific documentation, created an anti-culture which competed
against traditional psychiatry. In Great Britain, for example, R. Laing, inspired by
existentialism, phenomenology and social analyses conducted by the American
sociologist E. Goffman into “total institutions” (1963) and the unjustified power of
psychiatrists, experimented with new forms of group and family psychotherapy for
schizophrenic patients. At around the same time, David Cooper coined the term
antipsychiatry in his well-known book Psychiatry and Anti-psychiatry (Cooper
1967).
At the same time, leading intellectuals from other countries like the French phi-
losopher Michel Foucault, in his monumental work The History of Madness (1961a)
and the social psychiatrists Dorner (1969) in Germany, in his work Citizens and
Madness (Burger und Irre), and Foudraine (1974) in Holland, in his well-known
work Not Made of Wood, enriched the literature of critical psychiatry. All these
intellectuals, with the assistance of Franco Basaglia, who set himself apart from
antipsychiatry by calling himself and his approach anti-institutional (Basaglia and
1 A Brief Historical Overview of Madness in Social Psychiatry 13

Tranchina 1979; Stylianidis et al. 2010; Tzanakis 2008; Louzoun and Stylianidis
1987), agreed that instead of performing the humanitarian and scientific role which
they professed in treating mental disorders, traditional psychiatrists were in effect
merely servants of a repressive, alienating power which aimed to ensure social con-
trol over socially and politically deviant citizens.
The impact of these antipsychiatry and deinstitutionalisation movements, despite
their occasionally simplistic formulations about understanding the complexity of
mental illness, made a decisive contribution to the development of social mental
health structures, fully replacing psychiatric asylums with best psychiatric reform
practices and improving the exploration, acceptance and destigmatisation of mental
illness.

1.7 “Rationalism” (1980 to the Present Day)

In the age of humanitarian psychotherapies and the antipsychiatry and anti-

institutionalist movement, social care and psychotherapy reached their apogee. All
these changes are consistent with the accelerating rise in requests from the public
for social mental health services including counselling services and treatment for
“normal” people. In many Western countries, psychotherapeutic practice was an
integral part of public mental health and the increase in requests for psychotherapy
made the cost of these services skyrocket. The gradual rolling back of the welfare
state and its collapse at the present time in quite a few European countries, and the
dominance of the neoliberal dogma and the culture of financial capital and the mar-
kets, resulted in all public mental health services being “rationalised”. The now
urgent strategic goal in mental health policies inspired by liberal models was to
introduce the concept of “managed care” from the USA to Europe and to measure
cost-effectiveness of the system’s benefits using new diagnostic and treatment tools.
DSM-III (Gonon 2013) released in 1987 was now thoroughly “atheoretical” in
character, free of any psychodynamic or phenomenological approach (by abolishing
neuroses, personality structure and defence mechanisms in the new classification)
and formulated a purely neutral descriptive terminology which is supposed to
improve the credibility of psychiatry and put it on a par with other medical
specialisations.
The discovery of neurotransmitters, genetics, neurophysiology and psychoneu-
roimmunology, pharmaceutical research and new imaging methods (MRI, PET)
that allow us to see how the central nervous system works have generated significant
evidence that anomalies in brain function correspond to specific mental disorders.
Consequently, from the 1990s to the present day, the new treatment culture is based
purely on the biomedical model, to the extent that the interests of both mental health
policymakers and the pharmaceutical industry and the large majority of the psychi-
atric community “converge” about the adoption of low-cost, rapid, easy treatment
solutions for all forms of psychological functions. Whatever is not evidence-based
psychiatry and cost-effective and does not involve a standardised approach to the
treatment of mental disorders no longer has any place in the psychiatric landscape.
14 S. Stylianidis

Measurable effectiveness of behavioural/cognitive psychotherapies and an exten-

sion of the indications for using psychotropic drugs on “new pathologies” and on
younger ages (e.g. hyperactivity disorder in children, antisocial behaviour in adoles-
cents) require manu militari the dominance of biological psychiatry and short-term
psychotherapeutic interventions compared to any long-term, financially costly
forms of psychoanalytical approach or any holistic handling of complex biopsycho-
social and spiritual-cultural needs of the patient, compared to any long-term indi-
vidualised care and psychosocial rehabilitation plan for serious psychiatric disorders
(Stylianidis and Lavras 2012; Dimitriadis 2013; Stylianidis and Ploumpidi 2014).
However, new and constantly expanding complex needs for psychiatric care and
mental health in the general population and new vulnerable social groups afflicted
by globalisation and the economic crisis (Patel and Prince 2010) have necessarily
raised new challenges for psychiatry, governments and groups of users of services
as well as their families.
In order to rise to those challenges, a change in psychiatric culture and ways of
thinking is needed, and new practices and innovations via a new form of scientific
documentation must be promoted. In other words, a fourth psychiatric revolution is
needed which will promote a new scientific and social culture for psychiatry, mental
health, education and research focused on understanding and treating subjective and
social pain and diversity.

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Philosophical and Sociological
Foundations of Social Psychiatry 2
Stelios Stylianidis

Abstract
We will deal in this chapter some aspects of the work of Michel Foucault and
some of the major figures of existentialism, a work that laid the sociological and
philosophical foundations for the formation of the critical psychiatry and deinsti-
tutionalisation movement. We will also explore the subject formation problem-
atic, by looking into the contribution of phenomenological psychoanalysis and
the connection between the phenomenological approach to philosophy and
Franco Basaglia’s thought, which constitutes the essential challenge to the psy-
chiatric implementation of the biomedical model. In the same perspective, we
will finally analyse some of the transformations that contemporary psychiatry
underwent in the age of the ideological domination of neoliberalism in the
domain of mental health as well.

2.1 The Sociological Foundations of Social Psychiatry

Psychiatry and the Enlightenment, namely, the Age of Reason, diverge from one
another on two principal lines of thought. There is, on the one hand, the importance
attributed to the notion of reason, which, by promoting order in society and technical
solutions to human problems, leads to the event of the “great confinement”, as
Foucault (1972) put it. In its scientific, technical, and technological expression, this
tendency results in the creation of psychiatry, whereas another line of Enlightenment
thought focuses on the individual, the exploration of subjectivity and the Cartesian
forms of phenomenology and psychoanalysis. Scientific reductionism, i.e. the over-
simplification by academic and traditional psychiatry of complex psychopathological

S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 17

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_2
18 S. Stylianidis

phenomena or phenomena expressing the human psychic and mental function, is

formed at the end of nineteenth century. Reductionism is a one-dimensional attempt
to explain aspects of a multileveled individual and collective sensegiving (psychic,
social, mental, anthropological, political, historical) by means of scientific entities,
such as genes and neurotransmitters. The tradition of reductionism in psychiatry
places great emphasis on the role of experts, namely, those who have the privilege to
be the narrators in what happens during the technological framing of problems and,
therefore, in identifying and establishing the causal processes that can be scientifically
manipulated. Put schematically, there is no scientific knowledge if there is no
documentation.
This viewpoint establishes a methodological individualism; it focuses, in other
words, on aspects of human behaviour, such as the symptoms, independently of the
context within which the latter are observed. Therefore, when referring to the socio-
logical foundations of traditional psychiatry and to the criticism it underwent by
community psychiatry in order to transform itself into a new body of knowledge and
a novel social practice, it is important to remark that its primordial interest lies in an
understanding founded solely on science and in the promotion of therapeutic
approaches based on technology. Traditional psychiatry is interested in notions like
sense, values or relations only marginally, secondarily and in an attempt perhaps to
find a democratic alibi for its practice. In contrast to this epistemological, ethical
and philosophical approach, critical psychiatry, from whose current stems social
psychiatry, focuses primarily on the ethics and hermeneutics of madness, on social
malaise, social suffering and alienation. Its interest in the development and analysis
of special technologies is only secondary. In the first of the following figures, one
can discern the dissociation between biology, psychology and culture pertaining to
the viewpoint of the “hard” biomedical paradigm; the perspective changes radically
in the second figure, whereby the suffering subject and its lived experience is placed
in the centre of the intersecting domains. In this chapter, the ontology of mental suf-
fering, along with the soul-body dualism, will be studied in more depth within the
context of phenomenological psychiatry.
The hard biomedical model (Fig. 2.1) has biology, psychology and culture at its
centre, whereas the soft biomedical model (Fig. 2.2), the model on which social and
community psychiatry is based, has at its centre the experience forming the point of
intersection between psychology, biology and culture. There is no actual separation
between the biological, the psychological and the cultural outside of a unitary, com-
plex and historically determined human experience.

2.2 Existentialism and Social Psychiatry

We know that the fathers of existentialism are Søren Kierkegaard and, through his
philosophical individualism, Friedrich Nietzsche. With his notion of the free organic
individual opposing the uniformity imposed by contemporary society and by pro-
moting existential individuality (born biological beings, we have to become existen-
tial individuals assuming the responsibility of our actions), the French existentialist
2 Philosophical and Sociological Foundations of Social Psychiatry 19

Fig. 2.1 The hard Biology

biomedical model
(Bracken and Thomas
2001)
Psychology

Culture

EPISTEMOLOGICAL
DUALISM

CULTURE

EXPERIENCE

BIOLOGY PSYCHOLOGY

ONTOLOGICAL DUALISM

Fig. 2.2 The soft biomedical model (Bracken and Thomas 2001)

Jean-Paul Sartre is at the basis of the problematic and constitution of the concept of
subject in the area of critical psychiatry. Authenticity, i.e. the state of recognition of
the Other’s distinct liberty, must be the dominant virtue of the individual. While
referring to absolute freedom and the sense of responsibility, Sartre (1962) main-
tained that “people exist, objects just are”. According to Sartre, the concept of exis-
tence is particularly related with transience and the responsibility of the individual
before his/her freedom. Sartre claimed that a human being is nothing other than “his
life project”.
Following this line of thought, critical psychiatry promotes a genuinely demo-
cratic hermeneutical approach to understanding psychopathological phenomena, an
20 S. Stylianidis

approach acknowledging the possibility of autonomy and different perspectives for

a subject and emphasising its value as a citizen that can eventually manifest a psy-
chiatric or psychological problem. Critical psychiatry focuses, therefore, on the
value of the suffering subject, symbolically and effectively placed in the position of
active citizen. Moreover, critical psychiatry’s hermeneutics stresses the role of
meaning as a primordial concept referring to a complex human reality irreducible to
causal explanation and gives priority to ethics over technology or the discovery of
new therapeutic approaches.
Before proceeding to examine hermeneutics and phenomenology as philosophi-
cal approaches which influenced decisively the critical psychiatry movement, espe-
cially in its beginnings, we would like to mention first some basic points of
convergence between the two, points that will be analysed more thoroughly
subsequently:

1. Critical psychiatry’s approach to knowledge aims at turning it into an instrument

for a democratic debate; in other words, it puts the emphasis on the framework
determining the understanding of individual reality. Consequently, the under-
standing of the social, cultural, temporal or bodily framework comes first, fol-
lowed by the meaning of the subject’s problems and symptoms.
2. According to critical psychiatry, the hermeneutical interrogation of the meaning,
importance, significance and value of a suffering subject should always precede
causal explication, namely, the linear connection between cause and effect in the
understanding and description of psychopathology.
3. For critical psychiatry, diagnosis is not the opinion of an expert disconnected
from the life context of an individual. On the contrary, it is a process of shared
understanding and explanation, namely, a joint construction between the expert,
the intersecting therapeutic group and the suffering individual.
4. Critical psychiatry opposes the notion of temporality to that of chronicity. There
is no static phenomenology: nobody is a chronic patient or suffers from a chronic
disease. On the contrary, mental suffering is structured during observation by
past experiences and future possibilities. We probably have here a precursor of
the notion of recovery, which is developed in other chapters of this book.
Admitting “being towards death” into theory means bringing together our other-
wise scattered hypotheses in the realisation of the importance of the subject’s
being.
5. The attempt to a comprehensive interrogation into the role of science and exper-
tise in the field of mental health occupies an important place in critical psychia-
try. Understanding science as something originating with human experience and
interests is different from the “neutral, out of nowhere viewpoint”, namely, the
scientific demonstration of a phenomenon without an examination of the context
within which the latter arises. The problem of ethics and social priorities in clini-
cal practice is therefore primordial and cannot be merely reduced to a simply
demonstrative practice, namely, a kind of medicine and psychiatry based solely
on proof. Psychiatry has been the meeting point of multiple references and sci-
entific domains: medicine, law or philosophy (romanticism in the nineteenth
2 Philosophical and Sociological Foundations of Social Psychiatry 21

century, positivism in the twentieth century). As maintained at the end of this

chapter, twenty-first-century psychiatry largely disinvests and, by means of the
reductionism it promotes and the biomedical model upon which it is based,
obscures its own complexity. By contrast to a multileveled approach to subjectiv-
ity, this biomedical model is founded on two constitutive ideas:
(A) Mental illness is a disease commensurable to bodily diseases and, therefore,
potentially curable.
(B) The mentally suffering subject is never completely destroyed and may, as a
subject, actively contribute to his/her cure.

A madness-object and a partial, occasional madness of the subject constitute two

different approaches. In any case, subjectivity, in its relationship both to praxis and
to suffering, lies at the centre of clinical practice. The contradictions of traditional
psychiatry, which critical psychiatry tries to resolve through its theory and practice,
lie in the opposition between confinement and a humanist or therapeutic function of
psychiatry, between a therapeutic approach and the demand for social control and
management of every psychic deviation and between subjectivism and
objectivism.
In this perspective, the appearance of the asylum had a double function. As thor-
oughly described by Foucault in his The History of Madness, the asylum constituted
throughout the fifteenth century a space for the protection of society against trouble-
some individuals or outsiders; on the other hand, it was also a refuge for the insane
against the damaging effects of society. Therefore, while providing a space of con-
trol for outsiders or all those tearing at the fabric of society, the asylum offers at the
same time a real refuge for the mentally ill, who, as a result of the clinic’s creation
within the space of the asylum, become for the first time recognised as a distinct
medical and psychiatric entity. All of this means that the birth and constitution of
psychiatry as a distinct scientific realm take place within the asylum (Abatzoglou
1991). In 1793, at the asylum of Bicêtre, Pinel will propose a new kind of treatment
for the mentally ill named moral treatment. The latter is opposed to natural treat-
ment, namely, the therapeutic approaches used at that time, like bloodletting, enema,
various drugs or hydrotherapy. By contrast, moral treatment proposes methods and
rules aiming at the direct engagement of the mind and feelings and can, in a sense,
be considered the predecessor of institutional psychotherapy (psychothérapie insti-
tutionnelle), a school that dominated France’s mental institutions after 1948. Within
the institutions, however, the concentration camp living conditions, violence and
abandonment contrast with the implementation of a personalised care project and
the investment in the personal relationship between doctor and patient, aspects that
formed the basis for the realisation of Pinel’s proposal for moral treatment.
Owing to the ineffectiveness of moral treatment, a biological orientation domi-
nated psychiatry since the second half of the nineteenth century, while the asylum
remained the site of treatment. Throughout his innovative and challenging work on
knowledge, power, institutions, subject and psychiatry, Foucault describes with
great precision both the role of the asylum and the social mechanisms that brought
it about. Foucault adopts a critical stance, situating himself between Marxism,
22 S. Stylianidis

existentialism and phenomenology. His fundamental thesis is that “what matters

most is to point out the historical dimension of mental illness”. The latter can be
totally distinguished from normality only to the extent that society rejects and
excludes it. Until the eighteenth century, the mentally ill are considered demon rid-
den and appear as a symbol of moral decay. On the contrary, the consideration of
madness as alienation, a consideration based on modern humanist and medical
approaches, leads to its exclusion. As Foucault characteristically writes, “the lan-
guage of psychiatry, which is a monologue of reason about madness, has been
established only on the basis of such a[n imposed] silence. In our age, madness is
muzzled within the beatitude of a scientific knowledge, which analyzes it so much
that in the end forgets it. Exclusion and treatment thus coincide”. The intention of
treating and the intention of confining the suffering subject meet and go hand in
hand. Despite Renaissance’s wishful thinking, madness is identified with unreason,
as a result of the general confinement. Because of this identification, madness
acquires a moral dimension, turning into a scandal and a threat for public order.
Medicine then places a mirror in front of the patient for the latter to acknowledge in
it that he/she is objectively insane. According to Foucault, madness wasn’t liberated
but medicalised, i.e. objectivised as mental illness. It is important here to determine
and come to terms with the philosophical concept of the subject. Foucault’s book
Folie et déraison: Histoire de la folie à l’âge classique (1961), originally his doc-
toral thesis, poses at first as an anti-history of psychiatry and, more recently, in the
1970s, as a classic of antipsychiatry. For Foucault, fear, surveillance, humiliation
and censure within the asylum constitute the four active dimensions of Pinel’s moral
treatment. These four dimensions produce the alienated man under the conditions of
the asylum.
One can observe here an analogy with Burton’s notion of institutional neurosis
(1959) and Basaglia’s notion of double alienation, namely, the alienation produced
by the asylum, the violence and the abandonment, along with the alienation stem-
ming from mental illness. Which is the subject of madness, finally? As Tzanakis
(2008) characteristically mentions, Foucault (1963) raises the question of when
madness acquires the meaning of mental illness. In The Birth of the Clinic (1963),
Foucault analyses the procedures giving birth to the clinical gaze, the one which
observes the interior of the body: “This formation depends both on the space of
implementation of clinical practice and on the invention of a language by means of
which the point of view of death is shifted”. Within the asylums, “the gaze of the
doctor observes the pathological landscape giving birth to a new language.
Progressively, the gaze and the discourse representing what it saw, namely, pain in
its multiplicity, coincide with one another” (Tzanakis, op. cit., p. 51).
In his reading of Foucault’s work, Marcel Gauchet (1997) mentions that “the
insane is insane but, at the same time, alike. And since he/she is alike, the truth of
madness is the truth of subjectivity itself”.
Along with the antipsychiatry current of his time (Cooper 1970; Laing 1965),
Thomas Szasz (1982), professor of psychiatry at Syracuse University, New York,
rejected mental illness as an object. We know that, in its beginnings, antipsychiatry
was an Anglo-Saxon movement that called into question classical psychiatry by
2 Philosophical and Sociological Foundations of Social Psychiatry 23

presenting psychosis not only as an existential reaction to a sclerosed and alienated

family environment but also as a response to traditional medicine, accused of repro-
ducing the so-called patient’s confinement in his/her solitude and social isolation by
means of scientific data and proof. As Meyers (2005) remarks, English antipsychia-
try tries to situate itself between the social and the medical. From a social and politi-
cal point of view, psychiatry has been subjected to denunciation and condemnation
by the radical European movements, because of the violent and oppressive condi-
tions of treatment and hospitalisation of the mentally ill.
For Cooper and Laing (1970), “talking about violence in psychiatry, the violence
which blinds the eyes, screams its name and declares itself as such, means talking
about the subtle and disguised violence that the others, the normal people, exert
upon those who call insane”. Inasmuch as psychiatry represents the interests of
normal people, it can be claimed that the violence exerted in the context of psychi-
atric practice is principally the violence of psychiatry.
The particular intrapsychic functioning of people suffering from schizophrenia
or other psychoses is completely obscured by Cooper (1970). According to the anti-
psychiatry movement, what determines the generation of a psychopathology are the
“micro-social crises, in whose context the actions and experience of a singular per-
son are handicapped by the others for cultural or microcultural (often family) rea-
sons”. “The individual is highhandedly labelled schizophrenic by medical or
quasi-medical entities”.
Psychopathology is not a natural object but “a myth constructed by man”. As
Szasz explains, “psychiatry is conventionally defined as a medical specialty refer-
ring to the diagnosis and treatment of mental disorders. […] I would like to suggest
that such a widely accepted definition places psychiatry at the same level with
alchemy and astrology, making it a part of the pseudo-sciences” (Szasz 1982). For
Szasz, who has been defending these views for the past 40 years, mental disorder is
not an illness whose nature could be elucidated and explored by science. It is rather
a myth constructed by psychiatrists in order for them to achieve professional recog-
nition and social acceptance and to provide easy solutions to the problems of social
deviation and control.
Szasz wasn’t alone during that period. As Porter (2003) mentions, Foucault was
arguing in The History of Madness along the same lines: mental disorder should be
understood not as a natural event but as a cultural construction founded on a nexus
of administrative and medico-psychiatric practices. To write the history of madness
means to narrate not the disorder and its treatment but the problems of freedom,
control, knowledge and power it entails. After the great confinement described by
Foucault, a series of humanist efforts attempted to limit the power abuses within the
framework of the asylum. Pinel in France, Chiarugi in Italy and Tuke in England
inaugurated a period of humanisation of medical care, a period that paved the way
for a more rational and humanist approach to mental illness. By the nineteenth cen-
tury, the first steps were made into the study of the pathology of madness, the
description and classification of its clinical types and the acknowledging of the dif-
ferences between bodily disease and mental neurosis. Treatment became a subject
of preoccupation within university hospitals and extra-hospital structures, while the
24 S. Stylianidis

social dimensions of psychopathology began to draw the attention of researchers.

By the end of the nineteenth century, the road to the new ideas of Kraepelin (father
of the psychiatric nosography), Freud (father of psychoanalysis) and Charcot and
Janet (followers of the footsteps of Kahlbaum, Griesinger, Conolly and Maudsley)
was already open (Porter 2003, p. 5). Revolutionary changes took place in connec-
tion with the natural treatments of illnesses, the alienating conditions in psychiatric
hospitals underwent some kind of humanisation and the various therapeutic
approaches began to be connected with each other, thus achieving a more person-
alised form and becoming organised according to a more continuous therapeutic
process – what we would nowadays call the continuum of psychiatric care.
The biomedical model of mental illness starts dominating within the context of
positivism’s epistemological primacy. This paradigm establishes itself more widely
in the field of health and illness by placing at the centre of medical interest the
detection of pathogenic and pathological phenomena within the human organism or
the tracking of malfunctions in the anatomy of the organs. Canguilhem’s philo-
sophical and historical understanding of the birth of medical thought in his monu-
mental work The Normal and the Pathological (1972) sheds light on the double
conception of illness: there is, on the one hand, the ontological representation of
illness corresponding to the Pasteurian doctrines and the microbiological theory of
transmissible diseases and infection and, on the other, the poetic conception of ill-
ness, identified with ancient Greek medicine and departing from the local effects of
the anatomo-pathological substrate while defining illness as a disorder in the har-
mony and equilibrium between man and his/her environment.
As Anastasia Zisi (2013) mentions, “the starting point of the biomedical para-
digm is the negative definition of health and the concomitant focusing on the differ-
ent types of pathology and the biological factors generating it, leading to the
patient’s extraction from his/her natural and social environment”. It is from this
biomedical health paradigm that traditional clinical psychiatry draws its principal
arguments, in order to define mental illness as a result of changes in the organism’s
physiology, in the brain’s biochemistry and in the central nervous system’s func-
tioning. The outcome of the clinical psychiatric assessment, often completed by
neuropsychological tests of memory and other cognitive functions, is the psychiat-
ric diagnosis suggesting the type of medicinal treatment for the relief from and the
suppression of psychiatric symptomatology. Despite its interest in the patient’s
medical history and biography, the biomedical model imposes its biological ontol-
ogy pertaining to the nature of mental illness, leading to the suppression of the
patient as a social subject and of his/her symptoms as forms of experience and
modes of existence (Zisi, op. cit., p. 27).
Foucault’s work refers critically to Pinel’s contribution and realisation that by the
end of the nineteenth century, the insane – until then considered criminals or demon-
ridden people – are subjected, chained and confined to the most downgrading and
humiliating treatments. Pinel demonstrated that these people were ill and needed to
be treated humanely and kindly.
After the breakthrough of this understanding and compassionate outlook on
madness, psychiatry marched from conquest to conquest, establishing definitive and
2 Philosophical and Sociological Foundations of Social Psychiatry 25

concrete clinical pictures, constituting the first psychiatric classifications and trying
to describe scientifically the forms, types and evolutions of mental disorders.
However, Foucault reacts to and rejects this “expansionist” mission of psychiatry
for several reasons. The first one is that madness “does not constitute from the out-
set a medical object”. Madness is first and foremost a massive cultural construction,
a way of defining man as rational, normal being, thus excluding and rejecting the
mentally ill. This means that the attempt to grasp madness is founded precisely on
such a gesture of exclusion, a gesture reproduced for years to come. We therefore
find ourselves at the very opposite of the traditional history of psychiatry, which
refers to medical objectification as a liberating process for the mentally ill. Foucault’s
approach isn’t a romantically motivated endeavour to undermine the attempts
towards a scientific understanding of madness but an effort to reposition the latter
and grasp the risks and consequences of such a process on the modern identity. The
history Foucault writes does not follow the traditional lines of the history of science
(a history of monumental errors and great discoveries) in order to make a choice
between those promoting obscurantism and those favouring scientific truth. His his-
tory is archaeological: it is about excavating and bringing to light the deeper layers
lying beneath the surface of declarations and institutions. Foucault studies the expe-
rience of madness, taking into account not only the social practices and medical
knowledge but also the literary and artistic production referring to it. The Renaissance
treated madness as a form of wandering. The insane circulate from town to town,
boarded on ships, forced to live on cities’ gates and to undergo social exclusion. The
experience of madness brought to light by the Renaissance could be described as
“secular”. A very powerful problematic concerning the menace of world destruc-
tion, the menace of something absurd capable of disturbing social order and gener-
ating chaos underpins this condition of constant and structural wandering. After his
brief analysis of the Renaissance, Foucault devotes many pages to the description of
the experience of madness in the classical age. This description became the target of
many critics, philosophers and historians who called into question the very idea of
a great confinement of the insane during the seventeenth century.
Foucault highlights audaciously the historical moment of the great confinement.
The insane that had been living until then in a state of constant wandering were
confined behind the tall walls of the general hospital, along with those living on
charity and the homeless. Such a confinement presupposes a new experience and,
above all, a specific image of the mentally ill, which from now on will lie at the
centre of social problems (e.g. the disorder caused by marginal population groups
wandering from town to town) and political practices (like the institution of police
measures detaching themselves from or bypassing the judicial realm).
The mentally ill is no more a person carrying the mystical, superstitious and
disturbing aura conveyed by the absurd. He/she becomes a problem, with which
society is summoned to deal. In this perspective, the role of psychiatry is called into
question. Foucault manages to show that the distance between scientific objectivity
and what the subject experiences as suffering and, therefore, as psychopathology is
due to two factors: on the one hand, the police practices of confining the marginal
population and, on the other, the moral denunciation of the absurd, inasmuch as
26 S. Stylianidis

madness constitutes a figure of alienation similar to the categories of moral devia-

tion such as the homosexuals, the poor, the bandits or the common criminals. The
idea according to which scientific objectivity is impossible outside the framework
of police practices and moral condemnation will be considered a real provocation
both for the science of psychiatry and the social sciences trying to establish them-
selves as neutral and free of prejudice. Finally, madness becomes modern when
appearing not as a symptom of differentiation between truth and error but rather as
a revelator of the split between a pure conscience and a mystical, obscure nature.
This is what Foucault calls “the anthropological experience of madness”. Madness
becomes a mental illness defined as the alienation of the regular and normal mental
traits of an individual and based on a cerebral malfunction. Thus, it marks the dis-
tinction not between day and night – as in the Renaissance – but between the normal
and the pathological in human nature. In this way, madness becomes both very
distant and very close to us (Tsalikoglou 1987, 2007): subjected to confinement
through the domination and legitimisation of medical discourse, captive to its medi-
cal definition, madness nevertheless “comes closer” to us precisely because we
unconsciously recognise a part of our unfamiliar self in its representation. Madness,
therefore, becomes extremely human. The medical construction and the biomedical
model of madness are at the very opposite of such an existential experience praised
to such an extent by the Renaissance, literature and the arts and liberated by the
antipsychiatry movement. In conclusion, Pinel according to Foucault didn’t liberate
the mentally ill by breaking their chains and instituting a medical entity, namely,
mental disorder, but rather subjected them to a new form of power, namely, the
power of medicine. Consequently and according to the Foucauldian analysis, the
hospital appears as a field of forces of power and madness as a pole of resistance. To
treat or to be treated doesn’t mean to rehabilitate the truth but rather to subject or be
subjected to identities imposed by power mechanisms, which, by means of medical
discourse, rationalise the social exclusion of the Other.

2.3 The Subject and Phenomenology

Lived Experience and Self

The concept of the subject occupies a central place in the constitution of the theory
or rather the panorama of theoretical approaches articulating the clinic of the sub-
ject, lived experiences and mental phenomena with the tradition of the German
(mostly) phenomenological psychiatry and the theory and practice of understanding
and emancipating the mentally ill as a suffering subject.
The way Professor Tatossian (2002) formulated the necessity of reintegrating the
phenomenological approach in today’s clinical practice is characteristic: “Psychiatry
is in danger when, on the grounds of objectivity and positivism, it ignores its mul-
tiple origins situated in everyday experience and the living world”.
Let’s examine schematically the basic notions structuring phenomenological
knowledge in philosophy and in connection to psychiatry. Phenomenology is the
2 Philosophical and Sociological Foundations of Social Psychiatry 27

knowledge “we gain in the first person” through our everyday experience, by
observing nature and its qualities within a naturalistic framework. By the latter we
designate the studies compatible with the methodology of the natural sciences.
Phenomenological knowledge cannot be reduced to a third person; it is the con-
scious knowledge one has of his/her personal lived experiences. We should, how-
ever, distinguish between experience per se (e.g. the experience of pain) and
knowledge of this experience and of its qualities (e.g. the knowledge of the nature
and qualities of my toothache).
There are sensory, perceptive, emotional and affective subjective experiences
(like mental distress, sorrow). Living a conscious experience along with its set of
distinctive qualities cannot be reduced to the state of consciousness of experience as
such. The awareness of the qualities of an experience presupposes having a certain
knowledge, a certain set of concepts. For example, the awareness that an irritation
turns into pain or that nervousness turns into anger presupposes the “reflexive”
knowledge of the notions of pain and anger.
Founding the “reflexive” nature of knowledge presupposes distinguishing
between appearance and knowledge of appearance. As an example we will mention
Wittgenstein (1966) who, in his notes on psychology, remarks that a person express-
ing pain does not necessarily have some overall knowledge as to the nature of this
pain. In other words, the expression of pain is not the expression of some knowledge
pertaining to pain.
While this is a controversial topic among philosophers, it is less so among clini-
cians, given that every subject has a certain capacity to grasp his/her own lived
experiences. For example, a patient is justified and authorised to express the mental
or physical pain that discomforts him/her and that he/she wishes to avoid – a point
that medicine should take into account and trust.
Which is the source, however, of such a lived experience? Put schematically, one
philosophical conception considers that the description of a phenomenon is based
on a series of inferences having, directly or indirectly, a causal relation with the
phenomenon. According to a second, epistemologically distinct, philosophical con-
ception, there is some kind of possibility to observe, internally or externally, the
phenomenon. There is for instance a connection between the various mental disor-
ders and behaviours, as can be established through the different facial mimics cor-
responding to different mental states (a point made since the age of Darwin). It is
clear that we do not behave in the same manner when we experience an intense pain
or an intense orgasm.
At this point, phenomenologists could ask the following crucial question: can we
extract safe general conclusions about complex phenomena observed in others by
observing our own reactions and behaviours through a process of “neutral intro-
spection”? As we will try to show with the following remarks, this is a key contro-
versial point between the biomedical model, which unswervingly proceeds to
classify psychiatric symptoms in every detail, and the phenomenological approach
to subjective otherness within the framework of a unique encounter between two
individuals (Krauss 2003; Jaspers 1963; Minkowski 1927, 1948, 1966; Lanteri-
Laura 1957; Blankenburg 1982, 1991). We can argue, however, that introspection
28 S. Stylianidis

may lead us to false conclusions, even in connection with our own personal experi-
ences and mental phenomena. Nevertheless, it is sure that, despite the limitations of
“observational neutrality”, by using introspection we gain privileged access to the
content of such experiences, even if we commit mistakes in the description of some
of their aspects.
The example of jealousy is interesting both philosophically and in terms of psy-
chopathology. I can refer to the phenomenon of jealousy I experience in an objec-
tive and external manner, attempting to interpret it and extract some conclusions
from it, even if such a process is open to interrogation and doubt. This fact does not
in any way deprive me of my capacity to have access to what I experience in a more
specific way, namely, by means of the lived experience I feel when I am jealous.
This first person lived experience contains a quality auto-observation that does not
leave room for doubt. If we transpose such a reasoning to contemporary social psy-
chiatry – which, as we will see in the following chapters, considers the place of the
first person narrator-subject crucial (Jackson 1982), as a means of empowerment
and active participation in the process of recovery – it is easy to understand the
philosophical basis underpinning the co-construction of a new narration by the ana-
lyst and the analysand, aiming at the process of recovery-as-healing.
Jackson’s principal thesis can be formulated as follows: “Introspection can help
us learn something from this specific character of our first person experiences: we
can learn that this knowledge cannot be reduced and limited to an objective, scien-
tific approach”. In conclusion, the relationship between the experience of a phe-
nomenon and the knowledge deriving from the introspection of such an experience
constitutes a central problem with which every philosophical theory of introspec-
tion must come to terms. In other words, “the subject (S) cannot have access to a
phenomenological type of experience (E) unless it (S) has already experienced such
an experience (E)” (Stoljar 2009).
By contrast to the phenomenological approach, the alternative Cartesian one is
considered the most dominant among the philosophical community since the age of
Descartes. The basic idea of this “introspective approach” is the following: “the
spirit is penetrable as such, meaning that it disposes of a special access to the con-
tent of its various states”.
It is interesting that Freud (1957) was already interrogating the fact that “phi-
losophers frequently define mental states as being directly present and perceptible
to consciousness”. By “mental states” we can distinguish two types of states: (1)
attitudes like intentions, desires, wishes or choices and (2) occasional states like
sensations, emotions, perceptions, decisions, judgements and mental “acts” in
general.
The second type of states is the one to which we have privileged introspective
access, according to the Cartesian approach. More specifically, an individual can
gain knowledge of his/her feelings and perceptions without having previously
observed his/her behaviour: the recourse to introspection bypasses the observation
of the outside world. Consequently and independently of all doubts about the valid-
ity of such an approach, the fact that it is not based on external data provides it with
a strong epistemological privilege (Ludwig and Kabat-Zinn 2008).
2 Philosophical and Sociological Foundations of Social Psychiatry 29

According to the Cartesian approach, we become directly aware of the content of

a conscious experience the moment we experience it. This entails that our introspec-
tive judgement (what philosophers called “inner meaning”) is not affected by what
is considered fundamental. I do not need to think about my behaviour or the state of
my teeth when I have a toothache.

Subject, Psychiatry, Phenomenology and Philosophy of Mind

The bibliography and genealogy of psychiatric phenomenology is huge. We will

present here abstractly some points and historical references. It is necessary to make
a preliminary remark: phenomenology is not psychopathology, despite the fact that
it is precisely the ambiguous relationship between them which could probably
explain not only the special importance of the phenomenological approach in the
various psychological analyses (as in Jaspers and Bleuler) but also the value of a
psychology transformed, through phenomenology, into an existential psychology
(Tatossian, p. 13).
In this psychopathological context, phenomenology is defined as a change of
attitude (Broekman 1965) consisting in bracketing the natural or “naïve” attitude
according to which all of us psychiatrists and other mental health professionals
evaluate complex mental, social or material situations as an objective reality exist-
ing independently of us. Such complex clinical situations place us in front of epis-
temological dilemmas of interpretation and understanding (Tzavaras 2002).
Phenomenology is not interested in reality itself but in the conditions rendering
this reality possible. Therefore, phenomenology is practised only when it puts in
motion some form of abstraction. This abstractive process considers that all convic-
tions pertaining to natural reality along with the direct or indirect explanatory
stances regarding reality’s perception are “suspended”. This abstraction, reduction
or epokhe is the fundamental act of Husserlian phenomenology, something which
immediately raises the question of the relations between phenomenological philos-
ophy and psychiatric phenomenology (Husserl 1969). The psychiatrist may be
attracted to psychiatric phenomenology and seek, in the context of psychopatho-
logical observation, some kind of application of the “results and theories” which
supposedly belong to the body of phenomenological philosophy.
Binswanger (1958, 1971) compares the role played by physiology in understand-
ing bodily illness to the role played by Husserl’s transcendental phenomenology in
understanding psychopathology as “a cross section of consciousness”. Nothing is
more erroneous than the view that psychiatric phenomenology or Daseinsanalyse
“adheres” beforehand to some kind of “theory” or “systematic phenomenological
psychology”, which simply does not exist (Spiegelberg 1972).
Phenomenology rejects all preconceptions. The danger with a “preconstructed”
theory lies in the fact that the use of notions like corporeality, interpersonal com-
munication, and consciousness can vary from one philosophy to another. If the
phenomenologist-psychiatrist were to choose one or more among various existing
theoretical approaches before beginning with his clinical practice, he should not be
30 S. Stylianidis

considered a genuine phenomenologist. Psychiatric phenomenology is not grounded

on some king of initial “doctrine” (Blankenburg 1982, 1991): it is rather a “fluid”
way of working, aiming not so much at the simple application as to the integration
of philosophical principles into the clinical outlook of the psychiatrist.
Returning to E. Husserl and his notion of “epokhe” appearing for the first time in
his work in 1913, we can formulate five principal points concerning it:

1. The elimination of all latent or silent theoretical preconceptions by means of

which a psychiatrist accesses (or not) experience: the psychiatrist adopts an atti-
tude that “brackets” theoretical terms and nosographic classifications, which
could hinder any possible encounter with the patient’s lived experience.
2. The suspension of the positing of reality: the possibility of grasping the Other is
kept open by bracketing, instantaneously “deleting” what he/she says in order to
come back to it at a later stage. For example, the psychiatrist avoids saying that
he/she is in front of an “auditive illusion”, a perception without object or a delir-
ium and tries to listen carefully to what the subject he/she encounters is
experiencing.
3. The reflexive transformation, namely, the attempt to understand the way in
which the individual’s perceptions and his/her relations with life objects are
situated: it is necessary to grasp that these elements exist not only for the patient
but also for the psychiatrist. How are we to understand, for example, the place
of kitchen knives within the patient’s construction of a delirium of persecution,
and what is their place in his/her narration and in the attitude we adopt? (Eidetic
insight)
4. Imaginative variation is an attempt to modify the act of consciousness within
imagination. Up to what point can we push variation without altering the real
event, the nature of experience? The act of recollecting an ordinary experi-
ence by acknowledging the different versions given by two individuals (e.g.
the analyst and the analysand) allows us to realise if we are really referring to
what Husserl designated as the essence of experience (e.g. not only the nar-
rated fact but also the sentimental state in which the narrator found himself/
herself).
5. Phenomenology is interested not in the reproduction of external reality within
the subject’s consciousness but in the meaningful constitution of objects by con-
sciousness. In other words, it is interested not in facts but in the conditions that
render possible the constitution of meaning by transcendental thought.
Binswanger, for example, refers to a fact not as fact but as something that can
freeze or oppress the consciousness of an individual.

The above aspects of “epokhe” do not form a theoretical construction but a view-
point or an attitude adopted by the subject in view of the constitution of any theo-
retical construction.
Psychiatric phenomenology is also indissolubly connected with the notion of
intersubjectivity, which appears for the first time in Husserl’s Cartesian Meditations
(1929). One of Husserl’s principal theses, namely, nonrepresentation, could be
2 Philosophical and Sociological Foundations of Social Psychiatry 31

explained as follows: “Even if the face of my interlocutor cannot be considered the

same with mine, I can nevertheless relate them as if they were the same”. My body
and the Other’s body are the “same” in the sense that I perceive some of the traits of
the Other’s face as if they were mine (i.e. mimics of sorrow, joy, anger, etc.).
I perceive what I experience without seeing in the Other (i.e. a feeling) as some-
thing that I myself can experience. In other words, every expression I perceive on
the face of the Other refers me to a common lived experience. In his attempt to
understand mental phenomena, Husserl himself makes use of terms like ego,
ground, intention, psychologism, passive synthesis and genesis, terms that cannot
be analysed in the context of this chapter.
Our peregrination in the field of psychiatric phenomenology brings us to
Husserl’s famous pupil, Martin Heidegger. In his monumental work Being and Time
(Heidegger and Vezin 1964; Corvez 1965), Heidegger uses for the first time the
notion of Dasein, which we could reductively render by “existence”. In the frame-
work of a clinical psychiatric interview, for example, there are two people in a room.
Both of them share a series of characteristics pertaining to this encounter, character-
istics that the chair found within the same framework cannot experience. Heidegger
suggests an abstract construct, namely, Dasein, aimed against common sense and
having the following characteristics: being in the world, surrounding space, under-
standing, being affected by the other, being towards death, being with and tempo-
ralisation. All of these fundamental elements, which L. Binswanger (1958) included
in his work, constitute the “body” of Daseinsanalyse, namely, existential analysis.
Through his own special way of analysing clinical cases (cf. the case of Suzanne
Urban in particular), Binswanger (1960) demonstrated that, with the exception of
her delirium’s or mania’s theme, the patient’s specific way of being excludes every
other presence. Binswanger founded and developed Daseinsanalyse, a particular
mode of psychiatric phenomenological approach to the “analysis of existence”,
between 1933 and 1958.
Daseinsanalyse is not a therapeutic technique but a mode of approaching, diag-
nosing and understanding different from what traditional psychiatry proposes,
though not contrary to it. For example, despite the different kind of analysis to
which it resorts, Daseinsanalyse does not call into question the diagnosis of psycho-
sis operated on the basis of traditional nosography.
As semiotic basis for phenomenological psychiatry, the space of representation
constitutes for Binswanger “a rich ensemble structured by millions of fragments
sustained through the singularity of a personal trajectory”. In order for a space of
representation to be constituted, the conditions of the analogic and symbolic com-
ponents have to be satisfied. The analogic components form the structured develop-
ment of a set of elements allowing a better perceptive rendering of what an individual
is experiencing. The symbolic components of representation are the abstract sys-
tematic codifications (linguistic type of representations) based on the analogic com-
ponents through a process of linguistic mediation (i.e. a publicly articulated speech
without some specific content) or attached to intuition by means of an analogic
representation (cf. the recent studies of experimental psychology on embodied
cognitions).
32 S. Stylianidis

“Psychiatry as science must take into account the ontological foundations sup-
porting its discourse: the attitudes, the mental peculiarities, the psyche in the sense
of psychology and psychopathology, the character, the personality, the instinct and
the symptoms. All these notions lack ontological foundation”. “We came across
such a foundation in Heidegger and his Existential Analysis: psychiatry as a phe-
nomenological science of lived experience is based upon such an Analysis”
(Binswanger).
Psychiatric phenomenology is an attempt to comprehend the symptoms of
schizophrenic psychoses in particular and psychopathology in general. Put sche-
matically, Binswanger returns at the end of his life to Husserlian notions like tran-
scendence, intentionality and genesis of mental phenomena (Husserl et al. 1938),
without however calling into question the framework of Daseinsanalyse. “It is about
a change in perspective and not about some kind of recantation”, he observes. It is
interesting to stress at this point the substantial influence exercised on F. Basaglia’s
clinical, theoretical and political attitude by the German phenomenological psychi-
atric tradition and by E. Husserl’s philosophical thought (Basaglia 1976; Stylianidis
1985; Louzoun and Stylianidis 1987). Basaglia’s work hypothesis concerning the
formation of an anti-institutional approach was based on Husserl’s notion of
“epokhe”, a notion that allowed him to formulate the position according to which
“illness is bracketed” (and not negated in its existence), in order for the effects of
institutionalism (violence, abandonment, impersonal treatment of the mentally ill)
covering up the authentic expression of the subject’s psychopathology to be called
into question.
Besides the substantial use of Husserl’s notion of “epokhe”, Basaglia’s epis-
temological stance adopted phenomenological psychiatry’s refusal to allow any
preconstructed theory and conception into psychopathology, aiming at an
authentic and free encounter with the otherness of the suffering subject, without
the distorting glass of “objectifying” positivist psychiatry. Consequently,
Basaglia’s theoretical reference to Husserl’s philosophy and to the German phe-
nomenological psychiatric school is at the very opposite of antipsychiatry’s ini-
tial attitude of calling mental illness into question. His dialogue with Laing,
Cooper and Foucault was fertile and important, inasmuch as it converged around
the analysis of social mechanisms of control and of the alienating role of capi-
talist society’s institutions. However, they diverged radically from one another
in questioning the biomedical model “from the inside”, namely, through politi-
cal change and the transformation of the violent institutions of traditional public
psychiatry. Binswanger’s and other important German phenomenologists’
(Tatossian 2002; Minkowski 1927, 1948, 1966; Blankenburg 1982, 1991) con-
tribution in putting forward another approach of human existence, namely, a
description of the subject’s being in the world and of its pathological tonality,
constituted the favourable philosophical and ideological background against
which flourished the most radical attempts to challenge traditional psychiatry
and to put forward a new form of organisation for mental health services (dein-
stitutionalisation, community services, etc.), aiming at a real encounter with the
suffering subject.
2 Philosophical and Sociological Foundations of Social Psychiatry 33

2.4 Observations on the Transformations of Modern

Psychiatry

In The Power of Psychiatry (1986), Peter Miller and Nikolas Rose managed to put
together a series of stories and testimonies regarding psychiatry’s exercise of power.
To the observation that by the end of the twentieth century psychiatric practice
would not be using mechanical and chemical means of immobilisation against
patients’ will, Miller pointedly remarks in his own perspective as user of mental
health services: “… psychiatry is not something homogeneous but a loosely struc-
tured set of practices starting from the ‘hard’ core represented by the asylum and
electroshocks, passing through the recent creation of Mental Health Centers, and
extending to the ‘soft’ core of various psychotherapeutic approaches. The history of
psychiatry is the history of the ‘system’s’ reorganisations and transformations”.
In Goffman’s classic work (1961), the critique against the alienating conditions
of the asylums was aiming at the analysis of the profanation and deconstruction of
the confined patient’s subjective identity. Laing (1965) focused his study on the
subjective-existential experience of mental illness, whereas Szasz (1982) carried
out an overall critique against the detrimental effects of institutional psychiatry and
the incapacity of the mentally ill to have, as subjects-citizens, any negotiating power
within the psychiatric system. Put schematically, we could say that all three
approaches are inspired by an a priori philosophical position emphasising the pri-
macy of subjectivity and perhaps obscuring other aspects in the way modern psy-
chiatry is exercised at the age of postmodernity.
As Miller (op. cit., p. 29) pointedly remarks, “the promotion of subjectivity to
such a degree by traditional antipsychiatry not only fails to grasp the ways in which
power is exercised and operates within modern societies, but is also in no position
to understand the subtle mechanisms by means of which power invests (to the direc-
tion it wishes) subjectivity rather than crushing it”.
Globalisation and the ceaseless transformations of capitalism, the contemporary
domination of the market culture and the promotion of subjectivity through con-
sumption constitute problems that should be addressed in the perspective of psy-
chiatry’s contemporary transformations as well (Stylianidis 2011). The latter
reproduces old and new forms of stigmatisation and auto-stigmatisation, social
exclusion, extensive medicalisation and psychiatrisation of social distress and social
problems and domination of the DSM as an instrument of an expanding codification
of all forms of symptoms and deviations.
Such a novel understanding of these complex phenomena could be based on
Porter’s (2003), Doerner’s (1981), Foucault’s (1972), Basaglia’s (1975) and Scull’s
(1979) theoretical and historical contributions, on the one hand, and on contempo-
rary sociological approaches to modernity, postmodernity and the deconstruction of
the welfare state, on the other, approaches like Bauman’s (2013a, b), Castel’s
(1981), Beck’s (1992, 2002), Bracken and Thomas’ (2001), Rose’s (1989) or
Habermas’ (1994, 2000).
In his major book Governing the Soul, Nikolas Rose (1989) describes to the
point how “the management of the self” becomes a key element to contemporary
34 S. Stylianidis

societies’ governmentality. Whereas notions like “the self” or identity issues were
always historically related to a fundamental political questioning, this perspective is
nowadays completely obscured. Psychiatry’s transformations and the contemporary
boom in new psychotherapeutic approaches or new “psy” professions fall within
this emerging “expertise in subjectivity”.
Every human problem – not only relationship problems but diagnosed mental
disorders as well – becomes the object of investment by new therapeutic techniques
literally invading every space in their “lighter” version: from human resource man-
agement within corporations or organisms to the settlement of social or racial con-
flicts, the strengthening of the police in enforcing social control and the imposition
of cognitive-behavioural approaches within mental health services, the new tech-
niques proliferate, inasmuch as they are supposed to be efficient and measurable in
solving problems “here and now”.
Globalised capitalism can survive and thrive insofar as it manages to persuade
every citizen that he/she is a (potential) consumer not only of material goods and
products of a distinctive brand bearing a positive “narcissistic” sign and status sym-
bol but also of new techniques of promoting self-image and bringing about the
much-coveted self-realisation and social recognition.
As Hardt and Negri (2000) correctly remark: “The big industries and economic
powers produce not only the instruments for an easy living but also the subjectivi-
ties. They produce “agentic” subjectivities within the given bio-political framework:
they produce needs, social relations, bodies and minds”.
In the age and culture of postmodernism, the self-image provided by capitalism
is able to make a subject change his/her mood, to constantly adapt without the
slightest questioning or mental elaboration and to settle his/her accounts with the
past without the slightest guilt or reflection, since these processes are “evaluated” as
anti-productive.
“Narratives are no longer long and complicated. Our personal stories and grieves
must be brief. Our identities must be the product of our “lifestyle” choices, instead
of being the result of a personal struggle”, as Bracken and Thomas (2001, p. 97)
pointedly remark.
The new technology for diagnoses, the new indications for the use of psychotro-
pic drugs, the new psychotherapeutic techniques, all this “biochemical revolution
disconnects and liberates our self from depressing narratives”, as Bullard (2002,
p. 269) suggests.
Besides, despite the predominance of the biomedical model in clinical practice and
of treatment criteria and protocols in the operating mode of medicine and psychiatry,
there is substantial proof to the fact that the new classification systems are shaped by
the interests of the multinational pharmaceutical giants (Kutchins and Kirk 1999).
The new marketing tendency and technique is to provide increasingly long indi-
cations for the use of psychotropic drugs: this “scientifically unbiased” and ethically
neutral procedure aims to achieve the constant expansion of the market available for
these drugs.
Our basic argument could be summarised as follows: contemporary psychiatric
treatments and interventions are not in fact based on scientifically neutral
2 Philosophical and Sociological Foundations of Social Psychiatry 35

indications and assumptions. Contemporary psychiatric technologies are deter-

mined by the points of view, priorities, meanings and values of the market. In fact,
contemporary psychiatric interventions are based on the systematic manipulation of
the hopes for a rapid and efficient treatment of the population as well as on the
internalised expectations of postmodern man for self-realisation and evolution
(“The sky is the limit”).

2.5 The Psychiatrisation of the Defeated of Neoliberalism

The crisis of postmodern individualism has been a subject of study by important

contemporary philosophers and sociologists (Habermas 1975, 1994, 2000; Beck
1992, 2002; Morin 1987, 2008; Castel 1981, 1995, 2013; Balandie 1967; Lasch
1991; Laplantine and Nouss 1997; Lanteri-Laura 1957; Vattimo 1991, 1992, etc.).
The various approaches converge to the realisation that this new type of individual-
ism is culturally and historically determined.
This complex and paradoxical process is characterised by the retreat into a
“hedonist” ideal, by means of which the individual overinvests his/her body and
imaginary life, and by a tendency to realise all immediate desires pertaining to the
confirmation of every type of performance (athletic, professional, educational), the
overconsumption of new goods, the immediate and constant availability for endless
communication via the new technologies and the use-consumption of new psycho-
logical and psychotherapeutic techniques aiming at self-realisation and continuous
social upgrading.
This tendency to an “individualised socialisation” (Lacrosse 2007) allows us to
determine more accurately some aspects of the generalised phenomenon of “inter-
nal exile” touching both the individual and the “old collectivities”.
To begin with, we will briefly refer to the confusion brought about to traditional
symbolic points of reference with the fragmentation of nuclear family, the disparag-
ing of the paternal function and the zero tolerance to frustration and lack. These
profound changes result, among other things, in “the escalation of phenomena of
violence among children and adolescents” (Corcos 2011; Lazartigues et al. 2003),
within a context of “exile of the paternal figure”, economic and social crisis and
growing social precariousness and uncertainty.
Secondly, the predominance of a passive attitude leads to the withdrawal of large
parts of the population from participation in political, social or ecological collectivi-
ties, to the refusal to grasp the systemic cause of the crisis of globalised markets
and, even worse, to the identification of an important part of the socially excluded
groups with totalitarian, racist, anti-Semitic and neo-Nazi ideologies hailing a
nationalist type of return to an all-powerful, unadulterated by foreign mixtures,
state. In return, despair, fear and lack of hope for the future push to passivity and
retreat into oneself.
In the third place, the strong and all-powerful presence of the mass media and
advertising imposes artificial identification models implying the possibility for
everyone to have access to an immediate and limitless satisfaction “here and now”.
36 S. Stylianidis

Despite the numerous studies proving that the continuous exposition of children to
television favours the development of aggressiveness, individualism and attention
deficit hyperactivity disorder (ADHD) (Christakis et al. 2004; Barkley 2004), the
“society of the spectacle” (Debord 1967) persists unfailingly in exerting its mass
influence. The society of the spectacle and of the simulacra is not only a factor of
retreat into extreme individualism. Paradoxically, it constitutes a very efficient fac-
tor of homogenisation of people’s thought, by assembling a “machine of accep-
tance” through the brainwashing it performs (Chomsky 2007). Along the same line
of thought, Bourdieu (1996) and Ramonet (1999) uncovered the mechanisms by
which television, by entirely obeying to the laws of the free market and the maximi-
sation of profit, performs the manipulation of thought.
The society of the spectacle and consumption creates a constant confusion as to
the moral bearings of one’s existence: “a set of values loses its meaning: values like
trust, faith in the Other, in ideas, in ourselves” (Bénilde 2007).
Furthermore, the mass media contribute to the growing influence of a psycho-
logical and medical “scientific” discourse preaching a healthier way of life or the
need for a “well-being” movement able to manage the “health capital” of every citi-
zen. This widely spread culture is founded on the mass incrimination of individuals
failing to abide by specific standards of beauty, appearance, weight or lifestyle and
on the exacerbation of a narcissistic ideal hugely exceeding the real potential and
psychic economy of the average individual. Personal lacks are being psychologised
and psychiatrised, while every deviation from the rules and norms of social and
professional demand for efficiency and beauty seems to be “symbolically” penal-
ised. In addition to the reproduction of social inequalities and social exclusion, the
power of the neoliberal model consists precisely in the diffusion of this culture and
its reproduction as something “natural” for society’s cohesion.
Finally, the individualisation of the social bond is a process closely connected
with the extreme competition in work relations aiming at an immediate and ever-
growing profit. This process pushes the individual to an over-adaptation to the
unequal and inhumane work relations by means of a constant internalisation of what
is transient and impersonal in social relations.
Through his documented study on work relations in France, Christophe Dejours
(1998) unveiled the mechanisms by means of which the individual expresses his/her
fear and submission to the work atmosphere of fluidity and transience and which
lead to the retreat into oneself and the rejection of social and individual suffering.
As a result of the growing social insecurity (Castel 2013) and the deregulation of
work relations, the individual’s professional life is tightly connected with senti-
ments of fear, panic, despair and doubt whether he/she will manage to stay at work.
Caught up in such a vicious circle, the individual starts calling into question the core
of his/her own identity.
Neoliberalism is not only an economic conception and ideology; it seems to
dismantle all spheres of individual, psychic and social life.
The new narcissistic individualism is produced through a process of dehuman-
isation and social disintegration calling into doubt not only the state of law and
welfare but also the very foundations of democracy (Le Goff 2003).
2 Philosophical and Sociological Foundations of Social Psychiatry 37

While the social bond “is emptied” of its essence, the market steps up to fill the
gap and pose as the “solid” foundation of a reality that has to be modernised at all
costs by a constant headlong rush.
“Social disaffiliation” (Castel 2013) leads to an individualism of “disconnection”
and a refusal to commit to any objective or vision. Ehrenberg (1991, 2000) has
demonstrated in his work how economic competition generates a competitive indi-
vidualism channelled into an entrepreneurial activity and aiming at the recovery of
an individual identity and a professional and social success posing as “the natural
moral bearings which structure today’s world”.
The opposition between market laws, the reproduction of social inequalities and
the “relaxation” of moral standards in order to achieve ever-growing profits seems
to be efficiently absorbed by the magma of neoliberal ideology, which transposes or
transforms every political and social problem in terms of market, performance and
efficiency.
Psychiatry based on the biomedical model contributes in its turn to this process
of radical depoliticisation of problems and oppositions: the new classifications of
the DSM-5 (Corcos 2011; Caravatos 2014) offer answers to symptoms (i.e. world-
wide expansion of the antidepressants market) closely related to social and eco-
nomic problems (poverty, social exclusion, lack of investment in the future) through
the expansion of the indications for the use of psychotropic drugs.
The work of Gonon (2013), neurobiologist at the CNRS in France, is highly
interesting. Gonon deconstructed in an extremely documented way the pseudosci-
entific ideology of the new psychiatric classification systems (DSM-5) while uncov-
ering at the same time the multiplication of brain dysfunctions and deficiencies
provoked by the use of the new psychotropic drugs, even among children. For
example, the DSM-5 “allows”, by means of a purely abstract biomedical approach,
to connect behaviour, social disorder and biological deficiency, thus expanding the
indications and, at the same time, the profits for the pharmaceutical companies.
At this point, social psychiatry encounters new challenges: the need to revitalise
critical thought and to promote the complexity of subjective suffering not only in
terms of diagnosis but also in terms of the social, economic and cultural framework
within which psychopathology is applied. This “new clinical approach” should
become the new field of theoretical and practical investment by critical social
psychiatry.

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Psychiatric Epidemiology and Its
Applications in Social Psychiatry 3
Lily Evangelia Peppou and Stelios Stylianidis

Abstract
Epidemiology explores the distribution and key factors of an illness or other
health-related situations so as to apply those findings to the management and
treatment of the illness. In that sense, it is an essential framework for identifying
healthcare policy and service provision priorities and is also a vehicle that helps
to design effective and feasible prevention interventions. From that perspective,
it is – in some way – in the service of public health. While drawing conclusions
and extrapolate findings to the population from the sample, epidemiologists fre-
quently take into account the role of chance, bias, confounding and the direction
of causality on the association observed between the exposure and the outcome/
illness. Depending on the research questions posed and the availability of materi-
als and human resources, they select epidemiological designs that will make it
easier to achieve the goals of a study. The main research designs are ecological
studies, cross-sectional studies, case control studies, longitudinal cohort studies
and randomised controlled trials. They also make every effort to minimise the
occurrence of bias and to control for confounding. Despite the importance of
epidemiology worldwide with regard to its contribution to evidence-based
medicine and the provision of quality services, Greece has failed to establish an
epidemiology-based psychiatry culture. Nationwide studies are scarce, and links
between epidemiological findings and mental health policies have not been

L.E. Peppou (*)

Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]
S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 41

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_3
42 L.E. Peppou and S. Stylianidis

made. To date, policies appear to be based on intuition, extreme empiricism,

sloppy approaches, the “guild mentality”, political interests or individual beliefs;
and while there may be some examples of best practice in terms of the services
provided, overall services are not imbued with and integrated into a central,
national strategic plan for mental health. Under pressure from the global mental
health movement, the development of psychiatric epidemiology in Greece is not
only a vital necessity but also a major challenge.

3.1 Introduction: Defining Epidemiology

The term epidemiology has been defined as “The study of the distribution and determi-
nants of health-related states or events in specified populations, and the application of
this study to the control of health problems” (Last 1995). Epidemiologists firstly
describe a health problem and its extent: who gets ill, when and where. They then
attempt to explain those observations: why do people get ill? The description of ill-
nesses offers signs about potential risk factors, leading to the formulation of hypotheses
that can be tested in the context of well-designed studies. Studies targeting specific risk
factors can also provide additional evidence about the presence of aetiological relation-
ships. Consequently, epidemiology is above all a practical branch of science and
includes systematic exploration of health, illness and human behaviour in the natural
environment. It is, therefore, the main scientific tool in public health medicine.
Any descriptive endeavour must set out the necessary framework for setting pri-
orities in healthcare policy planning and service provision, while any explanatory
endeavour must lead to effective and feasible primary and secondary prevention
interventions. Consequently, epidemiology and public health are complementary –
if not interdependent – disciplines.
Psychiatric epidemiology lags behind as compared to other branches of epidemi-
ology, primarily because of difficulties in homogenising and measuring mental dis-
orders. As a result, the majority of contemporary psychiatric epidemiology studies
remain descriptive and focus on calculating the prevalence of disorders and their
various subtypes (Robins and Regier 1991); while other branches of epidemiology
have made progress in identifying risk factors and developing protective interven-
tions (Elwood et al. 1992). Psychiatric epidemiology studies which capture risk
factors tend to focus on broad categories of factors, such as gender or socio-eco-
nomic standing, rather than on modifiable factors, which could be used as specific
targets in an intervention.

3.2 Causality Relations

The drawing of conclusions in epidemiology (the so-called inferences) always entails

a shift from research observations to generalisations. However, the presence of an
association between two variables (i.e. between an exposure and an illness/outcome)
3 Psychiatric Epidemiology and Its Applications in Social Psychiatry 43

does not equate to there being a causal relationship between them. In epidemiology,
before exploring the degree to which causality criteria are met between two vari-
ables, one ought to take into account the role of chance, bias, confounding and the
direction of causality in relation to them.

Chance

The role of chance in explaining the observed association between two variables is
addressed in the statistical analysis of the results. More specifically, the p-value
(significance testing) and the confidence interval are used to demonstrate the likeli-
hood that chance explains the observed relationship. In the case of a hypothetical
association between an exposure and an illness/outcome, one can estimate the like-
lihood that an association exists in the data, if the zero hypothesis is true (in other
words that in reality there’s no association between the two variables, but the rela-
tionship observed in the data is exclusively the product of chance). Conventionally,
the widely agreed scientific limit for that probability is 0.05. In other words, the
results are considered real (meaning that they also occur outside of experimental
conditions) if the probability that they have occurred by chance is less than 5 %.
Concomitantly, 95 % confidence intervals give a range of values within which the
true value will lie on 95 % of occasions. However, it is worth noting that confidence
intervals do not reflect probability. For example, in 2005 the annual prevalence of
serious depression in Europe (meaning the percentage of people who were found to
meet the diagnostic criteria for major depression during the year before clinical
evaluation) was found to be 6.9 % with a 95 % confidence interval of 4.8–8.0
(Wittchen and Jacobi 2005). Congruent with this, if the study was to be repeated
100 times by following the same methodology, but by drawing different samples
from the same population, 95 out of 100 of those times the prevalence-estimate
would lie somewhere in the range 4.8–8.
Of those two methods for tapping the role of chance in the association observed
between two variables (significance testing and confidence interval), the problem
with significance testing is that it indicates only a probability (as already mentioned
the probability that the association observed can be explained solely by chance and
does not exist in reality). The size of p-value does not inform about the strength of
the association: a weak association of low clinical significance could be identified
with a very high statistically significant result, especially if the study sample is
large. On the contrary, the confidence interval can provide information about the
strength of association and its statistical significance. For example, in a randomised
controlled clinical trial investigating the efficacy of two methods of psychotherapy
in alleviating depressive symptoms (as measured by a relevant scale), the p-value at
the end of the trial merely provides information about which of the two groups per-
formed better and whether the difference between them is statistically significant or
not (if it is real or it is caused by chance). The confidence interval on the contrary
will provide information about (i) the size effect (ii) whether the difference is statis-
tically significant or not – in the case where the confidence interval includes the
44 L.E. Peppou and S. Stylianidis

value 0, then the difference is statistically non-significant, and (iii) the accuracy of
the measurement (a large confidence interval is associated with less accuracy).
Consequently, in modern epidemiology, confidence intervals are generally preferred
to significance testing methods.

Bias

Bias is systematic error arising either during the design or implementation of a

study. It is always unwelcome and cannot be corrected for during statistical process-
ing of the results, as it is frequently the case with confounders. The only way to
minimise it is by carefully designing and implementing a study carefully in a tar-
geted manner.
Bias can be divided into two main types: bias arising when the investigator
selects his sample or two comparable groups in population (selection bias) and bias
arising when measuring variables (information bias). Specific epidemiological
designs are more vulnerable to certain types of bias than others.
Information bias emerges during the process of measuring the variables of inter-
est. All measurements entail some degree of bias, even those relating to measure-
ment of bodily functions such as arterial pressure. When measurements relate to
categories of variables, such as diagnosing major depression, error in these cases is
called misclassification. Misclassification error becomes bias when it is systematic
and differential, i.e. when knowledge of other variables in the design systematically
leads to misclassification error of the independent or dependent variable. An illus-
tration of this point is when the classification of participants as depressed or non
depressed (outcome variable) is influenced by knowing whether they are employed
of unemployed.
Recall bias is another form of information bias and has to do with the partici-
pant’s ability to recall specific past information. For example, in a case-control
study exploring the association between perinatal abnormalities and the presence of
schizophrenia, participants are recruited based on the outcome (schizophrenia) and
divided into two groups: patients with schizophrenia and members of the general
population (the control group). To explore the existence of perinatal abnormalities
in the two groups, the investigator conducts interviews with the mothers (mothers of
patients with schizophrenia and mothers of people from the general population). If
some of the mothers in both groups do not have good memory, there is some error,
but it is non-differential and non-systematic. However, if mothers in one group sys-
tematically recall the desired information better or worse and in a way which sig-
nificantly differentiates them from the mothers in the other group, then there is
recall bias. Note that mothers of patients with schizophrenia may be more prone to
recall perinatal abnormalities – and may even confabulate in an attempt to attribute
their child’s illness somewhere or to cast off any tellings. That could differentiate
them in a systematic manner from the mothers of healthy members of the control
group, who have no reason to remember the birth process. In general terms, the
presence of an illness is frequently accompanied by efforts to attach to it, which in
3 Psychiatric Epidemiology and Its Applications in Social Psychiatry 45

epidemiology is known as “effort after meaning”. One way to address the specific
bias is by cross-checking information from different sources or by adopting a cohort
design.
The third well-known type of information bias is investigator bias. In the exam-
ple above concerning the association between perinatal abnormalities and schizo-
phrenia, an investigator who believes that perinatal abnormalities cause schizophrenia
may attempt to elicit that information from the mothers of individuals with schizo-
phrenia more strongly e.g. by being more pressing than the mothers of the control
group. One way to address this type of bias is to “blind” the investigator, so that he
does not know the participants’ group allocation or the research hypothesis or the
hypothesis in the study.
Selection bias primarily relates to the comparability of two groups in the study
design and usually emerges when the control group is not the most suitable. This bias
primarily occurs in case-control studies when the choice of an individual for the
patient group or the control group is related in some way to an exposure. For exam-
ple, in a case-control study on the association between arthritis (an independent vari-
able – exposure) and Alzheimer’s disease (a dependent variable – outcome), it was
found that arthritis is more frequent in the control group than in the Alzheimer’s
group implying therefore that arthritis is a protective factor against the onset of
Alzheimer’s disease. However, Alzheimer’s disease patients were recruited from a
specialized outpatient clinic, while the individuals from the control group were
drawn from a primary care setting. In primary care, visits pertaining to arthritis are
quite frequent and therefore probability of someone suffering from arthritis in this
population group (individuals who visit primary care facilities) is disproportionately
high as compared to the general population. Consequently, the lower frequency of
arthritis among patients with Alzheimer’s disease does not reflect a protect effect, but
it is related to the emergence of bias during the recruitment. In this rationale, in order
to reduce the probability of selection bias to occur, members of the patient and con-
trol group should be drawn from the same population (base population). One way to
check for this is to think of the following question: “if the individual of the control
group manifested the illness of interest, would he/she be in the patient group?” and
vice versa, “if the patient did not manifest the illness would he be in the control
group? he/she be found in the control group?”.
In cross-sectional studies and cohort surveys, a major source of selection bias
emanates from non-participation. It is widely accepted that people who agree to
participate in studies differ in a systematic manner from people who refuse. Refusers
are usually men, people with low educational attainment and unemployed individu-
als. However, for bias to occur, the difference between participants and non partici-
pants should be related to both the exposure (the independent variable) and the
outcome (the dependent variable). Consequently, seldom is non-participation trans-
lated to the occurrence of bias; however, it often limits the generalisation ability of
the study findings.
Likewise, attrition bias can occur as a result of loss to follow up in cohort studies.
As in non-participation bias, the two groups should consistently differ in terms of their
characteristics or reasons they were lost and these differences should be related to both
46 L.E. Peppou and S. Stylianidis

the exposure and the outcome of interest. For example, in a study exploring the
association between perinatal abnormalities and schizophrenia, bias will occur if all
those who have both perinatal abnormalities and schizophrenia are lost at follow-up to
a significantly greater degree than those with just schizophrenia (but not perinatal
abnormalities) and/or those with perinatal abnormalities but not schizophrenia.
Similarly to non-participation, bias is rarely observed in cohort studies; however, due
to loss to follow-up, there may be restrictions on the generalisation of study findings.

Confounding

Confounding expresses the situation where the measured effect of an exposure is

altered because the exposure is concomitantly associated with other factors, which
also exert an impact on the illness/outcome of the study. Confounding can cause of
prevent the outcome of a study, is not a mediating factor and is independently asso-
ciated with the exposure of interest. In other words, the confounding variable pro-
vides an alternative explanation for the observed association between the exposure
and the outcome. For example, in a study an association documented between grey
hair and mortality. The study is very well designed, no bias has emerged, the sample
is representative of the population and statistical testing substantiates a strong asso-
ciation. In this reasoning, the association between grey hair and mortality can be
extrapolated to the population. Nonetheless, such a claim fails to take into consider-
ation the role of confounding. In particular, in the above mentioned example, age
constitutes a confounder variable.
The effect of confounding can be addressed either during the design of the study
or during its statistical analysis. With regard to the former, the two basic strategies are
restriction and matching. As far as restriction is concerned, the sample is limited to
one confounding category. For example, if gender is a confounding variable, only
men will be recruited in the study. It is worth noting that in this way limitations
emerge concerning the generalisability of the results, since in this example, they can-
not be applied to women. On the contrary, the method of matching groups to specific
confounding factors requires careful selection of participants for the control group in
order for the two groups to be as similar as possible. For example, if gender is a con-
founder variable and the patient group consists of 60 % of men, then the control
group should include a similar percentage of male participants. Although this method
is helpful, it can become tricky when trying to address several confounding variables
simultaneously. Arguably, it is difficult for the groups to be similar in terms of gen-
der, age, marital status, educational level, socio-economic background, etc. The most
effective way tackle confounding variables is randomisation. The process of ran-
domisation ensures random (and by extension non-differential) distribution of con-
founding variables to the two groups. It is noteworthy, that this concerns both known
confounding variables (which have been measured in the study) and unknown (which
are not taken into consideration during the design of the study and hence they have
not been measured). However, in observational studies where randomisation is not
feasible, the most common way to deal with confounding is through statistical analy-
sis, using stratification or multivariate models.
3 Psychiatric Epidemiology and Its Applications in Social Psychiatry 47

It merits noting, that sometimes it is hard for researchers to disentangle confounders

from mediator or moderator variables. However, the decision about the nature of the
variable is usually subjective.

Direction of Causality

It is also important to determine the direction of causality when drawing conclu-

sions about the causal relationship between two variables. In other words, it is
essential to be able to demonstrate that the exposure causes the outcome and not
vice versa. For example, in a cross-sectional survey indicating an association
between unemployment and major depression, it is not clear from the nature of the
study’s design, if the individuals who are unemployed have a higher probability of
becoming depressed or if the individuals who are depressed – due to the illness and
the stigma associated with it – have a higher probability of being unemployed. As
cross-sectional studies collect information about the exposure and the outcome
simultaneously and case-control studies recruit on the grounds of the outcome, both
designs cannot determine the direction of causality.
On the contrary, in cohort studies, where participants are recruited based on the
presence/absence of an exposure while being free of disease, the temporal sequence
of events can be observed and thus, direction of causality can be substantiated.

3.3 Epidemiology Research Design

Epidemiologists are have a good knowledge and understanding of the principles of

research design. Ethical issues do not allow the random allocation of participants
into adverse conditions or the experimental distribution of harmful exposures. For
example, if one wants to investigate the effectiveness of involuntary hospitalisation
in patients with psychosis, he/ she cannot randomly allocate patients into two
groups: the involuntary hospitalisation group and the voluntary hospitalisation
group, due to ethical constraints. On the contrary, observational studies are less
susceptible to these issues but more prone to bias and confounding.
The design and analysis of a study seeks to maximise the accuracy and validity
of its results. The accuracy of a measurement (such as the prevalence of depression
in the general population) can be compromised due to error in sampling or measure-
ment process. However, errors of this type are random (in other words they are not
systematic, as in the case of bias) congruent with this, accuracy can be improved by
using larger samples and better measurement tools. On the contrary, bias and con-
founding are non-random and systematic errors that impinge on the validity of the
results. Therefore, the selection of a research design and the methods employed are
crucial for reducing bias and maximizing the study’ s validity.
The main types of research designs used in epidemiology can be divided into
three broad categories: (i) observational studies (ecological studies, cross-sec-
tional studies, case control studies, and cohort studies), (ii) experimental stud-
ies (randomised controlled trials) or (iii) systematic review (and meta-analyses).
48 L.E. Peppou and S. Stylianidis

Experimental studies are used to evaluate interventions, such as the effectiveness of

Cognitive Behavioural Therapy (CBT) in treating depression. In observational stud-
ies, epidemiologists endeavour to draw inferences about diseases through natural
observation of people, who have been previously classified as having/ not having
the exposure or outcome of interest. In this rationale, the researcher has no control
over the events under investigation.
Observational studies can either be descriptive or analytical. A descriptive study
elaborates on a specific disease (like depression) or an exposure (like unemployment)
with respect to the characteristics of individuals affected by it in a specific place at a
specific point in time. On the contrary, analytical studies explore the strength of asso-
ciation between exposures and outcomes. It is noteworthy noting that this distinction
is largely theoretical, since practice studies frequently entail both descriptive and ana-
lytical elements.
Moreover studies can also aggregate used data, for example, the unemployment
rate in Greece, and data gleaned from individuals. The advantages and disadvan-
tages of these research designs are summarised in Table 3.1, and a brief outline of
each research design is given below.

Ecological Studies

Ecological studies explore associations between exposures and outcomes, based on

populations defined either geographically, or temporally. Consistent with this, the
unit of analysis is populations or groups of people, rather than individuals. For
example, an ecological study has substantiated a significant correlation between
unemployment and suicide rates in Greece during the recession (Branas et al. 2015).
In the aforementioned example, the association found between unemployment rates
and suicide should not be interpreted as indicating that the vast majority of individu-
als who committed suicide in Greece was unemployed. Erroneous application of
conclusions drawn from the aggregate level to the individual level is termed “ eco-
logical fallacy”. Another shortcoming with ecological studies is that data are not
usually collected for research purposes and therefore information on potential con-
founder variables is not available. Lastly, as information about the exposure and
outcome is gleaned simultaneously, direction of causality cannot be determined.
One of the most popular ecological studies in psychiatric epidemiology is that
conducted by Emile Durkheim (1858–1917), who explored regional, national and
temporal variations in suicide rates in Europe. He recorded a significant association
between the suicide rates in 13 Prussian provinces and the number of residents who
were Protestants (Durkheim 1951).

Synchronic/Cross-Sectional Studies

Cross-sectional studies record information from a sample of people who have been
drawn from a base population defined by area (such as children aged under 16 in
 3

Table 3.1 Advantages and disadvantages of different types of epidemiological study

Case-control
Cross sectional survey studies Cohort studies Ecological studies Clinical trials
Subject selection Defined population Caseness Exposure Aggregated data Caseness
Source of bias Selection Selection Information Selection if population Selection information
Information (observer (reduced by blinding)
(recall and only)
observer)
Non response Recall and Loss to follow-up Ecological fallacy Investigator bias, reduced
information investigator (selection) considerably if blinding
Recall and observer bias methods are used
Probability of Medium Medium Low High Very low if randomised
confounding
Resources Quick and cheap Relatively quick Lengthy and Relatively quick and cheap Relatively expensive
and cheap expensive
Applications Planning services Rare outcomes Rare exposure Rare outcomes Efficacy of new
interventions
Mapping secular and Single outcomes Single exposure Rare exposures Effectiveness of new
geographical trends interventions
Identifying correlates Multiple Multiple Multiple exposures Hypothesis testing
Psychiatric Epidemiology and Its Applications in Social Psychiatry

exposures outcomes Population exposures such Mechanisms

as air pollution
Measurement of Prevalence Odds ratio Relative risk Correlation/regresson Relative risk/odds ratio/
effect coefficient difference between means
Adapted from: Ford, T. (2007). Introduction to epidemiological study designs. In M. Prince, R. Stewart, T. Ford & M. Hotopf, (2003). Practical psychiatric
epidemiology. New York: Oxford.
49
50 L.E. Peppou and S. Stylianidis

Greece) or some specific characteristics (such as patients who are voluntarily admit-
ted to psychiatric hospitals) in order to calculate the prevalence of an outcome as well
as to explore potential risk factors. They are inexpensive and easy to conduct,while
they are more frequently used for estimating the extent of a disease, to plan services
an to identify potential risk factors that can be explored in depth in analytical studies.
Since the information about exposures and outcomes is collected at the same time,
cross-sectional studies cannot shed light on the temporal sequence of events and thus,
they cannot indicate the direction of causality.
Low response rates in cross-sectional studies (r.e. that is below 80 %) may reduce
the validity of the results, since it is likely that individuals who refused to participate
differ in a consistent manner from those who participated. Recruitment strategy and
the mode of data collection (phone, on-site survey, post) are important in ensuring a
high response rate. The way in which participants are approached and the hassle
associated with participating ought to be taken into account in the design process in
order to ensure a high response rate.
Another aspect that necessitates consideration in the design of a study pertains to
the careful selection of tools that are valid (i.e. they study what they are intended to
study) and reliable (i.e. they are consistent over time or among different investiga-
tors). It is note worthy that tools should be valid for the population for which they
are intended to be used. For example, a tool which has been validated in a clinical
population is not necessarily be valid for the general population. Moreover, a tool’s
validity in one culture/ country is not tantamount to being valid in another culture/
country.
Cross-sectional studies frequently involve a large of participants and therefore,
they can become particularly expensive if the presence of mental disorders is
assessed with clinical instruments employed by psychiatrists. In this reasoning,
structured diagnostic interviews made by lay people are usually preferred over clini-
cal assessment made by psychiatrists. The structured content of the instruments,
good training of interviewers and continuous supervision throughout the study
design contribute to the validity and reliability of the assessment. Among the most
widely used structured diagnostic instruments employed by lay interviewers are the
Composite International Diagnostic Interview (CIDI) and the Revised Clinical
Interview Schedule (CIS-R).
It is noteworthy that cross-sectional studies are not the appropriate design for
investigating outcomes with low prevalence rate such as schizophrenia or autism. In
these cases, one needs to recruit a large number of participants to be able to explore
the outcome with adequate precision. Alternatively, oversampling of specific popu-
lation subgroups may occur.

Case-Control Studies

Case-control studies are primarily retrospective research designs. The aim is to

recruit a random sample of patients and non-patients from the same designated
population and then to explore their post exposure to possible risk factors. The odds
3 Psychiatric Epidemiology and Its Applications in Social Psychiatry 51

of being exposed are compared between the patients and their controls, resulting in
the computation of odds ratio, which is the most frequent measure of effect size in
this design.
Case-control studies are quick and inexpensive to carry out, while they are suit-
able for an initial exploration of rare diseases. Nonetheless, they are prone to selec-
tion bias, investigator bias and recall bias. Furthermore, as the information about the
exposure is collected after the disease manifestation, the direction of causality can-
not be determined.

Cohort Studies

Cohort studies have two key features:

(i) Participants are recruited on the grounds of exposure rather than disease, in
contrast to case control-studies.
(ii) They are longitudinal designs: The exposure is measured prior to the onset of
the disease.

Classical cohort-studies involve following-up a group of people who have been

recruited based on their exposure status ( presence vs, absence of the exposure) in
order to record the incidence of the disease, hence the direction of causality can be
establish. However, due to the large number of participants often required and the
long duration of follow up periods, cohort studies are usually very expensive to
conduct. For example, if one would want to study the association between perinatal
abnormalities and schizophrenia by conduction a cohort-study, he/she would have
to follow up participants for roughly 20 years (from birth to the onset of the disease)
and he/she should recruit a large number of participants, as schizophrenia has low
prevalence. In this rationale, a cohort study would be time-consuming and very
expensive.
The two main sources of bias in cohort studies are non-participation bias and
attrition bias (loss of follow-up).

Randomised Controlled Trials

In experimental studies, the investigator allocates the intervention (exposure) to cer-

tain individuals or communities and compares the outcome of interest among them.
When the allocation of participants to intervention and control groups is randomised,
the investigator endeavours to create similar groups with respect to confounding
variables, whether they are known or unknown. Random allocation is usually
ensured by using a statistical package such as SPSS; however, very often it is not
achieved if the study has a small sample size. One can test for this by statistically
comparing the characteristics if the two groups prior to the outset of the intervention
phase. Moreover, randomization itself cannot guarantee that the methodology in a
52 L.E. Peppou and S. Stylianidis

controlled trial is perfect,since it cannot deal with bias. Congruent with this, efforts
should be made to minimize its occurrence. Specifically, it is important to employ
blinding techniques for both the participants and the researchers (i.e. “double-
blinding” and in the case where the statistician does not know the hypothesis of the
study and the allocation of participants, it is called “triple blinding”) so as to prevent
the occurrence of information bias. Although many studies start by successfully
“blinding” participants and researches, during the study period. Very often patients
and/or investigators are able to determine to which group they belong, resulting in
unsuccessful “blinding”. A well-designed controlled trial should incorporate a
questionnaire to measure the degree to which “blinding” of participants and inves-
tigators was successful at the end of the study (e.g.. how many participants can
accurately recognize the group to which they belonged). It is noteworthy that in
randomized control trials, the selection of a control group necessitates careful con-
sideration. For example, in RCTs measuring psychotherapy effectiveness it is hard
to create a placebo intervention; while ethical issues prevent researchers from
depriving participants of an intervention with established effectiveness for their
condition. Moreover, a waiting-list control is often inadequate, as individuals know
their group allocation an hence have different expectations from participating into
the study as compared to individuals receiving an intervention. In this reasoning, the
difference between the two groups cannot be attributed exclusively to the interven-
tion but to different expectations held by the participants. Randomised controlled
tests are currently considered to be the gold standard in epidemiology. However, as
they can also be pone to bias, efforts should be made to minimize its occurrence.
When the intervention group is not comprised of individual but of groups of
individuals such as a community or a class in a school, the design is known as a
community trial or a cluster randomised trial. In these cases, both upon designing
the trial as well as when analysing its results, the researchers should take into
account that there two sources of variation in them: i) between individuals in a
group and ii) between different groups. For example, in a school intervention about
bullying, the pupils in one school (the intervention group) will have similar charac-
teristics setting them apart from pupils at another school (the control group).
In clinical routine settings, when randomisation is not always feasible to occur,
quasi-experimental designs are frequently adopted.

3.4 Epidemiology and Evidence-Based Medicine

There is frequently an overlap between the methods employed in epidemiology and

in health services. Research aims pertaining to clinical effectiveness of interven-
tions, are usually explored by using epidemiological methods. Evidence-based
medicine was developed in an attempt to substantiate clinical decisions on epide-
miological and statistical groups. The implementation of systematic literature
reviews so as to generate sufficient evidence that would inform routine clinical prac-
tice, is base on epidemiological principles and statistical approaches, known to
epidemiologists.
3 Psychiatric Epidemiology and Its Applications in Social Psychiatry 53

However, as a corollary of this, the movement for active involvement, empower-

ment and advocacy for the rights of service users and their caregivers, modern
trends in the fields of social psychiatry and psychosocial rehabilitation laid the
foundations for new scientific, ethical and institutional arguments for applying and
documenting psychiatric epidemiology in assessing and evaluating mental health
services (Rogers and Pilgrim 1993; Thornicroft and Tansella 2005).
Despite the fact that there are different perspectives among service users, their
families and mental health professionals (Mason et al. 2004), it has been docu-
mented in the research that user and caregiver movement in the research process of
evaluating quality of care, has a positive effect on therapeutic alliance as well as
treatment and case management outcomes (Roth and Crane-Ross 2002).
Conducted a study on quality of care from the standpoint of people with serious
mental illness in community mental health services in 3 regions of Italy. A total of
204 service users were involved and 8 different realms of care provision were
explored: the choice of therapist and patients stuff relationship, treatment effective-
ness, the natural setting; the availability of different treatment modes and the con-
figuration of services; the provision of information about diagnosis; the existence of
an individualize care play; the degree of patient participation in treatment decision
making; the length of a waiting list and the incorporation of home visits in services
provided.
Among the above mentioned domains, the three that emerged as being of out-most
importance-and in fact were significantly associated with users’ satisfaction - were:
the choice of professionals, the length of a waiting list and the provision of suffi-
cient information bout treatment and their overall care plan.
Furthermore, service users and mental health professionals held different views
with regard to patients’ autonomy as well as the need for empowering and respect-
ing them and their choices.
Therefore, the study demonstrates that service users can provide useful and reli-
able designs of care into aspects of care delivered and the responsiveness on the pt
of mental health professionals contributes substantially in improving the quality of
care and changing the culture of mental health services. Change cannot occure
about without utilising epidemiological principles and techniques.

3.5 Epidemiological Findings in Greece

At the international level, the most widely known cross-sectional studies are the
National Comorbidity Survey in the USA (Blazer et al. 1994; Kendler et al. 1996;
Kessler et al. 1997), the National Psychiatric Morbidity Survey in the UK (Jenkins
et al. 1997) and the WHO’s World Mental Health Study, 2000 (Kessler 1999).
Elaboration on these studies is beyond the scope of this chapter; however, readers
are encouraged to refer to these publications to gain a complete picture of the points
discussed.
At the national level psychiatric epidemiology firstly appeared in Greece when
two nationwide studies were conducted by the Professors Emeritus of Psychiatry,
54 L.E. Peppou and S. Stylianidis

Kostas Stefanis and Michael Madianos, in 1978 and 1984 (Madianos and Stefanis
as well as one study by Mavreas and colleagues in the Athens area (Mavreas et al.
1986). Those studies provided evidence about the general levels psychiatric morbid-
ity, while Madianos’ nationwide studies also addressed the epidemiology of major
depression in particular.
Over the last decade, and under the increasing pressure exerted from the
economic crisis afflicting the country, the University of Ioannina funded by the
Hellenic Ministry of Health designed and implemented a cross-sectional study
(“2009–2010 Psychiatric Morbidity Study”) on a random, representative sample of
households in Greece (Crete region was excluded due to financial constraints), so as
to estimate the prevalence of common mental disorders in the country (Skapinakis
et al. 2013). Psychiatric morbidity was assessment with the Revised Clinical
Interview Schedule (CIS-R), which had been employed in a similar UK nation-
wide study, and data were collected during the period September 2009–February
2010. Although the response rate was low (54 %) and the study had certain limita-
tions (e.g. the tool is validated for the adolescent – population, only the presence
of psychotic symptoms was not assessed, 35 % of the sample used a computer to
enter the answers, whereas 65 % needed the investigator’s assistance), it consti-
tutes the first attempt to generate epidemiological evidence and to explore specific
diagnoses in a nationwide sample. The results indicate that one week prevalence
of psychiatric morbidity (i.e. the number of people meeting diagnostic criteria the
week before the interview) in Greece was found to be 14 %, which is similar to
estimate by Mavreas and colleagues several decades ago (Mavreas et al. 1986).
The most mental disease was found to be generalized anxiety disorder (4.1 %), fol-
lowed by major depression (2.9 %), phobias (2.79 %), mixed symptoms of anxiety-
depression (2.67 %), panic disorder (1.88 %) and Obsessive Compulsive disorder
(OCD) (1.69 %). Futhermore, being female, divorced or widowed, having a low
level of education and being unemployed were found to constitute risk factors for
psychiatric morbidity.
At the same time, the University Mental Health Research Institute (UMHRI) in
a series of cross-sectional nationwide studies a steady rise in one-month prevalence
of major depression in the general population during the economic crisis from 3.3 %
in 2008 to 6.8 % in 2009 and 8.2 % in 2011 (Economou et al. 2013; Madianos et al.
2011). Conflicting findings between the two studies concerning major depression
can attribute to the different methodologies adopted: one-week vs one-month preva-
lence estimate, household vs, telephone survey, different tools for assessing major
depression and different response rates among others.
At the local level in 2005 and 2008, the Association for Regional Development
and Mental Health (EPAPSY) carried out epidemiological studies on the prevalence
of common mental disorders in the areas of Evia and Paros-Antiparos, respectively.
The studies were carried out in areas where EPAPSY provided services in order to
assess the population’s needs and to improve the design and implementation of
mental health promotion activities. The Evia study was carried out as part of an
international collaboration between EPAPSY and the World Health Organisation
Collaborative Centre of Lille, France, and involved an assessment of psychiatric
3 Psychiatric Epidemiology and Its Applications in Social Psychiatry 55

morbidity in a representative sample of the local population (Stylianidis et al. 2014).

The Mini International Neuropsychiatric Interview (MINI) tool was used to capture
mental health problems, along with a form for recording socio-demographic data.
The study demonstrated that 29 % of the island population suffered from at least one
mental health disorder at some point in their lifetime. Additionally, women dis-
played higher prevalence rates of mood and anxiety disorders as compared to their
male participants, with the exception of dysthymia, social anxiety and Post
Traumatic Stress Disorder (PTSD). On the contrary in the Paros-Antiparos study,
the methodology employed was similar to the 2009–2010 Psychiatric Morbidity
Study already mentioned. The results showed that the prevalence of psychiatric
morbidity on both islands was around 22 % with women, the unmarried individuals
and the unemployed displaying elevated odds of manifesting psychiatric morbidity;
whereas participants with higher education level and with higher income levels dis-
played lower odds of suffering from mental disorders (Stylianidis et al. 2010).

3.6 Discussion: Conclusions

This chapter endeavored to briefly present the key principles of epidemiology and
the main research designs that are used. This information is of paramount impor-
tance upon designing, implementing and critically appraising a study. It also delin-
eated the main cross-sectional studies which have been carried out in Greece the
past decades. Greek studies adopting a different research design (i.e. Other than a
cross-sectional survey) were not included, primarily because epidemiology starts
off with describing a health outcome and providing clues for its understanding. On
these grounds, it informs interventions and policies for tackling it and subsequently
assesses their impact.
In other words, if large scale epidemiological studies that explore mental health
outcomes and their correlates re missing, how can we proceed into developing tai-
lored interventions for offsetting their effect?
As already mentioned, descriptive epidemiology seeks to assist in setting priorities
in was hardly based on epidemiological evidence, either local or national, or on
applied epidemiological studies centered on how mental health services operate (qual-
ity of care, profile of the service, clinical outcomes, etc.). As a corollary of this, the
necessary complementary and dialectical relationship between psychiatric
care,psychiatric epidemiology and mental health is scarce in Greece. Policies seem to
be based on intuition,personal beliefs, improvisation and sketchy planning, while they
often promote political interests or those of trade unions.
At the same time, good practices have been recorded in the delivery of mental
health services (e.g. Evaluation of th Psychiatric reform, see the relevant chapter of
this book); however, they are not widely disseminated and they are not incorporated
in a national strategic plan for mental health.
Reports by foreign experts (EU, WHO, Institute of Psychiatry, readers can find
more information about them in the germane chapters of this book) appear to act
primarily as a political alibi for the leadership of the Ministry of Health and Social
56 L.E. Peppou and S. Stylianidis

Insurance rather than as a valuable tool that can guide the implementation and mon-
itoring of the psychiatric reform in the country. Consequently, in the absence of a
strong political will,epidemiology – which constitutes a tool of public health –
remains underutilized, at least in the mental health sector in Greece.
Psychiatric epidemiology should formulate insightful hypothesis and research
aims prior to the design of study, so that it can generate evidence that would contrib-
ute substantially at the individual level, improving the quality of care; to changes in
monitoring of the national operational plan.
In this reasoning, psychiatric epidemiology should not become an end in itself, a
self-referred and “fetishistic” object of public health. In other words, epidemiologi-
cal studies should not be conducted just for promoting epidemiology an for the
production of scientific publication.
Taking into consideration the special characteristics of Greece,public health and
epidemiology should meet in an organized and cohesive manner,so as to provide
solutions to the dead-end of the mental health care system in the country. This
change in mentality and practice – i.e. that public mental health priorities should be
based in epidemiological evidence –, must occur rapidly, given the growing dis-
semination of the global mental health movement,which in turn exerts pressures for
the homogenization and adaptation to a specific model of epidemiology worldwide
(Pearce 2004, see pertinent chapter of this book).
Soon, research areas will extend from the individual, community and national
level to the international. Congruent with this, there is a risk that conclusions ema-
nating from countries with advanced psychiatric epidemiology and evidence-based
mental health care, will be applied to countries that cannot generate their own evi-
dence base; ignoring, therefore, their cultural, institutional and social characteristics.
In conclusion, psychiatric epidemiology is still on its infancy in Greece and thus
its development remains challenging. Psychiatric epidemiology should be closely
tied to public health and to the development and improvement of services. It should
also substantiate the integration of innovations into the system (e.g. patient an care-
givers’ participation in research and service delivery, implementation of the recov-
ery model, cost-effective interventions, among others) in parallel with international
findings. Good knowledge of international scientific standards s well as examples of
good practice can provide framework fro developing our own national approach.

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Global Mental Health
4
Michail Lavdas, Stelios Stylianidis,
and Christina Mamaloudi

Abstract
The emergence of the term “global mental health” has been driven by the multi-
factorial aetiology of the onset of mental disorders, the need for equal access to
mental health services and the long-standing finding of inequalities in healthcare
and mental healthcare which prevail not just at international level but also at
national and local levels. As the human rights movement has promoted a form of
globalisation of rights, a more comprehensive view of mental health has gradu-
ally emerged, meaning it is now possible to perceive the data which affect it
depending on age, gender, geographical location, socioeconomic status, as well
as cultural factors that vary from location to location. This chapter seeks to out-
line the emergence of global mental health and explain the complex terminology
so characteristic of it, in an attempt to create a shared vocabulary for mental
health which allows one to recognise inequalities and engage in comprehensive
prevention and intervention for mental disorders.

4.1 Introduction

Global health has been defined as “the area of study, research and practice that places a
priority on improving health and achieving equity in health for all people worldwide”.
Global mental health is the application of those principles to the area of mental health.

M. Lavdas • C. Mamaloudi
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]
S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 59

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_4
60 M. Lavdas et al.

Table 4.1 Frequency (%) of individuals with physical and mental disorders treated in low-, mid-
dle- and high-income settings
High-income settings Low- and middle-income settings)
Physical disorders
Diabetes 94 77
Heart disease 78 51
Asthma 65 44
Mental disorders
Depression 29 8
Bipolar disorder 29 13
Panic disorder 33 9
Adapted from Ormel et al. (2008)

Respecting the rights of individuals with mental problems and equity in access to
mental health services is a central issue addressed in international treaties and con-
ventions, the most recent being the UN’s Convention of the Rights of Persons with
Disabilities (CPRD). However, despite the importance given to this topic, inequalities
in the protection of rights remain; inequalities that emerge on numerous levels, the main
one being segregation based on income bracket. The different levels have been set by the
World Bank (World Bank 2010) which divides countries into four categories depending
on per capita income: (a) low income (£US$995), low middle income (US$996–3.945),
high middle income (US$3.946–12.195) and high income (3US$12.196). Below we
will adopt the Thornicroft and Tansella (2013) distinction who have joined the two
intermediate categories into one (middle income), thereby giving three categories.
The main inequality lies in the fact that while low- and middle-income countries
are home to more than 80 % of the world’s population, they control just 20 % of the
mental health resources. Inequalities also exist in terms of available human resources.
In low-income countries, there are on average 0.05 psychiatrists and 0.16 psychiatric
nurses per 100,000 residents, but those numbers of 200 times lower than in high-
income countries (WHO 2005). Countries in sub-Saharan Africa have less than one
psychiatrist per one million people, compared to 137 psychiatrists per one million in
the USA (Ndyanabangi et al. 2004). Likewise, training courses and infrastructure for
mental health professionals are extremely inadequate (Saxena et al. 2007), while
there are numerous violations of rights, which are particularly serious when it comes
to individuals with mental disorders. As far as the right to equal access to health and
mental health services is concerned, international literature has devised the term
“treatment gap” to determine the number of individuals suffering but not receiving
treatment. It is a fact that more than 75 % of those diagnosed with severe anxiety and
emotional disorders, impulse control disorders and addiction disorders do not receive
any treatment in the countries they live in (low- and middle-income countries).
However, that problem remains on a smaller but equally serious scale in coun-
tries which are better off. In Greece, the rate of use of mental health services does
not exceed one third of the population of individuals suffering from some mental
disorder (Skapinakis et al. 2013). The treatment gap rate for mental disorders com-
pared to physical diseases is indicative, as we can see from Table 4.1 which helps us
4 Global Mental Health 61

better understand the discrimination against mental health within the range of
diseases and disabilities:
Patel and Prince (2010) have said that the failure to meet basic needs such as
food, clothing, housing, comfort and privacy is a failure of mankind and also
adds incarceration without control and monitoring mechanisms, as well as
recorded cases of abuse and torture, restraints, etc. Documenting effective treat-
ments and respect for human rights are two fundamental principles on which the
global mental health movement, which took form on 10 October 2008, is based
(Patel et al. 2011). The movement developed as a synergy between individuals
and institutions committed to collective action, which seeks to address the treat-
ment gap for individuals suffering from mental disorders irrespective of where
they live. Inequalities are not limited only to uneven deployment of services but
also resources invested in investigative and research activities. Less than 1 % of
resources for health research have been given for low- and middle-income coun-
tries, even though 90 % of the world population lives in those countries, while
the average allocation of resources for mental health in low-income countries
does not exceed 0.5 % of the total health budget. In short, there is a robust body
of evidence and documentation concerning the disastrous effects of mental dis-
order on a personal and social level. Among those unfortunate effects, it is
important to single out the fact that mental disorders are a major risk factor in
suicide, since 90 % of persons who commit suicide suffer from some mental
disorder and in particular mood disorders dominated by major depression and
bipolar disorder, which have been associated with 60 % of suicides (Mann et al.
2005). On an economic level, the impacts do not only relate to the cost of treat-
ment in the event of potential relapse or mental disorder episodes but the cost of
lost productivity which translates into an economic cost that globally exceeded
$2.5 trillion in 2010 and is expected to rise to $6 trillion in 2013 (Bloom et al.
2012). However, the strongest incentive for action is none other than the viola-
tion of the rights of individuals with mental disorders who frequently have to
endure unusual forms of restraint, isolation in psychiatric institutions, being
locked up in penitentiaries, being restrained and chained up in their own home,
being excluded from society and treatment and frequent abuse from traditional
treatment methods (Patel et al. 2012).
The aims of the global mental health movement have been summarised by
MGMH as follows:

Promoting the protection of human rights and prevention of discrimination and

prejudice against people with mental disorders and psychosocial disabilities
Strengthening the full implementation of the International Convention on the Rights
of Persons with Disabilities (CRPD) and the mechanisms for human rights
protection
Enabling people with mental disorder and psychosocial disabilities to make deci-
sions about their own lives and actively participate in issues that affect them
Ensuring equal access to people with mental disorder and psychosocial disabilities
in health, education, life and other activities in order not to leave “anyone behind”
62 M. Lavdas et al.

Bridging the large and increasing treatment gap in mental health and improving
access to health and social support
Integrating mental health into development activities

Likewise Patel (2014) supplemented those objectives, stating in a more practical

manner the importance of empowering individuals with mental disorders and their
families to provide mutual support. He also added that the creation of a diverse
workforce in mental health is important in provide psychosocial interventions, be
they suitably trained or supervised non-specialised healthcare professionals. Taking
into account the constantly growing technology sector, he proposed the use of tech-
nology to improve access to mental healthcare by using computers, for example, in
self-directed psychological treatment exercises. He also stressed the critical impor-
tance of early identification and treatment of mental disorders, such as interventions
in schools or other areas where children and infants are kept busy, and he considered
it equally important to reduce premature death rates by improving care for physical
health problems among those with mental disorders.

4.2 Historical Background

The scale of the mental health problem worldwide involves 450 million people suf-
fering from mental or behavioural disorder, while almost 1 million people attempt
suicide every year. One key indicator in epidemiology is mortality, with mental and
behavioural disorders occupying a low position. However the size of their impact is
demonstrated by the global burden of disorder since depression (unipolar depres-
sion) ranks in third place worldwide and is expected to climb to the first cause of
global burden by 2030. Moreover, four of the six main causes of years lived with
disability (YLD) are mental and behavioural disorders (depression, alcohol abuse
disorders, schizophrenia and bipolar disorder). More specifically, 33 % of YLD are
due to depression. While mental disorders have a relatively low mortality rate,
depression and substance abuse are associated with more than 90 % of suicide
cases. Moreover, higher mortality rates not associated with suicide have been found
in individuals who live with schizophrenic, bipolar disorder and dementia. Serious
mental disorders increase the probability of a stroke or heart disease in individuals
before the age of 55 and of living less than 5 years after the episode. The reasons for
this are that individuals with serious mental disorders frequently live in social
isolation and healthcare services are prejudiced against the health problems those
individuals face. Moreover, they are less likely to have a checkup and receive
preventative care. Lastly, psychotropic drugs also contribute to premature death.
The impact of mental disorders such as depression, for example, has been shown to
directly affect the outcome of a chronic disease.
It is particularly important to look at the key papers and scientific studies which
have shown the importance of mental disorders and the need to prioritise them when
planning policies worldwide. In 1993 the University of Harvard’s School of Public
Health working with the World Bank and the WHO assessed the burden of disorder
4 Global Mental Health 63

worldwide for the first time in a study which had been launched in 1988 to quantify
the burden of disease and trauma on the population and identify global health chal-
lenges. The objectives of the study into the Global Burden of Disease (GBD) were
as follows:

1. To facilitate the integration of nonfatal health effects in the international debate

on health policies that too often focused on mortality.
2. To disconnect the epidemiological assessment of the pressure for changes in
policy and to calculate the mortality and disability caused by a disease as
objectively as possible. At national and international level, individuals taking
decisions (decision-makers) often accepted estimates of the burden of a disorder
or injury that makes a group of people who are seeking a specific change in
policy.
3. To quantify the burden of disease using a tool that can also be used in cost-
effectiveness analysis.

The DALY (disability-adjusted life years) unit was designed to meet the above
objectives by measuring the treatment gap in health and combining the lifetimes lost
due to premature mortality and those of “healthy life” lost due to disability. The
formula for calculating DALY is set out below:

DALY = (Years Life Lost − YLL ) + (Years lived with disability − YLD )

Desjarlais et al. (1995) then went on to draft the first global report on mental
health (the World Mental Health Report) recognising problems and priorities in
low-income countries and providing documentation of the consequences of the
health burden worldwide in terms of epidemiology, anthropology and mental health
and behavioural problems. Mental health disorders are responsible for 8.1 % of lost
years of quality life.
The next turning point for global health and mental health was 2001 when the
WHO published its 2001 World Health Report (WHO 2001) which referred to the
burden of mental and behavioural disorders and estimated (Tables 4.2 and 4.3) that
they relate to more than 25 % of people at some point in their life. At the same time,
it stressed the global impact of disorders on individuals irrespective of country,
society, age, gender, economic status or urban or agricultural environment. The
common disorders which normally cause severe disability include depressive disor-
ders, substance abuse disorders, schizophrenia and epilepsy. Alzheimer’s disease,
mental retardation and childhood and adolescence disorders were also studied. The
factors related to the prevalence, onset and course of mental and behavioural disor-
ders include poverty, age, conflict and disasters, major physical diseases and the
family and social environment. The relationships between mental health and pri-
mary healthcare which had already been stressed in the Caracas Convention of 1990
were also studied.
In 2004 the WHO extended and bolstered the GBD study, which was updated in
2008 (WHO 2008a).
64 M. Lavdas et al.

Table 4.2 Wider economic burden of mental disorders (WHO 2003)

Cost of care Productivity cost Other costs
Sufferers Treatment and cost of Inability to work, Pain, side effects of
services lost earnings treatment, suicide
Family and friends Informal care Time off work Pain, isolation, stigma
Employers Contribution to care and Reduced –
treatment productivity
Society Mental healthcare and Reduced Lives of people lost,
general healthcare productivity untreated diseases
(taxation/insurance funds) (needs not addressed),
social isolation

Table 4.3 Type of estimate cost (WHO 2003)

Core cost Other costs unrelated to health
Direct cost Treatment and payment for services Management of social welfare
Burden on judicial system
Transportation
Indirect cost Cost of lost productivity Value of time of caregivers in the family
Cost due to mortality

In 2005 in the spirit of ensuring social justice, the WHO set up a Commission on
Social Determinants of Health which undertook to collect documentation on the
promotion of equity in health, to bolster the steps needed to be taken as part of a
global movement to address inequalities. The Commission completed its report in
2007 setting out key social determinants of health (Solar and Irwin 2007).
The 2008 World Health Report made health equity a priority, requiring a renewal
of primary healthcare with an emphasis on integrating mental health into it. The
factors identified relate directly to mental health since a multifactorial aetiology in
mental disorders has already been documented (Patel and Kleinman 2003; Susser
et al. 2006; Goldberg and Huxley 1992). There are multiple social determinants of
mental disorders which impact directly or indirectly on the emergence of a mental
disorder.
Those determinants require comprehensive prevention and intervention to
improve mental health, using strategies that improve the conditions in which indi-
viduals are born, raised, work and grow. Inequalities at the socioeconomic level, for
example, directly affect the rate of onset for mental disorders. For example, depres-
sion and anxiety disorders do not appear with the same frequency in all social
groups. Individuals who experience inequality and financial difficulties more
intensely have those mental disorders more frequently. Documentation of the link
between financial debt and an increased probability of the onset of a mental disorder
is important and appears in the WHO’s recent report on the social determinants of
mental health (WHO 2014). To be able to understand how socioeconomic status is
associated with the onset of mental disorder, one merely needs to realise that the
4 Global Mental Health 65

frequency, intensity and duration of “stressful” experiences coupled with skills and
defences at individual and collective levels that an individual or society has make
someone more or less vulnerable to mental disorder. Individuals who lower down
the social ladder are more likely to experience financial difficulties as well as
tougher social and environmental living conditions and to have reduced access to
support and care mechanisms. Those inequalities begin even before the individual
is born and normally accumulate over the course of his life, but we should not forget
that no individual, even if he shares certain common “burden factors”, who does not
react to his vulnerability in the same way. Below is a summary of the areas of inter-
vention that could reduce the risk of mental disorder or provide a chance for
intervention:

• Life expectancy: Prenatal period, pregnancy and perinatal period, early child-
hood, adolescence, working life and development of family and older age – all in
relation to gender
• Parents, families and households: Parental behaviour, material conditions
(income, resources, food, water, hygiene, accommodation, work), working
conditions and unemployment, parents’ physical and mental health, pregnancy
and maternal care and social support
• Community: Trust and security in the neighbourhood, involvement in local
community life, violence/crime and isolation
• Local services: Early childhood and education, schools, services for adolescents
and youth, health services, social services and services ensuring local hygiene
conditions such as fresh water
• National level: Reduction in poverty, inequality, discrimination, “prudent”
government, human rights, military conflict and national policies relating to
access to education, work, health, housing and social policies

Returning to the key aspects of global mental health, it is essential to cite the
2007 edition of the scientific journal The Lancet which brought together the work of
many experts in the field. Researchers who participated in writing the articles dem-
onstrated the high burden generated by mental disorders, which account for 14 % of
the global burden (Prince et al. 2007), the connections and interconnections between
mental disorders and other health disorders and the relationship between mental
health and the achievement of the Millennium Development Goals. They presented
the needs of mankind in general and compared these with the scarcity of resources
for mental health and the unequal distribution and ineffectual use of resources
(Saxena et al. 2007). They recorded the documented efficacy of interventions to
treat and prevent mental disorders in low-resource conditions and showed the inad-
equate infrastructure which existed for mental healthcare (Patel et al. 2007; Saraceno
et al. 2007). The evidence collectively gathered has been used to formulate a call for
improvements in mental health services in all countries, especially those with low
and middle incomes (Jacob et al. 2007). Estimates about the financial cost have also
been made since $2 per person per year in low-income countries and $3–$4 per
person in middle-income countries are sufficient to improve mental healthcare
66 M. Lavdas et al.

(Patel et al. 2007). They also gathered together indicators which could be used to
map developments and research priorities. Chisholm et al. (2007) also stressed the
need for political will, for collective action by all stakeholders in global health and
for resources to implement solutions to address the mental health burden world-
wide. In 2008 the WHO’s Department of Mental Health and Addiction recognised
the importance of the call for global mental health and launched the Mental Health
Global Action Programme (mhGAP) (WHO 2008b). The programme’s aim was to
improve mental health services in low- and middle-income countries. The pro-
gramme’s main product, the mhGAP educational guide (WHO 2010), provides
treatment guidelines for nine basic categories of mental and neurological disorders
to increase the potential for recognising them in primary healthcare. It includes
depression, psychosis, epilepsy, developmental disorders, behavioural disorders,
dementia, alcohol dependence, addiction, self-harm and suicidality (Barbui et al.
2010).
A major turning point in the historical development of global mental health was
2013, when 194 ministers of health were adopted by the WHO’s comprehensive
mental health action plan. In doing so they recognised mental health as a global
priority in the health sector which requires immediate action.
The action plan’s vision is to help create a world where mental health is appreci-
ated, promoted and protected, while bad mental health is prevented and individuals
affected by it are able to fully exercise their rights and have access to high-quality
services that are culturally and socially sensitive to their requirements, with prior-
ity being attached to recovery and ensuring the best possible health and involve-
ment in the community and working environment without stigmatism and
discrimination.
The comprehensive mental health action plan (WHO 2013) will help the growing
endeavours of members of the global mental health movement and will increase
access to health services, improve reporting of human rights violations and promote
the social integration of individuals with mental disorders worldwide.
Mental health at global level now occupies a place on the global health agenda,
with robust documentation of the treatments available and best practices to be used.

4.3 Web Platforms and Global Mental Health

It is worthwhile referring to online databases and platforms which record these best
practices. The WHO has set up the WHO Mindu Bank (http://www.mindbank.info),
which is a web platform that contains basic sources of information about mental
health, substance abuse, disability, general health, human rights and development.
The Mental Health Innovation Network online database was also developed for the
World Innovation Summit for Health containing best practices for research and
clinical practice (http://www.mhinnovation.net). The Calouste Gulbenkian
Foundation has developed the Gulbenkian Global Mental Health Platform, which
includes best practices from the international arena to promote mental health and
provide continuing documentation of interventions which are taking place.
4 Global Mental Health 67

The dissemination of best practices using means such as the internet allows
national sources of information and best practices to be exchanged between coun-
tries, while efforts like those listed above reduce the fragmentary nature of record-
keeping and overlap in research documentation and applied practices. It also bolsters
advocacy and helps promote rights at a global level.

4.4 Mental Health Priorities Based on Needs and Resource

Availability

It is particularly important not to ignore the fact that resource availability not only
determines the ability to intervene but also affects the very form of psychiatric prev-
alence in an area. Documenting mental disorders does not end solely with looking
at their biological basis (which has been an area of particular focus over recent
years) but also extends to psychosocial factors which play a definitive role in the
onset of mental disorders. Reference was made above to the social determinants of
mental health, and now we will look at the difference in prevalence based on the
income ranking of countries. It can be seen in Table 4.4 below (WHO 2008a), which
presents the ten main causes of burden (DALYS) based on the income ranking of
various countries. For example, while dementia is the fourth most burdensome dis-
ease in high-income countries, it does not appear at all in countries with a lower
income. That can be explained in part by life expectancy which is clearly higher in
the former, and therefore, the probability of someone becoming ill with Alzheimer’s
disease is higher. Another important observation is that the top place is occupied by
unipolar depression in middle- and high-income countries, while it occupies eighth
place in low-income countries. High rates of depression are associated with psycho-
social factors which are not dependent on the economic situation of each country,
since the economic crisis has generated secondary unfavourable impacts on mental
health, which in turn may be contributing to phenomena such as a rise in suicides,
alcohol abuse and alcohol-related deaths (Skapinakis et al. 2013; WHO 2011).
The interventions possible based on resource availability conditions can be
divided into three categories: (1) low resource availability, (2) middle resource
availability and (3) high resource availability. One needs to bear in mind that
resource availability conditions do not only relate to countries but also to their offi-
cial categorisation based on income and on other issues. It is a fact that major dif-
ferences and inequalities have been noted in resource availability not just among
various cities but also between areas within the same large city.

Low Resource Availability Conditions

Emphasis needs to be placed on workers in primary healthcare and the community

who will take up roles to be shared out based on needs assessments, the identifica-
tion of mental disorders, the provision of short-term psychosocial interventions and
medicated treatments (Beaglehole and Bonita 2008; Eaton 2008). The limited
68 M. Lavdas et al.

Table 4.4 Main causes for burden of disease (DALYs), countries per income group, 2004
Disease or injury DALYs % of Disease or injury DALYs % of
(in overall Low-income (in overall
World millions) DALYs countries millions) DALYs
1 Lower respiratory tract 94.5 6.2 1 Lower 76.9 9.3
infections respiratory tract
infections
2 Diarrhoeal diseases 72.8 4.8 2 Diarrhoeal 59.2 7.2
diseases
3 Unipolar depression 65.5 4.3 3 HIV/AIDS 42.9 5.2
4 Ischemic heart disease 62.6 4.1 4 Malaria 32.8 4.0
5 HIV/AIDS 58.5 3.8 5 Premature 32.1 3.9
childbirth and
low birth weight
6 Cerebral vascular 46.6 3.1 6 Neonatal 31.4 3.8
disease infections and
other
7 Premature childbirth 44.3 2.9 7 Perinatal 29.8 3.6
and low birth weight asphyxia and
trauma
8 Perinatal asphyxia and 41.7 2.7 8 Unipolar 26.5 3.2
trauma depression
9 Road traffic accidents 41.2 2.7 9 Ischemic heart 26.0 3.1
disease
10 Neonatal infections and 40.4 2.7 10 Tuberculosis 22.4 2.7
other
Middle-income High-income
countries countries
1 Unipolar depression 29.0 5.1 1 Unipolar 10.0 8.2
depression
2 Ischemic heart disease 28.9 5.0 2 Ischemic heart 7.7 6.3
disease
3 Cerebral vascular 27.5 4.8 3 Cerebral 4.8 3.9
Disease vascular disease
4 Road traffic accidents 21.4 3.7 4 Alzheimer’s 4.4 3.6
disease and
other dementing
disorders
5 Lower respiratory tract 16.3 2.8 5 Alcohol use 4.2 3.4
infections disorders
6 Chronic pulmonary 16.1 2.8 6 Adult onset loss 4.2 3.4
disease of hearing
7 HIV/AIDS 15.0 2.6 7 Chronic 3.7 3.0
pulmonary
disease
8 Alcohol use disorders 14.9 2.6 8 Diabetes 3.6 3.0
9 Eye diseases 13.7 2.4 9 Cancer (throat, 3.6 3.0
lungs)
10 Diarrhoeal diseases 13.1 2.3 10 Road traffic 3.1 2.6
accidents
4 Global Mental Health 69

number of mental health experts, who are normally to be found in the capital of the
country, can only offer (a) training and supervision to professions in primary health-
care, (b) advice and feedback in difficult cases and (c) outpatient and inpatient
assessments and treatment in cases which primary healthcare cannot handle
(Mubbashar 1999; Alem 2002; Njega 2002; Saxena and Maulik 2003; Lund et al.
2011). The limited availability of human resources led Patel (2014) to propose task
shifting in mental health. He proposes utilising aware citizens in the mental health
sector after they receive special training, so be able to provide basic interventions to
treat mental health cases and to interface with any available services whenever
needed. To be able to achieve task sharing, Patel proposes that complex mental
healthcare tasks be broken down into individual elements, some of which can be
allocated to less-specialised staff or even to sensitive, capable individuals who have
received the right training. Shifting and sharing tasks are vital, according to Patel, in
the context of a team which will be coordinated by a mental health professional. The
individual elements listed by Patel are (a) managing care in each case, (b) support-
ing the family, (c) social support and supervision of individuals trained to provide
basic mental healthcare and (d) the prescription and administration of medication,
which must remain with medical staff. However, it should be stressed in relation to
these points that medication on its own is of limited efficacy, but if coupled with
task sharing and overall care offered by training members of the community, it can
have a high effectiveness rating (Buttorff et al. 2012).

Middle Resource Availability Conditions

Under these conditions, it is important to appreciate that there is still a need for a
robust primary healthcare in order to provide care to high prevalence, common
mental disorders in the general population (in some countries the annual prevalence
of diseases in primary healthcare is as high as 20–30 %). In addition to the emphasis
on primary healthcare, which must cover needs identification, the recognition of
mental disorders, psychosocial interventions and feedback – as in the previous cat-
egory – it is also essential to develop outpatient care services and short-term hospi-
talisation units, social mental health groups, acute case units, long-term sheltered
care units in the community and opportunities for employment for the mentally
disabled. Of these, major resources are used up by acute care units (Knapp et al.
1997); so in order to be able to stay open and intervene in crisis situations, it is
essential to keep the length of hospitalisation down, so that resources can be used
for supplementary services in the community (Lasalvia and Tansella 2010; Lelliott
and Bleksley 2010; Sederer 2010; Totman et al. 2010).

High Resource Availability Conditions

Having ensured primary healthcare and the integration of mental health into it, one
needs to put in place general psychiatry services for children and adults focused on
the community and to deploy specialised services based on resource availability.
70 M. Lavdas et al.

Specialised mental health services can provide care for eating disorders, resilient
psychiatric disorders, substance dependence or mothers suffering from mental dis-
order. Having carried out a needs investigation in each area in which action is to be
taken, one needs to develop services that meet the population’s needs. With the right
resources, community mental health groups could integrate Assertive Community
Treatment (ACT) groups which visit anyone in need at home (Deci et al. 1995;
Teague et al. 1998; Killaspy and Rosen 2011) and develop early intervention units
for psychotic or other mental disorders (Power and McGorry 2011). Moreover,
alternative methods for intervening in crisis situations would allow for better man-
agement while significantly protecting the rights of individuals with mental disor-
ders which are frequently violated via procedures such as involuntary hospitalisation
(Stylianidis et al. 2014; The Ombudsman 2007). Alternative crisis models are acute
day hospitals which offer daycare for individuals with acute and severe psychiatric
problems as an alternative to a stay in inpatient units, but their effectiveness in treat-
ing acute problems compared to inpatient units has not yet been documented
(Marshall et al. 2001, 2011). Thornicroft and Tansella (2013) have also examined
crisis houses, which are staffed by mental health professionals, which accept indi-
viduals who would otherwise have to be admitted for treatment to the psychiatric
ward. Limited research so far shows that they can offer an alternative to treatment
in the psychiatric ward or hospital, offering significantly better cost effectiveness
compared to hospitalisation (Sledge et al. 1996a, b· Mosher 1999). Another alterna-
tive option is home treatment/crisis resolution teams which are mobile units that
offer an assessment to patients in psychiatric crisis and offer intensive home care
(Johnson and Thornicroft 2008). A recent Cochrane systematic study (Murphy
et al. 2012) indicates that crisis resolution care is a viable solution in treating indi-
viduals with severe mental disorder, while studies by McCrone et al. (2009) show
that it is the most cost-effective solution than hospitalisation, both in terms of cost
and efficacy. Other specialised interventions are alternative forms of sheltered care
in the community (sheltered apartments, daycare, etc.) and interventions involving
supporting employment such as Individual Placement and Support which has been
effective to a significant degree (Priebe et al. 1998; Drake et al. 1999; Crowther
et al. 2001; Marshall et al. 2001; Lehman et al. 2002; Rinaldi and Perkins 2007;
Bond et al. 2008).

4.5 Barriers and Challenges to Applying the Global Mental

Health Principles

Ranking global mental health priorities is a particularly important objective. To that

end, Collins et al. (2011) carried out a large-scale qualitative survey using the Delphi
method which involved representatives from more than 60 countries, in order to set
targets and identify the most important barriers to implementing global mental
health principles.
We will attempt to present every objective and the challenges identified, starting
from the first which relates to recognising the causes of mental and neurological
4 Global Mental Health 71

disorders and risk and protective factors. For this target, barriers were identified
such as recognition of an addressable social and biological risk factor during an
individual’s life. Moreover, the need to understand the impact of poverty, violence,
war, migration and natural disasters was recorded and the need for research into the
biomarkers of disorders was stressed. At this point we should stress that there is risk
to global mental health from “psychiatrification” of the approach, impelled by the
concern to show that illness has a biological basis. However in his attempt to docu-
ment mental disorder and the struggle to identify its causes, Clark (2014) stresses
that there is a risk of neglecting the psychosocial side of things and ignoring the
different ways in which disorders manifest depending on the cultural context.
Another risk identified by the investigator relates to limiting interventions to indi-
vidual level without also bolstering community participation. That would result in
what are best practices in global mental health benefiting “privileged individuals”
and not communities.
The second objective relates to preventing and implementing early interventions,
in an attempt to support communities, promote physical and mental well-being and
reduce the duration of untreatable illnesses by developing cultural aware methods of
early intervention under different conditions. Cultural data and cultures vary con-
siderably from area to area and from country to country, and if we aim for efficient
practices, we need to design interventions to adjust to local social, economic and
cultural circumstances and to take into account the availability of human resources
(Patel and Saxena 2014). The need to develop a set of well-documented primary
prevention interventions for mental disorders has also been stressed, as has the need
to drawn up local, appropriate strategies to eliminate child abuse and improve pro-
tection for children.
The third objective relates to improving treatment interventions and disseminat-
ing them throughout the entire spectrum of care provided. Here research is still
needed into how to identify mental disorders and to integrate them into primary
healthcare. It is also important to reduce cost, to increase and safeguard the stocks
of effective medical supplies and to develop effective treatments for use by non-
experts, including healthcare professionals with minimal training in these matters.
Integrating a disability functionality assessment is also important, as is providing
efficient, cost-effective social care and rehabilitation. Improving child access to
well-documented forms of care provided by trained health providers in low- and
medium-income countries is one of the challenges that many countries have yet to
address. Using new technologies such as telemedicine could also make a real con-
tribution to access to well-documented forms of care.
The fourth objective is to raise public awareness about the global burden. Here
we face challenges relating to the development of cultural up-to-date methods for
addressing stigma, prejudice and social despair among patients and families in dif-
ferent cultural conditions. Another major challenge is to establish a common inter-
national “documentation database” to record cultural and socioeconomic factors
that cultivate inequalities in the prevalence, diagnosis, treatment and outcome of
neuropsychiatric disorders. An equally important challenge is to develop valid, reli-
able definitions, models and measuring tools for quantitative assessment of the
72 M. Lavdas et al.

burden at individual level, as well as at overall population level, for use in different
cultures and conditions. Lastly, this objective also includes establishing shared,
weighted databases to collect data to monitor the predominance of treatment meth-
ods and the availability of human resources and services.
The next objective relates to developing the production capacity of human
resources. This includes developing the production capacity in low- and medium-
income countries by creating regional centres for mental health research and train-
ing and practice for staff in light of local conditions and needs. Another challenge
that still needs to be overcome is to develop viable models to train and increase the
number of non-experts and specialised professionals of different cultures and back-
grounds in providing well-documented forms of services. To move towards that,
training received by all healthcare professionals needs to change to include the men-
tal health factors to a more satisfactory degree.
The last objective outlined by the experts in this study relates to transforming the
health system and policy-level responses. Here it is vital to enact and implement key
minimum standards/principles to deal with neuropsychiatric disorders worldwide.
In making this shift, health systems need to be redesigned to integrate neuropsychi-
atric disorders into the care of chronic diseases and to create conditions for equality
between mental and physical diseases. This means that resources need to be invested
equally into research, training, treatment and prevention, while mental health needs
to be integrated – both at national and international level – into international aid and
development programmes, for example.

4.6 Comments: Conclusions

As we move further towards a global mental health movement as we have been doing
over recent years, one ought not to let one’s attention slip from the barriers still to be
faced. While primary healthcare is a key pillar in improving mental health, both in
high- and low-cost conditions, Stewart et al. (2010) have recorded the reasons for the
“historical”, proverbial failure of primary healthcare models in attempts to integrate
mental health in developing countries. The reasons for failure can be summarised as
follows: (1) the fragmentation of primary healthcare programmes which focus on
special diagnostic categories (such as tuberculosis, HIV), (2) the prevalence of the
traditional model for checking for diseases which ignores the cultural context and
social determinants and (3) the serious inequalities in access to the health system for
the population. Quite often, one or more of these factors are present in global mental
health programmes, which partially explain their failure.
At the same time, as the global mental health movement has grown, we have
seen the simultaneous dissemination of a phenomenon of the globalisation of the
biomedical model of psychiatry. As Bracken and Thomas (2005) has succinctly
pointed out, “we see the globalisation of biomedical psychiatry as a non-demo-
cratic, non-sustainable phenomenon without any clear ethical focus”. It is also a
fact that in the view of Chowdhury and Bhuiya (2001), most intervention models in
global mental health are documented using the example of Western biomedical
4 Global Mental Health 73

psychiatry. The systematic obfuscation of diversity, the prevalence of mental

disorders, their prognosis and outcome and classification differ significantly in
different cultural and social contexts. One must ask how it is possible for the global
mental health movement to place emphasis on the global reach of Western diagnos-
tic and treatment systems and minimise or ignore the differences; this approach is
standard strategy for it.
As far as implementation of the above objectives is concerned, there is a lack of
programmes to reduce the negative effects of social determinants (Saraceno 2014).
In other words, interventions that are organised seek to relieve the symptoms of the
affected population and not to eliminate the factors that negatively impact on and
burden both the onset and outcome of mental disorders.
In the example of how depression and suicidality are dealt with, the approach
could focus not just on pharmacological treatment of the symptoms but also on
creating conditions that reduce the onset rate for depression, such as unemploy-
ment, unequal access to opportunities for economic growth and social inequalities
more broadly speaking. Interventions to combat poverty, such as micro-loans pro-
vided in areas with high levels of poverty, have generated important results (Bruno
2012; Khandker and Samad 2013).
The restrictive responses that traditional psychiatry gives do not cover the
constantly expanding mental health needs of the population. Consequently, an
approach which does not take into account the social determinants that affect mental
health is inadequate. Let us paraphrase Saraceno (2014) who described the vicious
circle thus: we get depressed because we are poor and get poor because we are
schizophrenic.

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World Health Organization (WHO) (2014) Social determinants of mental health. Available at
http://apps.who.int/iris/bitstream/10665/112828/1/9789241506809_eng.pdf. Accessed 29 July
2014
Psychiatric Reform in Greece
5
Panagiotis Chondros and Stelios Stylianidis

Abstract
This chapter presents the attempts to reform psychiatric services in Greece by mak-
ing extensive reference to the historical-statutory framework, current conditions and
the ethical basis of the change being attempted. It presents the achievements made
and analyses the problems being faced. It includes information about the legislation
and the rate at which structures have been developed. In the context of social psy-
chiatry principles, reform is viewed from the following perspective: reform must
seek to achieve a new form of psychiatric care which promotes tolerance of diversity
and social integration by developing mental health networks and other forms of
social networks. The discussion outlines factors which will assist in improving psy-
chiatric care and raises questions that must concern stakeholders in the reform.

5.1 Introduction

The reform of psychiatric services in Greece is considered to be one of the most

wide-ranging attempts at reform in Greece compared to reforms in other sectors,
such as the education system or primary healthcare. Despite conflicting views, we
cannot overlook the sheer duration of legislative, institutional and organisational
changes which have occurred, the abolition of old organisations and the creation of
new structures and workplaces.

P. Chondros (*)
Association for Regional Development and Mental Health EPAPSY, Athens, Greece
e-mail: [email protected]
S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 77

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_5
78 P. Chondros and S. Stylianidis

There has been extensive discussion about the reform philosophy, the degree to
which targets have been achieved, as well as the completion of individual phases of the
reform process. The problems (like the achievements) have been recorded to a satisfac-
tory degree (Sakellis 2009, 2012; Ministry of Health and Social Security 2010, 2012;
Deliverables for the project ‘Evaluation of ongoing implementation of the National
Action Plan’ PSYCHARGOS; Stylianidis and Chondros 2011, 2012). The discourse
which has emerged among direct stakeholders takes four very specific forms:

(a) The discourse which downplays reform efforts, transforming them from a
complex scientific, social and organisational issues into a administrative issue.
(b) The discourse which expresses a strict, inflexible biomedical model, reflective
of a conservative ideology, with emphases on strict evidence-based treatment
and the issue of safety.
(c) The dogmatic left-wing discourse about liberation from mainstream psychiatric
ideology that lacks any real scientific arguments, which results in a form of
nihilism along the lines of “all or nothing”, “all NGOs are forces for privatisa-
tion”, “the EU doesn’t help with reforms but only with driving home neoliberal
policies” and so on.
(d) An alternative reform-based discourse derived from left-wing, social-democratic
ideology which has become associated with the entire incomplete reform effort
in Greece.

In the context of social psychiatry principles, reform is viewed from the following
perspective: reform must seek to achieve a new form of psychiatric care which bol-
sters tolerance of diversity and social integration by developing mental health net-
works and other forms of social networks (Stylianidis and Chondros 2008). It must be
psychiatric care of the subject, for the subject, involving the subject. As a break from
both asylum-based culture and the biomedical model which classifies symptoms, it
proposes biological treatments, downplaying emotional and mental communication,
while promoting the attribution of meaning to suffering and the ability of new mental
health professionals to feel empathy. Patel et al. (2006: 1315) succinctly put it as fol-
lows: “We believe that our ultimate professional goal as mental health professionals in
a globalized world is to secure a reasonable opportunity for people with mental disor-
ders to achieve better health outcomes. We already have the evidence we need to make
the case for international mental health”. The change in psychopathology, self-stigma-
tism among patients and mental function goes beyond the individual level and is
directly associated with the reproduction of policies to counter social inequalities and
market cynicism, by transforming social pain, fear, withdrawal and passivisation of
the population into new networks and forms of solidarity, creativity and questioning
of our role as “technicians” of psychiatric care (Basaglia 1982).

5.2 Historical: Institutional Framework

In the Greek healthcare system, the National Health System (NHS) (introduced in
1983) coexists with mandatory social security and a voluntary and the private health
insurance system. It provides universal coverage of the population since it is based
5 Psychiatric Reform in Greece 79

Table 5.1 Selected data about resources in the health sector in Greece
National health spending 9,0 as a % of GDP (2006)
% of public health spending out of total spending 62.8 % (2005)
% of national budget set aside for mental health None (2005)
Persons practising medicine 5 per 1,000 people (2005)
Hospital clinics 4,7 per 1,000 people (2005)
(From: Tountas (2008)

on the principles of equality, equal access to services for all and social cohesion.
Private psychiatric clinics are regulated by two different laws, depending on the
year in which they were founded (Law 235/2000, which has been suspended, and
Law 517/1991), which lay down different operating requirements, thereby creating
a serious institutional problem.
The health system has undergone continuous reform in terms of primary
healthcare, regional administration, decentralisation, organisation and financing of
hospital care (Table 5.1).
The process of psychiatric reform was given operational form when the
PSYCHARGOS programme was established (Constantopoulos and Yiannoulatos
2004; Madianos 1994). It is important to stress that except from a few cases (such
as the Direct Support Programme for the Dromokaitio Psychiatric Hospital in
2000), the development and operation of units specified in Regulation (EEC) No
815/1984 and thereafter and in the PSYCHARGOS programme were funded in part
by the European Union (up to 75 % for a kick start, i.e. infrastructure and equipment
and running costs for 1 or 1.5 years). One result of this, inter alia, was an emphasis
on commitments to implement projects by applying agreed protocols specifically
outlined in various operational programmes (combating exclusion from the labour
market, health-welfare Programmes) rather than an emphasis on ensuring the matu-
rity of stakeholders in psychiatric care to allow them to adopt and promote reform.
The results of this special situation are numerous (and need to be documented).
Among other things, one could include the quality of the units which were founded
(under pressure of compliance with time frames) and the reactions and prejudices
that led to certain of them not being allowed to open and operate.
A key turning point in how services are organised was Law 2716/1999 on the
development of mental health services and other provisions, while another is the
segregation of Greece into sectors (sectorisation) and the establishment of sec-
toral mental health committees which had to operate in accordance with the
provisions of the law. The country has been divided into mental health sectors,
with each prefecture forming a sector, except several prefectures with low popu-
lations which are placed in a sector along with another adjacent, more populous
prefecture. Other exceptions were the prefectures of Attica and Thessaloniki,
which are divided into several sectors, with additional specialist sectors for chil-
dren and adolescents. Sectoral mental health committees have been set up
nationwide, and all sectoral children and adolescent mental health committees
have also been set up.
What is worth noting is that both the enactment of Law 2716/1999 (which is the
first time a separate piece of legislation on mental health was enacted) and
80 P. Chondros and S. Stylianidis

sectorisation were obligations Greece had made to the EU, rather than the result of
major internal processes. Numerous articles of Law 2071/1992 relate to defending
the rights of mental patients and the harmonisation of Greece’s legal framework on
psychiatric practice with modern scientific achievements. For those very reasons, it
is a major turning point. Law 4074/2014 will also play a key role in the development
of the legal and institutional framework. It was via this legislation that Greece rati-
fied the Convention on the Rights of Persons with Disability (CRPD) and the
Optional Protocol. That law, which has superior effect since it ratifies an interna-
tional convention, addresses issues such as the ability to deprive someone of their
freedom and therefore the involuntary hospitalisation of persons with disability, the
involvement of persons with disability in decision-making and monitoring and the
option to report violations of the rights of individuals with mental or other forms of
disability. Table 5.2 sets out the texts which shape the legal framework for mental
health services and mental healthcare in Greece.

Table 5.2 Legal framework for mental health and care services in Greece
Text Description
Law 1397/1983 National Health System, Government Gazette 143/A/7.10.1983
Introduced the right to health to the Greek legal system for the first
time
Law 2071/1992 Modernisation and organisation of the health system, Government
Gazette 123/A/15.7.1992
Introduced mental health units and reformed the rules on involuntary
hospitalisation
Law 2519/1997 Development and modernisation of the NHS, organisation of health
services, reforms pertaining of medicines and other provisions,
Government Gazette 165/A/21.8.1997
Law 2716/1999 Development and modernisation of mental health services and other
provisions, Government Gazette 96/A/17.5.1999
Law 2447/1996 The concept of “judicial assistance” was introduced
Ministerial Decision Method for organising and running psychosocial rehabilitation units
No. Α3α/ (boarding houses, hostels) and sheltered accommodation schemes
οικ876/16-5-2000 pursuant to Article 9 of law 2716/1999, Government Gazette
661/B/23.5.2000
Ministerial Decision Method for organising and running daycare centres pursuant to Article
No. Υ5β/Γ.Π. οικ. 8 of Law 2716/1999, Government Gazette 2444/B/2009
156618/ 25.11.2009
Ministerial Decision Method for running and staffing mobile mental health units pursuant
No. Υ5β/ to Article 7 of Law 2716/1999, Government Gazette 691/B/2001
οικ1662/21.5.2001
Law 3418/2005 Code of Medical Ethics (2005) Article 28
The framework for mental healthcare which the doctor is obliged to
provide to his patient, Government Gazette 287/A/28.11.2005
Law 4072/2012 Ratification of the Convention on the Rights of Persons with
Disability and the Optional Protocol to the Convention on the Rights
of Persons with Disability, Government Gazette 88/A/11.4.2012
5 Psychiatric Reform in Greece 81

Other milestones in the reform process were the agreements between the
European Commission and the Ministry of Health reached in 2009 and 2013. The
first agreement has become known as the Spidla Agreement (from the name of the
competent Social Affairs Commissioner who signed it) and was the result of insti-
tutional, administrative and economic problems which accumulated during imple-
mentation of the goals of the PSYCHARGOS programme and the consequent
pressure exerted by various bodies on the Ministry of Health and above all by the
Hellenic Ombudsman for Health and Social Protection. That pact specified the need
for continuation of psychiatric reform and identified specific measures: the creation
of a team of international independent experts, certification and licensing of all
mental health structures operated by bodies governed by private law, the conclusion
of agreements between the Ministry of Health and all stakeholders, secure financ-
ing, support for the social cooperatives and others. The relevant agreements must
include the following as a minimum: quality standards for the services offered, cost-
ing data for the services depending on the type of services, as well as monitoring,
evaluation and financial auditing criteria and procedures. The second was an update
of the first and included a time frame for implementing the pact.
The key principles in the action plan for implementing the MoU are:

(a) The new system to be in place from January 1, 2016 must be sustainable and
provide quality services which reflect the real needs of beneficiaries.
(b) Common operating standards must be adopted for all mental health units, irre-
spective of their legal format.
(c) Targets must be realistic, placing emphasis on financing interventions based on
measureable results.
(d) Interventions must be comprehensive and cohesive, to ensure multiplier effects.
(e) The Ministry of Health must finance the specialised/individual needs of benefi-
ciaries on the basis of cost per beneficiary and the type of mental health unit.
(f) The new system must be the product of consultation with stakeholders.

The first major developments in the field of social-community psychiatry in

Greece date from the 1970s. In terms of service provision, the Mental Health Centre
opened in Athens in 1956, and in 1972 the first daycare centre opened in Thessaloniki,
in 1978 the first daycare hospital opened at the Aeginitio Hospital, in 1979 the
Vyronas-Kessariani Community Mental Health Centre opened and in 1981 the
Prefecture of Fokida began offering mobile mental health services. Negative devel-
opments in Greece were the establishment of the Leros Psychopaths Colony in
1958 and the Paedopsychiatric Hospital in 1959 (Public Paedopsychiatric-
Neuropsychiatric Hospital with a 350-bed capacity, which was renamed the Attica
Paedopsychiatric Hospital in 1986). From the mid-1970s, criticism about traditional
psychiatry began to emerge in Greece, and groups to support psychiatric patients
locked up in asylums were formed. At the same time, small organised groups/move-
ments relating to the rights of mental patients appeared, but had no major ideologi-
cal influence on the development of psychiatry, compared to similar movements in
Western Europe. One move in this context was the Hellenic-French Social Psychiatry
82 P. Chondros and S. Stylianidis

Symposium (Lebovici and Sakellaropoulos 1984) held in 1981, at which criticism

of traditional psychiatry and the asylum culture which was radical for its time was
heard, and a working group was set up to take measures against the asylum on Leros
and other asylums in Greece. In general terms, up to 1981 there was a significant lag
in how psychiatry developed in Greece compared to other European countries
(Madianos et al. 1999; Stylianidis et al. 2007; Ploumpidis 2009).

5.3 Regulation (EEC) No 815/84

When emergency financial aid from the former EEC was introduced (Regulation
(EEC) No 815/84), Greece was the only case of direct financing to a member state:
the process of deinstitutionalisation began, improvements to hospital care were
made, preparations for shifting patients to protected or relatively autonomous homes
in the community were made and new, socially focused mental health services were
developed (Tsiantis 2004; Madianos 2005; Karastergiou et al. 2005).
As far as structures and services were concerned, the goal was to “develop a
complete network of community services to ensure at a healthcare region level
(mental health sector) operational capacity in terms of the needs of the local popula-
tion, a goal which is clearly wider than treating illness” (Ministry of Health and
Welfare 2001). At the level of service units, particular emphasis was placed on
developing psychiatric departments at general hospitals and mental health centres,
while on the other hand the burden fell on developing outpatient psychosocial reha-
bilitation units (hostels, boarding houses, sheltered accommodation) capable of
housing a large number of chronic patients who had been locked up in psychiatric
hospitals.
The new units also needed a wide range of mental health professionals in vari-
ous areas of specialisation and a person-centre approach by those professionals
towards the mental patient. For that reason, the necessity of major changes “in the
training and life-long education of mental health professionals, and the know-how
transfer procedures” was officially recognised (op. cit.). From the moment the sys-
tem had to have a social focus, it was recognised too that “support for local com-
munities and authorities, overcoming fear about mental illness which has shaped
prejudice and stereotypes [is a condition] for gradually eliminating the social
stigma associated with mental patients and their families, and comprehensive
social support and solidarity towards mental patients must be a national priority”
(op. cit.).
In short, the goals laid down for achieving psychiatric reform were:

To develop infrastructure and structures based on the principles of sectorisation and

social psychiatry and to ensure the continuity of psychiatric care
Deinstitutionalisation, psychosocial rehabilitation and social reintegration for
chronic patients in psychiatric hospitals
Ensuring full adequacy in terms of primary healthcare, outpatient care and hospital
care at general hospitals
5 Psychiatric Reform in Greece 83

Developing mental health services to prevent, diagnose, treat and care for patients
and to ensure psychosocial rehabilitation and social inclusion of persons with
autism spectrum disorders and learning problems
To develop preventative and direct crisis intervention actions for users of addictive
substances

5.4 Current Data

In Greece, the lack of epidemiological data remains a key problem. Until recently,
in fact until the Panhellenic Adult Psychopathology Study was conducted by the
University Psychiatric Clinic of the University of Ioannina (2009–2010) for the
Ministry of Health (Skapinakis et al. 2013), there were few studies on the preva-
lence of mental disorders in the general population and those that existed primarily
related to urban environments and limited geographic areas.
Older surveys have shown that 16 % of the general population in Greece suffers
from some form of mental disorder (Mavreas et al. 1986), while women, widows
and individuals in lower socioeconomic brackets have higher rates of psychiatric
morbidity. In one epidemiological survey in the general population carried out in
Evia, it was found that 29 % suffered from at least one mental disorder (Stylianidis
and Stylianoudi 2008; Stylianidis et al. 2014), while a similar survey carried out in
the general population on Paros-Antiparos in 2008 on a sample of 506 individuals
showed that 22 % of the sample had clinically significant morbidity (Stylianidis
et al. 2010). Women had significantly higher morbidity than men (30 % compared
to 13 %). The prevalence of depression in women was 7.88 % compared to just
1.14 % in men. Harmful alcohol use was found to be 13.06 % and 23.86 % in men
and 3 % in women. Another epidemiological survey in Greece carried out on the
general population in rural communities in the northern Aegean, on a sample of 428
people, showed that 14 % of the population had some psychiatric symptoms, while
women had almost twice the likelihood of men of presenting some psychiatric
symptom (Skapinakis et al. 2007).
According to more recent epidemiological data (Skapinakis et al. 2013), 1 in 6
Greeks aged 18–70 have developed clinically significant psychopathology and 1 in
12 (600,000) have serious psychopathology. International data showing that in
Greece 75 % of the population with some form of psychopathology do not receive
any treatment for their problem have been confirmed. In addition, the suicide rate
has risen from 2.8 per 100,000 in 2008 to 5.2 in 2010 (Giotakos et al. 2011;
Economou et al. 2013). As far as adolescents are concerned, research data confirm
that mental disorders, dominated by depression, affect 3–8 % of the population and
are directly related with negative health behaviours such as smoking, use of psycho-
tropic substances and alcohol abuse and with reduced performance at school, poor
social relations, bullying, high-risk sexual behaviour and even suicidal tendencies
(Giannakopoulos et al. 2009). A study conducted on Greek adolescents found that
the rate of attempted suicide in 2007 was 13.4 % of the population (Kokkevi et al.
2010). According to a survey conducted by the National School of Public Health
84 P. Chondros and S. Stylianidis

(Zavras et al. 2012), between 2006 and 2011 an increase was noted in the use of
both antipsychotics (+18/59 %) and antidepressants (+34.80 %). Hospital treat-
ments have also increased significantly (24 %), while there has also been a constant
drop in the use of private health services (Kentikelenis et al. 2011). See the relevant
chapter for a detailed presentation of the epidemiological data.
The next key indicators of the rate of reform are the rate of change in psychiatric
beds in use and the way in which they are allocated between hospitals and social
care structures. In 2001, 49 % of psychiatric beds were in psychiatric hospitals,
compared to 99 % in 1982. More specifically, 3 % were at general hospitals, 50 %
remained in psychiatric hospitals and 47 % were in social structures (psychosocial
rehabilitation centres) (Amaddeo et al. 2007: p. 237). In terms of the total number
of psychiatric beds (irrespective of where they are located) per 100,000 people,
Greece is close to the European average (10.2) at 8.7. There were 8,486 psychiatric
beds in public psychiatric hospitals between 1981 and 1982, 5,007 in 1996 and
3,500 in 2000 (Stylianidis et al. 2009).
As far as all structures are concerned, in 2008 there were 410 accommodation
facilities in operation (irrespective of the programme during which they were devel-
oped) designed to promote deinstitutionalisation, along with more than 180 com-
munity mental health structures and 14 social cooperatives (Stylianidis et al. 2009).
The number of chronic patients in public hospitals in the 2-year period 1981–1983
was 5,677 but by the year 2000 that figure had dropped to 2,922 (Madianos 2005;
Tountas 2008). Between 2001 and 2009 as part of phase II of the PSYCHARGOS
programme, four of the nine psychiatric hospitals were shut down. As a result of the
deinstitutionalisation programme, the number of mental patients living in 452 psy-
chosocial rehabilitation centres stood at 2,689 in 2009 (1,289 patients in 2002 in
146 psychosocial rehabilitation centres), while the number of long-term patients
being treated in psychiatric hospitals was below 2,000. In 2013 that figure had
dropped further; however, there is a lack of updated data. Compared to the targets
set in the National Plan for Psychiatric Reform (PSYCHARGOS), by 2008 78 % of
the necessary accommodation structures had been completed, but only 28 % social
mental health structures were in place (138 were missing) (these included psychiat-
ric departments at general hospitals for adults and children, mental health centres,
daycare centres, mobile units, short-stay hostels), and only 20 % of the 55 specialist
structures for alcohol, substance dependence, autism and Alzheimer’s disease were
in existence (Stylianidis et al. 2009; Stylianidis and Chondros 2010).
A key fact that needs to be mentioned is the major increase in committals on
orders from Public Prosecutors. The psychiatric reform committee of the Hellenic
Psychiatric Association (2008) conducted research for 2 years and concluded in its
report that in Greece there was a high rate of committals on orders from Public
Prosecutors. In 2007 the Attica Psychiatric Hospital accepted 2,900 admissions,
52 % of which were involuntary, the Attica Dromokaitio Psychiatric Hospital had
1,554 admissions (50.2 % were involuntary) and the Thessaloniki Psychiatric
Hospital had 3,770 admissions (28.9 % were involuntary). As the Committee
pointed out, those high rates are fictitious to a large degree since recourse to use of
Public Prosecutor orders is often abused to ensure a bed, which is otherwise hard to
5 Psychiatric Reform in Greece 85

find in the public psychiatric system. However, it is a strong indication that both the
mental health system and the welfare network in Greece are malfunctioning
(Stylianidis et al. 2009). (See the relevant chapter on the issue of involuntary
hospitalisation.)
In short, over the least three decades, some steps have been taken to improve and
develop mental health services (Stylianidis et al. 2009):

Law 2716/1999 was enacted, which is a quite comprehensive framework law, which
placed the development of community services on the Greek policy agenda.
The percentage of beds in psychiatric hospitals (out of all psychiatric beds) was
reduced by almost half.
A large number of young professionals acquired initial training and practical experi-
ence in community settings, which is the start of a change in the model used to
provide psychiatric care.
Examples of good practice at community level emerged, thanks to efforts to imple-
ment the principles of social psychiatric and provide comprehensive coverage for
the local population.

However we cannot in any sense talk about a successful reform process since the
problems at structural level and at the level of day-to-day functionality remain
numerous and critical.

5.5 Problems with Reforming the Mental Health System

Stakeholders in the field (professionals, administrators, caregivers and above all

patients) face shortages and policy contradictions in the entire psychiatric system
despite the need for the adoption of rational rules and procedures to ensure a posi-
tive outcome for the reform process.
More specifically, one key mistake is the fragmentation of the system and the
unequal allocation of services. Mental health services are provided by the NHS
(psychiatric hospitals, general hospitals and various bodies governed by private
law), the private sector, social security organisations such as the IKA social security
fund, local government agencies, military agencies, the Ministry of Education and
the Church. It is only logical that the lack of central co-ordination and the inability
to attribute responsibility create an ineffective, non-accessible and costly system
(Thornicroft and Tansella 2010).
The condition of political support for reform in effect came from “outside”, from
the officials and control mechanisms of the European Commission following inter-
national stigmatism of Greece when the international community “uncovered” the
scandal on Leros (1988). To the extent that the demand for reform did not come as
a social mandate backed by a wide-scale movement, but as a change imposed by
others, the entire venture was only supported by a small minority of mental health
professionals, who frequently face indifference, ambivalence or even outright hos-
tility from trade unions in the sector. Experts with various different professional and
86 P. Chondros and S. Stylianidis

institutional roles in the psychiatric sector have reached this conclusion about the
key reasons for failure of reform, namely, lack of any social movement to support
the philosophy underpinning the reform process (Madianos 2009; Stylianidis 2009;
Megaloeconomou 2005; Sakellis 2009; Chondros 2009).
The basic requirements to support a movement for mental health are missing.
There have been no collective demands for specific goals to be achieved. Only in
the last 5 years have different activities been organised to support the reform
process, such as demonstrations, meetings, official communication with the
authorities and relevant documentation. The key elements of a movement are
also missing (Tilly 2007), such as unity, involvement of a satisfactory number of
individuals and long-term, systematic commitment from participants in the
movement.
Another key mistake in how the reform was planned, which is frequently
encountered in other similar experiences (Maj 2010), is that the provision of
care and the way in which services are organised have been closely tied into
ideological and political frameworks. The logic of party politics and vested
interests and the prevailing culture of informal networks of corruption and inter-
twined interest for the two main political parties from the time of Greece’s
return to democracy after the dictatorship to the present day have resulted in the
irrational use of resources without any targeting or any evaluation – monitoring
of the actions taken. That led to a series of negative effects: it actually negated
the expertise and continuous training of the human resources so vital for reform,
there was resistance to adequate national resources being used (apart from
financing from the EU), there was resistance to epidemiological studies in the
general population and studies about how services operated and could be
adjusted to the changing mental health needs of the population, guidelines for
how services could operate properly were not adopted, and consequently there
was no systematic monitoring and evaluation of services, and there was opposi-
tion to promote a culture of synergy, networking and complementary activities
by the bodies involved at social level (Stylianidis 2009; Stylianidis and Chondros
2010).
The ethical and deontological basis of the changes attempted remained loose for
a long time, to the extent that any official annual reports of the independent authori-
ties responsible for protecting the rights of mental patients were not acted upon,
neglected by the Ministry of Health. Another barrier to real change was the failure
to implement existing legislation on mental health (Laws 2071/1992 and 2716/1999)
[perhaps the most progressive legislative intervention in the post-dictatorship period
that the lack of policy plan and the weakness of the reform movement turned it to
yet another piece of legislation that remained inactive]. Another barrier was the
failure to implement the sectorisation principle which only seemed to concern the
Greek state when it had to manage complaints from international organisations
about human rights violations. Note also that advocacy and empowerment of fami-
lies and users of mental health services is perhaps considered a marginal activity for
almost all the scientific community and is used more as a “democratic alibi” more
than as a necessary form of ethical and scientific documentation of psychiatric
5 Psychiatric Reform in Greece 87

practice. The increase in psychiatric treatments on the basis of Public Prosecutor

orders, which is over 53 % of all admissions to psychiatric departments or hospitals,
is scandalous. All this data paints a rather grim picture of a period of 20 years of
precarious reform (1989–2010).

5.6 Discussion

Firstly, one needs to be careful about the expectation of purely technocratic resolu-
tion of particularly complex problems faced by the endeavour to change psychiatric
care in Greece, given that we need to have a serious reflection on the conditions
required for wide-ranging restructuring of the system which is needed in order to
ensure that any reform effort is viable.
Key questions which arise are as follows: How can a modern state respond within
the context of the globalisation of markets, to immense needs and new demands for
health, mental health and social care which come from new emerging, socially
excluded social groups, when its policy is dictated by a hostile neoliberal frame-
work that promotes aggressive, lawless entrepreneurialism? How can the continua-
tion and support for collapsing psychiatric reform and a holistic approach to the
needs of individuals with severe mental disorders be propped up? How can this be
done especially when innovative experiences of social entrepreneurship and pilot
best practices with a positive cost-benefit result in terms of the social reintegration
of vulnerable population groups are not being supported in political and financial
terms? How can a new, valuable social and cultural movement emerge in Greece
against the background of the growing capitalistic void, the rise of profit, unre-
strained competition, egoism, individualism, illegality and the alienations of peo-
ple’s conscience, to retain a fluid, unsecure job, faced with the paralysing fear of
threatened long-term unemployment?
A prerequisite for any new plans for changes in the mental health sector contin-
ues to be real interest by players in the sector in meeting the actual patient. Meetings
must take place under the best possible actual, institutional and organisational con-
ditions for services and be focused on understanding the psychopathology of the
Other, on attempting to build together a new narrative about the mental disorder
between the parties involved, in other words the patient and his family and the men-
tal health professional, and the multidisciplinary treatment group he belongs to.
Moreover, the logic around which new mental health services are organised cannot
only be governed by administrative and quantitative criteria; instead mental health
groups must be able to pose themselves continuous questions and adjust the treat-
ment and care responses to the complex dialectic of needs, available resources and
complex answers (Rotelli 1988).
The steps required have been examined and evaluated in practical terms in vari-
ous health systems with different degrees of resource availability and varying social
conditions. Thornicroft and Tansella (2010) provide us with an overview of how we
can improve mental healthcare at local, regional and national level. Taking into
account the special historical, social and political conditions, as well as the major
88 P. Chondros and S. Stylianidis

objections to psychiatric reform taking place, we propose the following guidelines

and plans of action for better mental health in Greece (Stylianidis and Chondros
2010):

A public health perspective must be adopted along with a strategy for the entire
population, a strategy which will tie treatment, holistic care and psychosocial
rehabilitation together and will integrate all psychotherapeutic techniques and
models into an individualised care plan for each patient.
The gradual transfer of resources (financial and human resources) from institu-
tional care to the community requires that institutional structures be com-
pletely replaced by an alternative network of community mental health
structures. Preserving the present-day parallel system of institutional and
community care for a period of two decades has not only been financially
disastrous for the national budget, but has created confusing, conflicting mes-
sages about the entire reform effort. Funding for new services and support for
existing ones must be tied into the achievement of objectives by each service
based on evaluations. Planning effective services in the context of the eco-
nomical crisis which requires constant cuts is feasible, provided it is accom-
panied by radical, innovative practices (McDaid and Knapp 2010). The
attempt to abolish asylums cannot, of course, be taken to the other extreme of
unplanned and hasty closure of structures (based on other political or fiscal
interests) in a manner which could be characterised as violent on a political,
social and organisational level.
An updated national strategic plan for mental health needs to be drafted and pre-
pared. Greece’s emphasis must be on the concept of updating the plan (i.e. regu-
larly reviewing the plan) via procedures that do not allow doubt regarding the
work of all persons involved in drafting the plan.
Statutorily mandated, real involvement by associations, families and users of men-
tal health services in the planning, running and evaluation of mental health ser-
vices is needed. Support for organised actions to empower those associations is
needed.
Regular epidemiological studies must be carried out on the general population and
services to investigate the population’s changing mental health needs and how
services operate and their effectiveness. These studies must not merely be pub-
lished in scientific journals but must be tools for changing and improving the
day-to-day care offered by services.
A system for monitoring and externally evaluating services must be put in place.
The objective must be to operate a system of co-ordinated services.
A new type of training for staff in services must be introduced, involving universi-
ties and other educational institutions (medical schools, psychology departments,
social work schools, nursing schools, technological educational institutes, etc.)
focused on modern aspects of social psychiatry and public health.
Targeted actions are needed to educate the public about mental health and promote
mental health issues (to combat the stigma of mental disease, prejudice, social
exclusion) with a start, middle, end and a predefined evaluation method.
5 Psychiatric Reform in Greece 89

A policy of networking mental health services with primary healthcare and welfare
in the context of the sectorisation.
Evidence-based best practices (psychosocial rehabilitation, social entrepreneurship, cri-
sis interventions, cooperation with primary healthcare) are needed to ensure the
transfer and multiplier effect of innovation throughout the entire system of services.
Existing legislation needs to be implemented in relation to hospitalisation proce-
dures on the orders of the Public Prosecutor, and sectorisation needs to be fully
implemented for the entire range of the population.

The independent authority responsible for protecting the rights of mental patients
needs to be supported, with more extensive powers, in close cooperation between
the Ministry of Health, the Ministry of Justice and the Ombudsman.
Achieving all these objectives goes well beyond the current state of know-how in
the sector. It requires real involvement, not merely as a matter of choice, but as a
stance which as J. P Sartre stressed is a material part of the human state. It also
requires a responsible stance to defend not only universal values but the fate of spe-
cific mentally vulnerable individuals and fellow citizens, whom we should be genu-
inely concerned about.

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Health cks143

Further Reading
Examples of best practice from Greece:
Angelidis G, Giaglis C (2011) Petras olympos psychiatric hospital: closure of long-term psychiat-
ric treatment departments and the transformation of the hospital into a network of social
psychiatric services. Dodoni Press, Thessaloniki (in Greek)
Sakellaropoulos P (ed) (2010) The emotional bond between the therapist and patient as the
foundations of psychiatry. Papazisis Press, Athens (in Greek)
Stylianidis S, Ploumbidis D (ed) (2014) Psychosocial rehabilitation under conditions of economic
crisis. What changes for what new needs. Proceedings of the conference from 30–31 March
2014, Athens (http://www.me-psyxi.gr/images/proceedings_of_wapr%201.pdf) (in Greek)
Tsiantis I (ed) (1995) Children at the Leros psychopaths colony. Kastaniotis Press, Athens
(in Greek)
The Contribution of Psychoanalytical
Thinking and Practice to Social 6
Community Psychiatry

Michael A. Petrou

Abstract
This chapter examines the concept of “subject” and “subjectivity” in relation to
mental pain in the context of the development of psychiatry and psychoanalysis.
The issue of the “subject” of mental pain is of tremendous interest both for the
clinician and the human sciences, because the history of subjectivity is intimately
tied into the adventures of psychiatric approaches to mental illness from the end
of the nineteenth century to the present day.
We then go on to present the stance of psychoanalytical thinking and practice
within hospital structures, and outside of them, in other words in the commu-
nity, using illustrative examples, and the major, important role psychoanalysis
played in the move for psychiatric reform in the last decades of the twentieth
century.
An attempt is then made to (a) highlight the ways in which psychoanalysis is
present in psychiatric care structures and (b) determine the conditions for estab-
lishing a mental health structure governed by the principles of psychoanalytical
thinking. One part of this chapter is dedicated to depicting the aspects of how
such a structure could work.
Before the general discussion, we propose a series of conditions about how
individual and social pain are connected, which was an issue of concern to Freud
from as early as 1880s, and which today in a period of generalised crisis is par-
ticularly acute and challenging for clinical thinking and practice.

M.A. Petrou
Clin. Psychologist, Soc. Anthropologist and Psychoanalyst (IPA)3,
Alcimachou Street, 11634 Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 93

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_6
94 M.A. Petrou

6.1 Introduction

In the pages which follow, we examine how psychoanalysis, as a way of thinking

and practice, contributed to the movement for psychiatric reform which commenced
after WWII, which culminated in America and Europe in the 1960s and 1970s and
which finally saw the light of day in Greece in 1985.
Although the founding fathers of psychiatry, who focused on objective nosogra-
phy, did not lose sight of the patient as the subject of their interest, they needed
many decades before innovative psychiatrists more inspired by psychoanalysis
would manage to release mental patients from the alienating shackles of the asylum
and attempt to reintegrate them back into society where they belonged.
This chapter starts by examining the concept of “subject” and “subjectivity” in
relation to mental pain, and using illustrative examples presents the position of psy-
choanalysis within hospital structures, and outside of them, which is to say in the
community. It then goes on to present psychoanalysis’ contribution to the transfor-
mation of psychiatric asylums into primary and secondary care facilities for mental
patients and ends with a set of conditions for connecting individual and social pain
together.

6.2 Subject, Subjectivity and Mental Pain: The Subject

of Mental Pain

Every culture, every society and every professional group have their own myths. As
far as psychiatry is concerned, tradition has it that the doctor Philippe Pinel sets
inmates at the Salpêtrière Asylum in the revolutionary Paris of 1795 free of their
chains. The scene with Tony Robert-Fleury captured for all time in his famous
painting shows one of the founding myths of social-community psychiatry.
During the early years of the modern period, madness had been transformed
into a mental illness and had become firmly locked into the world of clinical medi-
cine, as the classic works of Michel Foucault (1963, 1964) have shown: centuries-
old madness became medicalised and the mad were locked up in medical
institutions, hidden away for many decades in asylums. This final link resulted in
perceptions and practices relevant to mental illness following the dominant medi-
cal standard in each case; today, for example, mental illness is suffocating within
the narrow straits of pure biological and behavioural medicine within the biomedi-
cal model, an approach where the patient and his experience of pain are in effect
absent.
On the contrary, the Age of Enlightenment placed man, thirsty for boundless
knowledge and constant progress, at the centre of its interest: the being endowed
with abilities, the producer of thoughts and deed who speaks in his own name, who
wants self-determination, the being called the “subject”.
The so-called human sciences, including psychoanalysis, derive from
Enlightenment concerns, and their development has been marked by the refutation
of the claims it made as modern history has unfolded.
6 The Contribution of Psychoanalytical Thinking and Practice to Social Community 95

Pinel’s legendary gesture, so-called traitement moral which he developed,

inspired by the practices of the hospital superintendant, and the no restraint idea of
Englishman William Tuke were archetypal standards for dealing with the mentally
ill, as mental patients were then called, in human and social terms. Even mental
patients were entitled to participate in the revolutionary ideal of liberty, equality and
fraternity.
Exactly one century later, the nosographical works of the founders of modern psy-
chiatry Emil Kraepelin and Eugen Bleuler, and then of Karl Jaspers and Eugene
Minkowski, took a phenomenological approach and are marked by a laborious effort
to describe and classify psychoses and emotional disorders based on objective clinical
criteria. Even through this insistence on objectivity, the subject is present in clinical
practice. Mental patients are not just the object of the social practice charged with
managing them, which was named psychiatry. They are, like every individual, subject
to desires, knowledge, feelings and forms of behaviour, part of society as a whole and
carriers of civilisation, just like their doctors, who together developed a special “social
relationship” (Pouillon 1970, p. 77) which has been restrictively named “treatment”.
At that same time, for Sigmund Freud, subjectivity became the central clinical
issue and the involvement of the subconscious, a defining factor in how mental
function was organised. For the father of psychoanalysis, mental pain did not lack
meaning, no matter the extent to which the patient was unaware of it. It had meaning
and content, and the patient was involved in the process of acquiring or attributing
meaning to it and consequently was involved in his own treatment.
Two excerpts from his early work demonstrate the importance Freud attributed
to the diagnostic and therapeutic value of the narration of mental pain.
Firstly, for the describing clinician (1893, p. 159–160):

The case histories I write should read like short stories and that, as one might say, they lack
the serious stamp of science. I must console myself with the reflection that the nature of the
subject is evidently responsible for this, rather than any preference of my own … a detailed
description of mental processes such as we are accustomed to find in the works of imagina-
tive writers enables me, with the use of a few psychological formulas, to obtain at least
some kind of insight into the course of that affection (he means the hysteria).

And clearly for the narrating patient (1893, p. 48, 62):

“Keep still! Don’t say anything! Don’t touch me!” .... Then she said in a definitely grum-
bling tone that I was not to keep on asking her where this and that came from, but to let me
tell her what she had to say. I fell in with this, and she went on without preface.

Thus, thanks to the exhortations of the patient Emmy von N., free association on
the patient’s part became the main instrument of treatment.
However, depending on its quality and severity, psychopathology affects, even
disorganises, the processes and contents of thought, emotion and deed. Subjectivity,
identity and relations with others are all called into doubt. For psychoanalysis, the
meeting between the patient and clinician allows for the painful subjectivity of the
former to be unfurled against the subjectivity of the latter, against the backdrop of
immense risks for both.
96 M.A. Petrou

The long European psychiatric tradition seeks to understand the patient’s subjec-
tivity through a thorough clinical approach and in terms of classification is governed
by an internal cohesive reasoning, organised around the concepts of psychosis and
neurosis.
On the contrary, current psychiatry, which has trapped itself within the so-called
atheoretical classification system (DSM-V, ICD 10, etc.), has abandoned logical
coherence in the organisation of diseases and has necessarily limited itself to the
need to understand the multifarious mental pain of each individual subject. In effect,
it is a system which is exclusively biomedical and behavioural, which psychiatrifies
human experience in its entirety through empirical classification, which ignores the
range of limits and the continuity between normalcy and morbidity (Canguilhem
1972) and the relations between diseases with similar sets of symptoms (Corcos
2013). How can one not raise the difference here with psychoanalytic thinking when
McDougal (1978) wrote the Plea for a Measure of Abnormality?
Psychoanalysis is not just a treatment for mental pain. It is a process of explora-
tion, a method for a therapeutic process and a theory (Freud 1923, p. 234) which
rests on a central hypothesis, applicable to each individual, according to which the
unconscious organises mental life, establishing conflict between diametrically
opposed demands, which are seeking out equally different solutions.
As S. Stylianidis showed in two recent articles (2011, 2012), the quality of the
clinical session is forged by a system which does not give the appropriate impor-
tance to the patient’s thoughts, feelings and deeds because in the dominant percep-
tion of psychiatry, they lack objectivity! Recalling the work of Ricœur (1996), he
notes the importance for the patient of establishing his role as narrator, through the
potential to express his subjective pain given to him by the clinical process (2012,
p. 17). In the author’s view, subject-based clinical practice ought to be developed
along four lines: patient experience, psychocognitive function, the conscious and
unconscious meaning of the symptoms and the patient’s position within the family
and social milieu.
The recently published DSM-V has abandoned the decades old multiaxial sys-
tem. In particular, the removal of the second axis, which described the patient’s
personality underlying the overt symptomatology, is another concession by scien-
tific thinking to the pressure of circles outside of medicine (Hochmann 2010,
p. 233). In contrast to the so-called atheoretical DSM, what is of immense impor-
tance is to highlight through clinical practice the latent structure of the patient’s
personality. That is because mental economy and dynamics are, according to Freud,
determined by the latent structure of personality, which is shared both during the
pre-morbidity period of the subject’s life and upon onset of the illness, and after any
possible recovery.
In lecture XXXI of the New Introductory Lectures, Freud describes the famous
crystal metaphor (1933, p. 58):
If we throw a crystal to the floor, it breaks; but not into haphazard pieces. It comes apart
along its lines of cleavage into fragments whose boundaries, though they were invisible,
were predetermined by the crystal’s structure. Mental patients are split and broken struc-
tures of this same kind.
6 The Contribution of Psychoanalytical Thinking and Practice to Social Community 97

Instead of making a standard DSM-based diagnosis, highlighting the latent men-

tal structure of the patient’s personality (Bergeret 1974) and the individual dynamic
lines which are present or potentially present (Roussillon 2007) and mobilising
them can prevent, ameliorate and/or reverse the pathological course of the illness, in
conjunction with the resilience to the illness the patient may demonstrate (Cyrulnik
2011). All these are vital clinical tools for a proper diagnosis, evaluation and prog-
nosis, for understanding the patient and for developing a tailor-made care plan for
him.
Consequently, the following dimensions are vital for a subject-based psychiatry
(Stylianidis, op. cit., p. 20; 2012, p. 20):

Psychodynamics like defence mechanisms, object relations, the intrapsychic conflicts

approach, interaction methods, object investment and separation models, cognition and
learning methods and procedures, the subject’s position in the family and the socio-cultural
context to which he belongs, different phenomenological aspects especially subjective pain
and its connection to social pain, adaptation methods, personality types, available mental,
family and social resources for preparing an tailor-made treatment and care plan for the
subject.

Referring to Racamier (1993) we can define care as an organic, cohesive set of

methods for a group governed by psychoanalytical thinking aimed at preserving and
bolstering the mental health dynamic of patients and their families, as well as the
inclusion of various psychotherapies and other treatment approaches.

6.3 Psychoanalytical Thinking and Practice in Hospital

Services and in the Community

Psychoanalytical Institutes in the Community

When the first psychoanalytical institutes were set up to train new psychoanalysts
and promote psychoanalytical thinking within the psychiatric and wider scientific
community, the first institutes to care for patients based on the psychoanalytical
approach were also set up. In this twofold way, psychoanalysis from the outset
acquired a position in both society and the community.
Between 1886 and 1896, pre-psychoanalytical Freud was responsible for the
Max-Kassowitz Institute’s “neurotic patients” clinic. It was the first public centre
set up in 1788 to provide care to indigent children in the Austro-Hungarian capital
(de Mijolla 2002).
After Freud himself established the International Psychoanalytical Association
(IPA) in Nuremburg in 1910 to safeguard the theoretical, clinical and educational
unity of psychoanalysis, the expansion of the psychoanalytical movement allowed
M. Eitingon, E. Simmel and K. Abraham to set up the Berliner Psychoanalytische
Poliklinik in Berlin in the early 1920s, which was immediately renamed the Berliner
Psychoanalytische Institut. It was the first institution which brought together educa-
tional activities (lectures, didactic analyses and supervised analyses) and wider mental
98 M.A. Petrou

care as part of a clinic. Just 2 years later came the Vienna Institute. Both closed their
doors when Nazism took hold and were silent during the course of the war.
The Tavistock Clinic was founded in London in the same year as the Berlin
Institute and since then has been providing diverse, top quality training and has been
engaged in important research and treatment activities, while after WWI came the
turn of Paris with the Société psychanalytique de Paris et Institut psychanalytique
de Paris (1954), though the psychoanalytical movement had been active in the
French capital from as early as 1926. This was followed by Frankfurt with the
Sigmund-Freud-Institut, involved in training, providing services and doing research
focused on psychosomatic issues and society.

Psychiatric Reform and Psychoanalysis

When WWII ended, against the backdrop of optimism and freedom which swept the
post-war Western world, two things relevant to psychiatry changed rapidly: the first
effective neuroleptic medicines were introduced (Chlorpromazine), and the antipsy-
chiatry movement began to spread inspired by Laing, Cooper and Esterson in England,
Szasz in America and Basaglia in Italy, while institutional psychotherapy began to be
developed by Daumézon, Koechlin, Tosquelles and Oury in France. Many other psy-
chiatrists, including psychoanalysts, although reserved about the activism and radical
ideas of those named above, systematically expressed concerns which soon resulted
in questions about the psychiatric status quo and in the asylum-centred structure of
psychiatry being overturned. The time for psychiatric reform had come.
Deinstitutionalisation does not only mean abolishing or restricting the number of
asylums or reducing the number of beds at psychiatric hospitals. Above all, it means
developing psychiatric services within general hospitals and health centres as well
as networks of outpatient structures that focus on prevention, treatment and psycho-
social rehabilitation, working in cooperation with the relevant community structures
and social institutions in each case. It means sectorising health services so that users
can turn to services based in the area where they live.
Users of such services are not cut off from the fabric of society since they con-
tinue to maintain interpersonal ties to the extent possible and become named objects
of new, real investments made by the staff of the structures, compared to the ano-
nymity and mass nature of older-style psychiatric services. Moreover, since the
number and importance of therapists increase by setting up a multidisciplinary
treatment team, patients are released from the need to repeatedly see the single,
traditional attendant doctor.
As far as the psychoanalytical movement is concerned, one illustrative example
of this endeavour was the establishment of the renowned outpatient care centres in
Paris’ 13th arrondissement (in addition to the aforementioned institutes and clinics
in the rest of the post-war Western world). The L’ Association de Santé Mentale du
13e arrondissement de Paris was founded in 1958 by Professors P. Paumelle,
S. Lebovici and R. Diatkine and was in effect the first attempt to “sectorise” care for
each age group and pathology for individuals living in that area of Paris. These
6 The Contribution of Psychoanalytical Thinking and Practice to Social Community 99

centres, working in partnership with public hospitals, also combined numerous edu-
cational activities in line with psychoanalytical tradition.
In Athens, D. Kouretas (at the Athens Psychiatric School), A. Potamianou (at the
Centre for Mental Health and Research) and P. Sakellaropoulos (at the Theotokos
Foundation) worked under adverse conditions to promote the psychoanalytical
approach in Greece. Inspired by the French example, and with the active support of
S. Lebovici, A. Potamianou set up the “Centre” which she has run since 1956, an
innovative venue for psychiatric reform with psychoanalytical training provided
within the unfavourable environment of post-civil war Greece which had been
marked by exiles and psychiatric confinement.

According to Anagnostopoulos et al. (2009, p. 348), greek psychoanalysts, indicating the

intention to proceed to some theoretical and clinical adjustments, have since 1980s played
a more active role in the development of public health services and, by extension, in psychi-
atric reform taking place in Greece. The most extensive psychoanalytical interventions
relate to the supervision of clinical work, primarily at units where psychiatry is practiced in
the community, and short-term psychotherapy, which is frequently provided in cooperation
with treatment facilities.

Generally speaking, in the overall move for psychiatric reform and in modern
attempts to sectorise psychiatric services, psychoanalysis has been present from the
outset in all attempts to promote deinstitutionalisation in the Western world after
WWII:

In hospitals: outpatient clinics, the placement of beds in general hospitals and

liaison-based psychiatry between hospital clinics.
Outpatient facilities: mental health centres, adult and child treatment centres, crisis
centres, psychosocial rehabilitation structures, mobile units in regions lacking
any fixed psychiatric services, home intervention and treatment teams, assertive
community treatment, outreach treatment, etc.
In the community: partnerships with local government authorities (welfare services)
and with the Church.
In education: schools (to prevent bullying) and universities (such as counselling
services for students).
In large-scale disasters and acts of violence: “the analysts are in the trenches” as
B. Skarlew et al. (2004) so eloquently put in the title of their book.

Two Illustrative Examples

Daycare Centres for Autistic Children

The development of psychoanalytical clinical practice relating to child psychosis
and autism based on the work of psychoanalysts Klein, Winnicott, Mahler, Meltzer,
Tustin, Bettelheim and others has declined dramatically over recent decades, thanks
to the global dominance of behavioural and cognitive methods such as ABA and
TEACCH.
100 M.A. Petrou

The fact that the older approach is receding has led us, as psychoanalysts, to reas-
sess and update our assumptions about the pathogenesis and approach to treating
child psychosis and autism. Today, daycare centres need to combine prevention,
treatment and educational activities for children, support their families and build
close partnerships with schools and the community. For Hochmann (2006, 2008),
treatment, education and school integration are the three prongs of care for autistic
children.
At daycare centres, in addition to the individual programme, method or tech-
nique used, it is the very organisation of the centre that allows treatment and educa-
tional activities to be developed. Different approaches, venues and people the child
can interact with function (a) as acceptors of the different sides of each child and (b)
create something like a “differential dynamic” that allows them to pass through one
form of process to another. It is the lack of similarities, the breaks in continuity
which create facts and the fact – when put together- which create opportunities for
narration, for telling stories. In this way, the daily extracts from the story of each
child become the object of a diverse process by different interlocutors, who work in
partnership, until they reach the end recipient, the child, in their final form as a unit
of meaning which can in time be appropriated.
Including children with autism in small groups of others of their own age, which
operate on the basis of a well-structured daily schedule, allows each child to distinguish
how to participate in different activities and to experience them as separate activities.
These different experiences are, however, combined together through systematic com-
munication with the child’s various interlocutors, allowing the development of creativ-
ity and the production of meaning, which are equally essential, with the overriding goal
being to create one’s own personal story (Petrou and Doxiadi 2009).
What we know as art therapy is an internationally accepted way of working with
children with emotional and mental difficulties. Cultural media (such as painting,
music, etc.) are preferred educational means for each child and for offering the
treatment to those who need it. They are mediation objects between the participants
in an activity, in other words the child and the experts. They are a pliable medium to
use Milner’s (1993) apt expression: flexible and easily adjustable media, just as the
instructor, the therapist, the partner and not only the child must be flexible.
When working with a child with pervasive developmental disorder, cultural
media can (under certain frameworks and cooperation conditions) help the child
give form and shape to aspects of himself and the world around him. The senses and
movement are stimulated by the physical properties of the object, leading through
the special relationship developed between the child and expert, to preverbal chan-
nels of communication and symbolisation, which can then be verbalised (Petrou
2010).

Halfway Houses
This term primarily means residential units and sheltered accommodation intended
to accommodate patients after they leave psychiatric clinics, before they are fully
integrated back into society, as well as any other structure which prevents patients
from staying long term in psychiatric hospitals or a transitional space between the
hospital and the community.
6 The Contribution of Psychoanalytical Thinking and Practice to Social Community 101

Serious psychiatric disorders require a relatively long-term stay in a clinic, fre-

quently resulting in the patient being institutionalised (whether out of passivity, due
to lack of initiative, etc.). If hospitalisation is coupled with the lack of any family
support framework and/or job, the patient will need a halfway house to help him and
to accompany him on the difficult path towards social reintegration.
During their stay in halfway houses, residents form a therapeutic community.
They have a structured daily schedule to learn individual and social skills. They
participate in individual and group meetings with staff, to take initiatives and
analyse day-to-day difficulties they encounter with themselves, with others, with
society, with the halfway house itself and with their process of social
reintegration.
However, halfway houses which attempt to replace asylums and their problems
frequently end up developing at least some of the same features of a total institution,
to use the phrase from Goffman (1961) which describes asylums, namely, that many
residential units have medical, nursing, occupational therapy, social work and
administrative services, even though they are supposed to be “homes”! Residential
units, even though they are halfway houses, frequently operate as a self-contained
“whole” which disavows any sense of “elsewhere”: an “elsewhere” where the man-
agement could be located, an “elsewhere” where the patient could meet his doctor
or therapist, an “elsewhere” where the staff could gather, an “elsewhere” where one
could report to, an “elsewhere” that the structure could be associated with and so on.
As in the case with daycare centres for autistic children, diversity and connection –
and not homogeneity – are the factors used to give meaning and to ensure mental
integration and social reintegration (Petrou 2005).
The position of psychoanalysis in institutions

Now let us assume that by some kind of organisation we were able to increase our numbers
to an extent sufficient for treating large masses of people. Then, on the other hand, one may
reasonably expect that at some time or other the conscience of the community will awake
and admonish it that the poor man has just as much right to help for his mind as he now has
to the surgeon’s means of saving his life: and that the neuroses menace the health of a
people no less than tuberculosis, .... Then clinics and consultation departments will be built,
to which analytically trained physicians will be appointed … This treatment will be free. It
may be a long time before the State regards this as an urgent duty. Present conditions may
delay its arrival even longer. Probably these institutions will first be started by private benef-
icence; some time or other, however, it must come.… It is very probable, too, that the large
scale application of our therapy will compel us to alloy the pure gold of analysis with the
copper of direct suggestion.

Those are Freud’s own words from his introduction at a psychoanalytical confer-
ence in post-war Budapest in 1918 (Freud 1919, p. 166–7). This historical talk pro-
voked a series of conflicts within the psychoanalytic community relating to the sort
of mix Freud was talking about and about the position of psychoanalysis within
institutions.
In any event, the link between psychoanalysis and public psychiatric care was
already a well-established fact during WWII. The development of psychoanalysis is
tied into the modern history of psychiatry, its practices and theoretical ideas and the
very education and training of psychiatrists.
102 M.A. Petrou

In 1917 Freud wrote (1917, p. 253–4):

You will grant that there is nothing in the nature of psychiatric work which could be opposed
to psychoanalytic research. What is opposed to psychoanalysis is not psychiatry but psy-
chiatrists. Psychoanalysis is related to psychiatry approximately as histology is to anatomy:
the one studies the external forms of the organs, the other studies their construction out of
tissues and cells. It is not easy to imagine a contradiction between these two species of
study, of which one is a continuation of the other.

To make this clearer from a pedagogical viewpoint, let’s assume that psycho-
analysis is present in three ways within psychiatric care structures, where it became
one of the theoretical and clinical means for deinstitutionalisation:

1. As part of the treatment of psychiatric patients. It is the psychoanalytical psycho-

therapy of psychoses, where changes in the framework and technique are neces-
sary in order to work with psychotic patients (Searles 1965a, b; Rosenfeld 1965;
Bleger 1981; Racamier 1990; Mentzos 1991, 2008; Benedetti 1992; Schermer
and Pines 1999; Tzavaras and Stylianidis 2002; Tzavaras, Vartzopoulos and
Stylianidis (eds) 2008).
2. In the hands of enlightened psychiatrists-psychoanalysts, who were responsible for
hospitals, clinics and so on, psychoanalysis becomes a working method within insti-
tutions and relates to all aspects of work within the institution. It is a psychoanalyst
without a couch, to quote the eloquent title of the classic work by Racamier (1973).
The psychiatric hospital has transformed from an asylum and place of restraint and
confinement to the medium for therapeutic processes, and its spaces and the relation-
ships which develop within it became institutional. What provides treatment is not
the institution but the setting, to use Oury’s classic phrase (2004), in other words the
process of creation and deconstruction once the risk of fossilisation or hegemony of
one or the other institution appears. It is the famous institutional psychotherapy,
whose pioneers were G. Daumézon, P. Koechlin, F. Tosquelles, F. Oury and others.
3. As a way of thinking about the work done within institutions and of intervening
in those cases where the work is blocked by conflicts, dichotomies, projections,
projective identifications, denials and other widespread archaic defence mecha-
nisms. It is all about supervision and more recently about institutional analysis
and intervention (Hinshelwood 2001; Kaës 1987, 2005; Nicolle and Kaës 2008;
Pinel et al. 2007; Boutin and Van der Stegen 2012 and others).

However, what are the aspects of the “model” and the conditions for introducing
and running a mental health institution along the lines set out in psychoanalytical
theory? For pedagogical reasons again, we can summarise them as follows:
The first, key condition is to allow the patient to have (perhaps for the first time)
the experience of a framework where, in relation to others and the institution
himself, desires, restrictions, frustrations, differences and conflicts are the
object of a process and not something to be avoided, confronted or repressed.
The institution is not the structure, the therapeutic organisation. It is a total social
fact, in the sense given to that term by the anthropologist M. Mauss, i.e. a fact
6 The Contribution of Psychoanalytical Thinking and Practice to Social Community 103

which “mobilises all component parts” and which are at once legal, economic,
religious, aesthetic, morphological and so on (1950, p. 274). It is a psychocog-
nitive institution, as Hochmann (2008) demonstrated: “When we decide to
abandon the comfort of an institution which is surrounded by walls and we
open up, without any particular protection … we find ourselves in a particu-
larly vulnerable position, in which we risk losing ourselves. In that case, we
need to refer to a theoretical model, which gives meaning to what we are
doing and who we are. A model that introduces a new institution against the
ill, and against the rest of society, as employees who perform a standard task.
The theory, what I call a psycho-cognitive institution (institution mentale) is
in our eyes and in the eyes of others who define it, through its own special
nature, the type of relations we develop during our practice” (1971 [2003],
p. 462–3).
For Hochmann, there can be no therapeutic approach to psychotic patients out-
side of institutions. The subject himself is the institution mentale to the extent
that he creates and organises his thoughts. A psychotic patient faced with the
difficulty of organising them in a non-delirious manner is the subject “in
search of an author”. That author or narrator is none other than the institu-
tional process: along the lines of motherly care, he gradually settles into the
framework of a “narrative envelope” (Stern 1992), a reality where therapist
and patient share meaningful relationships amid fragmented experiences and
with each other. That is mental care for Hochmann: consolation, whose main
instrument is narration, as he showed in his work of the same title (1994).
By multiplying their views (which Bion (1965, p. 90) called a vertex), the mem-
bers of a treatment team can build from the pile of episodic remnants of every-
day life and the biography of the patients, a history within which different
events assume a place and acquire meaning. This is a playful procedure, in the
same sense that Winnicott used when talking about therapy as a game (1971),
giving particular pleasure because it activates a mental autoeroticism
(Hochmann 2008). As something different from the satisfaction of release, it
relates to a pleasant mental function. It is tried out initially as team work
among therapists and is gradually shared with the patient, who discovers a
way to overcome the agony of separation, fragmentation anxiety, persecution,
etc., receiving pleasure from the processes of representation and symbolism
which are the foundations of thought.
The main aim of the psychoanalyst within the institution is not to interpret and to
highlight the unconscious meaning. It is to offer a panorama of images and
tales as materials to create the patient’s story, a creative process from which
the patient can draw pleasure and relief. It is psychoanalysis as “meta-narra-
tion” to use Schafer’s (1997) phrase, and the psychoanalyst is the person who
embodies that story-creating function.
As Boutin and Van der Stegen (2012) have shown, the purpose is not to
“play the psychoanalyst” of the staff, institution, relatives, patients, etc. The
psychoanalyst in the institution is “the witness of what psychoanalysis has to
say about being human”; in other words the human aspect must remain
104 M.A. Petrou

central, which allows everyone (therapist, patient or relative) to open up to life

and each other.
The various mediation media (painting groups, music, drama, dance therapies
etc.) which the institution provides are not activities in the service of sub-
maniacal defences and therapist-patient activism. They create transitional
spaces which allow the patient’s mental reality to be externalised, to connect
it to that of others and to the institution and to develop processes of shaping
and connection, as we explained above are so central to daycare centres for
children with autism.
The development of transference and counter-transference between patients,
therapists and the framework is the means for recognising recurring patterns
within which the patient is trapped and the lever for shifting out of them. If
the institution’s response is different from that of the archaic environment,
rather than providing an interpretation (which is frequently ineffective), it is
better for the patient to develop relations with himself and with others within
the team, rather than within a misleading, overprotective, rejective or contra-
dictory duality (Cahn 1991; Searles 1965).
Such laborious work, the Ego, especially that of someone with schizophrenia,
cannot be completed unless supported by institutional processes that allow a
connection between the inner mental world, the intra-family setting and the
intra-institutional world and consequently integration of the fragmented parts
of his psyche.
It is clear that an institution of this type must be able to distinguish between con-
flicts and dichotomies of the patient and those of the institution itself. The
treatment group in such a context is called upon to be quite robust, to endure
the large number of projections which it must separate from its own issues
and call it into constant question. Supervision, institutional analysis and inter-
vention focus precisely on those processes and the barriers that are encoun-
tered in working with psychotic patients.

6.4 Individual and Community Pain: Human Pain in Society

Freud’s interest in understanding social and cultural phenomena from the viewpoint
of psychoanalysis runs throughout all his work: from 1908 and the article entitled
“Civilised” sexual morality and modern nervous illness (1908), and the books Totem
and Taboo (1913), Group Psychology and analysis of the Ego (1921), The Future of
an Illusion (1927), Civilisation and its Discontents (1930), to his final work Moses
and Monotheism (1939).
Freud comes from the intellectual tradition of the Enlightenment and grew and
developed like his contemporaries, within the context of the claims and teachings of
that period. However, the neurotic individual of the previous century soon began to
realise that instead of experiencing the promised happiness and endless progress, he
was experiencing a sense of generalised discontent, doubt about meaning and a
sense of threat, particularly in light of two destructive world wars and the subse-
quent Cold War: a discontent within civilisation, whose origin and effects were
6 The Contribution of Psychoanalytical Thinking and Practice to Social Community 105

analysed by Freud in his work. He wrote that civilised man has swapped part of his
potential happiness for some security (1930, p. 114). Consequently, on the Freudian
hypothesis, civilisation was built on man giving up direct, complete satisfaction of
his instinctual desires: erotic, destructive and narcissistic desires.
Giving up erotic desires frequently leads to neurotic inhibitions and symptoms.
At the other extreme, any prevalence of destructive urges over the urge to live leads
to the dissolution of primordial violence, sometimes at personal level (psychosis,
destructive thinking), sometimes at interpersonal level (breaking of bonds, as in the
case of the threat of social dissolution) and sometimes at state level (conflicts and
wars). He emphatically stated that the battle between the urge to live and the urge to
destroy is what life is really about generally speaking, and for that reason the devel-
opment of civilisation ought bluntly to be described as the vital battle of the human
species (1930, p. 138).
The concept of instinct indicates the constant and unavoidable pressure from
instinctual drives that are at the basis of human sexuality, narcissism and destruc-
tiveness. The violence of instincts is more powerful than rational interests.
Where the overvalued strength of rational discourse failed, Freud counter-pro-
posed the mental process of unconscious forces. This task falls on the shoulders
of culture, as he quite unexpectedly concludes at the end of New Introductory
Lecture XXXI: “The therapeutic efforts of psychoanalysis, he writes, would
consist in strengthening the ego, to become more independent over the Superego,
widen the field of perception and transform its organization in order to appropri-
ate more sections of the Other. Where the Other was, the Ego must reach. That
is the cultural work, cultural activity, work of civilisation” (Es ist Kulturarbeit)
(1933, p. 79).
What is civilisation? Is it not the regulation of desires a product of the mediation
of the Ego between conflicting instinctual demands of the Other and prohibitions
emanating from the Superego? What relationship can civilisation have with the
Other, the Ego, Superego and the Id?
Kulturarbeit is a phrase which Freud did not explore in as much theoretical detail
as he did with dream work and grief work, nor did it receive the appropriate atten-
tion from his followers. Despite that, it retains an important position in Freudian
thinking. We consider that it is similar to and on a par with the mental work of the
individual subject, but at a social level. Mental work cannot exist or be understood
without Kulturarbeit, or vice versa (Petrou 2012).
If the Ego is present, he wrote in An Outline of Psycho-Analysis (1938), the
Other and the Superego are the past. The Other is the hereditary disposition, the
Superego is to be bequeathed. In New Introductory Lectures he once again said, the
Superego is not formed in the image of the parents’ prohibitions but by the content
of the parents’ Superego. It regulates social conduct, which represents tradition, the
ideals of the past, and may withstand for some time the challenges of a new eco-
nomic situation (p. 177). Humanity does not live only in the present; the past, tradi-
tion and civilisation survive via the Superego.
When he explores the ideology and influence of the leader in the book Group
Psychology and Analysis of the Ego, he writes that each member of the group
assigns part of his Id to the leader. That assignment gives rises to two
106 M.A. Petrou

identifications: one with the leader, who expresses the now common ideal, and the
other, the inter-egoic one, between members, which is the foundation of group ties.
Kulturarbeit and mental work develop along two lines relevant to each subject:
one outside of time which entails cross-generational ties and carries tradition and
super-egoic identifications and one which is of this time, entailing ties with those
existing at this time, inter-egoic identifications and narcissistic contracts.
The last decades of the postmodern world (Aubert 2004, 2010) led R. Kaës,
thanks to his clinical-theoretical approach to groups (2007), to reassess Freudian
views about the social origin of mental discontent which Freud had been talking
about since as early as 1908. In his books about the discontent modern subject face,
Kaës (2012) describes how psychoanalysis invents and works with those clinical-
theoretical standards of understanding changes and transforming in time, space,
ties, civilisations and mentalities. Those standards are clearly temporary and inad-
equate to allow us to think again about our relationship with the unknown.
The postmodern world violently and rapidly overturned the narcissistic basis of
our subjective and social identity, our perceptions and the myths on which our sense
of belonging and relations between members of society, civilisation and nature rest.
In a community of individuals, where processes lack subjects, ties (whether inter-
generational or intersubjective) are in deep crisis. Consequently, subjectification,
socialisation and symbolisation (the only things which can process the dispersion,
heterogeneity and gap between experience of the inner world and that of the exter-
nal environment) are gaping, leaving the crevice from whence violence and destruc-
tiveness emerge, quite unprotected.
The author identifies four features of our postmodern civilisation as responsible
for inadequate symbolisation:

A culture of control which pursues compulsory homogenisation and integration of

everyone can only result in controlled violence applicable within its very struc-
ture and uncontrolled social violence which rejects all laws foreign to it (lawless-
ness, racism, terrorism).
A culture without limits which promises to promote exaggeration, omnipotence,
“hubris” in a word: the idea that “everything is possible”. The result: unthinking
exposure to risk, ending in destructive injury.
A culture of urgency and immediacy, due to the shortening of our temporal horizons
due to hubris: “we have to manage to get everything done”. As a result, a specific
tie is retained in the present, but it is not recorded in history. The inability to
make medium-term plans further contributes to the disorganisation of thought, of
the ability to choose and of grief.
Lastly, a culture of melancholy, in other words endless, unprocessed loss and grief,
both personal and collective, at social level: the death of God, of man, of human-
ism, of ideologies, a culture of genocides, of destructive population shifts, etc.

Faced with this melancholic disenchantment with our culture, postmodernism

also cultivates maniacal promises, dreams of hedonistic dominance and uncon-
trolled destruction. The massive changes relate primarily to large structures which
6 The Contribution of Psychoanalytical Thinking and Practice to Social Community 107

frame and normalise social formations and processes: myths and ideologies, faith
and religions and power and hierarchy. They are meta-social guarantors of the key
structures of symbolisation, which is “culture” in its various manifestations and
forms, in short Kulturarbeit.
The crisis of meta-social guarantors also drags meta-mental guarantors (which
are the background of the psyche, the processes and environmental formations on
which the psyche of each subject is based, the fundamental prohibitions, intersub-
jective conventions and pacts, etc.) into crisis.
As far as the mental pathologies we have been seeing for decades and the gener-
alised discontent in both Western civilisation and in the entire Third World afflicted
by famines, diseases, violence and fanaticism are concerned, social scientists have
given us very useful methodological tools and well-documented analyses to help us
understand these phenomena.
Limiting ourselves to the more classic authors, in Suicide (1897), Durkheim
analyses the concept of social ties in relation to the forms of social solidarity and the
termination thereof in the case of lawlessness. In the Sociology of Mental Disorder
(1965) Bastide argued that the deconstruction of a social group and/or society is
accompanied by mental deconstruction for its members. Castel (1978, 2005, 2009;
Castel et al. 1979), working on the forms and processes of social exclusion, devel-
oped critical views about care institutions for mental patients and the relationship of
mental illness with modern social circumstances.

The “Third Difference” and the Ethnopsychiatric Approach

Let us now turn our attention to refugees and migrants who are seeking out a better
future in countries in the Western world. Whether these people are obviously
patients or not, they carry within them immense mental pain: personal pain, family
pain and cultural pain. The burden of those individuals raises serious questions
about our own capacity for tolerance towards difference and our own personal and
cultural pain compared to otherness in general and the ties and bonds within our
own Western societies which are suffering too.
Understanding these individuals and dealing with them at an institutional, social
and clinical levels are urgent and difficult, almost impossible one might say. If we
limit ourselves to the clinical work needed, the difficulties are already immense
(Kleinman 1980, 2008). Simplifying already difficult moral, epistemological and
theoretical-clinical issues, we either need to treat them as if they are patients whose
mental economy and dynamic we know or must work to understand the “third dif-
ference”, after that of gender and generation, referred to by Kaës et al. (2012): cul-
tural difference which gives rise of identification pain.
Thanks to the work of the ethnologist, psychoanalyst and Hellenist Georges
Devereux (1970, 1972 etc.), since the 1960s and 1970s, we have had the necessary
methodological tools to understand these people. It is called Psychoanalytic
Ethnopsychiatry: a twofold, nonsimultaneous approach characterised by absolute
respect for the autonomy of the conceptual and methodological framework of both
108 M.A. Petrou

anthropology and psychoanalysis, which demonstrates the complementary nature

of these two systems of understanding. Devereux writes (1972, p. 10):

The principle of dualist and non-simultaneous discourse categorically rejects all ‘inter-
disciplinary’ attempts to add, merge, combine or view things in parallel, in short to view
each discipline ‘as combined with’ another… It makes every ‘deduction’ from ethnology
and psychoanalysis or vice versa, utterly fraudulent.

This was supplemented by the anthropologist F. Laplantine, who stressed that the
ethnopsychoanalytic methodology seeks to “avoid the double barrier of (a) fully
relativising psychiatry and (b) psychiatrifing culture” (Laplantine 2007, p. 24).
Some of Devereaux’s students, Nathan (1986, 1988, 2007), Moro (2002, 2004),
Zajde (2005, 2011) and others set up a centre in Paris bearing their teacher’s name,
working with refugees, immigrants and second- and third-generation migrants, in
order to continue his research. Another psychoanalyst and anthropologist, Douville
(2000, 2007, 2014; Douville et al. 2012), has taken a different scientific path, study-
ing violence in history and introducing the concept of “the melancholisation of
social ties”, working on social exclusion among European and African
adolescents.

6.5 Discussion

What is the future of social-community psychiatry against the background of the

endless, drastic cut in social spending, the drive for cost-effectiveness and the suf-
focating framework wherein a form of psychiatry aimed at psychiatrifying the
human experience and suppressing it with medicines is coming to dominate?
It is beyond the bounds of a chapter like this to answer a question like that.
However, we cannot ignore the fact that as long as these two constraints continue to
play a decisive role in the future of the sector, we cannot overlook at least two inter-
nal limitations: our present identity and the very nature of psychosis.
In relation to the first, in one of his articles, Stylianidis (2012) raised the ques-
tion of the extent to which it is not just society but also the dominant model of
psychiatry that is afraid of psychoanalysis, and vice versa. “The presence of a psy-
chiatric team which makes reference to psychoanalysis … faces numerous uncer-
tainties”. Referring to the work of Ehrenberg (2007) and Castel (2005, 2009) about
the drop in the quality of day-to-day life and the rise in social pain and the sense of
insecurity, he points out the unheard-of type of meeting between society and the
psychoanalyst which entails strong moral, scientific and humanitarian (practical)
dilemmas: “Issues of managing and understanding the needs of collective and indi-
vidual pain are raised, which is not a well-known psychopathological subject area”
(see 18).
As far as the second constraint is concerned, it has to do with psychosis per se.
Depending on the country involved, asylums have either been completely done
away with or have reduced in numbers. That was a major scientific and humanitar-
ian necessity. However, one of the founding fathers of the movement to abolish
6 The Contribution of Psychoanalytical Thinking and Practice to Social Community 109

asylums, Hochmann (1994), wrote of his disappointment and the risks entailed by
the new structures that replaced asylums:

All attempts encountered over the last quarter of a century in the entire Western World
under different names: treatment communities, institutional psychotherapies, even anti-
psychiatry, end up with the same disenchantment. The asylum cannot change. It now tends
to be quickly rebuilt even within the most cutting-edge or innovative institutions.

Hochmann bases this unfortunate finding on his immense clinical experience and
active participation in the attempt to promote deinstitutionalisation: it is psychosis
itself which “secretes the asylum which requires the conditions of the asylum”. The
projections that emanate from schizophrenics are recorded within the very matrix
and form of the institution, which if left its own devices will work in favour of the
psychosis. Counter to the violent acting out and extreme passivity of the schizo-
phrenic (as a form of protection against fragmentation or annihilation anxiety), the
institution has to choose between adopting an equally passive stance (which is often
rejective) or an activist one (which often idealises the potential of psychosis and
treatment communities) or giving the chance to develop painful thought processes
and questioning of the framework and everything that happens in that context.
Mental health structures with a psychoanalytical focus cannot be the product of
administrative decisions or so-called scientific discoveries. They must be institu-
tions which do not institutionalise once and for all, where theories and practices are
not infallible truths, where their truth is partial and revisable. In other words, they
ought to be the product of innovative, radical, subversive thinking and above all
open to the potential of being overturned by newer thinking, by newer standards
which adopt new mentalities, new institutions and so on (Petrou 2005).
In recent years we have acquired the tools to advance, to move from theoretical
speculation to testing them in clinical terms, to move beyond ideological delusions
that came from previous decades and to think about our foundation myths, about
subjection as Castoriadis (1975) has called it and about the function for which the
institution is run by the institutional status quo.
One such tool is progress in understanding manifestations of the subconscious
within institutions noted in recent decades by group psychoanalysis. According to
Kaës this is a new methodological paradigm (2005, p. 8) within psychoanalytical
theory and clinical practice, which demonstrates the processes of connecting the
individual, as the subject of the unconscious and the group, with intersubjective
wholes. Kaës’ central hypothesis is that what is not symbolised by the mental pain
of the subjects in an institution “comes back within the institution in a setting where
mental reality is associated in a mixed up and confused manner with the realities of
other classes … It negates thinking and goal achievement, which are the main task
and social function of the institution” (Kaës, op. cit., p. 47).
The balance achieved from time to time by an institution is ephemeral, because the
mental ties (personal, interpersonal and institutional) are exceptionally prone to discon-
nect and to become rigidly locked into institutional processes. Institutional intervention
seeks to analyse these fixating repetitions and to restart institutional processes, which
Pinel has called processuality (Pinel and Morel 2001; Pinel 2005): the ability of the
110 M.A. Petrou

institutional group to preserve active processes for investing in the work done with
patients, associates and the institution itself, the thinking process and the process of
questioning practice.
In his book Darcourt (2006) asks “Are Psychoanalysis and Psychiatry Still
Useful?” Psychiatry always gained from using different theoretical-clinical
approaches, because on its own, none suffices to fully understand mental pain.
In short, psychoanalysis can contribute to releasing and freeing the dominant
form of psychiatry from the suffocating bind in which it finds itself through:

Recognising the importance of mental pain and its processes, because the diagnosis
cannot relate to a supposedly objectified body. Being empathic towards others is
the means for diagnosis which makes the process become intersubjective
understanding.
The therapeutic relief felt by the patient through the assignation of meaning to his
experience and through developing a tailor-made care plan. Pain is placed within
a narrative which tells the subject’s own story, because narration is a treatment
tool in the context of total care.
The satisfaction the therapist gets from working with mental patients and which is
transmitted over to the patient, in terms of mental function.
Showcasing the connections between individual aspects of pain and the social fac-
tors which define, augment and ameliorate it.
The trials and tribulations which we are constantly obliged to subject our theories
and clinical practice to and of course the constant development of networks of
prevention, treatment and psychosocial rehabilitation along the lines outlined in
this chapter.

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 Part II
Applications of Social Psychiatry
Promoting Mental Health: From Theory
To Best Practice 7
Stelios Stylianidis, Pepi Belekou, Lily Evangelia Peppou,
and Athina Vakalopoulou

Abstract
Health is not just a biological matter (in the sense of the absence of illness) but
also a social phenomenon, since it incorporates the quality of relations individu-
als have with each other and with their environment. The importance of mental
health, its interdependence on physical health and the burden that mental disor-
ders cause on a personal, family and social level have gained increasing recogni-
tion both by the relevant policymakers and by the general public.
Mental health is defined as the state of emotional well-being which prompts
individuals to recognise their skills, to effectively deal with stressful life situa-
tions, to work to produce results and to contribute to the society in which they
live. In our times, man appears to be particularly vulnerable in terms of mental
health, and the frequency with which mental disorders are appearing is con-
stantly on the rise. Both promoting health and preventing illness seek to ensure
the common goal of maintaining and improving health.
Late diagnosis of mental problems in the young can very likely lead to serious
mental illnesses in adult life with long-term effects. The World Health
Organisation (WHO) has highlighted the importance of promoting mental health
and prevention in children and adolescents and urges governments worldwide to
include mental health as a key part of their primary healthcare. However, there is
nonetheless an immense gap between needs and resource availability. However,
in all European Union countries, there is some activity in terms of mental health

S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
P. Belekou • L.E. Peppou • A. Vakalopoulou
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]; [email protected]; [email protected]

© Springer International Publishing Switzerland 2016 117

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_7
118 S. Stylianidis et al.

prevention and promotion. The availability of the practices, resources and infra-
structure which has been developed varies from country to country reflecting
different situations in healthcare systems, political history and traditions and
their understanding of both mental and public health.
A literature review highlights examples of best practices and evaluation of the
effectiveness of measures to promote mental health among individuals of school
age, since it recognises that education contributes to the prevention of the onset
of mental illnesses.
The programme to promote mental health in children and adolescents in
selected areas of Greece ran for the period 2011–2013. It was financed by the
Stavros Niarchos Foundation and implemented by the Association for
Regional Development and Mental Health on the islands of the NE and
Western Cyclades. The measure sought to ensure primary protection of the
mental health of children and adolescents. It included awareness-raising and
counselling groups for parents of children in each age group, awareness-rais-
ing and counselling groups for adolescents about mental health issues and
awareness-raising and support groups for teachers in preschool, primary and
secondary education.
The awareness-raising groups performed an educational support role. The
principles of assertive-experiential learning were chosen for the methodological
approach. The results were particularly encouraging in all sectors of interven-
tion. The chapter highlights the epistemological and social need for holistic
interventions on interactive local systems, to ensure the best outcome of pro-
grammes to promote mental health.

7.1 Introduction

Health is a wide-ranging concept which can include positive, negative, func-

tional and experiential definitions. The historic definition of health as the
absence of illness is clearly an example of a negative definition. On the contrary,
an example of a positive definition is the one from the WHO (1948) which states
that health is a complete state of physical, mental and social well-being. A func-
tional definition would refer to the ability to participate in normal social roles
while an experiential definition would take into account one’s sense of self
(Kelman 1975).
Consequently, health is not just a biological but also a social phenomenon, since
it incorporates the quality of relations individuals have with each other and with their
environment (Tountas 2001). It can be depicted as a complex model which reflects
the physical, mental and social dimension of well-being and illness.
The importance of mental health, its interdependence on physical health and the
burden that mental disorders cause on a personal, family and social level have
gained increasing recognition both by the relevant policymakers and by the general
7 Promoting Mental Health: From Theory To Best Practice 119

public. According to the Mental Health Declaration for Europe, “mental health
-representing a state wellbeing in which the individual realises his own abilities, can
cope with the normal stresses of life, can work productively and fruitfully, and is
able to contribute to his community- has been recognised as fundamental to quality
of life, enhances social cohesion, enhances peace and stability in the environment
and contributes to the economic development of societies” (Jané-Llopis and
Anderson 2006).

7.2 Concepts and Definitions: Historical Background

According to the World Health Organisation (WHO 2003a), mental health is defined
as the state of emotional well-being which prompts individuals to recognise their
skills, to effectively deal with stressful life situations, to work to produce results and
to contribute to the society in which they live.
In our times, man appears to be particularly vulnerable in terms of mental health,
and the frequency with which mental disorders are appearing is constantly on the
rise. According to a recent health report, in the USA one in five Americans suffers
every year from a diagnosable mental disorder, while 50 % of the American popula-
tion will present such a disorder during their life time (Sultz and Young 2010). It
also mentions that one in ten people will become ill with depression at some time in
their life. It is estimated that around 6 % of the general population suffers from
depression, in other words around 350 million people on the planet, 550,000 of
whom are in Greece (Skevington and O’ Connell 2004). One should not ignore the
fact that mental disorder, which reflects a social pathology and is the result of the
interactions of the psychobiological substrate with the natural environment,
increases in periods of economic recession and social crisis, like the one we are cur-
rently experiencing.
According to research carried out in all EU countries (Wittchen et al. 2011),
38 % of the population (including those in childhood) are estimated as presenting
some mental disorder every year. As far as adolescents are concerned, around
one in five has been diagnosed with some form of mental disorder. It is no coin-
cidence that mental disorders appear for the first time in adolescence or in early
adult life (WHO 2009) since they may be an early sign of the appearance of
mental disorders in adult life. According to the results of one study, 75 % of
individuals with a diagnosed mental disorder at the age of 26 had been diagnosed
for the first time during adolescence (WHO 2005). Around the world, almost
20 % of children and adolescents suffer from some mental illness, which degrades
their quality of life, while also raising social and economic barriers for them.
WHO surveys argue that mental illnesses and their symptoms are accompanied
by mental, social and economic burdens of a scale of € 240 billion in the EU. In
Europe 20 % of children and adolescents face developmental, mood-affective
and behavioural disorders, while 4 % of children aged 12–17 years old suffer
from depression (SOU Report 2006).
120 S. Stylianidis et al.

According to more recent epidemiological data (Mavreas et al. 2010), one in

six Greeks aged 18–70 have developed clinically significant psychopathology
and 1 in 12 (600,000) have serious psychopathology. International data showing
that in Greece 75 % of the population with some form of psychopathology do not
receive any treatment for their problem have been confirmed. In addition, the
suicide rate has risen from 2.8 per 100,000 in 2008 to 5.2 in 2010 (Giotakos et al.
2011). As far as adolescents are concerned, research data confirm that mental
disorders, dominated by depression, affect 3–8 % of the population and are
directly related with negative health behaviours such as smoking, use of psycho-
tropic substances and alcohol abuse and with reduce performance at school, poor
social relations, bullying, high-risk sexual behaviour and even suicidal tenden-
cies (Giannakopoulos et al. 2009). A study conducted on Greek adolescents
found that the rate of attempted suicide in 2007 was 13.4 % of the population
(Kokkevi et al. 2010).

7.3 Promoting Health and Preventing Illness

During the 1980s, and on November 21, 1986, in particular, the first international
conference to promote health was held in Ottawa, Canada, under the aegis of the
WHO, where the charter to develop actions to achieve health for all from 2000
onwards was presented. At that conference, a wide-ranging definition of health pro-
motion was presented and then adopted:

Health promotion is the process of enabling people to increase control over, and to
improve, their health. A necessary tool in health promotion is health education, which is
can be defined as a process which helps individuals take decisions, adopt behaviours and
act in accordance with the need to safeguard and promote their own health. (Tountas
1994)

Health promotion includes all aspects which affect the individuals’ choices about
his behaviour such as values, beliefs, attitudes and incentives which prompt them
towards a special form of health behaviour. In addition, it recognises that individu-
als do not make choices on their own but based on interactions with their environ-
ment (family, friends, social and community milieu, economic and political
environment). Consequently, health promotion requires an exploration of the meth-
ods used by social policy such as laws and regulations about how the state operates,
and social structures can change or support the positive dimension of health. Health
promotion activities seek to support individuals and their social environments, to
organise and set priorities and take action on health issues in line with social needs
(Whitehead 2004).
On the other hand, illness is defined as an interruption or irregularity in bodily
functions which causes pain or weakness. Anything that negatively affects the
7 Promoting Mental Health: From Theory To Best Practice 121

physical functionality of the body can be considered to be an illness. Although most

people do not try to get ill, they do adopt day-to-day habits which are harmful to
health, such as smoking or not exercising.
Illness prevention relates to any attempt to stop the onset of a specific illness or
condition, such as heart conditions, diabetes or cancer, for example (Breslow 1999).
In addition, prevention can include identifying illnesses during their early-onset
phase. Such types of prevention are considered to be more effective than any other
health promotion or behavioural strategy.
Both promoting health and preventing illness seek to ensure the common goal of
maintaining and improving health. The difference lies in the fact that health promo-
tion activities can be more general and seek to improve the individual’s overall well-
being. Illness prevention, on the other hand, focuses on preventing a specific disease.
Moreover, health promotion arises from the needs and priorities of each distinct
community, while illness prevention will most likely be based more on general data
which show the importance of a health problem in the community such as depres-
sion levels in the elderly, for example.

7.4 The Importance of Promoting Mental Health

Late diagnosis of mental problems in the young can very likely lead to serious men-
tal illnesses in adult life with long-term effects. Moreover, disorders that have not
been identified and treated can seriously reduce the abilities of adolescents in
becoming productive members of society and can lead to high levels of crime, major
family conflicts, destructive substance abuse, low self-esteem and alcoholism
(ASTHO 2002; WHO 2003b). The current socioeconomic crisis, the high demands
of modern life, the incomplete parenting, changes in the family structure, dysfunc-
tional interpersonal relations and new demands on adolescents have made it essen-
tial to identify mental health problems among adolescents in good time and provide
them with support (Patel et al. 2007). However, for that to happen, one must first
fully understand and approximate the environment of adolescents in terms of family
and school, since mental health problems which prevent functionality are reflected
in their reactions to social/environmental stressors (Appleton and Hammond-Roley
2000).
The World Health Organisation (WHO) has highlighted the importance of pro-
moting mental health and prevention in children and adolescents and urges govern-
ments worldwide to include mental health as a key part of their primary healthcare
(WHO 2004, 2011). However, there is nonetheless an immense gap between needs
and resource availability (Keiling et al. 2011). However, in all European Union
countries, there is some activity in terms of mental health prevention and promotion.
The availability of the practices, resources and infrastructure which has been devel-
oped varies from country to country reflecting different situations in healthcare
122 S. Stylianidis et al.

systems, political history and traditions and their understanding of both mental and
public health.

7.5 Best Practices for Promoting Mental Health:

International Standards

A literature review highlights examples of best practices and evaluation of the

effectiveness of measures to promote mental health among individuals of school
age, since it recognises that education contributes to the prevention of the onset
of mental illnesses. In fact, programmes that are implemented in schools that
focused on promoting general psychological skills (coping skills) for adoles-
cents appear to be more effective than those which focus on specific problematic
forms of behaviour (Mentality 2003). This approach includes interactive and
participative methodologies, which have been confirmed as being more effective
(Tobler et al. 2000).
After running the Responding in Peaceful and Positive Ways (RIPP) pro-
gramme on 600 adolescents to develop socio-cognitive skills to promote non-
violent conflict resolution and positive communication among them and teachers
and parents, it appears that the participants acquired important knowledge about
how to effectively communicate, manage anger, be empathic and control urges
(Farrell et al. 2001).
The interpersonal cognitive problem-solving programme (ICPS) appeared to be
equally important. It was run by teachers in the classroom to train adolescents about
effective thinking, listening and interpersonal skills for solving problems using
techniques such as dialogue, role playing, team spirit and relaxation (Shure and
Spivack 1988). The participants appeared to significantly improve their cognitive
conflict resolution skills and inhibitions, and spontaneity was significantly reduced.
The intervention had a major effect on the role of teachers and also contributed to a
reduction in psychological distress.
The Promoting Alternative Thinking Strategies (PATHS) programme was aimed
at educating adolescents within structured groups to recognise, understand and self-
regulate their emotions (Greenberg and Kusche 1998). For more positive results,
printed materials were provided to teachers and parents about how to manage ado-
lescents. The results of the programme confirm improve self-efficacy and positive
mental health among the adolescents.
Hains and Ellmann (1994) designed an intervention programme for adoles-
cents to reduce negative emotional arousal and other psychological conse-
quences of stress. The adolescents participated in 13 groups overall which were
briefed about stress and its harmful effects of health and were trained in stress
management and problem-solving techniques. After the end of the intervention,
7 Promoting Mental Health: From Theory To Best Practice 123

stress levels reduced but not to such an important degree as the improvement in
their attitude towards seeking health from mental health specialists. The aware-
ness-raising and information campaign applied to 472 adolescents in England
contributed significantly to the reduction in stigma about mental illness (Pinfold
et al. 2003).
The WHO has shown the importance of integrating health services into the con-
text of the school environment, which to a large extent is based on training the train-
ers (WHO 2010). Job satisfaction has been shown by many studies to positively
affect teachers’ ability to manage stress (Bindhu and Sudheeshkumar 2006) while
fostering self-efficacy and positive health among teachers who protect both their
own professional commitment and the mental balance of adolescents (Brouwers
and Tomic 2000).
In one programme to promote mental health in the school environment run for
adolescents, parents and teachers (Webster-Stratton and Hammond 2001), the
results were positive for all three target populations: after counselling groups, par-
ents appear to have lower levels of negative parenting and higher levels of positive
parenting. Moreover, the ties between school and family and the partnership
between teachers and parents improved, behavioural problems of children at home
and school declined and the role of teachers and how they managed classes were
improved.
In another interventionist programme to bolster the educational role and well-
being of teachers (Wyn et al. 2000), the latter participated in a total of ten group
sessions lasting 30 h which included experiential exercises such as exchanging pro-
fessional experiences with colleagues, recognising specific stressors and potential
coping strategies, using alternative ways of thinking and analysing specific methods
for dealing with unruly students in the classroom. After the end of the programme,
teachers noted a drop in psychological distress, improved social relations with each
other and a drop in levels of burnout.
Another programme for parents and teachers of primary school pupils used teach
learning methods to prevent early aggression in children and prepare them for
higher school classes (Hawkins et al. 1991). At the end of the programme, teachers
acquired stronger skills for teaching social skills to children and more effective
knowledge dissemination methods. For their part, parents improved communication
skills with their children, learned how to implement home discipline techniques and
increased their knowledge about adolescent issues.
In 2008 the WHO in partnership with the International Association for Child
and Adolescent Psychiatry organised an interventionist programme for adoles-
cents, parents and teachers and government bodies to provide information and
raise awareness about mental health issues faced by children and adolescents
(Hoven et al. 2008) in nine countries. Positive changes were recorded in terms
of the knowledge acquired by all participants, while the stigma attached to
124 S. Stylianidis et al.

mental illness dropped and mental health issues were integrated into public
debates and media coverage.

7.6 Best Practices in Greece

Programme to Promote Mental Health in Children

and Adolescents

The programme to promote mental health in children and adolescents in selected

areas of Greece ran for the period 2011–2013. It was financed by the Stavros
Niarchos Foundation and implemented by the Association for Regional
Development and Mental Health on the islands of the NE and Western Cyclades,
where two mobile mental health units have been in operation for the last 10 years.
These island areas are remote, meaning that social services either operate below
capacity or do not exist at all, and the problems frequently encountered by health
services make it difficult if not impossible to prevent and deal with mental health
problems.
The intervention was aimed at primary protection of the mental health of chil-
dren and adolescents and consisted of three levels, to support adolescents and chil-
dren within frameworks which are important for their development: (a) interventions
for the adolescents themselves, (b) interventions at school by working with teachers
and (c) interventions in the family. The programme was designed as follows:

(a) Awareness-raising and counselling groups for parents of children in each age
group (parents of children of preadolescent and of adolescent age). The main
goal of the parents’ intervention group was to improve positive mental health
and reduce mental distress (by focusing on promotion and prevention, respec-
tively). In addition, specific goals of the intervention were to reduce parental
stress, to cultivate coping skills, to expand social networks and to improve atti-
tudes towards mental health professionals and the idea of seeking out help for
psychological difficulties.
(b) Awareness-raising and counselling groups for adolescents about mental health
issues and theatrical play meetings, where the central goal was to improve posi-
tive mental health and reduce mental disorders. Secondary goals included
improving the degree of self-efficacy, cultivating coping skills and improving
attitudes towards mental health professionals and the idea of seeking out help
for psychological difficulties.
(c) Awareness-raising and support groups for teachers in preschool, primary and
secondary education. The main goal of this intervention was to improve the
ability of teachers to identify mental stress in children and adolescents and to
improve their professional self-efficacy. Secondary goals included learning
coping skills and expanding social networks.
7 Promoting Mental Health: From Theory To Best Practice 125

Planning the Intervention

The plan was that teacher and parent groups would attend nine 2-h long meetings
and adolescents would attend 18 meetings with two facilitators in each group (expert
mental health trainers specialised in group work). The groups were to meet every
15 days. Each of the meetings per group sought to address specific issues and cover
a particular topic. A manual was drawn up for each group meeting which consisted
of two parts: (a) a seminar-like presentation on the topic presented using interactive
media and (b) an experiential part to ensure deeper assimilation of the topic through
experience.
Preparing the manuals was the tool and joint basis for the interventions. The
content and subject matter was determined by an informal exploration of needs
done by a focus group of school advisors and educational bodies during the prepara-
tory phase. Members of the teams across the entire programme were also asked at
the first meeting as part of a brainstorming exercise. The final subject matter was
approved by the editorial committee, having taken into account the information
generated by the focus groups. The manuals were written by committees of group
facilitators appointed depending on the area of specialisation each one had. The
editorial team then edited the texts. Each manual was different and aimed at a spe-
cific target group. Depending on the subject examined, the epistemological focus of
the manual differed (psychoanalytical, systemic, cognitive-behavioural).
The content of the manuals was revised during the programme in line with the
intervention’s quality control process. The diaries designed as part of the pro-
gramme’s internal evaluation process to be filled out by the group therapists with
information about the process indicators for each meeting (a) ensured the unifor-
mity of the intervention at different stages of the programme and (b) allowed one to
identify weaknesses in the meetings and correct them later (such as subject matter
might have needed to be explored in more detail or required more time or fewer
experiential exercises may have been needed).

Methodology: Awareness-Raising and Counselling Groups:

Assertive, Experiential Learning

The awareness-raising groups performed an educational support role. Their primary

target was to create a framework to activate the individual as a “whole” (Senge et al.
2008). Implementing the project utilised key principles of group dynamics, such as
interaction, building a team spirit, developing social networking, creating familiarity,
developing communication and cooperation skills, expressing emotions and connecting
to personal meaning (Navridis 2005). Consequently, the educational process also aided
the personal growth of those who participated.
The principles of experiential learning were chosen for the methodological
approach. As stated above, the structured group interventions followed a manual
126 S. Stylianidis et al.

which included presentations and experiential techniques, such as how to present the
topic of small groups, role play games, case studies, simulations (goldfish bowls),
communication exercises and use of the group as a forum for social learning about the
target group. The approach was experiential and integrated the concept of assertive
learning and was aimed at the ability of participants to learn through experience.
Yalom (1995) states that the group process on its own has an experiential
character. In addition, experiential learning places emphasis on the important role
played by experience in the learning process and provides intellectual and emotional
stimulation seeking to integrate intellectual and emotional processes (Evans 1994).
At the same time, it is based on initiative and assertive involvement of the individual,
which gives the chance to act and take responsibility for the process (Mulligan
1993) and covers a longer time period since it mobilises the individual as a “whole”.
Learning is in depth and can help the individual grow, affecting his attitudes and
personality.

Results

A multifaceted approach was used to evaluate the programme in an attempt to

remain in keeping with the complexity of the programme itself and each such
mental health prevention and promotion programme. In particular, indicators
relating to structure, procedure and outcomes of the programme were included,
and information was collected in various ways relating to the outcome indicators:
number of referrals to mobile units, use of self-reporting scales, questions to sub-
jects benefiting from the programme, focus groups and open-ended questions
about satisfaction with the programme. A brief presentation of the results is set
out below.
Overall 1,259 received services as part of the programme over 2 years, and 66
individuals (teachers in the second round) participated in the programme in both
years. One thousand and twenty-three people received programme services in the
Cyclades, 140 in Evia and 96 in the northern suburbs of Athens. In each target
group, the figures for those who received services were 585 teachers, 513 parents
and 161 adolescents. The lower number of adolescents compared to other groups
can be explained by the difficulty in approaching and retaining the specific popula-
tion group in long-term, stable prevention measures, especially when the pro-
gramme is run outside of school hours.
As far as referrals to mobile units are concerned, there was a significant increase
which reflects the positive impact of the specific programme on the local communi-
ties in the Cyclades where it was run. In the first year, 23 % of referrals to paedo-
psychiatric services offered by the mobile unit came from the programme while the
corresponding figure for adult services was 16 %. In the second year, 29 % of refer-
rals to paedo-psychiatric services came from the programme and 17 % of referrals
for adult services.
7 Promoting Mental Health: From Theory To Best Practice 127

As far as adolescents are concerned, the interventions generated the following

statistically significant differences compared to the scales before and after the
intervention:

Improved self-efficacy (theatrical games and counselling groups)

Reduced symptoms of stress (theatrical games)
Reduced social dysfunction (counselling groups)
Increased use of emotional and practical support as coping strategies (counselling
groups)
Reduced mental stress in general (theatrical games)

Adolescents considered that the interventions helped them improve self-

confidence, learn more about themselves, become able to express their thoughts and
emotions without problems, make new friends and seek out help if they needed it.
The interventions do not appear to have improved their positive mental health (men-
tal well-being) but that change may require time to take place.
As far as parents were concerned, the intervention succeeded in large part in its
individual goals as is clear from the statistically significant changes noted between
the two points in time when the evaluation tools were used (before and after the
intervention). The following findings were recorded:

A reduction in psychological distress (psychopathologies of a neurotic type using

the GHQ scale)
Improved positive mental health
Reduced parental stress
Expanded social networks
More frequent use of coping skills

As far as teachers are concerned, the internal evaluation and quality control pro-
cesses resulted in the targets for the specific intervention being redefined as well as
in a change in methodology from year 1 to year 2. The lack of a statistically signifi-
cant impact of the intervention in year 1, the focus groups with group facilitators
and a supervisor and the focus groups with the teachers themselves held at the end
of year 1 led to a change in focus. During year 1 the intervention primarily related
to emotional difficulties faced by teachers themselves and to raising of awareness
about mental health issues. In year 2, however, the intervention focused on issues
such as identifying mental disorders, managing difficulties in the classroom and
fostering the role of the teacher so that he/she could provide effective, real support
to students.
The evaluation of that year, which also included teachers who had taken part in
year 1 and some who had taken part in year 2 (deeper examination of issues and
focus of specific school-based issues), showed that during year 1, teachers had
learned about mental health issues and awareness of them had increased, while in
128 S. Stylianidis et al.

year 2 they were given the opportunity to use that knowledge, to better organise and
manage their own issues in terms of their tendency towards emotional over-
involvement and their position in relation to the student, parent, colleagues and
headmaster.
The intervention led to better identification and recognition of mental health
issues among students, greater professional self-efficacy, better social networking
and cultivation of better coping skills.
The programme’s successes include the involvement and high response rate
among local communities which were helped in actively participating in all stages
of programme implementation. All procedures were made easier, since facilities
were provided for the interventions, thereby raising awareness and informing the
population and using the local process to spread news about the programme. For the
purposes of the programme, psychometric tools were translated and localised for
the Greek population, which can now be used to conduct other research into related
topics, and the scientific process used to document the manuals means they can now
be used for other mental health working groups, agencies and organisations.
Consequently, the programme’s contribution and effectiveness was evaluated on
many levels, since the programme itself appears to have benefited the attendees,
local communities, mental health services in the local area, mental health profes-
sionals and the scientific community in general.

7.7 Discussion

The literature and history of psychiatric reform in Greece shows that the reform
process was not accompanied by programmes of this sort which would have
improved primary prevention in the population against mental illnesses. Even agen-
cies which could have presented examples of good social psychiatry did not adopt a
structured programme to promote mental health.
The programme we implemented had positive effects on local communities, as
we mentioned, but also had specific constraints and limits. In many cases we have
seen islands of psychiatric reform collapse in the past because of lack of resources
and because of the medical focus of the culture within agencies/services, profes-
sionals and the wider healthcare system. (See the chapters on psychiatric reform in
Europe and Greece.) Reality has taught us that certain synergies are needed at insti-
tutional level to run programmes of this kind and that networks of services (net-
working) are needed to (a) ensure that reform is not put at more risk and (b) ensure
that it does not remain suspended in mid-air. Moreover, one disadvantage of the
situation in Greece is that mental health promotion and health education are not
taught in educational institutes, except in some isolated postgraduate courses.
Professionals therefore lack the ability to acquire the necessary tools and skills for
the relevant practices.
Talking about local communities, it is essential to stress the multifaceted aspect
of interventions of this kind, as well as the complex interactions between the indi-
vidual, family, wider community (local authorities, services, agencies) and the
7 Promoting Mental Health: From Theory To Best Practice 129

wider framework to which the community belongs. Fritjof Capra, an important

systems theorist, highlighted the idea of the web of life. For major social issues
such as health, he refers to direct connections and interactions with living systems:
individuals, social systems and ecosystems (Capra 1997, 2004). The concept of the
web of life in the humanities demonstrates the use of network networks at all sys-
tem levels. It is a dynamic process with numerous individual levels, which are both
affected and affect the system. We can identify the benefits of an intervention on all
the levels referred to but contrariwise the fact that the same benefits may also be
needed to affect the culture of the scientific sector, to shape policy, and the content
of interventions. Living systems respond to the effects they are subject to from
their environment by making structural changes (Bateson 1979; Maturana and
Varela 1987).
At the same time, the concept of interdependence of all phenomena allows us to
understand the multiplier effect of positive results on the members of a community,
and outside of it, by connecting the local with the global. Modern theories of net-
works talk about the “human superorganism” where local contributions to the
human social network can have global consequences (Christakis and Fowler 2010).
Consequently, interventions to promote mental health need to take these fundamen-
tal changes in the theory of humanities and the connections between phenomena
which were until now treated as “separate” into account and must approach the
individual from a holistic scientific perspective.

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Social Suffering and Mental Health
in Metropolitan Athens: A Qualitative 8
Approach

Stelios Stylianidis, Athina Vakalopoulou,

and Lily Evangelia Peppou

Abstract
Modern metropolises have now transformed into anonymous zones without his-
tory, similar to anywhere else in the world, overcrowded with various people who
do not know each other and who have never come into contact. Social inequalities
in such environments and the consequent social exclusion have a negative effect
on health, mental health and the well-being of the population. The aim of this
study is to explore social exclusion in metropolitan Athens and in particular to
record its socio-demographic profile, its self-image, experiences of social racism
and health problems for the homeless in the centre of the Greek capital. The
homeless characterise themselves as unfortunate and unlucky, and some have
experienced others as being indifferent towards them or have suffered social rac-
ism, while others have described a completely positive response from others. At
the same time, they have quite a few health problems, and almost one in two has
a clear sense of sadness and stress. A major percentage also report substance and
alcohol abuse, while quite a few appear to use alcohol as a form of self-treatment.
In conclusion, the city generates alienation, fear, insecurity and unhappiness.
Every community ought to use any resources it has to implement organised poli-
cies and create social networks to address the complex needs that arise.

S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
A. Vakalopoulou • L.E. Peppou
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]; [email protected]

© Springer International Publishing Switzerland 2016 133

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_8
134 S. Stylianidis et al.

8.1 Introduction

It is widely known that the migration movement mushroomed after the end of the
Cold War. It emerged as part of globalisation processes and lead to a deep restruc-
turing of the social geography of metropolitan areas. “The world became a city”,
said the historian Lewis Mumford in a characteristic phrase in 1961. Indeed his
forecast has become a reality, in the sense that the entire world was transformed into
an immense array of large urban areas, which have seen a shift from South to North:
social inequalities and exclusion, the stigmatism of poverty and the increasing com-
plexity of social suffering (Castells 1989). The city offers the ability to adapt for
survival, concealment and communication. However, it does not have the suitable
institutions and does not have any potential for gradual integration into the urban
space (Saraceno 2010). Marc Augé (1992), one of France’s best-known anthropolo-
gists, used the term “non-place” (non-lieu) to refer to anonymous places without
history, similar to anywhere else in the world, overcrowded with various people
who do not know each other and who have never come into contact. That definition
clearly reflects the social reality of metropolitan areas in Europe and more widely.
This trend began to dominate in the first decade of the new millennium, and for
metropolises with global influence, the specific movement was named “super-
diversity” (Vertovec 2007). The phenomenon of social fragmentation and margin-
alisation has spread not just to the metropolises of the South but to large Northern
European cities as well, despite the fact that they developed under completely dif-
ferent conditions compared to those of South America and the European metropo-
lises. “Rounded” approaches to dealing with this complex problems by formulating
proposals and guidelines for changes in social and sanitary policy have failed to
provide persuasive answers at local level, such as the problems of social suffering
and social exclusion in the world’s metropolitan centres (Thomas et al. 2005;
Saraceno 2014; Stewart et al. 2010).
The gap between generalised declarations and announcements by the planning
authorities to relieve the vulnerable populations who live in a constantly ephemeral
reality and understanding of the specific impact at local level are now immense
(Appadurai 2002). In the harsh and chaotic reality of modern metropolises, social
suffering is bound up with mental pain and psychiatric disorders and abandonment
with the lack of rudimentary care for individuals with problems of public health
work, identity and survival. The violence which exists in this context is not just sup-
pression, ghettoisation, social exclusion and lack of access to health, welfare and
mental health services and breach of all fundamental rights for a decent life: It is
also symbolic, mental, emotional, cultural violence and a lack of any investment in
the future (Bourdieu 1991). Pain in a metropolitan setting, in no man’s land, is a new
“paradigm” within which situations of pain are interdependent (Stylianidis et al.
2011). The responses are fragmented and noncontinuous, and respect for rights is an
“insignificant” problem compared to the “health bomb” waiting to go off that these
people represent, as a threat to public health. As B. Saraceno (2010) writes, the
North (no matter where it is located geographically) has its very own South.
The social inequalities of these metropolises have a negative impact on health,
mental health and well-being to a greater degree. Quite a few studies confirm the
8 Social Suffering and Mental Health in Metropolitan Athens: A Qualitative Approach 135

fact that they are accompanied by mental disorders, with most common ones being
stress and depression, followed by addiction and dependence problems and by car-
diovascular conditions (Stuckler et al. 2009). The most powerful risk factors are
unemployment, low levels of education, low income and degraded living conditions
(Fryers et al. 2003). The loss of work and long-term poverty impact even more on
individuals from minorities, such as migrants (Doorslaer et al. 1997; Wilkinson
2002), with depressive symptoms appearing often, especially in men (Stansfeld
et al. 2003). In addition, those individuals are twice as much as risk of early mortal-
ity and have increased morbidity (Bartley et al. 1997; Blane et al. 1997).
Greece, well known for its migrant flows, has today become a “host country” for
migrants with an inadequate migration policy (The World Bank 2011). The majority
of migrants in Greece are Albanian (Ventura 2006). This chapter will attempt to
show based on recent research data that there is a need for holistic, multifaceted and
integrated responses to such complex problems, in contrast to the fragmented
responses from services that are limited in a piecemeal fashion to looking at the
individual level only.

8.2 Observations About the Description of Metropolitan

Athens

Athens has a diverse distribution of different classes and ethnic minorities. The city
centre (Omonoia Square) is literally “abandoned” to the hands of various ethnic
groups including quite a few Greeks in an exceptionally perilous state.
Agios Panteleimonas Square is an extreme case study (Arapoglou 2006) which
allows us to understand in depth the complexity of conflicts within the endogenous
population. According to the mayor of Athens, Kaminis (2011), “both legitimate
migrants and migrants without anywhere lawful to stay enter the country, while 300
of them gather in the city centre every day”. He also states the constant stream of
migrants without a lawful right to stay leads to an increase in the number of victims
of the general social crisis. As a result, a new category of homeless people has
emerged, the new homeless: educated people, possibly with families, who suddenly
found themselves faced without a job or home. It is worth noting that in 2011 the
competent authorities recorded 25,000 homeless people who took shelter in aban-
doned buildings, squares and pavements in Attica alone (Giannarou 2012).
The link between fluidity and pain and crime rates is undisputed. It is illustrative
that in a recent evaluation by Mercer in 2011 (Global 2011), Athens “fell” eight
places in the rankings for safety and quality of life and is now in bottom place
in terms of European capitals. The increasing levels of migrants and the homeless
population in general have also led to a corresponding rise in crime levels. Recent
research by Kapa Research showed that 79.3 % of those questioned felt at risk
because of cases of violence happening daily involving migrants without any papers
(Tryfonas 2012). Migrants are pushed towards illegal acts because their fundamental
rights have been infringed and because of their position in the social pyramid. They
are perpetrators of crimes against property, such as theft, and crimes involving the
trafficking and use of drugs and prostitution, primarily involving women (Bui and
136 S. Stylianidis et al.

Thongniramol 2005). Official data from the Hellenic Police shows that of the 12,250
people detained in Greece’s prisons, 7,700 are foreigners (Souliotis 2012).
The sense of failure, deriving from the inability to meet basic needs, and the
sense of isolation and being cut-off from the social fabric lead the homeless to low
self-esteem, despair and a total lack of incentives to survive. Poverty has a direct
psychological impact on the sense of shame, low self-worth and stigmatism (Patel
and Kleinman 2003). On the other hand, social stigma lies not only in the lack of
work and poverty but also in the personal characteristics of the homeless person,
such as use of drugs, alcoholism and mental illness, trapping them in a single “iden-
tity”, that of social suffering (Major and O’Brien 2005). Because of the nature and
heterogeneity of the homeless situation, their only name is “the others”. Studies on
the homeless (Harter et al. 2005) have shown that self-stigmatism is intimately
bound up with low self-esteem, loneliness, the sense of being trapped, suicidal ide-
ation and the sense of guilt and low self-worth because the situation they are in
appeared to affect mental illness variables such as stress and depression. The major-
ity of the mass media and key figures who shape public opinion transform this
phenomenon into images and dialogues about extremely stigmatised ghettos, which
in turn form the cultural concept of homeless people for us.

8.3 Research Design

Against this background, the Regional Development and Mental Health Association,
working in partnership with the Panteion University, carried out a study to explore
social exclusion in Metropolitan Athens. The specific aims of the study were:

(a) To identify and capture the socio-demographic characteristics of homeless peo-

ple in the centre of Athens
(b) To explore the image they have of themselves and the image others have of them
(c) To record and capture key health and mental health problems they report

To achieve those objectives, a qualitative approach was adopted for three main
reasons. The study’s primary aim was to explore views, feelings and experiences of
the homeless in depth, spontaneously and freely, without the restrictions a quantita-
tive approach imposes. At the same time, the limited literature on the topic in Greece
meant that the study was more exploratory and less an attempt to verify or reject
some research hypothesis. Lastly, the absence of a weighted clinical tool for
migrants would limit the validity of the results.

Method

Sample
Feasibility sampling was used in this study to record a wide range of views, experi-
ences and emotions. Participants were recruited from various places where the
homeless congregate in Athens: in Koumoundourou, Amerikis, Koliatsou, Viktorias,
Vathi, Liossion, Acharnon, Exarchia, Omonia, Stournai, Polytechnio, Metaxourgio
8 Social Suffering and Mental Health in Metropolitan Athens: A Qualitative Approach 137

Table 8.1 Interview topic Questions:

guide
1. How would you characterise yourself?
2. How do people treat you?
3. How is your health?
4. How is your mental health? (how are you psychologically?)

and Agios Panteleimonas Squares. We approached both Greek and migrant home-
less people. The only criterion for inclusion in the study was their willingness to
participate, and the sole exclusion criterion was the lack of an ability to communi-
cate with the investigators in either Greek or English. The participants received
coffee and cigarettes for taking part.

Interview Tool
The interviews were semi-structured and included open-ended questions that pri-
marily focused on the socio-demographic profile of the homeless, their self-image,
experiences of social exclusion they may have had and their state of health, includ-
ing their mental health.
The interview tool (a topic guide) was developed by the investigating team and
is summarised in Table 8.1.
The face-to-face interviews were conducted by 11 final year students of psychol-
ogy at the Panteion University after a 3-day training course about the research meth-
odology and interview techniques using cultural competence tools (Gionakis 2010).
The students were supervised once a month.
Due to participants being suspicious about the use of recording devices, the stu-
dents noted the responses down on paper. Participants were approached by pairs of
students: one to conduct the interview and the other to keep notes.

Data Analysis
Thematic analysis was used to interpret the data in line with and Interpretative
Phenomenological Approach (IPA) to the narratives (Smith et al. 2009). Initially,
the two investigators read the narratives independently numerous times, noting
down the thematic titles in the margins which could be used to summarise them.
Then the themes in each narrative were tied together and classed, and in the final
stage, the investigators tried to identify recurring and new themes, taking into
account overlapping data from the narratives in the sample. The two investigators
found similar themes (reliability), and if they disagreed, the theme was determined
after a discussion held with the entire research team.

8.4 Results

Socio-demographic Profile of the Population

Table 8.2 shows the socio-demographic characteristics of the participants.

In total, 329 people participated in the study. 14.28 % of the people in the study
were aged 18–22, and a similar figure applied to the 28–32 age bracket. This was
138 S. Stylianidis et al.

Table 8.2 Socio-demographic Distribution Ν = 329 %

characteristics of the people in the study
Age
18–22 47 14.28
23–27 41 12.47
28–32 47 14.28
33–37 39 11.85
38–42 34 10.33
43–47 24 7.3
48–52 25 7.6
53–57 15 4.56
58+ 42 12.46
No response 1 0.3
Gender
Male 251 76.2
Female 78 23.7
Nationality
Greece 137 41.6
Lebanon 5 1.5
Afghanistan 27 8.2
Pakistan 29 8.8
Iran (Persia) 6 1.8
Iraq 6 1.8
Morocco – Tunisia 9 2.7
Africa 23 7
Bangladesh 16 4.8
Romania 5 1.5
Albania 15 4.5
Bulgaria 13 3.9
Nigeria 1 0.3
Pontus – Caucasus 1 0.3
Algeria 3 0.9
Syria 10 30.4
Latvia 1 0.3
India 5 1.5
Georgia 2 0.6
Palestine 4 1.2
Ukraine 1 0.3
China 2 0.6
Undisclosed 5 1.5

followed by 12.46 % for the over 58 age bracket. Moreover, 76 % of the sample
consisted of men and around half the participants were Greek (42 %), which con-
firms the state of crisis and utter uncertainty in modern Greek society.
8 Social Suffering and Mental Health in Metropolitan Athens: A Qualitative Approach 139

Axis 1: Self-Image

The thematic analysis of the narratives showed that 36.7 % of the sample focused
on unhappiness, poverty and misfortune. Quite a few said they felt “hurt, afraid,
unfortunate and without hope” (N18, N69). Family relations were quite illustra-
tive of their overall condition: “My parents never wanted me, my father used to
beat the living daylights out of me whenever he drank” (N60). On the contrary,
14.5 % of the population characterised themselves as “good people” struggling
to get by and hoping for something better: “I’m optimistic, I’ve got dreams for
the future” (N51), “I’m a good person, why do I have to endure all this?” (N117)
and “I’m good, spontaneous, hard-working” (N93). They have experienced pain
and instability as well as separation, situations which have activated feelings
of guilt and low self-esteem: “I’ve messed up. My parents don’t even want to
see me” (N56), “I feel like a great big nothing” (N92), “I feel like an idiot.
I didn’t grab opportunities” (N107) or “I’m ruined and I have myself to blame
for that” (N87). Lastly, a small part of the sample (9.5 %) considered themselves
to be happy, lucky and proud: “I’m not some random guy, I know who I am”
(N97) and “I’m a proud person. I don’t beg. If someone wants he will give me
money” (N13).

Axis 2: Treatment by Others

It is noteworthy that around 24 % of the sample gave conflicting responses.

Seventy seven of the 329 participants reported that people “help, give you cof-
fee, cigarettes and food” (N7) and “give you clothes and food” (N114), while on
the other hand, 79 participants described extremely stigmatising behaviour from
other people: “They don’t see as any different from dogs” (N33), “there’s rac-
ism. They say I stink because I’m black” (N70) and “They look down on us
because we are on the margins” (N62). 10.9 % of the population responded that
sometimes people treat them well other times with racism, while 8 % said that
people were indifferent: “No one pays attention. And rightly so, why should
they care?” (N76) and “People don’t care about me. It’s like I’m invisible to
them” (N69).

Axis 3: Physical Illnesses

Of the 329 participants, 121 replied that they have physical illnesses (36.7 %), the
most common being muscular-skeletal problems (13.6 %) because of their terrible
living conditions. That was followed by cardiovascular conditions (6.3 %) and den-
tal issues (3.3 %). 32 % of the sample denied any physical illnesses, while 8.5 % did
not respond.
140 S. Stylianidis et al.

Axis 4: Mental Illnesses

Of the 329 people in the sample, only 16 (4.9 %) replied that they did not have any
problem or felt happy/hadn’t given up hope when asked how they felt psychologi-
cally. On the contrary, almost one in two (188 people, 54.7 %) described a palpable
sense of sadness/worry/melancholy: “I feel really sad and worried. I want to cry all
the time. I wish I’d just die in my sleep so that I wouldn’t understand a thing” (N13),
“I think I’ve probably got depression. It’s like I feel unhappy all the time and can’t
escape from it. Sometimes I’m so upset I want to throw up” (N99), “I usually feel
melancholic at night. I cry almost every night because of how unhappy I feel.
Sometimes I dream about getting away from all this, but the next evening it’s the
same thing over again, … trapped in the same situation, without being able to
escape” (N183) and “Sadness like a shadow over me every day. That follows me
wherever I go, whatever I do. I feel empty” (N305).
In parallel, a large percentage (154, 46.8 %) described intense and palpable
stress/anxiety: “All day I feel that I’m wound up, my nerves are on edge, I feel I
can’t calm down at all, that nothing can relieve me” (N113), “I’m stressed, very
stressed and anxious, about what to do, how I can escape from all this” (N278) and
“I’m in a bad way psychologically, I’m stressed out all the time. I can feel my heart
racing from the stress and panic, like I have a weight on my chest, a knot, I feel like
I’m boiling inside… I walk so I won’t have to think, but I can’t calm down… the
worst thing is when I can’t manage to sleep at night with my thoughts and the anxi-
ety” (N311). In addition to palpable sadness and stress which dominates the stories
from participants, a large portion of the sample (119 people, 36.2 %) had pessimis-
tic thoughts about the future and/or ideas of unworthiness: “I feel that everything is
a mountain … I don’t know if and how I will manage to overcome all these difficul-
ties that have arisen … I’m overcome with despair” (N98), “I’ve lost all trust in
myself and all self-esteem. Basically, I hate myself. I’m a piece of rubbish” (N106),
“I feel helpless, I’m not worth anything, I’m nothing” (N250) or “I’m very disap-
pointed by myself, I feel a failure, that I’ve come to this point, that I cannot over-
come my problems, that I can’t do anything” (N288). Lastly, a small percentage
(around 17 %, 56 people) reported physical symptoms such as sweating, rapid
heartbeats and breathing difficulties and/or disturbed sleep. It is worth noting that
12 participants had been hospitalised at some point in a psychiatric department of a
general hospital or in a psychiatric hospital and received medication for their mental
health problems (primarily: psychosis, anorexia nervosa, personality disorders and
depression).

Axis 5: Substance Dependence

As far as substance dependence is concerned, 121 people said that they never used
substances or alcohol. However, 51 participants (15.5 %) reported using substances,
heroin, hashish, cocaine and LSD primarily, and 45 (13.6 %) frequently used alco-
hol: “I love alcohol” (N34) or “Alcohol is my only prop” (N67). A small percentage
8 Social Suffering and Mental Health in Metropolitan Athens: A Qualitative Approach 141

(around 9.4 %, 31 people) reported occasional use of alcohol mainly for self-
medication to deal with stress, the cold or insomnia: “Alcohol is the only medicine”
(N7), “I drink alcohol occasionally, it helps with the void and mood” (N80), “I drink
win to forget” (N110) or “sometimes I drink beer to get rid of the stress” (N218).

8.5 Discussion: Conclusions

Reformulating the experiences and comments from this study, it is clear what the
key aspects of social suffering in the urban environment are. As far as the socio-
demographic profile of this population is concerned, the study has confirmed that
there is a mosaic of socially vulnerable groups in the centre of Athens. Migrants
from countries such as Albania, Afghanistan, Pakistan, Bangladesh, Iraq, Iran,
Turkish Kurdistan, Palestine, Sudan and Somalia form the vast majority of those
living in Metropolitan Athens without valid paperwork. The idea of a homeland dif-
fers and is complicated in the minds of those people because they are “on the move”.
On a symbolic, psychoanalytical level, this process has been described as abandon-
ment of an all-containing idea (Stylianidis 2011, 2012), such as the homeland, com-
munity, family, mother and the social roles assumed. They come via dangerous,
often fatal, routes.
The fragility of their personality and adjustment difficulties are balanced by
“proud isolation” from the wider society of the country they establish themselves in,
which is a condition for psychological self-protection (Stylianidis 2012).
As far as the mental health problems they face are concerned, almost one in two
homeless people found it difficult to function satisfactorily, mainly due to the pal-
pable sense of depression and/or stress. The extent to which that depression or stress
meets specific diagnostic criteria was not examined in this study, which aimed pri-
marily at recording the subjective views of the participants in the study. The palpa-
ble social suffering identified in the sample in this study cannot be
medicalised – psychiatrified and codified in terms of symptoms, to bring it into line
with the findings of modern epistemology (DSM) (Stylianidis 2012). Subjective
mental pain is tied into a wider framework of social suffering, which is being
explored by modern classificatory psychiatry (Stylianidis 2011). It has, in fact, been
found that interculturalism is tightly bound up with stress-related disorders and
depression and that the length of time migrants stay in Greece, without a family,
without a legal right of residence or right to work, significantly affects their depres-
sive symptoms (Madianos et al. 2008).
The fragmentation of government bodies and services which was noted confirms
the gap which exists. Primary healthcare and welfare services look down on and
stigmatise marginalised individuals, which has further repercussions on the conti-
nuity of their health, psychiatric and social care. At the same time, fear from resi-
dents and the sense of being trapped inside their own homes create the phenomenon
of polarised social exclusion.
Government policies on the various forms of social exclusion appear pointless in
the sense that they only provide piecemeal, ineffectual solutions. One could say that
142 S. Stylianidis et al.

the state appears unable to take action to effectively address the special, different
needs of this population and to create specialised services like mobile mental health
units for cities.
Cities undoubtedly generate fear, discrimination and a sense of insecurity.
Despite that, in every society (even in times of crisis) there is a wealth of sources,
technologies and social ties that could be used to implement organised policies and
to establish networks to address these complicated needs. Developing new networks
would be possible if the political authorities, citizens and those directly involved
focused on the key problems of those excluded from society, irrespective of the
environment where one lives and works, thereby creating a new democratic and
participative local culture.
This study had specific methodological constraints. Because of the qualitative
approach adopted, the findings are not considered representative of the population
overall and cannot therefore be generalised for Athens’ entire homeless population
(sampling was not done in a randomised fashion) or the homeless of other large cit-
ies in Greece. At the same time, the findings describe or attempt to systematically
present some in-depth observations rather than quantify the scale of the problem
and/or the phenomenon. As already mentioned, because of the explanatory nature
of the study and the fact that there was a large number of migrants in the sample, a
clinical tool for identifying mental disorders tailored to other population groups
(like migrants) was not included. A supplementary epidemiological study could be
carried out later, which would focus on all the issues thrown up by this study: a valid
distinction between social suffering and mental disorders, differences between
Greek and migrant homeless people, the profile of homeless people who have to
face social racism and the tie between social racism and mental illnesses.

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The Recovery Model and Modern
Psychiatric Care: Conceptual 9
Perspective, Critical Approach
and Practical Application

Stelios Stylianidis, Michail Lavdas, Kalomira Markou,

and Pepi Belekou

Abstract
The recovery model is a model that allows an individual to take back control of
his life. It was primarily developed for serious mental disorders for which the
biomedical model precluded any possibility of “real recovery” and control over
life by individuals with mental disability. From a biopsychosocial viewpoint, the
recovery model shifts the treatment objective from reducing symptoms to real
integration and assignment of meaning of the life of individuals and their partici-
pation on equal terms in society. In other words, the perception is that recovery-
as-healing goes beyond the concept of “therapeutic accompaniment” and “care”,
as formulated by Racamier (Le psychanalyste sans divan. La psychanalyse et les
institutions de soins psychiatriques. Payot, Paris, 1970, Les schizophrènes.
Payot, Paris, 1980, Le génie des origines: psychanalyse et psychoses. Payot,
Paris, 1992), and is transferred into modern psychotherapeutic concerns about
psychoses. In any event, that requires a change in culture and how psychiatry is
practised. In other words, it requires the individual to function as a user of mental
health services, as an “expert user” when it comes to his own illness and not as a
passive user who complies with treatment guidelines. This change must be
accompanied by a simultaneous change in the way services are structured and
operate, and in the more general attitude of the community, so as to accept differ-
ence and to make individuals adjust to the “norm” of a condition for integration.

S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
M. Lavdas • K. Markou • P. Belekou
Association for Regional Development and Mental Health, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 145

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_9
146 S. Stylianidis et al.

This chapter explores the history and conceptual meaning of the recovery model
and ends with critical remarks about how it has been applied at both Greek and
international level. This path is accompanied by presentation of a clinical case to
show how the recovery model can be used in practice.

9.1 Introduction

The concept and practice of recovery appears to have been gaining ground over the
last decade, particularly in the best practices of Anglo-Saxon countries and the
experiences of deinstitutionalisation and critical psychiatry in Europe.
The plethora of references in the literature to the concept of recovery and the
different perspectives of those involved in psychiatric care and psychosocial reha-
bilitation (mental health professionals, families, users of services, volunteers, man-
agers of mental health services) have frequently caused confusion and a sense of
fluidity about the real meaning of recovery and how it can be applied in practice.
This chapter attempts to clarify the conceptual confusion which exists about
recovery and how it has been perceived in Greece. Moreover, a systematic literature
review enables us to comment on objections to its adoption in practice by looking at
clinical examples, in the context of psychosocial rehabilitation at the Regional
Development and Mental Health Association.

9.2 Conceptual Framework and Definitions of Recovery

Laird (2002) proposes four different definitions for recovery: (a) returning to a nor-
mal state; (b) an act, instant, process or period of recovering; (c) something gained or
restored in the process of recovering; and (d) an act of acquiring useful substances
from untreated sources, such as scrap.
These four definitions (Davidson et al. 2005) can be used to clearly and accu-
rately identify four different categories in the context of holistic healthcare such as
(a) acute physical conditions, (b) injury and its consequences, (c) disorders caused
by substance usage and (d) serious mental disorder.
Babiniotis (2002) defines the Greek word for “recovery” (anarrosis) as “the
gradual rehabilitation of health after an illness” which is similar to the definition [a]
in the Webster dictionary which relates to physical health, even if chronic such as
asthma, diabetes, cancer etc. Likewise, Babiniotis (2002, p. 767) tells us that the
Greek word iasis (healing) makes a “rehabilitation of health”.
We can see that the concept of rehabilitation appears in both the definitions of the
Greek words for recovery and healing, but this cannot fully capture the fourth defi-
nition of recovery contained in the Webster dictionary. However, given the wider
heterogeneity of serious mental illnesses both in terms of diagnosis and treatment,
recovery is seen as having different meanings for people who have experienced or
are experiencing different developments and outcomes for their illness.
9 The Recovery Model and Modern Psychiatric Care 147

Despite the lack of uniformity, most definitions of recovery include the elements
of acceptance of the illness, hope for the future and the search for renewable self-
meaning and a different identity. Three of the most frequently citied definitions of
recovery in the literature are provided below:

1. Recovery presupposes the development of new meaning and life purpose for an
individual, as he grows beyond the destructive results of psychiatric disability
(Anthony 1993).
2. Recovery relates to the actual life experience of individuals who accept and
move beyond the challenge their disability poses (Deegan 1988).
3. Recovery is a process via which individuals with psychiatric disabilities can
rebuild and develop important personal, environmental, social and spiritual ties
and come to terms with the destructive effects of discrimination by integrating
them (Spaniol and Koehler 1994).

Definitions of this type, which clearly converge and complement each

other, differ from the definition used in clinical research. In that perspective,
recovery is defined as the disappearance of the symptoms which caused the
individual disability or, in the case of physical health, a return to the previous
state (Young and Ensing 1999 ). Consequently, recovery in clinical research is
the absence of some unwanted points or situations, such as illness or symp-
toms, or the disappearance of some problem that was not part of the individu-
al’s life before the illness, by using medication or hospitalisation (White 2000 ;
Whitwell 2001).
Although this model can include positive improvement indicators, such as work
and home, the focus nonetheless remains on overcoming barriers and on a return to
the previous state of health (Davidson and Strauss 1995).
From the viewpoint of users of mental health services and professionals
involved in psychosocial rehabilitation, recovery cannot be viewed as a “static
situation or result” (Deegan 1996a, b) nor is it the same as treatment; instead it is
a life process which involves an increasing number of steps towards different life
levels (Jacobson and Curtis 2000). The outcome of all this is that recovery, in
Greece, has begun to be experienced by the movement of users of mental health
services and their families more as an attitude, a way of life, a feeling, a vision
or experience (Deegan 1988, 1996a, b), rather than as a type of clinical outcome
per se.
Restoring the state prior to illness is a one-dimensional view of one’s overall
self-meaning, which is capable of forming an identity and of attempting to achieve
goals which have meaning for oneself, rather than merely the persistent, frequently
tortuous existence of the results and side effects of mental illness (Davidson 2003;
Davidson and Strauss 1992).
Combining the bibliographical references together, we suggest that recovery, for
the purposes of Greece, be seen as a continuous process of getting better that leads
to healing or in short “recovery-as-healing”.
148 S. Stylianidis et al.

9.3 Concerns About Recovery-as-Healing

and the Biomedical Model

The focus of the process of recovering from an illness includes, among other things,
the idea of the individual reacquiring habits and a life plan, which can be used to
define his personal identity day by day.
The aim of recovery, which does not include “healing here and now” as a goal of
the doctor-patient therapeutic relationship, presupposes a shift in attention from the
illness and its development factors to what is really in question: reinvestment in an
active life, improving to the maximum degree possible for the individual his day-to-
day conditions and social life. That presupposes that we rely on those “unused
resources” that allow us to overcome the consequences of illness, to highlight our
personal goals, and the role of faith or hope that a recovery/healing is possible.
This approach presupposes conscious “disconnection” of the history of the ill-
ness and the factors that affect it from the individual’s past, which also includes a
series of other definitive factors (Bowie et al. 2010). The perception is that recovery-
as-healing goes beyond the concept of “therapeutic accompaniment” and “care”, as
formulated by Racamier (1980), in contradistinction to the one-sided view of treat-
ment which has been transferred into the modern concerns of the psychotherapy of
psychoses (Mentzos 2008; Benedetti 1992; Hochman 1986; Rosenfeld 1965;
Searles 1965; Vartzopoulos and Stylianidis 2008).
Personal initiative and the individual assigning meaning in the recovery-as-
healing process, developing or redefining a life plan (Sartre 1985), which was bru-
tally interrupted by the onset of a serious psychiatric disorder, is a modern
development and transformation of the substance of deinstitutionalisation, as for-
mulated by F. Basaglia and the Italian Psichiatria Democratica (Basaglia 2005)
movement. This disconnection of illness from the individual’s life plan also includes
other factors. Psychopathological factors are not adequate to interpret the phenom-
enon of day-to-day life being temporalised, increased barriers to full psychosocial
rehabilitation and more so the future and personal life of the individual (Gerard
2011; Pachoud 2012; Warner 2004).
Even the disconnection of the clinical approach and holistic outcome for the
individual is not widely recognised in the international scientific community and
literature, but it is “familiar” to many clinicians. Take, for example, the many
patients with serious psychiatric disorders who present no symptoms after effective
treatment using psychotropic drugs but face immense difficulties in finding an
active social and personal life again. In any event, the so-called negative symptoms
of schizophrenia are a critical enigma and challenge in clinical psychopharmacol-
ogy. On the other hand, we have those patients who despite the chronic presence of
productive psychotic symptoms, such as delusions (audio, visual, sensory etc.),
manage to achieve a stable life and relative autonomy, with social ties and a job, and
participate in a process of persons improvement of their cognitive and social skills
(Liberman et al. 2002, 2008).
Recognising and accepting this “mismatch” between the biomedical model and
the process of recovery/integration/healing necessarily leads us to adopt two
9 The Recovery Model and Modern Psychiatric Care 149

discrete strategies which must operate as a complement to each other, to promote

the holistic approach to patients’ needs: in addition to the traditional medical strat-
egy which aims to address the symptoms of the disease and maximise the potential
for a positive outcome, it is also necessary to implement a strategy of equal impor-
tance that supplements one’s clinical practice and which methodically aims at maxi-
mising the individuals’ potential for recovery/healing/social integration. A key role
in the recovery strategy is held by life experience, testimony and narratives, which
in terms of qualitative research have the same important scientific value as epide-
miological studies about the prevalence and outcome of schizophrenia.
The study and practical implementation of projects in this direction, such as the
very important synthesis done by Amering and Schmolke (2009), highlight impor-
tant aspects of the recovery process, such as empowerment and the ability to choose,
or the role of self-determination, hope and in particular narrative ability and refor-
mulation of the subject’s identity (Giddens 2004). Narration and the creation of a
framework for highlighting and listening are for certain writers the preferred way of
describing human experience and changing the individual’s perspective and stance
towards the prospect for re-establishing his identity and life plan, while minimising
the consequences of mental disability (Davidson 2003).
This interpretation of the stories of users of services and the perception of mental
health professionals about recovery and psychosocial rehabilitation can give us the
opportunity to improve the qualitative methodology and document the implementa-
tion of recovery plans in a mental health service (Greacen and Jouet 2012).

9.4 Modern Developments in Recovery

Recovery from a mental illness, as narrated by Pat Deegan through her description
of her psychotic experience, is a process of personal development and growth, a
way of life (Deegan 1988, Deegan 1996a, b) and not a return to the situation prior
to the illness. Such testimony from other individuals who have experienced a seri-
ous mental illness and long-term studies over the last three decades opened the way
for further research and applications in the field of recovery, demonstrating that
individuals who suffer from schizophrenia can recover and enjoy positive results in
a life full of meaning (Anthony et al. 2003).
The findings of research show good long-term results for the majority of people
with serious psychiatric disorders. The best known research is by Harding et al.
(1987) which monitored a group of 269 individuals who on average had 10 years of
absolute disability and 6 years of continuous hospitalisation. Those individuals par-
ticipated in a dynamic psychosocial rehabilitation programme, completed it and
then received community mental health services. The results from the 10-year fol-
low-up showed that although 2/3 of the group lived in the community, they were
utterly dependent on services and were socially isolated, which was not particularly
encouraging. However, the second follow-up at 20–25 years showed that around
55 % of the individuals had regained functionality to a significant degree, did not
have problems or had very few problems and had recovered. At the same time, a
150 S. Stylianidis et al.

study carried out globally by the WHO into schizophrenia (Harrison et al. 2001)
followed up individuals diagnosed with schizophrenia in numerous countries after a
15- and 25-year gap. The results show that 56–60 % of those individuals had
recovered.
After these developments, interest began to grow in the recovery model as a re-
exploration of psychiatric care and its practices (Roberts and Wolfson 2004). Major
attempts to implement the recovery model have been made around the world in the
mental health sector, showing a clear trend of moving away from traditional, bio-
medical models. Some US states, New Zealand, Australia and more recently
European countries, like England, have begun to plan and develop mental health
services focused on the recovery model. In the USA, for example, the recovery
model was adopted as the central policy on mental health in 2003, as part of the
reform of the mental health system. We also have the example of states like
Massachusetts, Florida and Ohio which designed and developed recovery model-
based services. Likewise, in 2001 New Zealand and England integrated the concept
of recovery as central to the planning of mental health services.
Even though some of those services at first sight have not familiarised them-
selves with these concepts, and may appear to be services provided in a traditional
setting by many mental health systems, there is no such thing as a recovery-oriented
service whose central idea is not that recovery is possible and whose goals are to
foster hope, healing, empowerment and connection.
Since the experience of recovery from a mental illness is essentially personal and
individualised, and is something much wider than the remission of symptoms, we
see a constant need on the part of researchers to develop research tools to respond
to the sheer breadth of definitions of recovery. Despite that, the methodology of
traditional documented research cannot respond and evaluate new practices – meth-
ods for developing mental health services, like recovery (Anthony 2000). Most
researchers stress that qualitative methods will play an important role, making it
clear what the recovery process includes in order to achieve the transformation of
mental health services in that direction.
Personal narratives are particularly valuable here. Individuals narrate their sto-
ries explaining their personal journey over the course of their recovery and talk
about what has helped them. Those narratives, and the internal dynamic they have,
open the path to demystifying mental illness, demonstrating a dynamic path towards
achieving goals (MHC 2005).
The perceptions of mental health professionals and the culture of organisations
that provide services are very important factors since one needs to create such envi-
ronments or systems that favour the recovery process. The literature identifies
recovery-oriented services as those within which individuals are supported as they
grow and implement their personal recovery plans, which can encourage their per-
sonal preferences and allow the user of services to assume risks and move forward
(Weaver 1998).
In the systems providing mental health services referred to, employees are
trained in the principles of the recovery model to achieve two objectives: to explore
the concept of recovery and at the same time to explore the role of the mental health
9 The Recovery Model and Modern Psychiatric Care 151

professional in this case. In addition, these systems integrate services provided by

mental health professionals, services provided by service users and services
provided by a combination of the two.

9.5 Case Study: Implementation of the Recovery Method

Case
A.G. is 50 years old and suffers from organic psychotic disorder. The problem
presented at the age of 35 following excessive alcohol consumption. He pre-
sented symptoms of aggression, mainly verbal aggression, persecution com-
plex, suspiciousness and lack of trust in all around him. He has finished junior
high school and completed his military service, has worked and has been
married. When the problem started he separated, was left homeless and was
treated at Dafni Psychiatric Hospital where he received medication. He did
not follow medical guidelines and his situation deteriorated. After his last
period of treatment at Dafni, he was transferred to the Paleo Penteli Residential
Unit at the age of 47.
Problems the resident faced:

• Alcohol addiction
• No insurance coverage (for health insurance)
• No financial support (no job and no benefits)
• No family support
• No social contact with friends
• No love life

Treatment plan for the recovery process and to improve the quality of life

• Take medication and stop alcohol consumption

• Obtain a health insurance booklet and welfare benefits
• Pscyhoeducation
• Re-connect with family
• Social skills training
• Work
• Sheltered accommodation

A.G. is 50 years old, comes from Athens and suffers from organic psychotic disor-
der. According to his own testimony, the problem presented at the age of 35, at a
time when he was consuming excessive quantities of alcohol to escape difficult situ-
ations in his day-to-day life. When he drank, he would have symptoms of aggres-
sion, mainly verbal aggression towards parents, friends or unknown people, whom
he would shout at and pester. Often his outbursts of “anger” (as he called it) would
152 S. Stylianidis et al.

be accompanied by ideas of suspicion, persecution or lack of trust. He had finished

junior high school and done his military service and when he came back after the
army went to an iron and aluminium design school. His training helped him work as
an ironsmith sometimes in private companies and sometimes in his family’s busi-
ness, alongside his brother. At the age of 33, he married a foreign woman from Sri
Lanka and stayed with her for 6 years. However, when A.G. began to cause prob-
lems due to his drinking, his wife was forced to leave because she could not stand a
life like that. However, they continued in law to be married since they had not
divorced, because his former wife needed him to renew her visa and residence per-
mit in the country.
After they separated, he returned to his family home where he lived with his
brother and mother. His father had died a year earlier, when A.G. was 37.
Cohabitation was not an easy affair at all. He continued to drink and stopped work-
ing, and his brother was forced to seek a Public Prosecutor’s order to have him
admitted to the Dromokaitio Psychiatric Hospital. He stayed there a few days, was
given medication and returned home. When leaving the hospital, he asked his fam-
ily for money to go and live on his own, since he would cause problems if he con-
tinued to live with them. He did in fact rent an apartment, but did not keep up with
his obligations (he didn’t pay the rent or bills), and the owner evicted him. Since he
had no other choice, he returned to his family home again. However, because of the
incidents he caused, this time the neighbours obtained a Public Prosecutor’s order
and he was taken to the Athens Psychiatric Hospital at Dafni. Once again the doc-
tors administered medication but he did not take it.
When he was discharged, he did not return home. He remained homeless and
made a small shelter under the stairs of a church so he could sleep. He stayed there
for around 2 years and was cared for and supported by women from the neighbour-
hood, who gave him food and money which enabled him to buy cigarettes and drink.
He enjoyed that period because he felt free to do what he wanted and did not have
to give account to anyone, especially not his family. After much discussion and
exhortation from others, he decided to voluntarily admit himself to hospital so be
able to be transferred to some psychosocial rehabilitation unit. In April 2009, he
was transferred to the Palia Penteli residential unit; the scientific treatment team
there came into contact with the hospital, his family and residents of the area where
he lived to collect information, and this played a vital role in designing his individ-
ual treatment plan and implementing the recovery model.
When collecting all the information about his story, the team initially recorded
his problems, invited him to tell them why he had been transferred to the residential
unit and attempted to understand from the discussion whether he accepted that he
was suffering from a serious mental illness and needed help. A.G. accepted that he
had had a bad time and that all the negative things in his life had started from the
time he started drinking. He wanted to lay a new foundation and start over afresh,
which would allow him to acquire a normal, decent life. His “acceptance” of the
problem was the springboard for starting the treatment process.
Relying on the basic principles of the recovery-as-healing model (the recovery
model) which preach a renewal of hope and decisiveness, regaining of social
9 The Recovery Model and Modern Psychiatric Care 153

position, managing symptoms, overcoming stigma and redefining oneself, the team
explained to A.G. that the path to recovery is a constant struggle which goes through
various stages before the goal is reached. In those stages of recovery, mental health
professionals are there to help and guide. They offer hope and the belief that recov-
ery can happen; they train, support, inform and design the individual treatment plan
and focused on a structured programme that helps the individual improve his quality
of life in the community.
Taking into account the user of services’ problems, the team set a series of priori-
ties and started from the easiest and most achievable, which would bolster self-
confidence and provide satisfaction and the hope that the objective could be
achieved. For example, A.G.:

Was addicted to alcohol and was not taking medication

Did not have social security (to cover medical treatment)
Did not have financial support (or a job or benefits)
Did not have family support
Did not have social contacts

The team’s primary, main goal was to administer medication and get A.G. off
alcohol, and it proposed that he attend a detox programme and enrol with Alcoholics
Anonymous. He did not agree, insisting that he could manage on his own and that
he should stay at the residential unit. The initial period was not at all easy. He found
it difficult to sleep, had headaches, asked for painkillers to calm down and did not
participate in outings to avoid contact with places selling food and drinks since he
feared he would only be incited to drink. Every week he met with his psychiatrist,
and every day the scientific team talked with him and supported him as he continued
his efforts. It took about 6 months for him to come off alcohol, and during that entire
period, he received medication which he now continues.
He had no insurance coverage as mentioned. He did not appear to be registered
with any social security provider and that created problems because he had no
Medicare. Since he did not have access to public services, while he was receiving
training, the scientific team told him about his rights, and with the help of a social
worker, he collected together all the paperwork needed and submitted it to the wel-
fare department to get a welfare book and a welfare allowance. The allowance was
a small amount of financial aid, since at that time he did not have any financial
resources, other than the small amount of help he continued to receive from the
Church.
Seeing that he could resolve important practical issues, he began to trust himself,
to have hope and have an incentive to continue his attempts to regain a normal life.
Once he was able to recognise reality and set realistic goals, he started psychoedu-
cation. The purpose was to use face-to-face sessions with his psychologist to be able
to understand the situation he was in before the treatment; to place emphasis on the
continuity of care by continuing his medication, which was vital; and also to evalu-
ate his needs, interests and wishes, so that he could continue to improve his quality
of life.
154 S. Stylianidis et al.

The next step was to reconnect with his family, who had pulled away and did not
want any contact with him because it could not manage the problems his behaviour
created. When he entered the residential unit, his brother was quite distrustful and
appeared disappointed and considered that nothing would change, since this was a
tried and tested pattern of behaviour. The scientific team advised him to give A.G.
time, to visit him with their mother more frequently at the residential unit and to
have a positive outlook on the efforts A.G. was making, because this time he was
inside a structured framework now. A.G. received indirect support from the family
visits, tried harder and believed that he could regain their acceptance. In fact, their
relations today are back to normal and A.G. visits his family at regular intervals,
wants to help his brother and takes care of his mother. His circle still cannot believe
the change: it’s as if they are seeing another person.
A.G. lacked much in terms of social contacts and social skills. As an individual,
during his early days at the residential unit, we noticed that he was quite shut off and
solitary and found it difficult to speak, and there were days he only wanted to sleep
and the expression on his face was melancholic, as if something was missing. By
giving him time to adjust and by talking to him and ensuring he attended a social
skills training course, he managed to acquire friends, to go out, to attend social
events, to be more communicative and to be expressive. Having been able to work
in his past life (and having given that up because of drinking), we discussed with
him how interested he would be in working again. He thought that would be impos-
sible because of his medication, but it was something he wanted a lot. It was
explained what the role of social partnerships is, and he became a member and for
a year now has been working in a cleaning team at the Ministry of Labour.
Having taken quite a few steps, only the last, most difficult one remained: the
preparations for him to be able to become autonomous and live in the community,
either with a foster family or in sheltered accommodation. One year before this hap-
pened, with the help of staff, he began his training for living on his own and became
involved in all the relevant aspects of such a life (e.g. personal hygiene, maintaining
and cleaning his own space and communal areas, preparing meals, using public
transport and social services to deal with issues that arose etc.). Since last June,
A.G. has been living in sheltered accommodation with two roommates.
His own active involvement in planning his treatment, based on teamwork and
cooperation, and his incentive to change and rehabilitate himself, brought about the
desired result and one can talk of recovery here. According to Anthony (1993),
“recovery can be described as a deep personal process unique to the individual, dur-
ing which perceptions, values, emotions, goals, abilities and/or roles change. It is a
way of living a satisfactory, hope-filled, contribution-packed life even given the
constraints the illness imposes. Recovery includes developing new meaning and life
purpose, as the individual grows beyond the destructive consequences of the mental
disorder”.
Having said that, the positive outcome for this user of mental health services
entails several difficulties in implementing the recovery model. In addition to his
disappointment and withdrawal when did not manage to reach a target, which is
something the scientific team could deal with, there were serious issues faced by
9 The Recovery Model and Modern Psychiatric Care 155

staff. Since they did not have the necessary knowledge and training, they were dis-
trustful about whether he could recover and considered that he would not achieve
anything and clearly expressed this sense of pessimism.
In this case the head of the unit and scientific team had a dual role to play. On the
one hand, he had to encourage A.G. when he lost faith, and on the other, he had to
provide on-the-job training about the principles of the recovery model and our role
as mental health professionals. Of course it was only to be expected that this would
happen, and the employees were not directly responsible. The root of the problem
lies in the public mental health system which does not ensure that people are
recruited to these services based on specific criteria, nor does it ensure they receive
continuing training, meaning that they have erroneous perceptions, they have no
hope and their stigma about mental patients remains undiminished.
One should remember that individuals with mental problems may have special
characteristics and resistances to change, which are frequently viewed by the bio-
medical model as irreversible and which in quite a few cases are not even taken into
consideration. The fact is that such individuals continue to have abilities and skills
to relearn things and to adjust to the circumstances of their life plan. It is not the
diagnosis which defines the needs of the individual but the description of his needs,
functionality and the constraints the illness imposes.

9.6 The Recovery Model and Its Relationship to Public

Mental Health in Greece: Final Remarks

Implementing the recovery model as described above is a goal officially set out in
the report of the working group on revision of the PSYCHARGOS programme
(Ministry of Health and Social Solidarity 2012). The section referring to the struc-
ture of mental health care units and the functions of the overall mental health sys-
tem, in terms of service provision, highlights the importance of promoting the
recovery of patients and restoring them to their social roles and of social (re-)inte-
gration (p. 94). It is also included as one of the three main planks of education and
training. In conjunction with key issues in social psychiatry and quality of care in
mental health services and best practices for mental health promotion and education
in the community, the aim of education must be to “firmly establish reform in the
mental health sector, by disseminating cutting-edge examples of best practices in
vital sectors relating to the organisation of services and their adoption by employees
in the mental health sector” (p. 223). This is the PSYCHARGOS III Report and was
approved by Ministerial Decision No. Υ5β/Γ.Π./οικ 46769 as the National Action
Plan and sets out a series of actions over a 10-year horizon which seek to gradually
address all needs in the mental health sector at the national level. The Ministerial
Decision states it is “the operational arm of the Greek State’s policy on psychiatric
reform, deinstitutionalisation and modernisation of the system for providing mental
health services”.
Key aspects of deinstitutionalisation and real psychiatric reform are changes in
culture about how psychiatric care is provided. Four different approaches are needed
156 S. Stylianidis et al.

here (a) in the culture of care which must provide assistance and protection, but
frequently limits the autonomy of the patient; (b) the culture of care which places
trust in experts and requires “compliance” (not negotiation) by patients in the con-
text of the biomedical model; (c) in the culture of education which uses training
methods to achieve goals in a friendly, structured manner; and (d) in the culture of
empowerment which favours the transfer of power from experts to users of mental
health services, creating a balanced relationship which seeks to safeguard resources
and the environment, which are vital elements for the autonomous growth and
development of users of services. The recovery model demands this shift in power
and the commitment from the user of services to treatment via a process of negotia-
tion and joint decision-making. This process is the opposite of compliance, which is
defined as one-sided obeisance of medical orders and is a doubtful treatment goal
since it does not appear to take into account concepts such as empathy and building
up the importance of treatment (Molodynski et al. 2010). The special features of
each user of services and the fact that his personality is taken into account are
equally important factors as the skills and experience of doctors. Unfortunately, in
Greece there have been shortfalls in and objections to adopting a culture which
promotes real recovery, since the system has a lack of coordination, services are
unequally deployed, there are insufficient links between services and services can-
not network, all of which have negative repercussions on the continuity of care and
all of which are coupled with the lack of any increase in financing which would
ensure the viability of the system (Ministry of Health and Social Solidarity 2010).
The structural problems which external evaluation identified in the period 2000–
2009 also compound the difficulties in implementing the recovery model. More
specifically, the involvement of users of services and advocacy was found to be
underdeveloped, and there were major inadequacies in the destigmatisation of men-
tal illness.
The inflexibility of the public system and its inability to support the culture of
empowerment and recovery became particularly clear during the ongoing evalua-
tion for the 2010–2015 period (Ministry of Health and Social Solidarity 2013) dur-
ing which the scientific team from the Institute of Psychiatry found major problems
in how the mental health system is organised and noted that the organisational struc-
ture has not improved in real terms compared to the findings of the ex-post evalua-
tion (2010) which were presented above. It stated that “the system remains highly
fragmented and without coordination, without linkages between the agencies and
organisations involved. Users of services do not receive services in the context of
the Mental Health Region in which they live, meaning valuable human and eco-
nomic resources are not used rationally or efficiently”. The picture of the public
system in decline under current socioeconomic conditions (Kentikelenis et al. 2011;
Stylianidis and Chondros 2011) is supplemented by the lack of participation by
users of services since “users continue not to be involved in decision-making, in the
control of units and on sectoral mental health committees”. In addition, the high
number of involuntary admissions to hospitals noted by the external evaluation and
confirmed by Drakonaki et al. (2012) shows a major shortfall both in relation to the
rights of persons with mental problems and the real implementation of the culture
of empowerment and recovery.
9 The Recovery Model and Modern Psychiatric Care 157

In conclusion, using the recovery model, one does not just recover from mental
health problems but also manages the fact that one has lived in a psychiatric institu-
tion and endured the consequences of the stigma of mental illness and isolation
from society and work. However, the chronicity does not only lie in cases of long-
term hospitalisation in an institution but also in cases of “institutionalised day-to-
day life”, with its painful repetitiveness. A key principle of the recovery model is
that the chronicity of illness does not also mean that the situation has to be incur-
able, which is a prejudice a significant portion of mental health experts have, not
just experts but all those directly or indirectly involved in or called upon to shape the
“common language” which will create the conditions for implementing the recov-
ery model, free of personal expectations which prevent recovery. We have identified
a jigsaw of opposing views and expectations which is presented in diagram form
below.

Users,
Well
being,
good
health
th Mem
e
co be en
se mm rs o u rd
cu u f ,B
rit nit ily
y y, m
Fa

Me
stem
, Profe dical
c Sy ss
Publi ost Sym ionals,
C ptom
s

Sp ,
ons ers
Co ors, p loy ivity
t
st Em duc
o
Pr

Consequently, the development of a common language between users of mental

health services and mental health professionals is vital so that everyone can realise
that mental health concerns us all, as the WHO recommends, and for each partner
to shift his view of treatment from discouraging pessimism towards reasonable opti-
mism of creative risk and change.
158 S. Stylianidis et al.

9.7 Uses and Abuses of the Term Recovery

(Slade et al. 2014)

Abuse 1. Recovery Is the Most Cutting-Edge Model Around

Constant dissemination of the recovery model and recovery-oriented services

means the risk of fragmentary changes in the structure and function of an organisa-
tion without that entailing a change in the culture, which is essential, is common.
For example, 13 of the US states have committed to hiring users of mental health
services via a national security system. Placing individuals with mental health
problems in paid jobs is in line with the principles of the recovery model but does
not mean on its own that it is sufficient. They may be hired but they are subse-
quently marginalised by colleagues, and the duties they are assigned to do not
match their skills or are the minimum ones possible. In this way, empowerment
through work operates independently of recovery objectives and does not promote
equal participation, more hope and self-determination while also transforming
culture.

Abuse 2. Recovery Isn’t Applicable to “My Patients”

The ideology of recovery and the practice of achieving it have primarily developed
through clinical work with psychosis. However, a major portion of mental health
professionals declare that the model isn’t suited to their own patients who they con-
sidered to be “too ill” to respond or unfit for recovery due to a diagnosis that doesn’t
match psychosis.
However, the recovery model has shown that it can be directly applicable even
for individuals in crisis, while the literature also shows that the model can be applied
to individuals who are not suffering from mental problems in the psychosis cate-
gory, such as personality disorders and eating disorders, and to individual of differ-
ent ages and nationalities.

Abuse 3. Services Can Help Individuals Recover

Through Effective Treatment

Mental health professionals are more used to the clinical interpretation of recovery
which relates to recovery from the symptoms of an illness and to the “clinical treat-
ment” of an individual. However, the main meaning of recovery is to regain control
of one’s life – which anyone can do – and to give meaning to the roles one
performs.
These two approaches (the clinical and the more personalised) may be comple-
mentary but one may experience one independently of the other. Traditionally, men-
tal health services either supported the clinical aspect of recovery or (in the worst
9 The Recovery Model and Modern Psychiatric Care 159

case scenario) adopted the belief that recovery of any form is not possible for indi-
viduals with mental health problems.
To fully support the real sense of recovery, services and the mental health system
need to break away from the dominant biomedical model, which entails medication
and “compliance”, even if administered without the patient’s volition. Mental health
services must constantly invest in hope in individuals, helping them define them-
selves, secure access to the entire range of social services (accommodation, educa-
tion, work, self-help, crisis support and support in day-to-day life, psychological
treatments and advocacy), improve their social integration and protect their human
rights. Consequently, the treatment method can improve the personal growth of the
person in recovery but impede attempts to achieve self-determination if tied into
forced compliance practices.

Abuse 4. Forced Detention and Treatment Promote Recovery

Forced treatment is proposed as an effective way of dealing with an individual who

cannot take care of himself. The idea of a Community Treatment Order was intro-
duced in England in 2008, to reduce the number of involuntary admissions to the
psychiatric department, but it has not had the expected results and in fact the num-
ber of committals has increased from 2007/2008 to 2011/2012 (44,094 in 2007/2008
to 48,631 in 2011/2012). The issue of a Community Treatment Order entailing
forced treatment or committal was proposed as a less restrictive alternative solution
that forced psychiatric treatment in an institution or psychiatric department of a
general hospital. Despite the ethical, moral and legal problems of limiting the indi-
vidual’s freedom in the community, the idea has come to prevail in Anglo-Saxon
countries that the key advantages of this solution, such as secured living for chronic
patients in the community, a reduction in the “revolving door” phenomenon and the
multiplication of patient’s skills through social integration, could offset the disad-
vantages (Lawton-Smith et al. 2008; Monahan 2011). However, Stylianidis et al.
(2013) have raised questions about the measure, criticising it for the following rea-
sons: (a) lack of persuasive documentation, (b) a risk of increased use of coercive
measures during the practice of psychiatry, (c) unresolved ethical and moral aspects
of the entire procedure for the time being and (d) the potential to limit other alterna-
tive social care solutions.
A systematic review of the literature on Community Treatment Orders (Kisely
et al. 2005) shows that there is little support for its effectiveness in terms of the
use of health services, social functionality, the state of mental health, quality of
life and satisfaction with care. Researchers have also shown that 85 Community
Treatment Orders have prevented one readmission, 27 have prevented one indi-
vidual from remaining homeless due to mental illness and 238 have prevented
one arrest.
Community Treatment Orders appear to be becoming more common even
though recent studies show that it is ineffective in preventing readmission (Burns
160 S. Stylianidis et al.

et al. 2013). In addition, Community Treatment Orders work counter to the process
of regaining a life with meaning, a process which requires self-determination and
respect for the individuality of the person as a citizen in society.

Abuse 5. Focusing on Recovery Means That Services

Need to Close

Focusing on the recovery model is certainly not an adequate excuse for making
cutbacks. It’s not reasonable for one to assume that a meaningful life for an indi-
vidual is not one lived within the narrow confines of a mental health service, and the
view is frequently expressed towards users of mental health services that their con-
tact with services unrelated to mental health and with informal forms of care is more
important. The gradual reduction in contact with official mental health services and
the transfer of support to informal support-in-the-community networks (friend-
ships, self-help groups, community groups, work etc.) could possibly bolster the
recovery process.
However, that process is not linear and services must be available for whenever
they are needed again. The continuity of care means that someone may move from
an informal type of care to a more specialised one and vice versa. The doors of com-
munication must remain open to ensure continuous support for the individual, who
depending on his state of health and life circumstances may choose a different form
of support.
Clearly, ineffective services must be replaced or must adapt to the needs of users
of services via a continuous process of evaluation and monitoring, in which benefi-
ciaries themselves must be involved. A reduction in services is not justified under
any circumstances by a focus on recovery, which requires constant support for indi-
viduals in the process of regaining control of their life using different services
depending on their needs.

Abuse 6. Recovery Means Making People Independent

and “Normal”

The clinical aspect of mental health services that offer services to integrate people
into society primarily identifies problems those individuals have. Consequently,
clinical interventions seek to bring about changes through treatment so that they can
“fit in” and function “as normal” and “independent” individuals in the community.
However, recovery does not simply mean “getting better” or no longer needing sup-
port. It means “regaining control of one’s life” and the right to participate in all
cultural and economic activities as a subject of law and equal citizen. It requires a
system for providing services to be organised that is based on the principles of
human rights and the social model for addressing exclusion. Integration and citizen-
ship do not mean “becoming normal like others” but creating societies and com-
munities that accept the integration of those who are different, where everyone has
a place.
9 The Recovery Model and Modern Psychiatric Care 161

Abuse 7. One Only Contributes to Society Having Fully Completed

the Recovery Process

Work (whether paid, voluntary or in the home) is the main way of contributing to
the community. Work supports recovery. Most people who use mental health ser-
vices are able to work, but the rate of unemployment among this specific group is
over 70–80 %, which is much higher than in any other disability category.
Self-stigmatisation, expected discrimination and prejudice from services and the
community are key factors in the higher unemployment rates, while the benefits
offered are a factor promoting exclusion rather than mobilising such individuals to
find work. However, one needs to stress that society as a whole benefits from accept-
ing and recognising the equal right to work and equal opportunities for work for
persons with mental disabilities.

9.8 Annex 1. Key elements of the recovery model

Key elements of the recovery model

Element Description Sources
Renewed hope and The feeling of hope and trust in the Davidson et al. (1997, 2001),
commitment probability of a renewed sense of self Deegan (1996a, b), Fisher
and purpose, which is accompanied by (1994), Jacobson and Curtis
a desire and incentive to do things, is (2000), Jacobson and
vital for recovery. This sense of hope Greenlay (2001), Mead and
can come from within oneself or from Copeland (2000), Smith
others who believe in the potential of (2000), and Young and Ensing
the individual, even if he does not (1999)
believe in himself
Redefining oneself The most essential aspect of recovery Davidson and Strauss (1992),
is perhaps the one relating to Deegan (1996a, b), Fisher and
redefining oneself and re-evaluating Ahern (2000), Hatfield
mental illness as a part of a diverse (1994), Pettie and Triolo
identity that each of us has and not as (1999), Ridgeway (1999),
the dominant social role of the “mental Spaniol and Koehler (1994),
patient” and Young and Ensing (1999)
Reintegrating the The first step towards recovery is Deegan (1988, 1993), Hatfield
illness frequently described as recognition and (1994), Munetz and Frese
acceptance of the limitations the illness (2001), Ridgeway (1999),
imposes and discovering talents, gifts Sayce and Perkins (2000),
and abilities that allow the individual Smith (2000), Sullivan (1994),
to pursue and achieve life goals despite and Young and Ensing (1999)
the existence of the disability
Involvement in By expanding into and occupying Anthony (1993), Davidson
activities and roles normal, functional social roles (such as et al. (2001), Jacobson and
that provide spouse, employee, student, taxpayer, Greenley (2001), Lunt (2000),
meaning friend) and contributing creatively to Ridgeway (1999), and Young
the community which the individual and Ensing (1999)
himself chooses, the patient lays the
foundations for his own recovery
162 S. Stylianidis et al.

Key elements of the recovery model

Element Description Sources
Addressing stigma Individuals must recover from the Deegan (1996a, b), Houghton
social consequences and social stigma (2004), Perlick (2001), and
and from the effects of the illness Ridgeway (1999)
itself. Recovery includes developing
resilience to stigma and/or actively
fighting against it
Regaining control Individuals must take primary Anthony (1993), Bassman
responsibility for transforming (1997), Baxter and Diehl
themselves from people with disability (1998), Deegan (1988, 1996b),
into people in recovery. Regaining Fisher (1994, n.d.-a), Frese
control over one’s own life contributes et al. (2001), Hatfield (1994),
to the treatment through a redefined Jacobson and Curtis (2000),
sense of self as an agent and effective Jacobson and Greenley (2001),
subject. Opportunities must be Leete (1994), Lehman (2000),
available to people who make choices Lovejoy (1982), Lunt (2000),
and people who need to have choices, Mead and Copeland (2000),
from which they can choose. People Munetz and Frese (2001),
must also be given opportunities to Ridgeway (1999), Smith
succeed and fail (2000), Walsh (1996), and
Young and Ensing (1999)
Empowerment and As the sense of empowerment and Fisher (1994, n.d.-b),
exercising rights of control over one’s own life emerges, Jacobson and Greenley
citizenship people in recovery begin to demand (2001), Munetz and Frese
their rights (such as the right to decide (2001), Ridgeway (1999),
where they will live, who they will love, Walsh (1996), and Young and
how they will spend their lives) and Ensing (1999)
assume responsibility for themselves
(by paying taxes, voting, volunteering)
like any other citizen does
Managing Although full remission of the Deegan (1996b), Fisher
symptoms symptoms is not necessary, the ability to (1994), and Ridgeway (1999)
manage one’s symptoms in some way is
a vital condition for recovery. Recovery
includes good and difficult times,
setbacks and successes and moments
when the symptoms may be more or less
under control. The change lies in the
individual’s active involvement in the
treatment and his choice to manage his
own symptoms, so that they are under
his control instead of him passively
accepting the services he receives
Support from others Recovery does not happen in isolation. Baxter Diehl (1998), Fisher
Showing independence in the community (1994), Jacobson and
where someone has chosen to live and Greenley (2001), Mead and
the support he may received from others Copeland (2000), Ridgeway
and from the models one chooses for (1999), Smith (2000), Sullivan
oneself, be they family members, friends, (1994), and Young and Ensing
professionals, members of the (1999)
community or peers, encourages the
individual to overcome difficult moments
and reinforces good ones
This table has been adapted from Davidson et al. (2005)
9 The Recovery Model and Modern Psychiatric Care 163

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Mobile Mental Health Units
on the Islands: The Experience 10
of Cyclades

Stelios Stylianidis, Stella Pantelidou, Antonios Poulios,

Michail Lavdas, and Nikos Lamnidis

Abstract
Mobile mental health units were first introduced in Greece in 1981 and they were
later extended to geographically remote areas where there were inadequate men-
tal health services, as part of the process of psychiatric reform. The key aims of
such mobile units are to record needs; to provide timely diagnosis and interven-
tion; to offer psychosocial support, counselling and psychotherapy to adults and
children, as well as home interventions; to train volunteers; to liaise with local
bodies; and to develop actions to promote mental health. Against that back-
ground, we present the experience from 10 years of running mental health units
in the Northeastern and Western Cyclades. Emphasis is placed on the special
features of this intervention in the local community on the islands, and the fac-
tors defining needs, as well as the requests which emerged. Clinical work is also
presented and the special features of the psychosocial and psychotherapeutic
interventions which were used are pointed out. Measures to promote mental
health which were implemented are also described, and future targets for these
sectors based on new socioeconomic circumstances are sketched.

S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
S. Pantelidou • M. Lavdas • N. Lamnidis
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
A. Poulios
Clinical Psychologist, National and Kapodestrian University of Athens, Athens, Greece

© Springer International Publishing Switzerland 2016 167

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_10
168 S. Stylianidis et al.

10.1 Historical Background

1981 was a turning point, when mobile mental health units were introduced to
Greece’s public mental health system. The Social Psychiatry and Mental Health
Association founded by Panagiotis Sakellaropoulos began operating in the
Prefecture of Fokida, where a system for in-time intervention for acute cases was set
up, i.e. for individuals who suddenly or gradually went into crisis.
The chronicles of that Association (Sakellaropoulos 2011) state that “mobile units
work at the home of the patient in an acute phase and work with the family. An
attempt is also made at the same time to ensure that relatives and neighbours become
allies in the whole endeavour right from the outset. This means that from phase one
the patient calms down and is able to take part in his own treatment. It means that the
family trusts the treatment team and relies on it. It also means that the social milieu
is assisted in demystifying the risk from madness and can change its attitude towards
it”. The home intervention model was known as “psychiatric care at the patient’s
home” and was organised by the Association in rural areas based on the model used
in Athens, with the aim of preventing patient’s having to be forcibly hospitalised.
The key issues which emerged from pilot use of mobile units in the Prefectures
of Fokida, Evia and Thessaloniki (Ierodiakonou 1982, 1983; Ierodiakonou et al.
1983; Sakellaropoulos et al. 1983, 1987; Sakellaropoulos 1984; Dambassina et al.
1987) were (a) there was a need for psychiatric assistance in remote rural areas and
(b) the treatment responses had to be culturally compatible with the socio-cultural
environment and local community networks (Stylianidis 1989).
The model of mobile mental health units was developed with certain modifica-
tions and adjustments, depending on the theoretical approach of the body involved
and the special features of each area based on geographical, social and cultural cri-
teria. These units were a key element in how mental health services were organised
in the Greek regions as part of psychiatric reform. The result of long-term operation
of mobile mental health units was that they were incorporated into the legal frame-
work in Law 2716/1999 as autonomous mental health units as part of the psychiatric
reform process. Compared to other mental health units, these mobile mental health
units have certain special features, since they operate in the manner outlined below
(as is clear from Ministerial Decision No. Υ5β/οικ.1662 (Government Gazette
691/B/5.6.2001) laying down the modus operandi and staffing requirements for
mobile mental health units specified in Article 7 of Law 2716/1999 and all other
modalities required to give effect to that Article):

(a) In mental health sectors whose geographical area and layout, residential diver-
sity and social, economic and cultural conditions coupled with the nature of
mental disorders make it difficult for residents of those areas to access mental
health services
(b) In neighbouring mental health sectors when there are no adequate mental health
services

Consequently, the key aim in setting up mobile units was to meet mental health
needs in geographically remote areas, where there were either no mental health
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 169

services or existing ones were not adequate, by using the minimum own infrastruc-
ture and maximising use of infrastructure belonging to other healthcare services.
The precise work done by mobile mental health units was identified in Law
2716/1999 and in subsequent texts such as the ex ante evaluations (Ministry of
Health & Social Solidarity 2010). Their task is:

In-time diagnosis – intervention to prevent the onset of disease or a remission

Home intervention to deal with and manage crises
Home treatment and monitoring of medication, follow-up of the course of the illness
at regular intervals, and to ensure the continuity of psychiatric care for the patient
Help and support for the patient in meeting his practical needs with emphasis on
teaching him skills and preparing him for the end goal, which is an independent
life
Counselling – support for the family of the patient to ensure better communication
and reduce stress for both the family and the patient
Training volunteers
Combating social stigma through community training programmes

The mobile units operated under a scientific officer. A multidisciplinary inter-

vention team was also appointed by the management team of the body to which
the mobile mental health units belonged, following a recommendation from the
scientific officer. The staff comprising that multidisciplinary intervention team
could include a psychiatrist, psychologist, social worker, nurse, industrial thera-
pist and health visitor, as well as administrative and auxiliary staff who were
suitably trained, an expert pedagogue, speech therapist or other healthcare pro-
fessional. However, the key function of these mobile units is determined by local
needs and the resources available to run them. In Greece, there are a total of 27
mobile mental health units being operated by not-for-profit private bodies as
hospital units.

10.2 Key Principles and the Running of Mobile Mental Health

Units

The key principles relating to the design and running of community mental
health services like mobile units, broken down into sections, are presented below
(WHO 2001; Mechanic 2001; Thornicroft and Tansella 1999):

A. Deinstitutionalisation
A shift in core psychiatric care from the psychiatric hospital to the community
Synergy with local social policies
Respect for human rights
B. Effectiveness
Treatment method that includes the patient’s families
Development of programmes to promote mental health
Evaluation of services provided
170 S. Stylianidis et al.

Equality of access and provision of care

Development of self-help resources for patients
Ensuring the continuity of care
C. Liaising
Interdisciplinary approach to the provision of services
Working in networks
Interconnection between mental health services and primary healthcare
D. Demedicalisation
A shift in the interest of mental health professionals from illness to the person
himself and his social disadvantage.
An individualised care plan based on the special needs of each patient (Stylianidis
and Pantelidou 2006a).

Based on these principles, mobile units primarily focused on:

(a) Providing diagnoses and treatment for mental health problems and the psycho-
social problems of children, adolescents and adults at individual and family
level
(b) Assessing and recording mental health needs within their area of remit, to plan
interventions focused on specific needs (Slade et al. 1999)
(c) Developing mental health education and promotion programmes in the
community
(d) Liaising with primary healthcare and social and educational bodies in the
community
(e) Mobilising local authorities and integrating the activities of units into the social
policy of each municipality (Stylianidis and Pantelidou 2006b; Stylianidis et al.
2007)
(f) Training volunteer local support groups
(g) Developing evaluation activities for the services provided
(h) In-time diagnosis and prevention of relapses and hospitalisation for serious
psychiatric cases

10.3 The Liaison Model for Mobile Mental Health Units

and Primary Healthcare

Primary healthcare is the first line of contact for patients and consequently for mental
disorders which are in an early stage or an advanced – yet undiagnosed – stage.
Primary healthcare means “the general system of providing outpatient healthcare
services, which ensures equal access for the entire population at individual and fam-
ily level of primary healthcare services. The system seeks to prevent, maintain, pro-
mote, restore and bolster health, by providing certified medical services, tests and
medicines, and by adopting common primary healthcare rules”.
Cooperation with primary healthcare bodies is a top priority, since patients with
ordinary mental disorders such as depression with chronic physical illness in
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 171

co-morbidity or with the presence of psychosomatic symptoms come to this level of

care to receive suitable assistance. Primary healthcare coordinates the individual’s
healthcare, has direct access to the patient and his family and ensures the continuity
of case is the entry point for more specialised care (Barbato 2008). Consequently,
the timely identification and handling of a psychiatric problem is a priority in
attempts to integrate mental health into primary healthcare. Mental health in pri-
mary healthcare is defined by the WHO as “providing basic preventive and curative
mental healthcare at the first point of entry in the health system”. The “best” out-
come in terms of health and mental health is ensured by identifying and dealing
with mental disorders and cases of co-morbidity in good time, with the aim of really
reducing the treatment gap in mental health (see the Chapter 4). The diagram below
allows us to comprehend the importance of integrating mental health into primary
healthcare for achieving a “smooth outcome” for disorders (adapted from WHO,
WONCA 2008):

Strengthening
partnership with
mental health services

Effective
Cost-
use of
effecitveness
available
in care
resources

Human rights
protection

Different interfaces with primary healthcare have been proposed depending on

the responsibility and competence of healthcare professionals working in primary
healthcare in relation to psychiatric illness and the accompanying symptoms.
The main cooperation and interface models are listed below:

(a) The training model which stresses the improvement in knowledge and skills of
primary healthcare professionals in recognising and managing mental disorders
(WHO 2001; Thompson et al. 2000; Bower and Gilbody 2005).
(b) The consultation-liaison model based on mental health professionals acquiring
a training relationship with the primary healthcare team and providing
172 S. Stylianidis et al.

counselling and supervision in the management of difficult cases (Gask et al.

1997; Bower et al. 2004).
(c) The collaborative model which combines elements of the two previous
models in changing the role of primary healthcare professionals and mental
health professionals in general healthcare (Bower and Gask 2002; Simon
et al. 2001).
(d) The replacement/referral model which focuses on the psychiatric problem
being managed by mental health professionals while having primary healthcare
professionals has general clinical responsibility (Bower 2002). In Greece,
psychiatric disorders are primarily managed by mental health professionals, but
frequently the role of GPs is undervalued, with the recognition level for
psychiatric disorders in primary healthcare being quite low (Mavreas et al.
1986). Nonetheless, in remote rural or island areas with few to now specialised
mental health services, the role of primary healthcare remains central, since it is
the first line for dealing with and for contact with patients.

Although great emphasis was initially given to a model of interface between

mobile mental health units and primary healthcare, quite a few difficulties arose in
practice from implementing this model, mainly due to problems associated with
primary healthcare. The inadequate development of primary healthcare structures in
Greece and the lack of networking between services and inadequate training for
primary healthcare professionals about mental health issues, coupled with the lack
of psychiatric departments at general hospitals in the regions and understaffed pri-
mary healthcare structures, contribute to the role of primary healthcare as a gate-
keeper being weakened and had downplayed the role of the GP as someone in the
first line for psychiatric disorders. Such a role would have included initial diagnosis,
basic treatment, and referral to a specialised service or mental health professional
(when that was considered necessary) to ensure the continuity of care and provide
suitable specialised treatment in keeping with subsequent levels of care.

10.4 Examples of How Mobile Mental Health Units Operate

in Europe

Lausanne’s pilot experience of mobile units, which has been in operation since
2002, uses Assertive Community Treatment (ACT) as its theoretical basis. The mul-
tidisciplinary team which intervenes in rural areas of the Canton of Vaud ensures
psychiatric follow-up for the community of patients suffering from serious psychi-
atric disorders with a high drop-out rate from routine psychiatric follow-up (Bonsack
2008). After that experience, the investigators identified three target populations: (a)
patients considered to be “frequent consumers of care” who visited the emergency
psychiatric care department quite frequently or who were hospitalised without
being put into any real care plan, (b) patients who refused all care despite the inter-
vention of the primary healthcare network or secondary healthcare in the area and
(c) patients who presented symptoms of the onset of psychosis and did not seek help
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 173

of their own initiative nor on the initiative of their family. The mobile mental health
units in the Vaud Canton covered patients in all age groups.
In Belgium (Jacob 2014), mobile mental health units have also been deployed in
the context of psychiatric reform. There are two types of mobile units:

(a) Mobile mental health units for intensive follow-up purposes used to deal with
crises and acute cases
(b) Mobile mental health units for continuous follow-up of individuals with chronic
and complex problems

Mobile units were introduced as part of the process of deinstitutionalisation and

a reduction in the number of psychiatric beds in hospitals. In doing so, the economic
and human resources saved were transferred to the innovative concept of mobile
mental health units.
The role of these units in Belgium complements the psychiatric system of care
which is focused on reform with the aim of providing mental health services in the
community, recovery, empowerment of local networks and liaising with primary
healthcare. The country currently has 40 mobile mental health units and the process
of evaluation is underway to determine the size of the network needed to cover the
entire territory of Belgium. Early results indicate that the units have contributed to
a reduction in hospitalisations and to keeping individuals in the community.
The WHO pyramid (2009) helps us better visualise the position of mobile mental
health units and the linkage to lower and more specialised levels of healthcare, in con-
junction with the cost required to run them and the needs of the population covered.

10.5 Experiences and Best Practices

The Regional Development and Mental Health Association (a NGO) is responsible

in scientific and administrative terms for two mobile mental health units in the
Cyclades (whose permanent recorded population within the area of remit is 78,267).
The NE Cyclades mobile mental health unit commenced operations in June 2003
and the one in the Western Cyclades in January 2004. Financing to run the mobile
units comes from national resources (MHSS), European funding, local government
authority resources, donations and other specialised European programmes and
multidisciplinary partnerships. The NE Cyclades mobile unit is based on Paros and
is responsible for the islands of Syros, Andros, Mykonos, Tinos, Paros and
Antiparos. Likewise, the Western Cyclades mobile unit is based on Milos and is
responsible for the islands of Milos, Kimolos, Sifnos, Serifos, Kea and Kythnos. In
terms of how the two mobile units work, every 15 days, a team comprised of a psy-
chiatrist, child psychiatrist, psychologist and social worker visit the islands referred
to (the specialisations are determined based on needs and available financial
resources). Sessions are held at the unit’s headquarters in premises provided by
health centres of local government authorities. Experts also make home visits.
In addition to their clinical work, a variety of mental health education and
174 S. Stylianidis et al.

promotion activities take place on each island, based on the operating targets of the
mobile units, and there is also a central secretariat in operation on Paros which orga-
nises treatment and community work.
It should be stressed that these two mobile units are special in that they cover
island areas that are difficult to access, especially during winter months. The 12
islands within the remit of the units do not have any other mental health services to
deal with psychiatric and child psychiatric cases. There is only one child psychia-
trist at the Syros General Hospital. In addition, social services are limited and health
centres and regional medical surgeries are now understaffed. Before the mobile
units commenced operations, one key feature of local communities was a lack of
any cultural or well-designed activities relating to public mental health and social
exclusion. In addition, difficulties in access to and lack of an adequately organised
communication network reinforced the insecurity of residents and fostered an
inward-looking outlook, apparent self-sufficiency and in some cases discrimination
and social exclusion (Stylianidis and Pantelidou 2006a).
The special features of each local community determined the mode of interven-
tion at clinical and community level when the mobile units became operational:

Interventions were tailored to the special needs of each island.

Using an ethnopsychiatric approach, the socio-humanitarian features of each com-
munity were identified: specific cultural codes, attitudes towards differentness,
prejudice about mental health issues and all factors which play an important role
in shaping psychiatric requests and how symptoms manifest.

The activities of the mobile units in the NE and Western Cyclades are presented
by looking at the following areas: (1) needs, (2) clinical work, (3) interface with
primary healthcare, (4) mental health promotion and networking with local bodies
and (5) evaluation.

Needs

A key condition in designing and developing special actions (treatment, social, etc.)
for a mental health services is to assess the needs in the area of remit (Thornicroft
and Tansella 1999). In the case of the mobile mental health units for the NE and
Western Cyclades, needs were initially assessed at empirical level when the units
became operational and an epidemiological study was carried out into the preva-
lence of mental disorders in the general population on Paros and Antiparos.
The needs assessment began by collecting data from primary healthcare and social
services on the islands. Working groups were also set up with key persons in the com-
munity: local government representatives, doctors, teachers, priests and policemen.
This process allowed important information to be recorded on each island relating to:

• Chronic psychiatric cases in the community

• Cases of families with severe psychosocial problems
• The frequency of Public Prosecutor orders for involuntary hospitalisation
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 175

• The frequency of requests for intervention in cases of child abuse – negligence

• Needs and requests relating to children and families which come through schools
• Problems faced by vulnerable groups, such as migrants, and people with chronic
physical conditions
• The need for mental health promotion activities

In addition, in 2007, an epidemiological study was carried out to examine the

prevalence of common mental disorders on Paros and Antiparos (Stylianidis et al.
2010). The study was carried out in partnership with the University of Ioannina
(Psychiatric Department, Medical School) and the Panteion University.
The primary synchronic study was conducted on a sample of 506 people from
the general population chosen by ordinary random sampling (from 776 people cho-
sen, 506 agreed to participate, which is a 65 % participation rate). Psychiatric mor-
bidity was assessed using a fully structured interview, namely, the Clinical Interview
Schedule Revised (CIS-R, Lewis and Pelosi 1990; Singleton et al. 2003). The aver-
age age of the sample was 44 (age range 18–74). Clinically significant psychiatric
morbidity was found in 22 % of the sample. Women had significantly higher mor-
bidity than men (30 % compared to 13 %). In addition, the prevalence of major
depression of at least average severity was 0.6 % in men and 3.6 % in women, while
mild depression was 1.1 % in men and 7.8 % in women. In contrast with the often
more frequency prevalence of depression in women compared to men (1:7), the
harmful use of alcohol assessed by AUDIT (Babor et al. 1992) showed a figure
higher than the general population (13 %) which the vast prevalence being in men
(23.8 %) in the sample compared to woman (3 %). Anxiety disorders and clinically
significant stress had a prevalence of 6.8 % in men, 12.73 % in women and 10 %
overall. As far as correlations with socio-demographic variables were concerned, it
was found that women, single people and the unemployed had a higher rate of mor-
bidity, while individuals with higher and university level education and individuals
with a high reported family income had lower morbidity.
A similar study on the prevalence of common mental disorders was also carried
out on a sample of 323 high school pupils on Paros (Stylianidis et al. 2010) and the
results are presented in the next chapter.
Moreover, a descriptive study of the prevalence of mental disorders in migrants
being followed up by the Paros-Antiparos team was also carried out in the period
2004–2006 (Pantelidou et al. 2008). In total, 43 adult migrants (81 % of Albanian
descent) received services from the mobile unit on Paros and Antiparos between
2004 and 2006, accounting for 8 % of all users of the service at that time. Of that
figure, 48 % were men and 62 % women, aged 20–40. The most frequent requests
from migrants related to psychiatric symptoms, mainly mood (affective) disorders
(30 %), psychotic syndrome (14 %) and problematic family relations (18 %). As the
results clearly show, high percentages of migrants contacted the service about severe
mental disorders and relationship problems (including domestic violence problems)
compared to the percentages for the total patient population who received services
over that period. The study showed the need to develop actions focused on the spe-
cial features of minorities in island areas, taking into account the serious social
problems they face in certain cases (Pantelidou et al. 2010).
176 S. Stylianidis et al.

Table 10.1 Absolute frequencies of the number of persons receiving services during the first
decade the NE and Western Cyclades mobile units were in operation
Users of services NE Cyclades Western Cyclades Total
Adults 4.636 1.547 6.183
Children/adolescents 1.339 567 1.906
Total 5.975 2.114 8.089

Since the main aim of the mobile unit was to prevent recurrences and avoid hospi-
talisation for severe psychiatric cases, in 2005, a study was launched to record prob-
lems associated with the process of involuntary hospitalisation and to record the
number of hospitalisations from the Cyclades (Stouraitou et al. 2009). During the first
years of the study, an increase in hospitalisations was noted, which may have been
associated both with highlighting severe psychiatric cases that had remained untreated
in previous years (since there were no mental health providers before 2003) and with
the general trend towards higher involuntary hospitalisations in Greece at that time.
The study is under way still in order to capture the trend in subsequent years. From the
information collected, we also noticed difficulties associated with the detention and
transfer of patients, for whom the Public Prosecutor had issued a hospitalisation order.
Due to the geographical isolation of some islands and the lack of a psychiatric depart-
ment at the Syros General Hospital, patients were transferred from the islands to
Syros in order for a first expert opinion to be provided by the hospital’s psychiatrist
and were then sent on to Athens. That resulted in long waits (due to the absence of
frequent sailings to and from Syros) for patients in detention cells, especially on
islands that did not have health centres, coupled with long journeys on ships. Following
an intervention from the mobile unit which worked with the Syros Public Prosecutor’s
Office, a request was made for patients to be sent directly to Athens, and not via Syros.
Moreover, when psychiatrists from the mobile unit are on the islands, they play the
role of expert report-writer in the case of Public Prosecutor orders for hospitalisation,
which has also significantly improved the procedure.

Clinical Work

The mobile units’ clinical work includes diagnostic assessments, individual coun-
selling and psychotherapy sessions, group psychotherapy, family and couples coun-
selling sessions, setting up a social club for individuals with severe psychosocial
problems, carrying out social studies into cases of child abuse, psychosocial support
for families facing numerous problems (psychiatric symptoms, socioeconomic
problems), as well as home interventions.
From the time when mobile units commenced operations up to 2013, a total of
6,109 adults and 1,891 children and adolescents had received services. As far as the
NE Cyclades are concerned, 4,580 adults and 1,327 children and adolescents
received services. In the Western Cyclades, 1,529 adults and 564 children and ado-
lescents received services (see Table 10.1). As far as demographic data for the
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 177

Table 10.2 Demographic Variable F %

data pertaining to adult users
Gender
of services from the NE and
Western Cyclades mobile Male 1988 32.2
units while in operation Female 4186 67.8
(N = 6.183) Origin
Greek 5581 92.5
Other 455 7.5
Marital status
Single 1218 21.1
Married 3246 56.4
Divorced 556 9.7
Widowed 654 11.4
Cohabiting/living together 80 1.4
Employment
Employee 3849 77.7
Unemployed 414 8.4
Working occasionally 690 13.9
Visited mental health professional in the past
Yes 2189 40.5
No 3213 59.5

service users was concerned, for adults the average age was 49.7 years (SD = 18.8
min = 18 max = 104) and for children and adolescents it was 9.2 years (SD = 4.1
min = 1 max = 18). Table 10.2 summarises the other data about adults (the next chap-
ter presents more data about children and adolescents). It is worth noting that around
10 % of the permanent population on the areas these mobile units covered have
benefited from the services they offer.
Table 10.2 shows an increase in the influx of new cases in the first 2 years, which
reflects the fact that communities were learning that the mobile units were in opera-
tion, which was achieved through mobilisation at community level, contacts with
local professional bodies operating in the communities and through specific mental
health promotion activities. The consequent drop, with the lowest absolute frequency
point after the commencement of operations being achieved in 2009, can be explained
by the increased financing difficulties at that time, which made it difficult for mental
health bodies to operate and made their operations more precarious, undermining
plans and making it difficult to keep adequate staff levels up, having adequate budget
to pay accommodation of staff, make more trips to distant islands (etc).
From 2010 onwards, an increased influx of new cases was noted. This was the
time when the socioeconomic crisis began and consequently, as is well-known, psy-
chosocial difficulties increased as is clear from the demand for such services. Note
that in 2012, another serious difficulty in financing brought another drop in new
cases, but figures recovered the following year. The flow of cases was partially
determined by the continuity of funding and the continued assurance of the problem-
free operation of teams on each island.
178 S. Stylianidis et al.

1000
949 Adults
900
800 Children/Adole
scents
700
634 628
600 595
538
500 493 472 510
467
400
346 324
300
240 220 218 192
200 179 161 187
174
146 123
100
0 27
03

04

05

06

07

08

09

10

11

12

13
20

20

20

20

20

20

20

20

20

20

20
Fig. 10.1 Absolute frequencies of new cases for adults and children/adolescents while the
Northeastern and Western Cyclades mobile units were in operation (N = 6,182 and 1,906 for adults
and children/adolescents, respectively)

Table 10.3 Relative frequencies of diagnostic categories for adults (ICD10) who received ser-
vices at the Northeastern and Western Cyclades mobile units during their first decade in operation
(N = 4,636 and 1,547 respectively)
Diagnostic category NE Cyclades Western Cyclades
Organic mental disorders (F00-F09) 7.8 % 12 %
Disorders due to substance use (F10-F19) 2.4 % 1.2 %
Schizophrenic, delusional disorders (F20-F29) 6.9 % 3.4 %
Mood (affective) disorders (F30-F39) 28.2 % 27.9 %
Neurotic, stress-related disorders (F40-F48) 18.5 % 23.4 %
Eating disorders, non-organic sleep disorders (F50-F59) 0.7 % 0.7 %
Disorders of personality and behaviour (F60-F69) 2.4 % 4.7 %
Mental retardation (F70-F79) 1.1 % 1.9 %
Disorders of psychological development (F80-F89) 0.2 % 0.4 %
Unspecified mental disorder (F99) 0.1 % 0.1 %
Counselling (Z71) 6.6 % 4%
Relations problems – social issues (Z60-F63) 18.1 % 13.8 %
No psychopathology – certificates – other 7.1 % 6.5 %

Although there were also fluctuations noted in relation to children and adoles-
cents as well, the fluctuations were not so intense. That could be explained by the
fact that (a) the population is more limited and (b) by the fact that the caregivers for
children are usually mobilised to seek out help if problems arise, irrespective of
socioeconomic conditions (Fig. 10.1).
Looking at diagnoses for adults who have received services so far (see Table 10.3),
the most frequent diagnoses relate to mood (affective) disorders and nervous disor-
ders and disorders associated with stress, as one might have expected based on
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 179

Table 10.4 Relative frequencies of diagnostic categories for children and adolescents (ICD10)
who received services at the Northeastern and Western Cyclades mobile units during their first
decade in operation (N = 1,339 and 567 respectively)
Diagnostic category NE Cyclades Western Cyclades
Organic mental disorders (F00-F09) 0.3 % 0.2 %
Disorders due to substance use (F10-F19) 0.1 %
Schizophrenic, delusional disorders (F20-F29) 0.3 % 0.9 %
Mood (affective) disorders (F30-F39) 4.1 % 5.7 %
Neurotic, stress-related disorders (F40-F48) 11.4 % 13.4 %
Eating disorders, non-organic sleep disorders (F50-F59) 1.8 % 1.4 %
Disorders of personality and behaviour (F60-F69) 1.7 % 1.1 %
Mental retardation (F70-F79) 2.4 % 3.9 %
Disorders of psychological development (F80-F89) 25.2 % 19.6 %
Behavioural and emotional disorders with onset usually 22.2 % 21.6 %
occurring in childhood and adolescence (F90-F98)
Unspecified mental disorder (F99) 0.1 %
Relations problems – social issues (Z60-F63) 25.9 % 26 %
No psychopathology – certificates – other 4.7 % 6.2 %

Table 10.5 Relative frequencies of sources of referrals to the Northeastern and Western Cyclades
mobile units during their first decade in operation
Source of referrals NE Cyclades Western Cyclades Total
Self-referral 48.9 % 30.6 % 44.4 %
Primary healthcare 23.3 % 26.6 % 24.1 %
Private doctor 5% 2.9 % 4.5 %
Community body 6.8 % 5.1 % 6.4 %
Public authorities 1.5 % 3.8 % 2.1 %
Church 0.3 % 0.3 % 0.3 %
Educational body 6.1 % 22.3 % 6.6 %
Other 8.1 % 8.4 % 11.6 %

previous epidemiological studies (Skapinakis et al. 2013). That was followed by

requests relating to relationship and social problems, which emphasises the neces-
sity of adopting a biopsychosocial approach to providing mental health services in
the community. Although there is no epidemiological data for the Cyclades as a
whole, the numbers do appear to reflect the relevant frequencies of organic and
psychotic disorders which could possibly apply to a population overall which under
other conditions would need to travel to the capital or even endure involuntary hos-
pitalisation while in crisis.
Likewise, Table 10.4 relating to the diagnoses of children and adolescents shows
that the most frequent diagnoses had to do with psychological development and
behavioural and emotional issues which onset during childhood and adolescence,
along with relationship problems and other social issues.
As is clear from Table 10.5, most referrals came to mobile units of their own
initiative. One could argue that this was based on social mobilisation of the staff of
180 S. Stylianidis et al.

public services and the dissemination of information about how mobile units oper-
ate by persons who received services, i.e. word of mouth. The next source of refer-
rals was primary healthcare providers. Although the second highest figure, this
percentage does not reflect what was initially expected. In reality it appears that a
multidisciplinary structure, like the mobile units, partially mobilised the referrals
from primary healthcare due to the dysfunction arising from the crisis in the public
health system. It appears that (a) primary healthcare is not operating properly in
Greece’s regions, in contrast to the massive enlargement of secondary and tertiary
care in the capital, and (b) there is a potential lack of training among doctors in the
interface between primary healthcare services and mental health and chronic wel-
fare cases.
Of course, having said that, one cannot assume that within a decade of mobile
units being in operation, a system of liaisons with primary healthcare providers
operating within the territorial remit of the mobile units has not been built up. The
lowest frequency for sources of referrals was for the Church. Here we can see a lack
of information as well as the systematic preparation work that needs to be done in
order for a different culture (relating to prejudice, different conceptual approaches
to these matters and mutual resistance) not to be a barrier for many priests referring
individuals with psychosocial problems to mental health services. However, given
the close contact between priests and the community, especially in areas outside of
urban centres, an attempt has been made in terms of community activities in coop-
eration with the local dioceses, to offer training seminars for priests run by experts
from the mobile units. The “Other” source of referrals relates primarily to referrals
in the context of community activities such as workshops, mental health promotion
teams and local mental health teams.
Looking more deeply at the issue of sources of referrals, it is clear that over time
they differ in a statistically significant manner (chi-square statistical verification
(18) = 295.69, p < 0.001). As Table 10.5 shows, the assumption about self-referrals
and referrals from primary healthcare has been confirmed. In addition, there was an
initial stability in the frequency of self-referrals in the first 6 years; the mobile units
were in operation, which was then followed by a major rise, which corresponds to a
drop in referrals from primary healthcare providers.
Certain other conclusions could be drawn by exploring the longitudinal changes
in adult diagnoses, which were statistically significant (chi-square statistical verifi-
cation (24) = 477.51, p < 0.001) (Fig. 10.3). In all cases, relatively lower frequencies
were noted in the distribution of each diagnostic category in the period 2007–2009.
In some cases, such as psychoses and organic psychotic disorders, this could be
explained by the fact that the majority of these cases were identified when the
mobile units commenced operations, to the extent that one of the aims of this inter-
vention in relation to such psychopathologies was to reduce hospitalisations and
relapses. Moreover, during that 3-year period, the first serious difficulties in terms
of organising and funding mental health structures were dealt with, which had made
it difficult for the structures to operate and consequently to accept new cases.
As is the case with any community intervention where there are no other mental
health services, the frequency of psychotic disorders dealt with by the service will
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 181

Fig. 10.2 WHO Service Organization pyramid for an optimal mix of services for mental health
(WHO 2009) (Reprint from http://www.who.int/mental_health/policy/services/mhsystems/en/.
Accessed on 14th January 2015)

initially be higher and will then gradually decrease. According to Peritogiannis and
Mavreas (2014), individuals suffering from psychotic disorders have greater needs
and also greater difficulties in receiving mental healthcare. At the same time, seri-
ous psychiatric disorders in areas which do not have specialised psychiatric care at
primary healthcare level are frequently not diagnosed and are undertreated (Tylee
and Walters 2006), and systematic attempts are then required to effectively deal
with this through early intervention. The special feature of the clinical and statutory
framework within which the mobile mental health units operates is that there is no
direct possibility of referral to a specialised psychiatric unit or psychiatric depart-
ment in a general hospital, meaning that it is vital to utilise mobile support networks
in the community and for the multidisciplinary team to be “clinically inventive” in
order to reduce relapses and to manage them as best as possible in the community
context. Current socioeconomic conditions which are associated with the onset or
increase in factors burdening mental health, such as financial debt, lack of resources
to access private mental health services, lack of resources for medication, unem-
ployment, etc., make individuals more vulnerable to the development of mental
disorders. Recent studies show an increase in psychiatric problems in relation to
these factors (Economou et al. 2011, 2012; Giotakos 2011; Skapinakis et al. 2013).
The data for the populations within the mobile units’ territorial remit show that
the increase relates to mood (affective) disorders, neurotic, and stress-related and
182 S. Stylianidis et al.

70

60

50
2003-2006
40
2007-2009
30
2010-2013
20

10

0
9

c.
F0

F1

F2

F3

F4

F5

F6

F7

F8

Z6

et
0-

0-

0-

0-

0-

0-

0-

0-

0-

0-

es
F0

F1

F2

F3

F4

F5

F6

F7

F8

Z6

at
ic
tif
er
C
Fig. 10.3 Relative frequencies of diagnoses while mobile units were in operation in the
Northeastern and Western Cyclades for adults who received services (N = 6,183, the relative
frequencies have been calculated for each diagnostic category)

somatoform disorders, to behavioural and physiological-related disorders and

syndromes associated with physical factors, and to problems associated with the
primary support framework, which includes family circumstances. As far as the
latter category is concerned, one may also need to add that the increase for such
requests may be attributable to raise awareness due to the mental health promotion
programme for groups of parents, teachers and adolescents, funded by the Stavros
Niarchos Foundation.
Clinical observations about psychosocial-psychotherapeutic interventions and
the current status of the mobile units. Examination of the clinical treatment work
done by the mobile units revealed a series of interesting indications about the forms
that psychopathology can take and about the course of treatment and the final out-
come on the islands where the units are engaged in clinical activities. We will refer
to just some of these and set out a series of hypotheses to be explored, relating to
their emergence, and the beneficial consequences of psychotherapeutic
management.
Borderline personality disorders. Despite morphological differences, given that
a borderline individual on Milos will not be as openly suicidal as a borderline indi-
vidual in New York (Clarkin et al. 2004), the fundamental hallmark signs of the
disorder remain unchanged. Traumatic stress in light of (real or threatened) loss of
an object (vital for mental “survival”) remains the core of the disorder. What the
most common “threatened loss curves” are is a complex matter which includes
modern Greek customs and habits (Kapsomenos 2008) and systematic social trau-
mas (Hopper 1996) which have reached a climax now with the current economic
and social crisis. Closeness to school age for each child, and especially the last child
in the birth order, makes a vulnerable mother, in terms of capacity for mentalisation
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 183

and reflectivity, a suitable candidate to fall ill (Fonagy et al. 2002). Even if such
vulnerability has been associated with genetic predisposition (Lieb et al. 2004), the
onset of the illness will almost always be the direct consequence of psychotraumatic
burdens. This point is exceptionally important for psychotherapeutic interventions
and for more the systematic psychotherapies which take place in the context of
mobile units. Moderation and realism in treatment goals and a balanced ratio
between empirical clinical approaches (such as treatment as usual, TAU), psycho-
analytic theorising – which is sometimes backed up by cognitive or systemic theo-
rising or even ordinary behavioural approaches Kernberg et al. 2008) – and
evidence-based approaches help contribute to optimum formulation of these clinical
cases. The countertransference risks (Rosenfeld 1987) from the therapist being
merged into and absorbed in the treatment situation are reduced in this way, and it
becomes easier to implement a sort of phased step psychotherapy which is a key
part of what Thomä and Kächele had to say about psychoanalysis (1987): a continu-
ing series of variable duration short-term psychotherapies which can be renewed or
terminated at critical points. Thus, psychotherapy can last a few months (given that
the frequency at which therapists visit each island is every 2 weeks, the maximum
number of sessions could be 2 on the weekend of the visit, or 4 a month, or a total
of 20–25 sessions overall) up to 4–5 years (i.e. almost 200 sessions). It is important
to note that the total cost of relatively “long-term” psychotherapy provided by
mobile units continues to be much less than the amount required to pay for even a
small part of any long-term hospitalisation. As is well known, it is highly likely that
some of those patients will also require additional treatment for various other cases
such as anxiety crises, intense stomach pains (which may even require investigative
laparoscopy), psychiatric hospitalisation or depression and attempted suicide even
(Kienast et al. 2014). Consequently, further research is needed with a long-term
follow-up period to show that such psychotherapy cannot only improve the patient’s
quality of life but also to a large extent reduce co-morbidity (Leuzinger-Bohleber
et al. 2003) and the cost corresponding to it.
Depression. This was the most common disorder which came in a number of “dis-
guises” associated with physical complaints, paranoid ideation or behavioural disor-
ders, requiring detailed clinical investigation in order to establish the diagnosis.
Middle-aged women who need to deal with the gradual loss of their reproductive
capacity are a group vulnerable to the onset of depressive disorders, in addition to other
burden factors. In some cases, responsiveness to antidepressants may affect the diagno-
sis, thereby requiring frequent collaboration between the therapist and psychiatrist.
Suicidality is once again relatively limited and complex nosological-
anthropological studies need to be carried out to show what share of the affected
population is at a higher risk of suicide.
Of the various types of psychotherapy that exist, it appears that the relational
approach (Diamanti 2014) has a very good response rate for certain categories of
depression (Blatt and Luyten 2009), on a par with that of the CBT approach
(Tzanoulinos 2014).
Narcissistic disorders of personality and psychopathy. A frequent initial finding
in this category of disorders is the charm and allure exerted on the supervising team
184 S. Stylianidis et al.

when such patients are presented by their therapist. They are men and women with
a reported “rich” sex life, who frequently defraud their milieu and who have been
involved in crime and with reported cases of marginal or threatened violence and
systematic (projective) attribution of responsibilities to members of the family envi-
ronment; with a background of involvement with the police or judicial authorities;
and with complex psychosocial-cultural difficulties which are interwoven with
social services provided by local government authorities (which are very poorly
organised in any event).
It is not at all uncommon for a careful study of the background of such cases to show
complex traumatic burdens that could even relate to previous generations, a back-
ground that may only be obtained after quite a few sessions and quite a few months of
meetings and may often be hidden or more often involve dichotomies, denials and
refusals (Hatziandreou 2012). In this case, the search for help is associated with a
recent psychotraumatic event which sits atop the unconscious traumatic substrate.
In cases like these, it is possible for the patient to seek help because of depressive
complications, which spring from unconscious wounds from pathological narcis-
sism which can create exceptionally dangerous situations of threatened suicide.
Usually all this is attributed to significant others. There is relatively low compli-
ance with treatment, frequent dropouts and a restoration of the treatment relation-
ship when new difficulties arise. It is not at all rare hallmark of such cases for the
police, Public Prosecutor, therapist, local doctor and parents to be involved.
Potentially, at least one part of the population in subsequent criminal or illegal activ-
ity may consist of individuals with such disorders.
A very large part of the treatment in cases like these is recognition and awareness
of the innate psychological factors and personal contribution/responsibility of the
patient for what is happening to him (since this primarily affects males) or her
(which is a much rarer case).
Developmental disorders. These disorders are common in such populations
given the low level of psychiatric services, especially primary, prevention-oriented
care. Children and adolescents with psychopathology are not diagnosed and are not
dealt with, meaning we have clinical pictures of chronic regression, neglect and
sometimes mental decline.
Even if such patients are lagging behind in terms of family and social relations,
they can remain functional and achieve a degree of adjustment which in some cases is
far from negligible. Here traditional societies may be “better” (from a wider anthropo-
logical viewpoint) than “hyper-diagnostic” modern Western societies (Kessing 2005).
Psychoses. It is critical for them to have adequate follow-up so that schizophrenic
and bipolar disorders can be distinguished from psychotic episodes (Kessing,
op. cit.) which need a different psychotherapeutic approach. A real diagnostic and
treatment question is when is the right time to start antipsychotic treatment and
provide short-term hospitalisation, if it is considered necessary.

The Interface with Primary Healthcare

Taking into account the problems relating to how primary healthcare operates in
Greece and the difficulty in developing and evaluating a model of cooperation
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 185

between the mobile units and primary healthcare, quite a few measures were taken
to lay the foundations for a more effective interface in the future.
Major emphasis was placed on training primary healthcare professionals in how
to prevent, recognise and manage mental disorders. Training included regular semi-
nars held locally on each island or conferences arranged in cooperation with the
Hellenic Society for Genetic/Family Medicine, aimed at all doctors and nurses
involved in primary healthcare in the Cyclades. In addition to seminars held at health
centres at regular intervals, a total of four training workshops were held centrally on
Paros and Syros over the course of 2 days for primary healthcare doctors in the
Cyclades, in cooperation with the Hellenic Society for Genetic/Family Medicine and
the participation of Greek and foreign experts (e.g. from the WHO).
In a qualitative study which employed semi-structured interviews carried out by
the Regional Development and Mental Health Association in cooperation with the
University of the Aegean to evaluate the first training seminar held on Syros, views
about mental disorders and the educational needs of 17 staff in primary healthcare
were recorded (Stylianidis and Zisi 2005). All those questioned agreed that users of
services frequently contacted primary healthcare services to deal with their mental
health problems. The responses showed that in the case of adults, depression and
anxiety disorders were the most frequent, while in children, behaviour and speech
problems were the most common. The treatments proposed by those questions
included counselling and referral to a mental health professional, especially to deal
with schizophrenia and when the treatments of GPs failed or when the symptoms
were persistent, with a poor response to medication. However, most doctors agreed
that the treatments at primary healthcare level were not sufficient and emphasised the
need to organise training on mental health issues. When asked about their views on
depression and schizophrenia, there appeared to be a relative inability to scientifi-
cally formulate the nature of these disorders. The seminar which was held was
viewed in a positive light by primary healthcare staff (Stylianidis and Zisi 2005).
In addition, over the last 3 years, the WHO’s MhGap guide (WHO 2010) has been
translated into Greek and is being used in training. This guide has been used to suc-
cessfully carry out training seminars for primary healthcare doctors on Syros, Tinos
and Paros. It is essential to remind readers that during the first years that the units were
in operation, a system of referrals to and from the primary healthcare using special
forms had been put in place. Over time, referrals and cooperation on cases being fol-
lowed up were primarily done via regular meetings with doctors at health centres.

Promoting Mental Health and Networking with Local Bodies

Networking with local bodies on the islands and developing activities to promote
mental health are an integral part of the mobile units’ activities, which are primarily
community-focused services operating in the context of the public mental health
system (Stylianidis and Pantelidou 2006b; Pantelidou et al. 2010; Pantelidou et al.
2012). In general terms, these actions included:

Workshops and other special events (such as a mental health festival and activities
of a cultural and sporting nature) aimed at the residents of each island, to provide
186 S. Stylianidis et al.

information about the mental health of children, adolescents and adults. The aim
of these measures was to reduce stigma about mental illness and to provide
information and allow for the timely search for help from mental health experts.
One or two such activities take place on each island every year.
Special events with a less theoretical and more experiential character relating to
specific population groups: the elderly, the disabled, people with physical
illnesses, parents, children, etc. For example, over the last 3 years, parent support
groups, support groups for relatives of patients with dementia and empowerment
groups for women who have suffered domestic violence have been held.
Programmes aimed at providing information and training for specific professionals
in the community: training groups to provide information about key psychopa-
thology issues in children and adolescents and issues of how to deal with behav-
ioural problems, training seminars for GPs, training for police officers about how
to handle Public Prosecutor orders for involuntary hospitalisation and cases of
domestic violence and training for priests about key aspects of mental health.
Planning and development of voluntary support groups comprised of patients, rela-
tives and other individuals from the local community. Once such group was
recently launched on Paros, after a seminar held in cooperation with the National
Disabled Confederation (May, 2014) to provide information about the rights of
individuals with mental disability and how to organise self-advocacy measures.
A network of local bodies was developed which entails regular meetings of local
groups of representatives from health services, social services, educational
bodies, local government authorities and public authorities whose aims are (a) to
improve networking between local services, (b) to continuously record needs, (c)
to cooperate in managing serious psychiatric cases in the community, (d) to
cooperate in the planning and implementation of mental health prevention and
promotion measures and (e) to develop broad institutional synergies on wider
local development issues along with local government authorities and other
bodies (whether formal or not) in each community, taking into account special
cultural and social features.

Assessment

A key aspect of how mobile mental health units operate is evaluation of the services
they provide in order to use those results to improve how the service functions
(Pantelidou et al. 2010).
During the second year that the mobile units were in operation, a pilot study was
conducted (in cooperation with the Universities of Ioannina and the Aegean) to
assess levels of satisfaction among patients and their relatives with the services
provided by mobile units. A Patient/Relative Mental Health Services Satisfaction
Scale (based on the Verona Service Satisfaction Scale-VSSS, Ruggeri and
Dall’Agnola 1993) was used which was filled out by a sample of 126 individuals,
users of services from the start of operations until the time of the study (ordinary
random sample). Eighty-one percent of the sample was women and 19 % men, and
10 Mobile Mental Health Units on the Islands: The Experience of Cyclades 187

67 % were still using the service, while the others had received services in the past.
The majority of those questioned (78 %) said they were quite satisfied or very satis-
fied with the effectiveness of the service in handling their requests and with the
ability and behaviour of staff (94 %). A large percentage of those questioned (63 %)
said they disliked sessions being cancelled because of problems therapists had in
travelling to the islands (difficulties in accessibility of the islands because of weather
conditions in winter months).
The services provided continue to be evaluated even today and in 2012 a process
of assessing the clinical interviews on a systematic basis was launched. In this con-
text, each new recipient of services is evaluated when he starts using services and
then 6 months later, and when he finishes using them. The following scales have been
used in this context: World Health Organisation Quality of Life-Bref (WHOQOL-
bref) (WHOQOLGroup 1998; Ginieri-Coccossis et al. 2009), the revised version of
the Symptom Checklist-90 (SCL-90-R) (Derogatis and Savitz 2000; Donias et al.
1991) and the Strength and Difficulties Questionnaire (SDQ) (Goodman and
Goodman 2009; Giannakopoulos et al. 2009) for children and adolescents.

Conclusions
It is important to examine whether the mobile mental health units model could
be spread in order to firmly establish psychiatric reform in the difficult socioeco-
nomic period of crisis by taking a different perspective: (a) the mental health
needs of the population in remote areas and in the rest of the country are rapidly
increasing, and consequently the line-up of the multidisciplinary team would in
turn have to be bolstered in order to be rudimentarily adequate to address the
needs which arise; (b) the current crisis in the public health system overall and in
primary healthcare in particular (the National Healthcare Service Provider,
known by its Greek abbreviation EOPYY, and the National Primary Healthcare
Network, known by its Greek abbreviation PEDY) coupled with the dramatic
reduction in staff, the decline in working conditions and the increased needs
because of the crisis have made it significantly more difficult to organise a strat-
egy to integrate mental health into primary healthcare; and (c) the innovative
aspect of best practices need to be showcased and documented in cooperation
with Greek and European networks.
Taking into account the new conditions which have shaped socioeconomic
circumstances over recent years, the challenges and future goals for how mobile
units can operate include:

Developing specialised measures for vulnerable population groups affected by

the economic crisis, such as families with members suffering from serious
physical or psychiatric conditions and who also face socioeconomic prob-
lems, unemployed support groups, etc.
Measures relating to the prevention and handling of mental health problems and
the social problems of immigrants
Developing actions to evaluate special treatment interventions for special
psychopathologies
188 S. Stylianidis et al.

Carrying out economic studies, cost-benefit analyses and efficiency analyses into
the long-term operation of mobile units
Organising self-help groups for individuals suffering from depression and other
mental disorders
Empowering patients and relatives to take steps to defend their rights and pro-
mote self-advocacy
Developing programmes aimed to assisted work for individuals with mental
health problems
Liaising with European mental health service networks which offer mobile units
in remote areas to provide theoretical and scientific documentation of best
practices

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Community Child Psychiatry:
The Example of Mobile Mental Health 11
Units in the NE and Western Cyclades

Stella Pantelidou, Vicky Antonopoulou, Antonios Poulios,

Jenny Soumaki, and Stelios Stylianidis

Abstract
This chapter outlines innovative measures in the field of community child psy-
chiatry in Greece and abroad, with emphasis on the special features of interven-
tions in geographically remote areas. It presents the work done by mobile mental
health units in the NE and Western Cyclades in the child psychiatry sector.
Reference is made to the clinical work and the differences noted in terms of new
cases, initial requests, referrals and diagnoses over the 10 years the units have
been in operation. In addition it presents measures taken to record needs, pro-
mote mental health among children and adolescents, and in terms of the preven-
tion and management of abuse. The data and the measures taken are directly tied
into the new conditions which have emerged in Greece as a result of the socio-
economic crisis.

11.1 Introduction

Good mental health is essential to the development processes of children and ado-
lescents. It ensures optimum psychological and social functionality (WHO 2005a)
and plays an important role in the development of identity and healthy interpersonal

S. Pantelidou • V. Antonopoulou • JennySoumaki

Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]; [email protected]; [email protected]
A. Poulios
Clinical Psychologist, National and Kapodestrian University of Athens, Athens, Greece
e-mail: [email protected]
S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 193

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_11
194 S. Pantelidou et al.

relationships, bolsters learning ability and the ability to manage developmental or

other challenges on the path towards adulthood.
Using international literature (WHO 2005b) we can document the reasons why it
is necessary to develop and implement effective interventions for children and
adolescents:

A large percentage of the psychopathology which manifests in an individual’s adult

life starts in the early development stages, during which it is feasible to prevent
future psychopathology.
The value of early intervention in mental disorders is particularly important and
reduces the likelihood of chronic mental disability.
Effective interventions to promote the mental health of children and adolescents
reduce the burden of psychiatric disorders in the individual and his/her family,
thereby reducing the cost of long-term care for the health system.

Available research data supports the view that the prevalence of mental disorders
in children and adolescents is high internationally, at around 10–20 % (Kieling et al.
2011). Studies point out that in geographically isolated areas, in particular, the
occurrence rates for mental disorders are clearly higher (Ellis and Philip 2010),
mainly where there are other risk factors as well, such as low socioeconomic levels,
parental psychopathology and the effect of stressors.
It is also a fact that only 10–22 % of all those suffering from child and adolescent
mental disorders can be identified by primary healthcare, which shows the inade-
quate levels of human resources and know-how in public mental health and the
particularly significant treatment gap (WHO 2005a; Saxena et al. 2007). In addition,
only the minority of high-risk children are monitored by mental health experts
(Belfer 2008; NIMH 2001; Brugman et al. 2001). However, mood (affective) and
behavioural problems of children appear to be stable over time, affect their quality
of life and tend to develop into psychiatric disorders in adult life especially when
there is no suitable intervention (Costello et al. 2003).
In a previous chapter, we reported on psychiatric reform in Greece and the essen-
tial change in the model from the provision of psychiatric care in asylums to com-
munity psychiatric care. However, as the national action plan PSYCHARGOS III
(2011–2020) has recorded, “psychiatric reform has made deinstitutionalisation of
chronic adult patients and the abolition of psychiatric hospitals a priority, with the
result that few mental health structures have been created for children and adoles-
cents” and concludes in relation to the modern Greek situation that “existing struc-
tures do not under any circumstances constitute an adequate network, while large
geographical regions of the country have no child psychiatric services at all”.
One can therefore understand that in order to abolish institutional care for children
and adolescents, it would be necessary to operate an effective network of child and
adolescent mental health services which would ensure that comprehensive child psy-
chiatric care is provided at all levels of care, in the context laid down by international
conventions and declarations on the protection of the rights of children (MHSS 2012).
As Kolaitis and Tsiantis (2013) have noted, “the lack of an adequate number of
specialised community structures and services for child psychiatric care in Greece,
11 Community Child Psychiatry: The Example of Mobile Mental Health Units 195

which are suitably staffed by well-trained child psychiatry experts in adequate num-
bers, is a major barrier to the protection of the rights of children”. The rights of chil-
dren and adolescents may be neglected or violated in various ways, from the prenatal
stage (such as great poverty in the family, socioeconomic inequalities), at the time of
birth (such as inadequate health services in remote areas), during infancy (such as
inadequate mental healthcare for young mothers) and during childhood and adoles-
cence. In this regard Anagnostopoulos and Soumaki (2012) have pointed out that the
methods of violating rights may be clear-cut as in the case of abuse or less obvious in
the context of family conflicts and divorces. These situations can have physical and
psychological effects and frequently lead to poor educational adjustment, low perfor-
mance and early dropout from school with clear, long-term repercussions in terms of
economic cost. It can also lead to increased levels of unemployment and reduced
social integration and participation (Kolaitis and Tsiantis 2013).
The development of services to care for the mental health of children requires
specific organisational plans as a starting point, with the aim of recording needs and
developing and disseminating services to cover geographically remote areas as
well, and to ensure that they are accessible to all citizens. If this is not done, there is
a risk of services being created in a piecemeal manner, offering ineffective, expen-
sive or hard-to-access care (WHO 2005a).
This chapter will place particular emphasis on community-focused child psy-
chiatry services and the special features of interventions in geographically remote
areas by looking at how mobile mental health units operate.

11.2 Definitions

Child psychiatry refers to services provided to children and adolescents and their
parents that relate to:

Child psychiatry services in the community/at the child’s place of residence based
on the principles of sectorisation
Recording the mental health needs of children and adolescents, to develop services
tailored to the special needs of each community
Child psychiatric evaluation and development of a customised treatment plan in
cooperation with other bodies in the community such as schools, health services
and social services
Actions for mental health education and promotion for children in the community
Prevention of relapses in cases of severe child psychiatric disorders

These points reflect the principles in the UN Convention on the Rights of the Child
and aim to promote emotional well-being and the right to multifaceted development
on an emotional, social and cognitive level to promote his/her abilities to the greatest
extent possible while taking into consideration “his/her interest” (WHO 2005b).
The framework within which mobile mental health units operate (which is the
prime example of community-focused services) is a basic example of how child
psychiatry services can be provided in the community. As a form of organising
196 S. Pantelidou et al.

psychiatric care and treatment, mobile mental health units’ key features are that they
provide comprehensive, quality mental health services while interfacing with
primary healthcare and cooperating with existing health, educational and social ser-
vices. Another feature is that they require minimal infrastructure of their own and
maximise existing infrastructure which either belongs to other health services or
local government authority services or agencies. Under Law 2716/1999 (Government
Gazette 691/A), mobile mental health units provide services:

(a) In mental health sectors whose geographical area and layout, residential diver-
sity and social, economic and cultural conditions coupled with the nature of
mental disorders make it difficult for residents of those areas to access mental
health services
(b) In neighbouring mental health sectors when there are no adequate mental health
services there

Mobile mental health units are aimed at children and adolescents and adults suf-
fering from mental disorders and/or psychosocial problems or who are in groups at
high risk of manifesting mental disease. They are also aimed at the healthy popula-
tion, through the mental health prevention, education and promotion programmes
they run. Mobile mental health units operate in line with the principles and philoso-
phy of social psychiatry (Mechanic 2001; Tansella and Thornicroft 2001).

11.3 Historical Background

Innovative steps towards psychiatric reform first began to be taken in Greece in the
1960s. During the 1970s and 1980s, community services were set up, cut off from
traditional academic psychiatry, and the prime player in this field was Professor
T. Sakellaropoulos. The Institute of Social Psychiatry was set up first in Pagrati fol-
lowed by the Social Psychiatry Association, the first mobile unit in the Prefecture of
Fokida (in 1981) and various structures in Evros (Livaditis 1995). At the same time,
other social psychiatry services were set up such as:

The Paediatric Psychology Department at the Agia Sofia Children’s Hospital in

Athens
The Community Mental Health Centre in Thessaloniki
The University Clinic of the Ioannina Medical School
The University Mobile Unit for the Thessaloniki Region
The Vyronas – Kessariani Community Mental Health Centre

These structures provided satisfactory public care within their area (at that time
the psychiatric sector as an area of remit was considered to be an innovation) to
only 8 % of the country’s population, due to the failure to complete sectorisation of
services, the real lack of a central plan for deploying services in the regions, the
absence of sufficient structures and the lack of coordination and cooperation
(Sakellaropoulos 1995).
11 Community Child Psychiatry: The Example of Mobile Mental Health Units 197

Today, the continued implementation of psychiatric reform is at risk both because

of the economic crisis and its effects (Anagnostopoulos and Soumaki 2012, 2013b)
and because of the attitude of public bodies to issues relating to how mental health
services are deployed and organised (see the chapter on psychiatric reform in Greece
and the chapter on the economic crisis and mental health: key issues).
The aim of modern child psychiatry is that all mental health problems are dealt
with by keeping the children and adolescents in the community, providing them
with the entire range of specialised psychosocial care and rehabilitation services
they need (Anagnostopoulos and Lazaratou 2005).
Even though the system of mental health services for children and adolescents
developed in a positive manner, it continued to be inadequate and limited in terms
of development compared to the modern needs of children and adolescents and their
families, while services are mainly focused in large urban centres, with the result
that 30 prefectures in Greece do not have any child psychiatry services at all, and
therefore a large proportion of the Greek population has no child psychiatry services
at all (Asimopoulos 2007).

11.4 Current Situation

The current socioeconomic and cultural crisis (from 2009 onwards) highlighted a
series of chronic dysfunctions which have hindered – but above all divided and
fragmented – the psyche of individual subjects and of Greek society overall.
These chronic defects in the structure and organisation of the very state and gov-
ernment have resulted in inadequate institutional functions and have also high-
lighted a plethora of contradictory forms of behaviour at social and individual
level.
The combination of these factors, which are associated with the crisis, such as
unemployment, insecurity, the abolition of institutions, continuous defeated expec-
tations, lack of boundaries, serious conflicts and lack of a harmonious family life,
has led to a major increase in new cases and therefore for demand for child psychia-
try services and to a qualitative change in the psychopathology being encountered
in day-to-day clinical practice.
Constant cuts in general spending on health and welfare have led to a shrinking
in the already inadequate child psychiatry services offered by the Greek NHS and
the abolition or reduction in real childcare policies for vulnerable groups of children
and adolescents.

11.5 Literature Review

In one European study which covered 36 countries, it was found that the number of
community child psychiatry units and the number of children and families treated
were lower in general terms than the corresponding services for adults (Levav et al.
2004) even though the majority of mental disorders have the age of 14 as their start-
ing point (Kessler et al. 2005). In addition, only 7 % of countries worldwide have
198 S. Pantelidou et al.

enacted a comprehensive plan for their child and adolescent mental health policy
(Shatkin and Belfer 2004). As far as access to existing community child psychiatry
services is concerned, a key barrier – in addition to the stigma over mental disorders –
is geographical inequality in the spread of such services, with non-urban areas being
at a clear disadvantage (WHO 2005b).
Based on this data, increasing emphasis is being placed on developing commu-
nity-focused child psychiatry services in geographically remote areas, which is a
need the Greek mobile mental health units were called upon to meet in large part.
The philosophy behind the mobile mental health units derives from the principles of
assertive cooperation between mental health experts in all available agencies oper-
ating in a community.
The relevant literature relating to the provision of child psychiatry services by
mobile mental health units abroad is relatively limited. Mobile mental health units
have been deployed in Switzerland targeted specifically at adolescents who are
either in high-risk groups for the development of serious psychopathology or who
refuse to continue treatment after hospitalisation or who find it difficult to access
child psychiatry structures. Bonsack et al. (2008) described an intervention model
based on Assertive Community Treatment. The model is based on setting up and
implementing a customised, holistic intervention plan which involves the reporting
child psychiatrist, mental health experts operating the relevant community and the
school and the parents of each adolescent. An essential factor in each intervention
is to develop a robust treatment alliance and cultivate a climate of trust with families
and to gradually empower the socialisation of, and development of activities by,
each adolescent. To achieve these goals, the treatment plan also includes specialist
carers (nurses) who make daily home visits and provide real help in implementing
the treatment plan. In addition, clinical meetings are held weekly, to help assess
each intervention and redefine treatment targets. The results of interventions are
considered to be satisfactory, when there is a clear improvement in the adolescent’s
level of functionality.
In the USA, the charity the Children’s Health Fund provides funding for mobile
medical units that focus on the child population in areas where such services do not
exist. Fifty mobile units operate in 16 states in the USA to provide services to poor
families and minorities (Brito et al. 2010). To effectively run the mobile units, they
have adopted a holistic programme and integrative approach. Paediatricians, nurses
and mental health experts cooperate to develop intervention protocols whose primary
aim is to identify mental health problems and increase referrals to specialised treat-
ment. The main principles of the holistic model they follow are (a) ensuring acces-
sibility, (b) ensuring the continuity of the intervention, (c) liaising with other services,
(d) getting families and schools involved in the treatment plan, (e) making it easy to
travel to and carry out medical tests and children’s hospitals and (f) tailoring the
intervention based on the special cultural features of each area covered.
Similar mobile units have also been deployed in the USA so that they are ready
at any time to travel to areas affected by natural disasters (Madrid et al. 2008). In the
field of child and adolescent mental health in particular, a model is used which pos-
its the coexistence of mental health experts and paediatricians to deal with problems
11 Community Child Psychiatry: The Example of Mobile Mental Health Units 199

arising from a natural disaster from different angles. The initial focus takes into
account the basic needs, while, as the programme continues, emphasis is placed on
training professionals in the community and teachers to identify any mental health
problems in children and adolescents in good time, as they emerge.
Although the existing literature is limited, it is clear that the key aspects of how
mobile mental health units operate are that they must reflect the principles of pri-
mary, secondary and tertiary prevention, bearing in mind well-documented prac-
tices in the field of modern child psychiatry.
Interventions by community child psychiatry services such as those provided by
mobile units must necessarily include programmes to deal with negative, stereotypi-
cal views in the community about the mental disorders of children and adolescents,
in order to enable specialised help to be sought in good time (Naylor et al. 2009).
In addition, a key part of community interventions by mental health services for
children and adolescents is to develop a stable partnership with schools and teachers
(Bailey 1999; Eskin 1995). Schools are one of the most important community struc-
tures where mental health promotion programmes have a definitive impact (a) on
combating stigma and (b) on improving the emotional and social functionality of
students and (c) on identifying children with mental health problems (Rowling
2002; Zins et al. 2004; Payton et al. 2008). Early interventions to address emotional
and behavioural problems and to train teachers to integrate techniques to promote
student skills lead to long-term benefits in the field of child and adolescent mental
health (Tennant et al. 2007; Wells et al. 2001).
Another feature of community-focused mental health services for children and
adolescents, such as mobile units, according to the international literature is that the
intervention team must have a multidisciplinary line-up which will enable it to tar-
get its work on the entire family. Some researchers have argued that in order for a
child psychiatric diagnosis to be submitted, it is essential to know about and exam-
ine the interaction each child has with his family (Carr 2000; Cicchetti and Tucker
1994). A successful outcome from each treatment approach ought to include paren-
tal involvement, and when this is achieved, the results of treatment are clearly better
(Dowell and Ogles 2010; Karver et al. 2006).
Another key area of intervention for child psychiatry services in the community
is training primary healthcare doctors to identify children and adolescents with
mental health problems early on (Hagan et al. 2008). This is vital since primary
healthcare doctors tend to under-diagnose mental health problems in children and
adolescents (Hickie et al. 2007) and consequently limit the number of referrals to
mental health experts (Warfield and Gulley 2006).
Best practices: the example of mobile mental health units in the NE and Western
Cyclades operated by the Regional Development and Mental Health Association.
A key priority of the mobile mental health units in the NE and Western Cyclades
during their 10 years in operation has been to develop special prevention and pro-
motion measures for the mental health of children and adolescents in the commu-
nity within their territorial remit and to implement special treatment measures for
children and adolescents and their families.
200 S. Pantelidou et al.

The child psychiatry department of the mobile units employs child psychiatrists,
clinical psychologists specialised in children and social workers. The services are
provided fortnightly, primarily at premises provided by health centres on the islands,
at specially designed spaces in town halls and at the headquarters of the units. In
addition, there is a special Family Clinic on Paros for children and adolescents with
mental health problems. Systematic supervision of child psychiatry cases is also
provided.
In short the operating targets for mobile units when providing services relating to
children and adolescents can be summarised as follows (Pantelidou and Stylianidis
2010; Stylianidis and Pantelidou 2006; Stylianidis et al. 2007):

(a) To assess and record mental health needs for this age group
(b) To provide child psychiatry evaluation, diagnosis and treatment services for
mental disorders and the psychosocial problems of children and adolescents
(c) To prevent, educate and promote mental health for children and adolescents by
implementing special programmes and training groups of professionals working
with children and adolescents and parents and to identify mental health problems
in good time and refer them to a specialised service
(d) To liaise with primary healthcare, social and educational bodies in the
community and to more effectively record needs and provide comprehensive
interventions
(e) To develop specialised measures to prevent and deal with child abuse and
victimisation

The section below provides a brief overview of the activities of mobile units in
relation to those goals.

Clinical Treatments

During the 10 years the mobile mental health units have been in operation, they
served a total of 1339 children and adolescents in the NE Cyclades and 567 in the
Western Cyclades, whose average age was 9.2 years old (SD = 4.1, min = 1 max = 2).
The key demographic characteristics of children and adolescents who attended the
units are presented in Table 11.1.
Monitoring the change in new cases over time, as shown in Fig. 11.1, during the
first years in operation, there is a gradual increase in new cases. There was then a drop
in new cases which probably reflects changes from funding cuts (reduced numbers of
staff). There was another drop in new cases attending the units in 2009 for the same
reasons. This was followed by a gradual rise in requests, which is probably associated
with the impacts of the socioeconomic crisis and also with the activities the mobile
units had engaged in relating to prevention and awareness raising about the psycho-
social health of adolescents and their families (due to the increased number of requests
from the community for actions of this sort). It is also worth noting that the influx of
new cases in the Western Cyclades had fewer fluctuations over time compared to the
11 Community Child Psychiatry: The Example of Mobile Mental Health Units 201

Table 11.1 Demographic Demographic variables f %

characteristics of children
Gender
and adolescents who received
services from the mobile Boy 1121 58.8
mental health units in the NE Girl 785 41.2
and Western Cyclades in the Country of origin
first 10 years they were in Greece 1728 90.7
operation (N = 1906)
Abroad 178 9.3
Prior contact with a mental health expert
Yes 391 24.5
No 1199 75.3

180 W Cyclades
160 165 162
156 154 NE Cyclades
140 138
120 123
107 111
100

80 85 82 82
76 72
60 61
56
50 51
40 41
36 33
27
20

0
03

04

05

06

07

08

09

10

11

12

13
20

20

20

20

20

20

20

20

20

20

20

Fig. 11.1 Absolute frequencies of new cases of children/adolescents during the time the NE and
Western Cyclades mobile units were in operation (N = 1.339 and 567, respectively)

NE Cyclades, even though increases and reductions in new cases probably follow the
same trend. This can be attributed to the fact that this area has a clearly smaller popu-
lation and consequently the corresponding fluctuations are smaller.
As far as diagnoses are concerned, it appears that frequencies follow a similar
trend for both mobile units. More specifically, as one might have expected, the most
frequent diagnoses related to psychological development disorders, behavioural and
emotional disorders normally diagnosed in childhood and adolescence and psycho-
social problems, followed by mood (affective) disorders (see Fig. 11.2).
Monitoring the distribution of diagnoses over the time period the mobile units
were in operation (chi-square statistical verification (24) = 132.7, p < 0.001)
(Fig. 11.3), one can see that in the last 4 years, the frequencies of psychopathologies
of almost all types have increased. Exceptions are organic psychotic disorders, sub-
stance dependence and abuse and psychoses, possibly due to their low prevalence in
the general child and adolescent population. As far as cases of developmental
202 S. Pantelidou et al.

30 F00–F09

F10–F19

25 F20–F29

F30–F39

20 F40–F48

F50–F59

15 F60–F69

F70–F79

10 F80–F89

F90–F98

5 F99

Z60–Z63

0 No psychopathology
NE Cyclades W Cyclades Certificates – Other

Fig. 11.2 Relative frequencies of diagnoses for children/adolescents who visited the NE and
Western Cyclades mobile units during their first decade in operation (N = 1.339 and 567,
respectively)

120

100

80
2003–2006
60 2007–2009
2010–2013
40

20

0
F1 09

63

c.
9
F2

F3

F4

F5

F6

F7

F8

F9
F1

et
F

Z
0–

0–

0–

0–

0–

0–

0–

0–

0–

0–
0–

es
F0

F2

F3

F4

F5

F6

F7

F8

F9

Z6

at
ic
tif
er
C

Fig. 11.3 Relative frequencies of diagnoses during the period the NE and Western Cyclades
mobile units were in operation (Ν = 1906)

disorders are concerned, one can see a drop in frequency and then a rise over the last
4 years, which could be attributed to the raised awareness of parents and teachers
about such matters.
11 Community Child Psychiatry: The Example of Mobile Mental Health Units 203

As Table 11.2 shows, the most frequent source of referrals was self-referral,
which in the case of children and adolescents in effect means requests originating
from their parents. The second most frequent source of referral was the school,
which is the prime place outside the family where psychosocial difficulties become
perceptible, which emphasises the need for close cooperation between community
mental health structures and schools. The phenomenon of primary healthcare some-
how being bypassed by mental health structures also appears in the case of children
and adolescents since the frequency of referrals by this source (third in the rankings)
could be characterised as rather lower than expected, which is perhaps indicative of
the problems in the running of primary healthcare (reduced staff levels, lack of pae-
diatricians on most islands within the area of remit, etc.).
By comparing the sources of referrals separately for the two mobile units, one
can see that self-referrals were more frequent in the NE Cyclades than in the Western
Cyclades, where the percentage of referrals from “other” sources is clearly higher,
which may show another form of social networking in place in the Western Cyclades,
in what are mostly more closed communities with a smaller population. The lower
frequency of referrals from primary healthcare and private doctors in the Western
Cyclades reflects the dearth of health professionals in those areas. The higher fre-
quency of referrals from community bodies in the NE Cyclades may reflect the
larger number of services on those islands.
Reviewing the sources of referral over time, which revealed a statistically sig-
nificant change, χ2 (14) = 83.7, p < 0.001 (see Fig. 11.4), shows that over time
self-referrals increased and in fact that increase was higher over the last 4 years,
i.e. since the socioeconomic crisis started. The crisis may have led a large portion
of the population to seek out psychosocial help given the impacts it has had, and
in the last 2 years in particular, the population has become more aware, thanks to
mental health promotion programmes aimed at parents, adolescents and teachers.
Those programmes also explain the increase in schools as a source of referrals.
After 10 years of the mobile mental health units in operation, the number of self-
referrals has increased significantly, which indicates an improvement in the level
of basic trust between the multidisciplinary child psychiatry team and the popula-
tion receiving services, the more pressing nature of requests due to the

Table 11.2 Relative frequencies of sources of referrals to mobile units in the NE and Western
Cyclades in the first decade in operation (N = 1339 and 567, respectively, 1906 in total)
Source of referrals NE Cyclades (%) Western Cyclades (%) Total (%)
Self-referral 49.3 34.3 45.2
Primary healthcare 11.6 8.7 10.9
Private doctor 3.9 1.3 3.3
Community body 4.6 2.3 3.9
Public authorities 0.9 4.6 1.5
Church 0.2 0 0.1
Educational body 22.5 25 23.3
Other 6.9 23.7 11.8
204 S. Pantelidou et al.

55
Self-referral
50
Primary
45 healthcare
40 Private doctor

35 Community
body
30
Public
25 authorities
Church
20

15 Educational
body
10 Other
5

0
2003–2005 2006–2009 2010–2013

Fig. 11.4 Relative frequencies of sources of referral during the period the NE and Western
Cyclades mobile units were in operation (Ν = 1906)

Table 11.3 Relative frequencies of initial requests made to mobile units in the NE and Western
Cyclades in the first decade in operation (N = 1339 and 567, respectively, 1906 in total)
Initial request NE Cyclades (%) Western Cyclades (%) Total (%)
Psychiatric symptoms 18.8 15 17.5
Learning problems 15.3 29.1 19.8
Behavioural problems 27.6 20.6 25.2
Substance dependence/abuse 0.2 0 0.1
Problems with family relations 16.4 14 15.6
Speech problems 5.8 6.2 5.9
Developmental disorders 1.9 1 1.6
Eating disorders 1.1 1.2 1.2
Mental retardation 0.4 0.8 0.5
Certificates, etc. 1 2.3 1.5
Social surveys 11.4 9.9 10.9
Medical report/certificate 0.1 0 0.1

socioeconomic crisis and the way the units operate in the networks within local
communities.
As is clear from Table 11.3, initial requests made by individuals who contacted
the mobile units most frequently related to psychiatric, learning and behavioural
problems. That was followed by family problems and social studies, which is clear
from the fact that over the last years mobile units undertook to carry out social stud-
ies on certain islands in cooperation with the public authorities on Syros. Comparing
the two mobile units, one can see that a higher frequency of requests related to
11 Community Child Psychiatry: The Example of Mobile Mental Health Units 205

learning difficulties in the Western Cyclades, which is due to the fact that this mobile
unit carried out interventions of this type in its first years in operation. However,
over time those interventions were limited in number, thanks to a rise in other types
of interventions, as is clear from a look at the types of requests over time. So it is
clear that in the last 4 years, behavioural problems rose to a large degree as the type
of requests made, as did psychiatric symptoms, since the initial requests differed in
a statistically significant manner in the period under examination (chi-square statis-
tical verification (22) = 148.62, p < 0.001). These phenomena can clearly be associ-
ated with the impact on the socioeconomic crisis on the family.

Special Measures
A Family Clinic opened on a pilot basis on Paros in 2012, funded for the first year by the
Stavros Niarchos Foundation. It offered family therapy from therapists specialised in the
systemic approach. Families were referred here by the Child Psychiatry Department of
the mobile unit and by other community bodies working with children and families.
The need to develop a specialist family therapy programme on islands like Paros
and Antiparos emerged, thanks to increased needs for interventions on multiple
levels for individuals and families, the constantly increasing number of requests
related to the economic crisis and the well-known effectiveness of family therapy in
dealing with child and adolescent mental disorders (Campbell et al. 2003; Carr
2000; Tomaras and Pomini 2007). At the same time, family therapy seeks to improve
the quality of life of the family and support all its members (not just the child/ado-
lescent who has presented some symptoms).
During the first year, 60 sessions were held with families and the intervention
was evaluated. The intervention’s specific goals were (a) to reduce the psychopa-
thology of children, (b) to reduce parental stress, (c) to improve family functioning
and (d) to improve the family’s quality of life.
To evaluate the intervention, the following scales were presented to six families
which took part on the pilot operation of the family clinic (the scales were adminis-
tered at the start and end of the intervention):

(a) Parental Stress Questionnaire (Berry and Jones 1995) to assess parental stress
(b) Family Assessment Device (FAD) (Epstein et al. 1983) to assess family functionality
(c) WHOQOL Bref (WHOQOL Group 1998; Ginieri-Coccossis et al. 2009) to
assess the quality of family life
(d) Strengths and Difficulties Questionnaires (Goodman and Goodman 2009;
Giannakopoulos et al. 2009)

A total of 9–11 sessions were held with each family. The initial results show that
there was an improvement in the level of family functionality, and the symptoms of
emotional disorders and behavioural problems that children and adolescents ini-
tially presented declined, and their clinical picture overall improved. Parental stress
decreased by the end of the intervention, but it appears that there was not a major
change in the quality of the family’s lives. The evaluation process is under way at
present since the Family Clinic is still in pilot mode.
206 S. Pantelidou et al.

The Role of Supervision

A child psychiatry team working in the community needs to follow specific princi-
ples and practices, such as providing services with the maximum therapeutic benefit
in the shortest time period and the least possible cost and ensuring the continuity of
care, availability and the type of treatment approach which the individual or family
is entitled to have.
Another important issue is to ensure accessibility since the layout of the service
must allow for easy access both for users of the service and therapists.
However, the most difficult subject is the principle of dialectical interaction,
which relates to ongoing interaction between the mental health expert and each
community, since he needs to understand cultural values and habits, applied health
policies and the economic and ideological viewpoints they serve, in order to be able
to assess real needs and prepare the corresponding programmes (Madianos 1994).
The child psychiatry team meets the child and the institutions and is required to
synthesise all the relevant types of thinking (medical and therapeutic, psychologi-
cal, pedagogical and institutional) which do not all operate according to the same
rules, and do not all have the same influence, even though they intersect and are
interwoven.
The importance of supervision, i.e. of continuous analysis of the team’s actions, is
vital so that everyone is aware of the difficulties arising from working in the community,
in order to reveal the conscious and unconscious barriers and the synthesis going on. It
is a process which seeks to promote the mutual exchange of information and views and
the sharing and collective processing of day-to-day treatment practice and experience.
In this special setting, the supervisor will need to bear in mind the real conditions
of the setting and balance them out, as well as the needs of the therapists being
supervised, group and community dynamics which give rise to mass projections and
multiple transferences.
Frequently, in difficult situations where the case is severe or the bodies involved
face specific difficulties, it is easy for the institution to be considered as the only,
undisputed objective value and for members to adopt “easy” solutions such as the
suggestion of hospitalisation without adequate interaction with the child/adoles-
cent’s support network, or a shift in treatment responsibility to another specialised
service in an urban centre, or for there to be divided opinions between therapists
about the type of treatment or competition between institutions.
It is clear from this how essential supervision is as a complex process of learning
and education, which can provide greater awareness of the counter-transference
emotions of the therapists, as a meeting, as a body of experience and as a “space”
for analysing and bringing together the child’s and family’s narrative in the social
setting they belong to.

Assessment and Recording of Needs

It is important for the plan to deploy mental health services to be based (a) on epi-
demiological data about the prevalence of mental health problems that children and
11 Community Child Psychiatry: The Example of Mobile Mental Health Units 207

adolescents face and (b) on the assumption that each problem must be explored by
taking into account the cultural, geographical, social and family environment of the
child (Grimes 2004).
The methodology employed over the 10-year period the mobile units have been
in operation to assess and record needs includes the following:

Focus groups with teachers within schools. These groups discuss issues relating
to child and adolescent behavioural problems as seen at school, cases of
school violence and cases of possible neglect – abuse – and record teachers’
requests to mobile units for support to manage such problems. After the
groups are finished, needs and requests formulated by teachers are officially
recorded.
Meetings with other professionals working with children in the community: paedia-
tricians, speech therapists, occupational therapists and social workers (at health
centres or social services) during which an empirical picture of needs in terms of
mental health problems and the social problems faced by children and adoles-
cents is obtained.
Systematic analysis of data relating to the reason why children and adolescents and
parents have come to the units and the psychosocial profile of people receiving
services from the mobile units.
Needs are recorded for this age group, especially via research activities which
have been carried out over recent years in the context of how the mobile units
operate. For example, on Paros a study was carried out to assess the preva-
lence of common mental disorders on 323 adolescents at the island’s two
high schools (among 16–18 year olds). The study was carried out in 2007 in
cooperation with the Psychiatry Department of the University of Ioannina
Medical School and is part of a wider epidemiological study on a sample of
5614 adolescents from schools in Epirus, Etolo-Akarnania and Attica
(Skapinakis et al. 2011; Magklara et al. 2010, 2012). For Paros in particular,
the key finding was that the prevalence of depression among adolescents who
participated in the study was 12.7 % (the figure was almost twice as high in
girls as in boys (OR = 7.12, CI = 3.42–14.82). The highest percentage was
noted in students in the final year of high school and in students whose per-
formance was average (OR = 4.31, 95 % CI = 0.97–19.13). A high positive
correlation existed between reported victimisation in cases of school vio-
lence and the onset of depression (OR = 3.47, 95 % CI = 1.04–11.63). The use
of cannabis also positively correlated with depression (OR = 4.23, 95 %
CI = 1.29–13.89).

The general results of the nationwide study found that 32 % of adolescents

have symptoms of psychological stress (42 % of girls and 20 of boys, p < 0.01)
and there was a statistically significant correlation between mental health and
the subjective assessment of the family’s economic difficulties (Μagklara
et al. 2010 ). It was also found that the likelihood of the onset of suicidal
ideation was higher for adolescents who reported that they were victims of
208 S. Pantelidou et al.

school violence especially when it happened weekly and that finding is inde-
pendent of the existence of any psychiatric symptoms (OR = 7.78, 95 %
CI = 3.05–19.90).

Mental Health Prevention and Promotion Actions in Cooperation

with Community Bodies

As part of their operations, the mobile units place particular emphasis on developing
mental health prevention and promotion measures in the community (Pantelidou
and Stylianidis 2009). Just some of these are listed below:

In the period 2011–2013, a special 2-year programme was implemented to pro-

mote the mental health of children and adolescents funded by the Stavros
Niarchos Foundation. During the programme groups were run for parents,
teachers at all levels and adolescents on the Cyclades (within the remit of the
mobile mental health units operated by the Regional Development and Mental
Health Association). More than 900 people took part in the programme over the
2 years.
The aim of the monthly parent groups was to brief them about child and adolescent
mental health problems, improve communication and parent-child relations, sup-
port them in their parental role, identify child and adolescent mental disorders in
good time and refer them to specialised services.
Likewise, teacher groups were also held monthly, and they were able to learn about
child and adolescent mental health issues so that they could recognise behav-
ioural problems and emotional difficulties in good time. Particular emphasis
was placed on communication between the school and family, on supporting
them in organising actions to promote child and adolescent mental health at
school and on prevention measures and measures to address school bullying.
During the 2 years of the intervention, supervision groups for teachers were also
in operation.
Support groups for adolescents were also run twice a month as well as a theatrical
play workshop to promote mental health.
All special measures at schools included frequent meetings with teachers in
order to ensure cooperation in supporting children with mental health prob-
lems and in dealing with cases of school bullying. In addition, special mea-
sures were taken to address the stigma of mental illness at school and
workshops held to prevent school bullying for primary school pupils. Other
special measures included organising workshops for teachers in cooperation
with the Theseus Centre for the Prevention of Use of Addictive Substances in
the Cyclades and the Prefecture of the Cyclades Health Prevention and
Promotion Network based of Syros. The workshops held over the last 2 years
were focused on prevention and dealing with problems of behaviour in the
classroom and on prevention and managing cases of child abuse and
victimisation.
11 Community Child Psychiatry: The Example of Mobile Mental Health Units 209

In cooperation with health centres on the islands, training courses were held for
paediatricians, GPs and rural doctors, to enable them to identify child psychiatric
disorders in good time and refer them.
A total of ten workshops are held a year on the islands covered by the mobile units
featuring theoretical presentations and experiential seminars to brief parents and
teachers about child and adolescent mental health issues.

All these measures were implemented in cooperation with community bodies,

especially schools, health providers and social services, with the support of local
government and the Southern Aegean Region.

Preventing and Dealing with Child Abuse

Over recent years, because of the increase in requests for intervention in cases of
child abuse and neglect, particular emphasis has been given to the development of
measures to prevent and address those cases. In the 3-year period 2010–2013 in par-
ticular, experts at the mental health units dealt with 40 cases of child abuse. In coop-
eration with the Public Prosecutor and the competent community bodies in Syros and
in Athens, social studies were carried out by social workers from the mobile units,
and specialised intervention plans were drawn up to support the children and their
families. Special educational seminars were organised to raise awareness among the
police, so that they could suitably handle such cases, and special workshops have
been held for teachers and doctors to brief them about how to identify such cases,
how to suitably intervene and about the statutory framework. Cooperation with
schools and community bodies was also important in developing the treatment plan.
Working groups have also been set up with all local bodies on the islands (health
services, social services, public authorities, educational bodies) in cooperation with
the Ombudsman and Children’s Ombudsman, to provide better liaisons with bodies
so as to more effectively manage cases of child abuse and neglect.

11.6 Conclusions: Challenges and Prospects

In light of these points, it is essential to adapt how the community child psychiatry
services provided by mobile mental health units are run in geographically remote
areas to the new social and economic circumstances and the emerging needs in each
community.
The challenge when faced with a lack of resources and the lack of consistency in
institutional terms from the Greek state is to bolster the inventiveness of the multi-
disciplinary team in its dealings with local networks to implement innovative initia-
tives to deal with the complexity of requests for treatment and with societal demands.
In terms of secondary prevention, the importance of timely intervention in popu-
lations at high risk of developing mental disorders is well documented. Studies
show that children with parents with severe mental disorders are vulnerable to the
210 S. Pantelidou et al.

development of emotional, behavioural, social and learning difficulties due to the

simultaneous impact of genetic, environmental and psychosocial factors (Royal
College of Psychiatrists 2010). Consequently, it is important to develop interven-
tions targeted at parents with such problems and their children.
To that end, emphasis needs to be placed on interventions aimed at vulnerable
population groups which are more affected by the economic crisis, who also have
difficulty in accessing services: families with severe economic problems and unem-
ployed parents, families of migrants, children who have been abused, children of
parents with severe health problems and single-parent families (Tsiantis and
Asimopoulos 2009; Reiss 2013). Specialised programmes relating to these popula-
tion groups are expected to be launched soon on Andros as part of the operations of
the NE Cyclades mobile mental health units, funded by the Moraitis Foundation.
These programmes will include prevention actions and interventions at family and
individual level (by setting up a Family Clinic).
Over recent years, research has also focused on identifying the qualitative
criteria that ought to govern how community-oriented child psychiatry services
operate (Bickman 2008; Warren et al. 2010). One key issue in increasing the
quality of care provided is to ensure the commitment of children and families to
treatment, since studies stress that a percentage of around 40–60 % terminate
treatment at community services early (high dropout) (Gopalan et al. 2010). To
that end it is vital to train mental health professionals on evidence-based treat-
ment choices and to integrate research methods to evaluate the services provided
(Glisson et al. 2010).
Finally, it is necessary to extend mental health promotion measures for children
and adolescents, via special programmes aimed at the general population and vul-
nerable groups, which could be implemented in cooperation with educational bod-
ies and community health providers (Hoagwood et al. 2001; Hooven et al. 2011)
and in cooperation with bodies from abroad which have implemented and evaluated
similar actions already.

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A Modern-Day Community Daycare
Centre in Operation 12
Stelios Stylianidis and Dimitris Trivellas

Abstract
This chapter presents the complexity of definitions for and operations of a day
hospital and a daycare centre, their historical development within social psychia-
try and the main features of a well-designed framework for running and operating
such structures. Those features include a multidisciplinary team and the use of
mental institution, case management, psychotherapy interventions, psychosocial
rehabilitation and recovery programmes as well as the essential networking of
services offered. A detailed presentation of the Franco Basaglia Daycare Centre
run by the Rural Development and Mental Health Association in the Northern
Suburbs of Athens highlights the need for a change in the biomedical paradigm,
as well as the clinical, institutional and theoretical prerequisites for avoiding the
phenomena of chronicity and neo-institutionalisation in the community.

12.1 Introduction

For many years, the well-established thinking in the mental health sector was that
serious mental illnesses unavoidably worsen and become chronic. The practice
which was based on that perception was that professionals focused on only manag-
ing the psychopathology and the symptoms. Over time a wider perspective focused
its interest on a new approach which singled out the effectiveness of outcomes and

D. Trivellas (*)
Psychiatrist, Day Centre EPAPSY Scientific Assistant, 1st Department of Psychiatry,
Eginition Hospital, University of Athens, Athens, Greece
e-mail: [email protected]
S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 215

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_12
216 S. Stylianidis and D. Trivellas

patient care, in addition to the clinical side of things. Functionality in assuming

social roles, in relationships, in work and in leisure, in quality of life and in family
burden all became areas of major interest (Rössler 2006; Lieberman et al. 2008).
Empirical data and narratives direct from the mouths of patients now support
the idea that recovery is possible (Farkas et al. 2007; Anthony 2000; Deegan 1988).
The recovery model includes elements of acceptance of the illness, hope for the
future and the search for renewable self-meaning and a different identity. Recovery
cannot be understood as a static process or end result, nor is it the same as treat-
ment; instead it is a life process which involves successive steps at different stages
of life. Viewed from this perspective, it can be seen more as an attitude towards life
or lifestyle, as a feeling, a vision or an experience. In recovery-oriented services,
people are supported as they develop and implement their own personal recovery
plans, are encouraged in their personal preferences and are allowed to move ahead
while accepting uncertainty and potential risks (Stylianidis et al. 2013).
According to the WARP Declaration, psychosocial rehabilitation methods
include ways of organising services to maximise the continuity of care, treatment
and integrated interventions that foster the abilities of individuals and ameliorate the
excessive pressure they are under, so that it is possible to avoid relapses and to pro-
mote optimum economic and social involvement. It is a joint effort between profes-
sionals and service users aimed at transforming the social roles of service users.
Psychosocial recovery seeks to reduce stigmatism and disability, promotes equal
opportunities and aims to help individuals fully enjoy their rights (WHO 1996).
Continuing day treatment (CDT) programmes focus on community stabilisation
through comprehensive individualised rehabilitation and provide a unique level of
care. CDT programs promote recovery through a variety of practical clinical thera-
peutic interventions. They are designed to “maintain or enhance current levels of
functioning and skills, to maintain community living, and develop self awareness
and self esteem through the exploration and development of strengths and interests”
(Handa et al. 2009).
The aim of psychosocial rehabilitation at a daycare centre is to help individuals
with persistent, serious mental disorders develop the emotional, social and cognitive
skills they need to live, learn and work in the community with the least possible
support from professionals. Without denying the existence and effect of the mental
illness, psychosocial rehabilitation changes the way in which the illness is
approached (Rössler 2006).
Although the majority of individuals in psychosocial rehabilitation programmes
have been diagnosed with schizophrenic disorder, other groups of patients with psy-
chotic and nonpsychotic disorders also make up the population rehabilitation is
aimed at. According to a 2009 study in the USA, serious mental illness relates to
4.8 % of the adult population, while in the age group 18–25, it relates to 7.3 % of
the population and rises to 9.1 % in adults living in poverty (Substance Abuse and
Mental Health Services Administration 2012). All patients suffering from serious
mental disorders need rehabilitation. The core group includes patients with persis-
tent psychopathology, major instability, frequent relapses and difficulties in social
integration (Rössler 2006).
12 A Modern-Day Community Daycare Centre in Operation 217

12.2 Definitions

Psychosocial recovery programmes designed to offer daycare come under many

different names. Partial care programmes, psychosocial programmes, daycare cen-
tres, social clubs, day hospitals or daycare units are just some of the terms fre-
quently used. The situation is complicated further since structures with the same
name differ considerably. In their endeavour to offer effective services, programmes
develop and incorporate elements from different structures and innovative practices,
which to a certain degree justify their diversity (Pratt et al. 2007).
Day hospitals or daycare units have been described as hospitals without treat-
ment beds, as a structure which provides medical follow-up and a series of leisure
and skills-cultivation activities (life, social and professional skills) to individuals
who need intensive, short-term support, as an alternative to inpatient treatment or as
a continuation of care after a period of hospitalisation has ended. They are aimed at
the general population, which includes persons recently hospitalised, those in crisis
who would otherwise need to be hospitalised and those suffering from chronic and
serious mental disorders (Torrey and Fisher 1998). The term “day hospital” incor-
porates a heterogeneous set of mental health services, reflecting multiple functions
and goals, even within the same organisation. That fact can be seen as an attempt to
respond to multiple needs and as an inability to clarify its role in the spectrum of a
modern social network for providing mental health services (Briscoe et al. 2004;
Wilson 2008). The confusion in definitions has been confirmed in practice by
researchers who have not identified differences in the symptoms of patients in hos-
pitals and daycare centre examined and proposed two terms which could be used in
the alternative (Holloway 1991; Briscoe et al. 2004). Research at a day hospital in
Great Britain showed that a small percentage of available spaces were being used as
an alternative solution to inpatient treatment. The majority of places were being
used for “rehabilitation”, but almost half of the patients with psychotic disorders
only received general support. Those patient’s needs could have been addressed by
a daycare centre (Mbaya et al. 1998).
To more clearly define the content and role of complementary services necessary
for a comprehensive care network, the literature has proposed, as distinction be
drawn between day hospitals dealing with acute cases as an alternative to admis-
sion, transitional day hospitals to reduce the length of hospitalisation, daycare cen-
tres for rehabilitation and stabilisation and day treatment programmes to support
outpatient treatment (Marshall et al. 2001).
It is important to distinguish day hospitals from daycare centres, whose primary
aim is to provide social support to individuals with chronic and persistent mental dis-
orders and to promote rehabilitation, social integration and recovery (Ives 1975). In
the view of both those who receive services and those making referrals, day hospitals
offer short-term, more intensive “treatment” in acute cases that need close follow-up
of mental health. Daycare centres are perceived as a structure that offers more long-
term psychosocial support to individuals with more resistant and longer-term prob-
lems, who are normally suffering from psychotic disorders (Catty et al. 2005).
218 S. Stylianidis and D. Trivellas

Service users at daycare centres acting of their own accord as “volunteers” plan,
choose and implement a series of activities and participate in and enjoy a social
experience. As transitional structures, daycare centres promote liaisons with the
family and social environment, so that they function and serve as a place aiding the
return to normal living and working conditions.
Daycare centres can be divided up depending on the population they are aimed at:

Daycare centres for individuals with mental disorders or serious psychosocial needs
which include:
(a) Daycare centres for children and adolescents
(b) Daycare centres for adults
Daycare centres for individuals with autism spectrum disorders
Daycare centres for sufferers of Alzheimer’s disease and related disorders (Guide
for organising and running daycare support and follow-up centres/PSYCHARGOS
Phase II 2005)

Social clubs are a different model of psychosocial rehabilitation. They are organ-
ised by their members, offer a meeting place for socialising and function indepen-
dently of the mental health system and may offer leisure, education, work
opportunities, support on housing issues and other services the members decide on.
The philosophy and development of the social club model is described in more
detail in the following section (Novotny 2011).

12.3 Historical Development

Partial hospitalisation and social clubs are two different historical approaches that
date back to the early movement that eventually led to modern-day all-day psycho-
social rehabilitation programmes.
In the USSR in the 1930s, Dzhagarov, director of the Moscow Psychiatric
Hospital, introduced the concept of partial hospitalisation. A number of patients at
the hospital returned home in the evening. This innovation may have been prompted
by increasing demands and limited resources, and Dzhagarov noted that the results
of partial hospitalisation were similar to those of traditional hospitalisation.
Industrial therapy was the basis of partial hospitalisation. In 1946 the first daycare
centre in the Anglo-Saxon world opened in Montreal, Canada, to encourage social
life. Attendance at the programme during the day and the return home in the evening
was similar to being absent at work and did not cut the individual off from aspects
of his day-to-day life (Cameron 1947). That was followed a short time later by the
first day hospital in England aimed at patients who needed support after being dis-
charged from hospital (Bierer 1948). One of Bierer’s innovative ideas was to ame-
liorate the mass psychotic transference by setting up a multidisciplinary team
(Chevallier-Fougas 2009). Similar structures were also in operation in the USA at
that time at Yale University and the Menninger Clinic (Barnard et al. 1952). The first
day hospital opened in Paris, France, in 1962 (Hôpital de jour de l’Élan). The
12 A Modern-Day Community Daycare Centre in Operation 219

director, Prof. Sivadon, influenced by the ideas of Bierer had initially set up a mul-
tidisciplinary team within his department which transformed into a treatment and
social reintegration centre. Professional reintegration was the main aim of Sivadon’s
efforts (Bleandonu and Despinoy 1974). Early programmes took a psychiatric
approach and placed emphasis on individual and group therapy and expressive ther-
apies using art. They predated the deinstitutionalisation movement and were aimed
at less burdened patients, compared to those for whom asylum-based treatments
were reserved (Pratt et al. 2007; Mak 1994). In the 1960s the closure of large hospi-
tals in the USA led to a boom in daycare programmes, with an emphasis on
deinstitutionalisation.
In the 1940s former patients from the Rockland Psychiatric Center in New York
set up a self-help group. In 1948 private resources were secured to house their
endeavours in a building named Fountain House, which was a social meeting and
support venue for its members, which operated outside the mental health system
and became known as a social club. Participants were members, not patients, and
remained for as long as they wanted, as is the case with any club. The initial aim
was to improve the quality of life and satisfy basic needs, like housing, work,
socialisation and leisure. As the club expanded, its members decided in 1955 to
engage professionals without changing the atmosphere and philosophy of their
endeavour. The basic principles governing the venture, which were later adopted
by modern rehabilitationists, were an emphasis on the important role of individuals
and their own responsibility for their own life in the rehabilitation process, recog-
nising their abilities and right to live a normal life, and the value of voluntary par-
ticipation. The way in which Fountain House operated met the basic human needs
of belonging to a community and being productive. The emphasis on work was
provided both in the club via teams responsible for caring for the space, cleaning
and preparing meals and by placing members in jobs in the community with the
support of the club’s staff. Fountain House was the inspiration for the development
of the social club model. In the 1970s there was a national training programme
based on this approach, and 10 years later the model expanded abroad with similar
structures being developed in many countries (Raeburn et al. 2013; Edward 1994;
Warner 2006).
The first daycare centre opened in Greece in 1971 at the Thessaloniki branch of
the Mental Health and Research Centre. It was followed by the first day hospital in
1978 (Mantonakis et al. 1994) and in 1984 came the psychosocial rehabilitation unit
of the Vyronas-Kessariani Community Mental Health Centre (Madianos 2005),
operating under the aegis of the University Clinic of the Eginition Hospital.

12.4 Theoretical Model

Work in a daycare centre requires the integration of different psychotherapy models

to meet the individualised needs of the person and promote social integration in line
with the principles of psychosocial rehabilitation and recovery. It requires a combi-
nation of strategies aimed at developing skills which allow interaction in a stressful
220 S. Stylianidis and D. Trivellas

environment and strategies to mobilise resources and change the environment, mak-
ing it more facilitative and supportive for patients to gradually become
autonomous.
Milieu therapy, CBT techniques, psychodynamic understanding and family and
psychoeducational interventions enrich the theoretical armoury of the multidisci-
plinary team at the daycare centre. The modern outlook dictates that we develop an
approach that integrates different psychotherapy schools and techniques bearing in
mind the complexity of patient needs and the coherent use of case management in
the context of how the multidisciplinary team works.
Milieu therapy relates to a supportive interpersonal environment which teaches,
creates standards and bolsters healthy interaction between individuals. The term
was introduced by A. Aichom in the early twentieth century (Shorter 2006). From
the viewpoint of milieu therapy, any interaction between members and staff con-
tains the therapeutic potential for self-awareness and the adoption of new, more
functional ways of interacting and negotiating. It is inspired by the assumption
that an individual’s difficulties are born and expressed in their relations with other
people. Each interaction ought to help create an environment of mutual trust,
respect and support. Gunderson (1978) described five key elements of milieu
therapy:

(a) Containment (the sense of support and control from the environment)
(b) Support
(c) Structure (an organised and predictable environment)
(d) Involvement (participation and integration into the environment)
(e) Reassurance (confirmation for the individual from his environment)

Washburn and Conrad (1979) proposed another element, negotiation, referring to

the process of intermediation whereby members and staff set targets and devise a
treatment plan (Pratt et al. 2007).
The therapeutic community is a small, cohesive community where members
have a high degree of involvement in decision-making and the practical running of
the unit. Based on the ideas of collectivity and empowerment, the ability for each
one to enjoy his rights as a citizen, therapeutic communities are structured to encour-
age personal responsibility and to prevent dependence on professionals. Members/
patients are viewed as sources of strength and creative energy for the treatment
framework, and equality in relations within the team is considered to be the basis for
a strong therapeutic relationship. Horizontal hierarchies and collective decision-
making can wrongly be seen by some external observer as chaotic functioning of
the group, but the staff of modern-day therapeutic communities are aware of the
need for strong leadership and their responsibility for providing a safe framework
for therapeutic work (Association of Therapeutic Communities 1999). The practice
of therapeutic communities aims to be something more than a mere framework
hosting patients with serious disorders who happen to be in therapy. In 1960 in his
work Community as Doctor …, Rapoport described four principles which define
work in the therapeutic community (Dickey and Ware 2008):
12 A Modern-Day Community Daycare Centre in Operation 221

Table 12.1 Therapeutic community principles

Origin in Culture in a Structures in Rapoport’s original
Theoretical principal development community a community community themes
Attachment Primary Belonging Referral,
bond, losses joining,
as growth leaving
Containment Maternal and Safety Support, Permissiveness
paternal rules,
holding boundaries
Communication Play, speech, Openness Groups, Communalism
others as ethos,
separate visitors
Involvement Finding a Living-learning Community Reality
place among meeting: confrontation
others agenda and
structure
Agency Establishing Empowerment Votes, Democratisation
self as seat of decisions,
action seniority
From Haigh (1999: p. 257). Source: Haigh (1999, p. 257)

(a) The principle of democratisation

(b) The principle of permissiveness
(c) The principle of communalism
(d) The principle of reality confrontation

Later, Haigh (1999) attempted to define the substance of milieu therapy. He

described five key qualities and presented them as a continuum, associating them
with developmental stages, culture and structures of a community which adopts and
serves them. The table above correlates these to Rapoport’s principles cited above
(Campling 2001) (Table 12.1).
The psychoanalytical perspective helps us attribute meaning to what we are
doing in each moment both for the patient and in terms of organisation, administra-
tion and team work and the relationship between the institution and the community
itself. What models could provide guidance and what metaphorical references could
be used to provide care? Winnicott’s holding, Bion’s containment and the concepts
of attachment have already been associated with the running of a therapeutic com-
munity (see the table above). The protective sheath that involvement at the level of
therapy techniques with the patient’s actual body offers must not be ignored espe-
cially in pathologies which are exceptionally regressive. Talking therapies provide
us with resources for action and, according to P.C. Racamier, are acts which give
meaning and which talk to the patient, his family, staff and the team more widely
speaking.
The psychoanalytic literature on the theoretical understanding, technique and
treatment of psychosis is very significant and useful. It includes not just the classic
authors (S. Freud, P. Federn, O. Fenichel, M. Klein, K. Abraham, D. Winnicott,
222 S. Stylianidis and D. Trivellas

S. Arieti, M. Balint), the British Kleinian and post-Kleinian school of object rela-
tions (W. Bion, H. Rosenfeld, H. Segal, B. Joseph, B. Hinshelwood, J. Steiner,
N. Symington, J. Gottstein) and the contribution of French social psychiatry (psy-
chiatry without a couch) which developed after WW II (J. Hochmann, P.C. Racamier,
S. Lebovici, R. Diatkine, M. Bouvet) (Hatzistavrakis and Sakellaropoulos 2010).
The contribution of psychoanalysis to applied social psychiatry is explored in more
detail in the relevant chapter.
The need to refer to a theoretical model which gives meaning to the work and
identity of the therapeutic team was stressed by J. Hochmann (2003a), a theory
which he calls mental institution. It starts off from the risk of the asylum being
reborn within the modus operandi of new community structures which were
intended to abolish the asylum. The source of the rebirth of the asylum function lies
in the “fear of madness” which is attributed to feelings of being invaded, of empti-
ness and of futility born from contact with psychosis. Those feelings are probably
responsible for the tendency of the person to defend his mental space from the
group of patients using artificial boundaries and distinctions, to avoid therapeutic
activism, and for the prevalence of a type of anti-thinking which paralyses the struc-
ture and makes it appear to be an imitation, a parody of life, dominated by stereo-
types and the bureaucratic handling of relationships (Hochmann 2003a).
J. Hochmann understands psychosis primarily as a defence rather than as a defi-
cit or failing. The task of the preconscious, thanks to which we can think and also
envisage what we are perceiving, is the transformation and representation of stimuli
and unification of stimulus with the representation. Bion (1955) introduced beta
elements to describe the clear sense that has not been reproduced by the sensory
organs and alpha elements for those transformed in such a way that they are recog-
nised by consciousness. Transformation takes place in the preconscious of the
mother where the child projects unprocessed materials. Through reveries the mother
associates and favours the projections, which are returned to the child in an accept-
able form. Through those representations of an object, the preconscious of the
child – his own alpha function – is formed. Following that approach, it is considered
that in a psychotic function the preconscious is reversed in structure, causing frag-
mentation in relationships, attacking connections, projecting and fighting symbols,
instead of connecting, introjecting and symbolising.
The psychoanalytical theoretical approach, described by J. Hochmann, leads him
to a view of care where through daily interventions he attempts to modify the pre-
conscious’ defences and function. He considers care to be a mental activity whose
object is to put the activity of thinking, the associative process, back into operation.
That attempt may be made via numerous transactions, whether verbal or nonverbal,
structured in the form of psychotherapy, or through day-to-day activities like play,
hobbies or a shared meal. The therapeutic process begins when these transactions
place priority on the symbolic aspect. The cognitive substrate, whether explicitly
expressed or not, exists as a fantasy in the therapist’s thoughts, pleases him, gives
him meaning and satisfies him since it associates the events and builds a single
story. Intellectual processing within the therapist presupposes the existence of a
model he can refer to. For the therapist this interplay with the model is equivalent to
12 A Modern-Day Community Daycare Centre in Operation 223

the mother’s reveries, when she transforms beta elements into alpha elements. It is
an “alchemy” which occurs in the mind of the therapist and resembles the pleasure
which he receives when he communicates a clinical case to colleagues or to his
supervisors (Hochmann 2003b).
The cognitive model of psychotherapy on the other hand applies the initial ideas
of Beck to understanding and treating psychosis (Beck et al. 2009). In this model,
the way in which we interpret facts affects the way in which we feel and behave.
These interpretations are frequently maintained by unhelpful thoughts, prejudices
and behavioural reactions and are affected by core beliefs which are formed as a
result of life experiences. Various cognitive models of psychosis and psychotic
symptoms or experiences have been developed by writers such as Chadwick, Garety
and Morrison who argue that the way people interpret psychotic phenomena rather
than the psychotic experiences themselves cause a sense of malaise and disability
(Morrison 2008). Cognitive-behavioural therapy (CBT) is proposed as an effective
way of dealing with the symptoms of schizophrenia, particularly in patients with
persistent symptoms, coupled of course with suitable medication. The extent of the
effectiveness of this approach has been explored in later studies (Jones et al. 2012;
Jauhar et al. 2014).
According to Beck, cognitive therapy cannot affect the basic neurophysiologi-
cal predisposition or vulnerability involved in schizophrenia, but can modify the
resulting dysfunctional beliefs and consequently provide better protection from
stress. Psychotherapy and medication can ameliorate overactive cognitive sche-
mata and free up resources for further control of reality (cognitive compensation)
(Beck et al. 2009).
Negative beliefs about oneself, the world and others (such as “I am vulnerable”,
“other people are dangerous”), and beliefs which reinforce the adoption of paranoia
as a strategy for managing interpersonal threats, are associated with psychosis.
From the cognitive viewpoint, psychosis may be seen as a primary physiological
experience with comprehensible consequences for the emotions and behaviour,
consequences which are due to evaluation and handling of those experiences and
not as an illness. Destructive or negative inferences drawn from experiences cause
burden and a sense of malaise. It has been assumed that cognitive and behavioural
responses, such as selective attention, repressing thoughts and safety behaviours,
preserve psychotic experiences and the consequent burden (Jauhar et al. 2014).
The theory of social learning and the study of behaviour have significantly
affected the development of psychosocial rehabilitation programmes. The function-
ality of patients with schizophrenia and their quality of life is significantly degraded
because of difficulties that they have in social contact. The social deficits in patients
with schizophrenia include difficulty in starting and keeping a conversation going
and an inability to achieve goals or satisfy needs in situations which require social
interaction. These difficulties significantly reduce their ability to respond in adult
roles. Poor social functionality and stigmatising experiences in the past, coupled
with stress in social contexts, contribute to social isolation and inadequate social
support which in turn limit the individual’s ability to develop and improve his social
skills.
224 S. Stylianidis and D. Trivellas

The social skills model offers a different perspective on how to approach social
functionality. In this model, adequate social interaction is based on a set of three
constitutive skills: (a) social perception or inference skills, (b) social cognition or
processing skills and (c) behavioural response or expression skills (Liberman 2008;
Vyskocilova and Prasko 2012).
The use of the term “skills” stresses the view that social interaction is based more
on a set of learned abilities than on any fixed features, needs or internal processes.
The relevant literature and research data argue that behaviours can be modified
through experience and learning. So learning social skills is a structured educational
process which can use teaching guidelines, imitation of models, breaking skills
down into their component parts, role play and positive social support in order to
teach social behaviour (Jauhar et al. 2014).

12.5 Features of How Daycare Centres Operate

The Space: The Infrastructure

The daycare centre must allow groups to be held and numerous day-to-day activities
to be carried on in parallel. In addition, it must ensure privacy for one-to-one meet-
ings. It is essential for the centre to have adequate space for all members and staff
to meet, ancillary areas for preparing meals, etc. Adequate lighting, ventilation and
heating, security and cleanliness are all conditions for a therapeutic space being
suitable. It is also important for the centre to be sited within the fabric of the com-
munity and for it to be easily accessible by public transport (Pratt et al. 2007).

Staff

The daycare centre’s scientific officer plays a critical role. He is responsible for
annual planning, organising and ensuring the problem-free running of the centre.
His duties include being responsible for organisation, continuing training, evalua-
tion of staff and services provided and for drawing up the annual report on evalua-
tion of the unit which is submitted to the management body to check if targets set
have been met. Along with the multidisciplinary team, he prepares the overall
schedule and the individual treatment plans for each attendee. He is also responsible
for co-ordinating and implementing the work of the multidisciplinary team (Guide
for organising and running daycare support and follow-up centres/PSYCHARGOS
Phase II 2005).

The Multidisciplinary Team

The creation of multidisciplinary teams was proposed since different approaches to

therapy by professionals from different areas of specialisation are required to meet
12 A Modern-Day Community Daycare Centre in Operation 225

the needs of mental patients. Psychiatrists, psychologists, psychiatric nurses, social

workers and industrial therapists comprise the multidisciplinary team.
Multidisciplinary team working is described by Jefferies and Chan (2004) as:“the
main mechanism to ensure truly holistic care for patients and a seamless service for
patients throughout their disease trajectory and across the boundaries of primary,
secondary and tertiary care”.
Carrier and Kendall (1995) described a team as “a group of people with comple-
mentary skills who are committed to a common purpose, performance goals, and
approach, for which they hold themselves mutually accountable”.
The research evidence supports multidisciplinary team working as the most
effective means of delivering a comprehensive mental health service to people with
mental health problems, especially those with long-term mental health problems
(Tyrer et al. 1998).
It is not just a matter of getting different mental health professionals together and
magically multidisciplinary team working happens. Teams need to have shared
goals and values, need to understand and respect the competencies of other team
members, need to learn from other disciplines and need to respect their different
views and perspectives.
Multidisciplinary teamwork and support from colleagues is often cited as an
important source of reward to team members (Onyett and Ford 1996). While many
multidisciplinary team members experience the work as demanding, job satisfac-
tion and personal accomplishment tend to be high (Carson et al. 1991; Onyett et al.
1995).
The advantages to mental health professionals of multidisciplinary working
include:

(a) Close-knit peer support for all health professionals and consideration for the
complex and sometimes distressing clinical work to be done, i.e. involuntary
admissions, violence, suicide, etc.
(b) Division of labour to ensure multidisciplinary service delivery, i.e. ensuring that
all “biopsychosociocultural” components of intervention and care are
delivered
(c) Ensuring that all members of the multidisciplinary team are used in a way that
is maximally effective, i.e. service users who need a specific input/skill set can
have access to that immediately, rather than having multiple assessments
(d) Cross-fertilisation of skills between professionals (Hoult 1986)
(e) Multidisciplinary peer review of all casework at team meetings
(f) Staff acquire new skills, participate in decision-making and take on more
responsibility leading to increased job satisfaction (Onyett and Smith 1998)
(g) Delivering services that are planned and co-ordinated (Ovretveit 1993)
(h) Delivering services that are cost-effective (Knapp et al. 1994)
(i) Enhancing information sharing and streamlining work practices (Hornby1993)

Working in teams also presents challenges to the mental health professionals

involved and the mental health services, particularly around management,
226 S. Stylianidis and D. Trivellas

leadership, confidentiality and conflict management and resolution. Creative ten-

sion between disciplines can easily give rise to conflicts between them (Norman and
Peck 1999). Team members typically place varying degrees of emphasis on the
distinct elements of the biopsychosocial model of mental health and ill health
(Hannigan 1999), so much so that there may be divisive debate about treatment
approaches (Norman and Peck 1999). Hence, clear mechanisms for conflict resolu-
tion are required (Onyett et al. 1997; Byrne 2005), preferably through multi-
professional consensus. Recognition of some authority structures to resolve
disagreements may be required (Burns 2004). Having such clear mechanisms may
in and of itself predispose to less conflict (Onyett et al. 1997).

The Services Provided

In close cooperation with other units in the sector, the daycare centre provides care
and treatment on an individual, family, group and community level. According to
the Guide for organising and running daycare support and follow-up centres/
PSYCHARGOS Phase II, these services are primarily those listed below:

Needs assessment, preparation and implementation of individualised care and reha-

bilitation plans
Treatment interventions at individual and group level, with emphasis on training in
social and individual skills
Developing and promoting professional skills to promote employment and integra-
tion into the labour market
Preparing meals and catering for beneficiaries
Leisure and cultural activities
Running a social club
Family support programmes and special treatment interventions (such as
psychoeducation)
Training courses for staff and new professionals
Ongoing evaluation of activities and corresponding research activities
Community info programmes to address social stigma and prejudice associated
with mental disorders

Services are planned by the scientific officer and multidisciplinary team and
cover a 6-month period. Depending on the type of service, they are offered at indi-
vidual and/or group level, at the daycare centre’s facilities or elsewhere, with each
member participating in selected activities for a specific time, based on the individu-
alised care plan. Preparation, implementation and evaluation of the plan must take
into account interventions relating to the individual himself which are being imple-
mented at other mental health units (such as mental health centres, the psychiatric
department of the general hospital, etc.). To that end, the multidisciplinary team
cooperates closely with other mental health units to jointly prepare an individual-
ised care plan which needs to be unique and uniform for the entire sector. In areas
12 A Modern-Day Community Daycare Centre in Operation 227

where there are no other mental health services, the daycare centre can meet the
psychiatric follow-up needs to patients and implement treatments provided staff in
the relevant areas of specialisation exist.
Case management plays an important role here, not just in co-ordinating and
integrating mental health services but in mobilising community resources, in sup-
port for housing, work and other aspects of the individualised care plan, as described
in detail in the section below.

12.6 Case Management

Case management is considered to be a relatively old methodological tool for organ-

ising community mental health services. In Greece this methodology is not widely
used in a systematic way and has not been widely evaluated, despite similar con-
cepts being described in the Greek literature: individualised care plan, individual
treatment plan and co-ordination and integration of community mental health ser-
vices. However, these have not been clearly formulated, other than in general prin-
ciples of social psychiatry, both in relation to the theoretical model which dictates
case management and the specific targets it sets, in order to be implemented and
evaluated in the context of how the multidisciplinary-interdisciplinary mental health
team which intervenes at various community units operates: daycare centres or day
hospitals, ACT units or outreach teams or mobile units, as described in the relevant
chapters of this book.

Theoretical Model and Principles

Parsons’ (1977) model organises the information the team collects into the follow-
ing levels: (1) values, (2) processes and (3) interactions. This model presupposes
that each organisation is defined by a continuous feedback loop. The values create a
frame of reference for actions. Procedures are the means for implementing actions.
Interactions are the effects actions have on the environment. In a two-way manner,
these interactions have an impact on the frame of reference and in turn modify the
values.
For example, (1) the asylum model’s basic principle was to promote the “good”
of the ill person and to “protect” him, even though that meant sacrificing his auton-
omy. In “benign” cases of asylums, the institution had to do everything for the good
of the “ill” who had psychiatric disorders, frequently against their will and by
depriving them of their liberty. Those values required hierarchical functions (2), in
the context of which preserving and safeguarding the status quo and security were
of primary importance, even if it meant ignoring the fundamental rights of patients.
The interaction with the environment (3) created the impression from the 1960s
onwards of negative effects of asylums and institutionalisation, such as stigmatism
and self-stigmatism, loss of autonomy and dominant social exclusion. As is well
known, these findings lead to the logic of asylums and the culture which defined the
228 S. Stylianidis and D. Trivellas

operation of these “total institutions” being condemned (see Goffman, Basaglia); to

the idea of moving beyond asylums; to the emergence of concepts such as auton-
omy, recovery and advocacy for the rights of the mentally ill; and to the structural
changes in the entire system of psychiatric care. We need to change our practice, our
thinking and our services and to raise certain fundamental questions. Who does
what? With whom? For what purpose? To what end? Using what values? With what
ability to learn from his experiences and above all from his mistakes? Have there
been enough declarations about psychiatric reform and about showcasing of recov-
ery as a new concept which in practical terms can promote empowerment and the
life plans of patients? Taking these questions into account, we believe that case
management can be a valuable methodological guide and a framework for thinking
about change: change in our identity, development and transformation of our ser-
vices and our psychiatric culture.
The values which define the use of case management as a tool for continuous
monitoring and evaluation of psychiatric care in the community can be presented in
very general form as follows:

(a) The transition from the concept of chronicity to psychosocial rehabilitation and
a continuous recovery process
(b) Criticism in theoretical and methodological terms of clinical practice and the
biomedical model
(c) The necessity for critical time intervention for an individual after hospitalisa-
tion (see the historic use of the ACT model)
(d) Dissemination of the recovery model to all parties involved in the social psychi-
atric care of the individual
(e) Changes to the life care plan of the individual based on this treatment plan
(f) The primary role the patient has in his own narrative despite institutional, cul-
tural, therapeutic, social and contextual barriers and objections

Procedures are aimed at patients who are in the process of deinstitutionalisation

or in follow-up after hospitalisation, such as individuals with severe psychopathol-
ogy in the community. The targets are intended (a) to ensure the continuity of care
and to establish a psychosocial support network, (b) to improve professional and
social reintegration and (c) to prevent relapses, new periods of hospitalisation or a
worsening in the individual’s condition.
Six steps are normally followed by the mobile units of the University Psychiatric
Clinic in Lausanne (Bonsack et al. 2013) to successfully prepare for case
management:

1. Application: All patients who were hospitalised voluntarily or involuntarily at

the psychiatric department or in the psychiatric hospital in that area are safely
identified.
2. First contact with patient: The patient is briefed about the follow-up plan and
accompaniment in the community, in cooperation with the hospital team at first.
12 A Modern-Day Community Daycare Centre in Operation 229

3. Evaluation: The patient’s clinical situation, family situation, support network

and the resources needed for case management are evaluated.
4. First counselling session during hospitalisation: A necessary step to ensure that
it is possible for the patient to return to the normal environment and that the sup-
port network is aware and on stand-by.
5. Adjustment of optimum case management in conjunction with individual needs
and the needs of the actual support network.
6. Evaluation at 1 month and joint preparation of and consent to a new plan by the
hospitalisation team and the case management team.

12.7 Objectives of Case Management Intervention

Intervention Example of various actions that

objectives – areas Description and objectives can be taken
1. Co-ordination of Co-ordination of all health, Information provided about
the care system mental health and social care objectives, boundaries and
services ensured by the case responsibilities of each individual
manager for the patient’s benefit or body information
Case manager appointed
List of individuals who can be
involved in the network prepared,
and all of them are contacted
2. Commitment to Commitment to each individual Interventions with negative
the care plan objective and reduction in the representations of traditional and
length of the recovery process asylum-based psychiatry
Prevention of barriers and Actions to promote
objections destigmatisation, psychoeducation
and connection of patient
complaints to his pain, functional
difficulties and symptom
management
3. Commitment to Long-term commitment to take Briefing about and management of
and consent for medication the day-to-day aspects of
medication medication
Monitoring of unwanted side
effects, changes in treatment when
needed, management of difficulties
arising from side effects,
cooperation with family members
4. Support from and Support for and empowerment Information provided about smart
involvement of the of relatives’ skills ways to manage upsets in
patient’s Prevention of exhaustion and day-to-day life
environment domestic violence Showcasing “lost” skills and
evaluating the need to support/
rehabilitate members of the
support network for a transitional
period
230 S. Stylianidis and D. Trivellas

Intervention Example of various actions that

objectives – areas Description and objectives can be taken
5. Support for Evaluation of skills to integrate Raising the employer’s awareness
professional into an appropriate work or to prepare for the patient’s return
integration professional activity or initially to his previous post
volunteer work which would Preventing failure short, medium
open up the potential for and long term
employment (such as social The patient may need a
cooperatives) transitional period by joining an
industrial therapy group
6. Day-to-day skills Support, empowerment and Preparing and setting objectives in
development of day-to-day a daily schedule while respecting
skills existing limitations in that phase
and support from analogous
resources
Exploration of alternative
solutions from the support network
7. Ties to the Improvement of existing ties, Accompanying the patient in the
community contribution to reactivating process of reactivating his contacts
older ties, development of new or creating new ties
ones to promote social Training in communication skills,
reintegration participation in service recipient
groups or self-help groups,
development of communication
skills via role playing
8. Support and Ensuring that the patient Daily “at-home” evaluation,
supervision of receives all the help and care he inclusion of volunteers into the
day-to-day care needs case management process, support
Finding auxiliary or for the legal, social and insurance
complementary resources rights of service users, etc.
9. Prevention of Ensuring the continuity of the Evaluation of suicidality
relapses recovery process Use of appropriate tools, scales
Preventing suicidality/suicide Limitation of dangerous
Preventing any possible return equipment
to substance and alcohol use Development of a strategy to
manage stress and adjustment
difficulties
Learning relaxation techniques,
participation in sporting activities,
daily exercise, etc.
Psychoeducation about decision-
making depending on the
assessment of the patient’s skills
and abilities in each case
Activation and co-ordination of
services if readmitted to hospital
12 A Modern-Day Community Daycare Centre in Operation 231

Intervention Example of various actions that

objectives – areas Description and objectives can be taken
10. Conveying Ensuring the continuity, flow Crisis plan: open discussion with
information – and quality of information the patient about the flow of
communication Supporting the integration and information
comprehension of information Organising the network and
evaluating it
Information exchange forms
Joint assessment of the situation
by all stakeholders, including the
case manager, and agreement on
supplementary, integrated action
by all

Mapping out the network may be a useful tool in ensuring a successful outcome for
case management. It is a graphic depiction – photograph of the network at the time
of the first intervention:

A. The primary network consists of the individual’s milieu and is not limited to his
family, contrary to the belief commonly held by mental health professionals. It
may consist of neighbours, colleagues, pets or even individuals who are no lon-
ger alive!
B. The secondary network may be formal or informal and includes health, mental
health and social care professionals. While the formal network is mapped out in
terms of services, the informal network is created on the initiative of members
of the primary network, in order to find answers and solutions to their needs
(such as associations for the family, service users, volunteers, etc.).
C. The tertiary network consists of services and organisations who exercise politi-
cal, judicial, health or welfare powers. All these institutions are directly or indi-
rectly involved in patients’ rights. Consequently, it is self-evident that members
of the case management team or case manager need to cooperate, intervene and/
or exert pressure in the process of defending patients’ rights.

The Example of How the Franco Basaglia Daycare Centre

Operated by the Regional Development and Mental Health
Association Works and Has Developed

The Melissia Daycare Centre was set up in 2004 as part of the PSYCHARGOS
programme/Phase II. It offered services to 15 members aged 18–45 from the fifth
Psychiatric Region, offering comprehensive psychosocial rehabilitation services.
During the first 8 years, it was in operation, 42 patients received services.
In 2013 the Franco Basaglia Daycare Centre was upgraded when a centre provid-
ing community mental health services to residents in the fifth Psychiatric Region
was developed in the context of the HR Development Operational Programme
2007–2013 in priority area 14 “Consolidating reform in the mental health sector”.
232 S. Stylianidis and D. Trivellas

Table 12.2 ICD 10 Diagnosis of attendees

% of attendees at the % of attendees at
Franco Basaglia mental health centres
ICD 10 Daycare Centre (1997); (Madianos
Diagnosis code (2013–2014) (%) 2010) (%)
Organic mental disorders F00–09 2 3
Mental and behavioural disorders F10–19 0 2.2
due to psychoactive substance use
Schizophrenia, schizotypal and F20–29 30 17.8
delusional disorders
Mood [affective] disorders F30–39 25 20
Neurotic, stress-related and F40–49 13 22
somatoform disorders
Behavioural syndromes F50–59 0 –
associated with physiological
disturbances and physical factors
Disorders of adult personality and F60–69 10 –
behaviour
Mental retardation F70–79 4 –
Disorders of psychological F80–89 0 –
development
Behavioural and emotional F90–99 5 –
disorders with onset usually
occurring in childhood and
adolescence
Others/not diagnosed 11 35

The centre is cofinanced by the Ministry of Health and the European Union. The
aims of the 2-year pilot programme were to provide psychosocial interventions in
the community, to reduce the number of hospitalisations and their duration to net-
work services and to limit the treatment gap between needs and services provided in
the region.
Diagnoses of attendees at the Franco Basaglia Daycare Centre, as shown in the
diagram, appear to be dominated by schizophrenia spectrum disorders (F20–29)
(30 %) followed by emotional disorders (F30–39) (25 %) and neurotic, somato-
morph and stress disorders (F40–49) (13 %).
Table 12.2 attempts to compare the available data from 24 mental health centres
in Greece for 1997. Differences exist because of the different classifications used
and the significantly higher percentage of attendees at the Franco Basaglia Daycare
Centre suffering from schizophrenia, schizotypal and delusional disorders (30 %
compared to 17.8 %). That difference could be explained by the tradition in the
previous operating period (2004–2012) where the daycare centre was aimed at
individuals with psychotic disorders, but also perhaps by the emphasis given in the
12 A Modern-Day Community Daycare Centre in Operation 233

second phase of pilot operation (2013) to caring for individuals with serious and
persistent mental disorders, by networking with inpatient psychiatric services and
close cooperation with the psychosocial rehabilitation unit and the Assertive
Community Treatment (ACT) team.
The extended services the Franco Basaglia Daycare Centre (run by the Regional
Development and Mental Health Association) offers include:

The psychosocial rehabilitation unit for patients with serious and persistent mental
disorders
Psychiatric and psychological assessment
One-to-one and group psychotherapy, art psychotherapy
Psychiatric follow-up – prescriptions
Assertive Community Treatment (ACT)
Social club
Networking, promoting mental health
Research, evaluation, documentation

12.8 Intervention Areas and Networking at the Franco

Basaglia Daycare Centre

The Psychosocial Rehabilitation Unit

Getting a member to successfully commit to a treatment relationship is the first

step towards rehabilitation. The clinician needs to build a constructive relation-
ship with members and their families. Professionals and patients need to iden-
tify the other’s agenda and seek out some common ground to develop a
comprehensive care plan, an individualised recovery-focused plan (Sadock and
Sadock 2008).
The process of rehabilitation and developing and implementing the individual-
ised care plan includes the following stages:

(a) Assessment/Diagnosis: This helps the member identify or cultivate his readi-
ness for rehabilitation, to set general goals and to identify skills, resources, and
strengths and weaknesses relating to those goals.
(b) Planning: He works out in detail how to cultivate the skills and obtain the nec-
essary support to achieve his goal, ties assessment into the intervention and
develops a schedule for starting and ending the intervention.
(c) Intervention: This includes developing skills in an individual or group context
and planning how to use them in vivo, co-ordinating and modifying the environ-
ment and available resources (Anthony and Farkas 2009).
234 S. Stylianidis and D. Trivellas

In developing individualised care plans at the daycare centre in cooperation with

the Istituto Mario Negri in Milano, the innovative methodology and technique
called “Shared Care Pathways” (derived from the Italian method known as Percorsi
di Cura Condivisi) is used, which empowers a change in the patient’s position and
involvement in the treatment process and follow-up which monitors the symptoms
and functionality, as assessed and managed by all those involved and cooperating
with him in this process (Biasi et al. 2006).
The innovation lies in the involvement of users and their families in jointly man-
aging the treatment contract, in planning, in implementation and in the prevention
of any possible future relapses. A third party, the guarantor, is involved in this model
and takes part in the joint management plan.
To implement the plan a team needs to be set up which agrees joint practices set out
in the plan and cooperates in making the plan a reality. The team members are the
patient, the professional (the point of reference at the daycare centre), the relative or
caregiver and the guarantor. The guarantor helps participants periodically verify the
plan. The guarantor’s role can be taken up by a mental health professional or not,
provided he has no professional other relationship with the patient the plan relates to.
His presence guarantees equality between team members and confirms the reliability
of assessments. The presence of a third party in the customised psychosocial rehabili-
tation plan of the patient ensures the greatest possible democratic guarantee and
defence of the patient’s rights as a citizen with a mental disorder. The main objective
is to place the patient in a more assertive and adult position, assigning him a signifi-
cant part of the responsibility for self-assessment of his mental condition and his treat-
ment choices. The concept of the reality of the therapeutic relationship is introduced
in a clear, but controlled, nonthreatening way for the patient, thereby preventing rever-
sion to psychotic defence mechanisms as much as possible. In addition, the patient is
not alone in dealing with the burden of mental pain. The presence of third-party guar-
antors balances out the therapeutic process, ameliorating any paranoia towards the
therapist and the patient’s family environment, which frequently emerges during
relapses. The presence of the family in the team is also very important since they
actively participate but do not have an exclusive or primary role and do not receive all
the violence of the psychotic process which they cannot handle and which is fre-
quently returned to the patient in an unhealthy manner.
The “Shared Care Pathways” approach consists of three contracts (forms which
are read, filled out and signed by the team) which relate to:

1. The relationship (the quality of relations and achievement of interpersonal rela-

tions between team members)
2. The intervention plan (setting special goals in four areas:
(a) Symptoms
(b) Social and family relations
(c) Work and community activities
(d) Accommodation
3. Prescriptions (as specified by the attendant doctor) and the taking of medication
12 A Modern-Day Community Daycare Centre in Operation 235

Two cards are also filled out relating to:

“Early signs of crisis”

“Expectations and wishes in the case of crisis”

Assessments take place every 6 months (half-yearly for 2 years in total). During
verification, compliance with procedures and achievement of pre-agreed goals set
by the team are evaluated. Where goals are not met, they are redefined so that they
continue to be individualised, flexible and realistically achievable (Papakonstantinou
et al. 2008; Papadaki et al. 2012).
The development, implementation and constant reassessment of the individual-
ised care plan is monitored at weekly one-to-one meetings between members and
their contact person. At those meetings, the member will agree to participate in all
or part of the daily treatment plan depending on his needs, preferences and goals,
recorded during the assessment and intervention planning stages. Client needs are
assessed using the Client’s Assessment of Strengths, Interests and Goals (CASIG)
scale. At the start of the intervention and while it is underway, psychometric tools
are used to monitor psychopathology, quality of life and family burden (PANSS,
WHOQOL, Family Habits and Family Burden Scale).
The contact person also collaborates with the client’s families, to reduce the fam-
ily burden, modify dysfunctional behavioural patterns and provide the necessary
support as the client moves towards recovery. Patients, suffering from schizophrenia
in families with high levels of criticism, hostility or over-involvement, have higher
levels of relapse compared to those whose families express emotion less frequently.
Special psychosocial interventions can reduce the emotion expressed and modify
the course of the illness. Interventions take place at the daycare centre or in coopera-
tion with the Association of Families and Friends for Mental Health. A recent meta-
analysis argues that family intervention can reduce the frequency of relapses and
admissions to hospital and can encourage the taking of medication but does not
affect the tendency of the individual and family to terminate contact with services.
Family intervention also appears to improve social dysfunction and levels of emo-
tion expressed within the family (Pharoah et al. 2010).
The daycare centre’s daily treatment plan includes the following groups/
activities:

Social skill training Documentaries/videos

Art Gardening
News Cooking/day-to-day life skills
Group psychotherapy Computers
Exercise Board games
Self-care and health promotion Empowerment, rights and claims
Industrial therapy Client meetings – organising oneself
Storytelling General meeting/community
Photography Social outings
236 S. Stylianidis and D. Trivellas

Involvement in daily programme groups as part of the individualised care plan

serves many general and special goals. The programme includes groups for training,
psychotherapy, managing the illness and medication, leisure/free time activities,
skills training, cognitive rehabilitation, empowerment and so on.

For Example
The client meetings – organising oneself group and the general meeting/community
group, attended by all clients and staff – promote the assumption of adult roles, initia-
tive, cooperation and empowerment in the spirit of the recovery model, the principles
of the therapeutic community and the tradition of the social club model. Along the
same lines, the empowerment and rights group helps clients seek out the necessary
social resources and rights of clients as equal citizens participating in society.
The exercise, self-care and health promotion groups highlight the issue of the
physical health of individuals with serious mental disorders which is frequently
neglected, seek to modify dysfunctional behaviours and promote the adoption of a
healthy lifestyle. Obesity, smoking, lack of physical exercise and metabolic syndrome,
which is frequently associated with the taking of antipsychotics, are some of the risk
factors that appear to contribute to the early onset of cardiovascular disease and a
20–30 % reduction in the life expectancy of individuals with serious mental disorders
(Casagrande et al. 2010; Saiga et al. 2013; O’Brien et al. 2014; Casey et al. 2011).
The cooking/day-to-day life skills groups aim to improve skills essential for liv-
ing on one’s own. Money management, housework, personal hygiene and use of
public transport are all skills which daycare centre clients may need to be trained in
and practise under protected, real-life conditions (the social outings group) in order
to achieve a better quality of life. The most effective way to acquire these skills has
not been confirmed by research (Tungpunkom et al. 2012).
Social skills training (Vyskocilova and Prasko 2012), cognitive remediation
(McGurk et al. 2007) and CBT along with psychoeducational interventions for fam-
ily and relatives, referred to above, appear from the literature review to show strong
signs to being effective psychological therapies alongside the use of medication
(Pfammatter et al. 2006).

Psychiatric Diagnosis and Follow-Up

The Franco Basaglia Daycare Centre provides psychiatric follow-up and prescriptions
without any time limitations. Emphasis is placed on posthospital follow-up of patients
with serious and persistent disorders in cooperation with the psychiatric clinic of the
fifth Psychiatric Region General Hospital and specialist psychiatric hospitals. The
multidisciplinary team meetings make it easier to provide comprehensive care based
on the biopsychosocial model. The service is frequently offered in conjunction with
interventions by the psychotherapy team, the psychosocial rehabilitation unit or the
ACT team as part of an integrated care plan that meets the patient’s needs.
12 A Modern-Day Community Daycare Centre in Operation 237

Psychotherapy Service

The psychotherapy service has to meet the community’s needs in the fifth
Psychiatric Region, given the very limited availability of public psychotherapy
services for “ordinary” mental health problems. Over recent years the socioeco-
nomic crisis has in all likelihood contributed to the rise in referrals to the service
of cases of stress-related and depressive disorders and has highlighted the com-
plex, multifactorial nature of the problems. Under current conditions, what is
needed is a flexible, pluralistic perspective, both during and in the theoretical
orientation of psychotherapy practice in the community, in order to respond to the
diverse, increased needs.
The service provides one-to-one psychoanalytical, CBT and cognitive analytical
psychotherapy as well as one-to-one and group art, family and systematic psycho-
therapy. Psychotherapy is short term lasting 15–52 sessions, depending on the cli-
ent’s needs and the theoretical approach chosen as the most appropriate. At present,
31 % of new referrals to the daycare centre receive one-to-one psychotherapy and
13 % group psychotherapy. The majority of cases dealt with by the service are diag-
nosed as having mood (affective) disorders (F30–39).
Outcomes are assessed using the CORE-10 tool, a questionnaire which is filled
out by the client before and after therapy which explores stress, depression, trauma,
physical symptoms, functionality and risk.
A detailed description of short-term psychodynamic psychotherapy in the com-
munity is provided in the relevant chapter.

Social Club

The social club serves around 70 clients with serious mental disorders who live on
their own or in sheltered accommodation. It is run by professionals and supported
by volunteers and clients. It runs in the evening and includes training, entertainment
and treatment groups. At present the groups on offer relate to:

English lessons
Empowerment and rights
Self-care/how to organise one’s free time
Music, dance, theatre
Board games
Film club

The social club’s aim is to raise awareness, provide training and mobilise volun-
teers and users of services to create a network of similar structures which they
organise themselves, which are separate from mental health services.
238 S. Stylianidis and D. Trivellas

Assertive Community Treatment (ACT)

The Franco Basaglia Daycare Centre’s Assertive Community Treatment (ACT)

team is aimed at patients with severe, mainly psychotic, mental disorders which are
in an acute phase of the illness, especially those with a history of multiple relapses
and repeated hospitalisations. It is also aimed at individuals with chronic, persistent
psychopathology with greater need of psychosocial rehabilitation in relation to
medication, psychotherapy, housing and work.
The team’s main aim is to reduce hospitalisations and to prevent relapses, while
also accompanying the individuals through the recovery process. The team consists
of a psychiatrist, psychologist, social worker and nurse (see the chapter of Assertive
Community Treatment – Home intervention in psychiatric events).

Networking, Promoting Mental Health

As part of community mental health practice, we can identify three levels of net-
works, as we saw in relation to how case management is implemented: the primary,
secondary and tertiary levels, each with their own functions, typology, relations and
content.
Mental health interventions are defined as “network interventions” when the pro-
fessional does not approach the sufferer as a unit cut-off from the whole but consid-
ers the individual’s problem to be tied into a network of relationships and interactions.
Viewed from this perspective, networking is a way of thinking and acting for any
professional and not the task of a specific service at the daycare centre. However,
the lack of a statutorily mandated, generally accepted philosophy on how mental
health services should operate in networks means a co-ordinated effort is required
to set up, expand, bolster and firmly establish the use of networks (Stylianidis and
Chondros 2007).
Statutorily mandated communication with health services, the involvement of
the local authorities, ties between users of the services, participation of the local
community in solving specific problems, the involvement of volunteers at an indi-
vidual and collective level and empowerment of existing local networks are all goals
which the service has.

12.9 Networking at the Daycare Centre

The aim of community actions is also to educate and promote mental health, to
provide information about the daycare centre, how it works and what it does, to train
professionals about mental health issues and to interface with primary healthcare,
social bodies and local government authorities. These activities can include work-
shops, open events to provide information about mental health and talks at associa-
tions, to specific population groups like the elderly, school pupils and parents,
individuals with physical conditions or disabilities and so on. Activities are also
12 A Modern-Day Community Daycare Centre in Operation 239

arranged to provide briefings to and train specific professionals in the community:

teacher groups, training for policemen about how to handle difficult cases in the
Public Prosecutor-issued orders, and priest groups to provide information about
basic mental health issues. Promoting mental health and social cohesion can also be
done by setting up self-help groups for families and volunteers.
As part of the networking initiative and attempt to mobilise community resources
and expand job opportunities for clients, the Franco Basaglia Daycare Centre sup-
ports the Association of Families and Friends for Mental Health, the Heliotrope
Social Cooperative and self-help groups dealing with depression and suicide
prevention.
The aim of the Association of Families and Friends for Mental Health is to
engage in extensive dialogue about mental health and mental illness, to share expe-
riences with other families coping with similar problems and to open a door to life
because often difficulties in talking to someone about mental disorders can lead to
a loss of social ties, to isolation and to the refusal of help. The 129 registered mem-
bers are relatives, caregivers (parents, spouses, etc.) (61), users of mental health
services (12), friends (of the family or aware citizens) (29) and mental health pro-
fessionals (27).
Social cooperatives are statutorily mandated social enterprises that operate in the
context of solidarity-based social entrepreneurship. They promote socioeconomic
integration and the reinclusion of individuals who have suffered from mental ill-
nesses in the labour market and seek to provide high-quality services and products
in a competitive environment. They function as mental health units which contribute
to improved levels of autonomy for employees/persons with mental problems and to
improving the social and individual skills of those persons to ensure they integrate
into the socioeconomic fabric of society and the labour market and also function as
businesses providing high-quality services and products in a competitive
environment.
The Heliotrope Social Cooperative in the fifth Psychiatric Region was founded
in July 2008 on the initiative of mental health professionals and agencies in NE
Attica. It cooperates with public and private sector bodies, local government author-
ities and mental health bodies in the fifth Mental Health Region. The Heliotrope
Social Cooperative became operational in October 2010, in partnership with the
Municipality of Melissia and school committees, cleaning school playgrounds in
the Melissia area. Individuals who have completed the relevant psychosocial reha-
bilitation programmes are involved in these activities. The cooperative also collabo-
rates with the Ministry of Labour and Social Security to allow its employees to
clean the Ministry’s offices and communal areas. A canteen and restaurant are
expected to open soon in the Marousi area, where light meals will be prepared and
distributed.
The public care system’s inability to deal with the constantly increasing number
of cases, and the complex psychopathology that the crisis has allowed to emerge,
makes it vital to set up a protective net for the general population based on interven-
tion on multiple levels, whose goal is to prevent depression and, by extension sui-
cide, to encourage treatment interventions in the community. The depression
240 S. Stylianidis and D. Trivellas

Table 12.3 Evaluation indicators

Structure Procedure Outcome
Funding Average waiting time Severity of symptoms
Funding rate % of users per type of Quality of life
treatment
No. of staff per area of No. of treatments Satisfaction with services
specialisation
Max. no. of service users Active cases Functionality
Accessibility Dropout rate Hospitalisations
This entire process is under way at present in cooperation with the Istituto Mario Negri in Milano

self-help groups are a particularly important means for dealing with depressive
symptoms since they promote increased social participation, life satisfaction and
reduced stigma (Bologna and Pulice 2011), while it has also been observed that in
people to take on such a role, their psychiatric symptoms reduce and their interper-
sonal relations and skills improve (Moran et al. 2012). Introducing these interven-
tions is a priority since the report on the review of the PSCYHARGOS III Programme
(2011–2020) (MHSS 2012) stated that, “in Greece there are very few self-help
groups due to the stigma attached to mental illness and the short tradition of involve-
ment in such endeavours, and also non-involvement by services in such endeavours
(with few exceptions)”. In cooperation with the Hellenic Society of Mood Affective
Disorders (MAZI), the Athens Archdiocese and the Salten Psychiatric Centre (in
Bodo, Norway), the Regional Development and Mental Health Association under-
took to implement an innovative action called “Self-Help, Networking and
Therapeutic Support in dealing with depression in urban and island areas” which
was financed as part of the “We are all Citizens” programme, which is part of the
EEA Financial Mechanism for Greece. The programme seeks to empower and bol-
ster civic society in Greece and is being implemented by the Bodossaki Foundation
in cooperation with the EEA’s Financial Mechanism Office (http://www.weareall-
citizens.gr).

Research, Evaluation and Documentation

Evaluation of the clinical effectiveness and regular documentation and presentation

of daycare centre services are integral to its operations. The evaluation of services
is done at local and individual levels in relation to structure, procedures and the
outcomes of treatments, using the Matrix Model. Emphasis is placed on the opinion
of the users of services. Table 12.3 shows three aspects of the evaluation indicators
(Thornicroft and Tansella 2010).
12 A Modern-Day Community Daycare Centre in Operation 241

12.10 Discussion

Documentation, Research and Evaluation

The documentation of the effectiveness of the daycare centre as a structured set of

psychosocial rehabilitation interventions is not adequate at present. Even though
individual interventions have been documented, a recent systematic review did not
manage to identify randomised controlled studies relating to the overall operation of
such a structure, which in the research is defined as a non-medical sector daycare
centre (social welfare structures and not-for-profit organisations (Catty et al. 2007).
Note that the major diversity of services provided makes research difficult. Research,
ongoing evaluation and documentation of services require resources but are neces-
sary and a condition for establishing, disseminating and developing best practices.
The limitation on available resources in general, and especially those available for
research, the possible objections from professionals to the study of measurable out-
comes, the downgrading of empirical studies and the disproportionately low interest
in narratives and the viewpoint of patients are major risks for the future of quality
psychosocial rehabilitation services in Greece’s mental health system.

A Change of Paradigm

The focus of rehabilitation services on the recovery model determines the services’
philosophy and practice, redefines their relationships with users of services and
opens the path for development. The recovery model does not justify a cutback in
services but a transformation. It is reasonable to suppose that the path to recovery
includes a gradual reduction in the contact users of services have with mental health
services and increasingly greater use of community resources. The daycare centre
operates as a locus in the wider community network, giving form and structure to
care, combining different services in an attempt to respond to the individual’s com-
plex needs at that specific point in time and the needs of the community the indi-
vidual belongs to.
The transformation of daycare centres requires that in organisational terms they
be included in a sectorised network of community mental health services. The
proper running of such a structure requires a culture of enquiry and for one to con-
stantly call into doubt established practices. Main considers that ideas expressed in
the ego of a generation shift to the superego in the next and acquire a ritual charac-
ter, thereby losing their creative urge (Campling 2001). Rotelli (1988) talked about
a perpetual process of renewal, deconstruction and reconstruction of new institu-
tions in the community as an ideological and scientific framework for limiting the
neo-institutionalist culture.
242 S. Stylianidis and D. Trivellas

The Risk of Chronicity Outside the Asylum’s Walls and Neo-

institutionalist Phenomena

Neo-institutionalism, meaning the transfer of the asylum’s functions and chronicity

to community structures like daycare centres, is a constant threat and has been a
reason for the criticism they have received about their role in a network of services
and even about their necessity and very existence. Every psychiatric care institution
need not necessarily be considered a therapeutic institution a priori. Even after the
spread of the social psychiatry movement and the deinstitutionalisation movement,
modern history teaches us that an initial intention to treat patients or an ideology
that seeks to overturn traditional practices can gradually slip back into a rigid, ste-
reotypical anti-treatment, asylum-like way of working even outside the asylum’s
walls. P.C. Racamier (1992) points out that “care organisations have a tendency to
adjust to psychopathology and to treat it. When that adjustment is very good, then
they retain it and reproduce it in perpetuity”.
According to J. Hochmann, identifying, understanding, processing and giving
meaning to the chronicity which arises from the illness, from the viewpoint of psy-
chocognition, can contribute to defence against the phenomenon of chronicity and
fatal repetition. The dialectic of “dependence-autonomy” at the core of the individu-
alised care plan requires persistent work by both the treatment team and also by the
patient, so that their relationship is not an end in itself and simply a means of repro-
ducing complete dependence or assimilation, but is a tool for change. The relation-
ship sits within an institutional, organisational and mental setting that can favour the
autonomy of the subject. The way in which the multidisciplinary team operates,
coupled with external supervision, treatment agreements with a clear start, middle
and end, as well as case management which is recorded and re-evaluated at regular
intervals in the presence of a third-party guarantor, are just some of the institutional,
organisational and psychocognitive attempts being made to overcome the assimilat-
ing dualist relationship and achronicity which leads to phenomena of institutionali-
sation. Therapeutic or rehabilitative activism, the constant search for action far from
the needs and preferences of the users of services, may well be the diametrical
opposite of what we have been describing, a maniacal defence of the institution in
relation to chronicity, which also removes the assignation of meaning and conse-
quently proves to be equally futile and a dead end (Stylianidis 2002).

Optimum Use of Resources or Limitations on Costs and Care

The tendency to limit the development of services and the dramatic reduction in
economic costs through the recent adoption of “managed care” by the Greek
Ministry of Health, as a part of liberal policy in the health sector, could lead to the
degradation of services and a widening gap between the level of treated and
untreated morbidity in the general population. The recurring finding that psychoso-
cial treatments are being used less is worrying. The long-term impact of managed
care and the clinical and social effects on patients with schizophrenia still need to be
12 A Modern-Day Community Daycare Centre in Operation 243

fully assessed. It is likely to increase the gap between needs and the services pro-
vided (Mojtabai et al. 2009). The unquestioning transfer of epidemiological and
management data from some other country to the Greek context would be arbitrary
but does add another dimension to the complex problem that exists. The almost total
lack of epidemiological data about mental health services in Greece, except for
recent studies about the crisis, makes it harder to assess the situation and plan
actions.

Towards a New Paradigm?

The complete transformation of the traditional biomedical model of care into a

comprehensive network of community mental health services focused on recovery
is a complicated process, in both historical and social terms, whose outcome
depends on numerous factors and parameters. One of those is the adoption of inno-
vative, documented best practices in how daycare centres can be run so as to avoid
phenomena of neo-institutionalism in the community and to promote the empower-
ment of users of services and the networking of services.

Acknowledgements The authors would like to thank K. Papakonstantinou (scientific officer of

the Franco Basaglia Daycare Centre 2007–2012) for his important contribution to developing
the daycare centre and transforming it and would also like to thank clinical psychologist
K. Papadaki.
Many thanks to the present and past employees and volunteers of the Franco Basaglia Daycare
Centre who seek out stories and meaning via the multidisciplinary team.

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Assertive Community Treatment: Home
Intervention for People with Severe and 13
Enduring Mental Health Problems:
Designing the Greek Model

Alex Krokidas, Xenia Varvaressou, and Stelios Stylianidis

Abstract
Home intervention for people with severe and enduring mental health problems –
assertive community treatment (ACT) – is an intensive intervention programme
in the community for people with severe mental illnesses. In the 35 years since
the introduction of this specific model, numerous intervention teams were estab-
lished worldwide, while the criticism directed at the model on the matter of
methodology (intervention techniques and targeting) as well as the cost-
effectiveness of similar programmes is interesting. Hereinafter, the authors
examine the attempts made to form similar teams in Greece, while focusing on
the particular socioeconomic conditions and legal/institutional framework in
which such attempts were made.
Finally, they present the EPAPSY Day Centre Home Intervention Team and,
at the same time, raise the question concerning the manner in which such teams
will be supported and framed.
“Tonight we Improvise” (Questa Sera si Recita a Soggeto)
(Luigi Pirandello, 1929)

A. Krokidas
Service Manager, EPAPSY Recovery and Rehabilitation Day Centre, Athens, Greece
e-mail: [email protected]
X. Varvaressou
Home Intervention Team Manager, EPAPSY Recovery and Rehabilitation Day Centre,
Athens, Greece
S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 249

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_13
250 A. Krokidas et al.

13.1 Introduction

Home intervention – (Assertive Community Treatment, ACT) – is an intensive

intervention programme in the community for people with serious mental illnesses
(usually schizophrenia or psychotic disorders). As a community intervention model,
it has been in operation over the last 35 years. It was developed initially as a pilot
programme in the USA by a team of psychiatrists who concluded that traditional
psychiatric services did not offer targeted patients’ continuity of care. Emphasis was
placed on the intensive and methodical use of community resources towards improv-
ing social skills and quality of life, without offering any specific medical-oriented
approach focusing on pharmacotherapy and the reduction of symptoms.
An ACT team is called to deal with an “abnormal” condition. Abnormality is
defined on the basis of a fundamental and necessary conceptual clarification: the
distinction between an emergency and a crisis.
An emergency psychiatric event is a series of conditions where (Stylianidis et al.
2006):

1. The condition and behaviour of an individual is deemed by someone – and not

the individual himself – likely to have a rapid catastrophic effect on the indi-
vidual or another person.
2. The resources available at the time the emergency psychiatric event occurs are
not sufficient to cope with it.

Consequently, a crisis situation may include some and/or the above characteris-
tics, but evolve at a slower pace, the effect is not immediate and care for the situa-
tion may be delayed for a short period of time.
The aim was to address every patient need (Drukker et al. 2014), such as hous-
ing, food and clothing (basic subsistence needs) and develop skills to enable them
to manage the needs of a normal social life, particularly for people who, because of
repeated admissions, were deprived of the continuity of a normal life in the com-
munity. Another significant goal was the possibility of employment (sheltered and/
or competitive) and to support a patient self-empowerment system free from depen-
dence relationships (Nordén et al. 2012). Parallel goals were how to teach patients
to approach diversity (Leete 1989), marginalisation and stigmatisation. Finally, a
significant part of intervention involved educating significant others in the life of the
patients (Mavreas et al. 1992) and/or how to reconnect with these significant others
so as to enable the extended family system to function relatively smoothly (Tschoop
et al. 2001; van Vugt et al. 2012; Watts and Priebe 2002).
In the 35 years since the introduction of this specific model, numerous interven-
tion teams were established worldwide, while the criticism directed at the model on
the matter of methodology (intervention techniques and targeting) as well as the
cost-effectiveness of similar programmes is interesting.
The concept of “coercion” has been from the outset a structural dimension of the
Community Living Programme as well as a high point of the criticism directed at
the model. This specific dimension is subject to many interpretations because of the
13 Assertive Community Treatment 251

close and assertive therapeutic relationship developed between the therapist and the
patient. The dimension of “coercion” and the “strategies” designed to commit the
patient to the programme raise both moral issues and ontological and epistemologi-
cal issues concerning the application of the ACT model.
A key point of criticism refers to the paternalistic practices for which the ACT
model has been accused of using. More precisely, it is aimed at patients who show
increased resistance to any therapeutic intervention and, therefore, reproached as
one of the most “directed” approaches which seems to be contrary to the basic prin-
ciples of the recovery practice advocating a patient’s freedom of choice, the gradual
process of empowerment and dynamic presence, autonomy, participation and co-
decision in therapy and recovery (Stylianidies et al. 2013; Deegan 1988; Dubuis
et al. 2006; Amering and Schmolke 2009; Farkas 2007; Kidd et al. 2010).
An interesting point is that the founders of the model argued that an ACT pro-
gramme should not be applied to this end and that it should, conversely, through its
application aim to allow patients to live freely in the community and improving
their quality of life and the convergence of the ACT model and the recovery model
(Salyers et al. 2009, 2013; Salyers and Tsemberis 2007). According to the founders
of the model, ACT teams operating through coercion or patient “compliance” mech-
anisms must radically change their practices to the extent that such operation is
contrary to the philosophy of the model.

13.2 Structural Features of the Model

An Assertive Community Treatment programme is intended for patients suffering

from severe psychopathological illnesses (psychosis, major depressive episodes
with suicidal tendencies) who are in an acute phase of the disease, show increased
symptoms (highly active symptoms or suicidal tendencies) and a poor track record
of relapses and admissions (Rosen et al. 2007).
The target population of this model are, among others, homeless people with a
manifest mental disorder, people with dual diagnosis (history of use/abuse of sub-
stances and mental disorder) and people facing problems with justice. Issues associ-
ated with mental illness are organic health problems (hepatitis, diabetes) and there
is an almost complete absence of a social network that could provide support and
benefit the patient. A structural feature which serves as a common denominator is
that ACT programmes are intended for people who show a high degree of non-
functionality in daily autonomous life issues.
A basic, “traditionally” structural feature in the workings of an ACT programme
tending to limit the extent of application of the model which is an additional point
of criticism is its purely clinical orientation. More specifically, a primary objective
for patients who enter the ACT programme, which also spearheads the clinical ori-
entation of the model, is to stabilise the symptoms, avoid relapses and admissions
and the regular receipt of medication. The key difference from an inpatient therapy
model with a clinical orientation is that the ACT team and the way it operates must
be assertive, directed at the patient with a view to “keep” him/her in therapy and
252 A. Krokidas et al.

provide stability in the treatment effort, as well as continuity in the provision of

services (Stanhope and Matejkowski 2010; Phillips et al. 2001).

Basic Characteristics of an ACT Team

Multidisciplinary medical team: The responsibility for treatment, support and reha-
bilitation is shared among the members of the team. There are certain distinct
roles (such as the team co-ordinator and the psychiatrist); however, responsibil-
ity is shared among the members of the team.
Continuity in the provision of services by the entire ACT team.
Team approach techniques: The Assertive Community Treatment model has been
criticised for the level of pressure/“coercion” exercised on patient with the aim to
commit them to the treatment.
Low patient-therapist ratio; usually each member of the team is responsible for
about 10–15 patients.
Any intervention by the team takes place where the problem is located each time,
i.e. in the community (in vivo).
Management of medication.
Focus on the management of daily life issues.
The services are provided 24 h a day.
An individual treatment plan is always designed for each patient.
There is no time limit as to the duration of each intervention.
The team operates assertively with respect to the commitment of patients to the
treatment and supervises their progress.

13.3 Alternative Community-Based Services:

From the Mental Hospital to the Community

The USA

In the 1970s, at the Mendota Institute of Mental Health (Madison, Wisconsin,

USA), the psychiatrists Arnold Marx, Mary Ann Test and Leonard Stein (Dixon
2000) established that inpatient services could only provide a temporary adjustment
of their medication and a temporary remission of symptoms to specific patients
diagnosed with schizophrenia who very frequently used their psychiatric services
because of repeated relapses and compulsory admissions. The provision of limited
and repeated services to this specific patient group led to the revolving door patient
effect without any possibility of consistent therapy and rehabilitation. The patients
not only failed to show any improvement but also showed, subsequently, a high risk
of relapses. At the same time, the specific characteristics of these patients, such as
the inability to cope with stressful situations in the community and their “dependence”
13 Assertive Community Treatment 253

on the services provided by the mental health system, were serious indications of
the failure of the traditional psychiatric model and, inevitably, their referral to the
community for care.
With a view to reverse this established “traditional” treatment of patients with
schizophrenia, Leonard Stein and his team designed a pilot programme called
Training in community living. The purpose of this programme was to work within
the community with patients with a poor psychiatric track record and the develop-
ment and improvement of social skills and living skills to enable them to regain the
ability for social integration. The philosophy consisted of an assertive move
“towards the patient”, in their natural living environment and a clear – initially –
clinical orientation of the intervention. At the same time, the objective was also the
smooth transition of the patient from the mental hospital to the community, helping
the patient adapt to the community after a prolonged hospitalisation and the need to
provide continuous care rather than the usual fragmentation of mental health ser-
vices observed in the community.
In an attempt to conduct a “field test” of the new community intervention model,
Stein set up two main groups with common characteristics based on importance but
also on the qualitative characteristics of the disease, specifically, an “experimental”
group consisting of patients participating in the programme and two control groups
consisting of patients receiving inpatient services. This test seeks, among other
things, to respond to the criticism directed at the emerging model regarding its
effectiveness and implementation cost (Drake et al. 2009).
Overall, the findings showed that the services provided in the community helped
significantly these specific patients, by mitigating the development and intensity of
symptoms, relapses and mandatory admission. In addition, they helped in the devel-
opment of qualitative of daily living aspects associated with reacquired social skills
and living skills.
The pilot phase (community treatment group) of this first form of intervention
in the community for patients with schizophrenia during the acute phase of the
disease was renamed Community Treatment Program and, subsequently,
Assertive Community Treatment or Program of Assertive Community Treatment
(PACT).
Starting with the Mendota Institute of Mental Health, the new community inter-
vention programme was adopted by a number of Centres for Psychosocial
Rehabilitation in many states. A significant historical reference is the programme
implemented by the Thresholds Centre for Psychosocial Rehabilitation in Chicago.
In this Centre, ACT teams were set up since the late 1980s for people with severe
mental health problems who are deaf, people with dual diagnosis (mental illness
and drug/alcohol abuse) and people with a mental illness who had committed a
punishable act (Salyers et al. 2003).
Similar ACT teams were set up in many English-speaking countries, indicatively,
(based on the Thresholds Centre for Psychosocial Rehabilitation) in Canada,
Australia, Italy (following the Trieste “example”), France and the UK.
254 A. Krokidas et al.

The UK

In contrast with the American model, ACT in England was introduced within an
already integrated (despite all its serious institutional and organisational prob-
lems) community mental health services framework, with the most important
structure being the Community Mental Health Team. The process of deinstitution-
alisation and transfer of care to the community was, generally and essentially,
“completed” when the pilot Assertive Outreach Teams (AOT) were launched in
the UK in the 1990s.
To be precise, when we refer to the “completion” of the process, we don’t mean
that the care in the community system functioned effectively and free of problems.
Indeed, the purpose underlying the establishment of the first AOTs in the UK was
precisely to solve problems, such as dealing with “difficult” patients, i.e. patients
who were unable (or refused) to cooperate with the existing services (difficult to
engage), or patients with multiple admissions (revolving door patients). We simply
mean that Victorian asylums were permanently closed and the last “chronic” patients
were transferred to the community. The fact that the institutional framework and the
various host structures were unable, as it turned out, to respond effectively on a
treatment/rehabilitation/organisational level to the psychosocial need of a particu-
larly vulnerable population does not mean a framework did not exist. Furthermore,
from the outset, the manner in which the asylums were closed without adequate
community care structures in place was criticised (Chapman et al. 1991; Langan
1990; Webb and Wistow 1987).
The decision to shut down the most emblematic Victorian asylum, the Colney
Hatch Lunatic Asylum, renamed later Friern Hospital (the largest in nineteenth-
century Europe), was taken in 1989, and the building was finally sold in 1993
(together with 165 ha of land). The closure of Friern Barnet marked the end of the
asylum era. The fact that the building was converted into luxury flats was perhaps,
also symbolic of an era indelibly marked by the neoliberal ideology and politics of
Margaret Thatcher’s government. The fact that, although the vision of care in the
community existed since the 1950s, Care in the Community was officially adopted
as a policy by Thatcher’s government in the early 1980s should not escape our his-
torical attention.
It is not our intention here to position ourselves ideologically vis-à-vis Thatcher’s
and her successor John Major’s neoliberalism but to at least adumbrate the general
guiding parameters within which Care in the Community was built and further
developed at that particular historical juncture.
Briefly, these were the introduction of a mixed economy of care and the creation
of an internal market in the field of care services and the introduction of legislative
frameworks such as, for example, Compulsory Competitive Tendering which pro-
moted competition between service providers principally based on cost and with a
view to reducing drastically local government expenses.
So, the official intended purpose for the deinstitutionalisation policy and the
transfer of care to the community, other than for romantic and humanitarian rea-
sons, was to reduce costs and government expenditure in the mental health
13 Assertive Community Treatment 255

domain. Whether this objective was finally achieved remains to this day an open
question.

The Establishment of Assertive Outreach Teams

To comprehend the particularity of the ACT approach as implemented in the UK,
we must carry out a comparative analysis between Assertive Outreach Teams and
“traditional” CMHTs.
CMHT, as mentioned above, was the central community structure for the provi-
sion of mental health services until 3–4 years ago, when the system changed.
Specifically, and in somewhat simple terms, the system of services may be divided
into four categories: (1) community based outreach teams, i.e. primarily CMHTs, as
other teams were established later, as we shall see below; (2) inpatient services; (3)
day services, i.e. day centres; and (4) housing and rehabilitation structures.
Before examining the home intervention teams, it would be useful to have a gen-
eral picture of the other three service categories, since such teams do not operate in
a vacuum but are developed along with other parts of the system.
Inpatient services. Following the closure of asylums, psychiatric wards were
mainly relocated in general hospitals. The involuntary admission process is gov-
erned by the 1983 Mental Health Act (amended in 2007). At this point, it is impor-
tant to state that, contrary to Greece where patients are transferred to mental
hospitals by police without the presence of any other person in pursuance of a court
order, in the UK involuntary admissions are not permitted without the presence of
at least one approved social worker and, after 2007, an approved mental health pro-
fessional and two psychiatrists (and in special cases, only one). Theoretically, plan-
ning for the discharge of patients begins on the first day of admission. Where
necessary, the patient is referred to a CMHT or any other team which will be respon-
sible for his/her care in the community. Both parties have an institutional obligation
to cooperate so as not to prolong hospitalisation only because a support programme
in the community has not been established.
Daycare structures include mainly day centres and recovery centres. On an insti-
tutional level, the difference between the two is that the first operates independently
from the NHS mental health structures and is managed by non-profit organisations,
e.g. MIND, while the latter are from the NHS facilities. As a result, recovery centres
(called day hospitals up to a few years ago) also provide psychiatric monitoring and
prescription services, while classic day centres don’t. Both are governed by the
psychosocial rehabilitation philosophy and strive to operate under the recovery
model. The programme offered by recovery centres is, in principle, more intensive
and short term, usually up to 2 month, whereas the day centre programme is more
long term. Until recently, i.e. about 5 years ago, day centres were not subject to time
limitations, i.e. patients could stay in day centres for as long as they wished. In
recent years, this has changed for many reasons. A significant concern was the
development of a transmuted form of institutionalisation and chronicity, where day
centres operated as “ghettos” sustaining and encouraging patient reinstitutonalisa-
tion, with a “protection” logic consistent with that of earlier asylum structures. The
message to day centres was clear-cut: “You may not operate as final destinations,
256 A. Krokidas et al.

but as stepping stones in a patient’s journey, a practice intended to ensure the maxi-
mum possible level of patient independence. If you are unable to contribute substan-
tially to the social rehabilitation of patients, you are of no further use”. The message
was not rhetorical since it was translated into financing mechanisms leading to radi-
cal cuts in funding and the closure of many day centres.
Housing structures cover a wide range of needs and are generally divided into
those providing a relatively short stay (up to 2 years) and those providing a long stay
for individuals who are assessed as very difficult to move to independent residential
accommodation. However, even structures designed for long-term patient stay are
subject to the institutional requirement of re-evaluating at regular intervals the prog-
ress of each patient and documenting in detail the medical and rehabilitation inter-
ventions carried out with a view to encouraging each patient to acquire the
appropriate skills that would allow him to move to short-term stay structures and,
finally, to sheltered or independent residential accommodation with the support of
home intervention teams. Whether such structures are satisfactory and compliant is
a major subject for empirical research. The risk, as already mentioned in the bibli-
ography, is the development of a new form of institutionalisation or re-
institutionalisation in the community. A long stay in structures is one aspect of this
phenomenon (Priebe 2004).
Getting back to the home intervention teams, the basic structure of the system on
the level of referrals (again on a somewhat simplified basis) over the last 30 or so
years (significant changes were made over the last 3–4 years) operated with the
CMHTs accepting mainly, but not exclusively, referrals from primary healthcare
professionals (GPs, i.e. general practitioners) following an assessment process, or
undertaking to care for patients in the community, or referring them to other ser-
vices, or both.
A typical CMHT has the following characteristics (Burns and Guest 1999):

This is an interprofessional/multidisciplinary team consisting of specialised mental

health professionals, psychiatrist(s), social workers, nurses (community psychi-
atric nurses), occupational therapists and psychologists. Each team has its own
secretarial support. It is also customary, although not required by law, for the
teams to include a welfare rights specialist and, sometimes, an occupational ther-
apist who provides occupational rehabilitation.
The multidisciplinary nature of the team is not random and reflects the institution-
ally established multidisciplinary and comprehensive provision of mental health
services in the community to individuals with severe and persistent psychosocial
issues. The terms “severe” and “persistent” are used to translate the established
terminology “severe and enduring”. How one defines traditionally the term
“severe and enduring” is an interesting question raised somewhat arbitrarily in
the daily life of CMHTs. Arbitrarily, in the sense that up to at least the introduc-
tion of the HoNOS system a few years ago, the evaluation of cases referred to
CMHTs and the decision as to whether such cases were appropriate was not
based on a common scale, such as, e.g. PANSS, BPRS, although these were used
rather ad hoc (Bond and Salyers 2004).
13 Assertive Community Treatment 257

It should be noted that, historically, CMHTs provided services to individuals

across a broad diagnostic spectrum. So, they did not exclude individuals with depres-
sion, personality disorders, obsessive-compulsive disorders and related disorders, so
long as they fell within the category of “severe and enduring mental illness”.

Detailed Description of the Services Provided by a CMHT

Any member of the team, whatever their specialty, may carry out a comprehensive
needs assessment. A common practice is that the assessment is carried by two mem-
bers from different disciplines, e.g. a psychiatrist and a social worker. However, this
varies from team to team. This assessment includes:

An examination of the current mental state (CMS) and psychiatric history

Personal and family history
Potential impact/burden on family and dependents
Support networks
Use of substances and/or alcohol
Risk to self and/or others
Forensic history
Other health issues (physical health)
History of previous contact with mental health services
Skills and competencies (strengths)
Social background, including housing, financial situation, benefits, etc.

Following this assessment and if it is decided that the team will take over the care
of the patient, a care co-ordinator or case manager is assigned. This is followed by
the planning stage of an individualised care plan (formulation of care plan). When
this is agreed, it is recorded and signed by the patient, the case manager and others
involved in the plan.
But what is the exact meaning of case management? It is quite simply the organ-
isational and therapeutic principle of any individualised care plan for each benefi-
ciary. In theory, it’s the principle on which the care plan designed for each patient is
based on an assessment of his/her needs, expectations and competencies. This may
sound obvious but, actually, it is not that simple. All we have to do is remember the
different “asylum logic” or Ervin Goffman’s (1968) “total institutions” models. The
asylum/institution logic does not ask: “Why are you here, where did you come
from, where do you want to go, how can I help you reach this goal?” It provides an
a priori answer to a question that was never asked, saying: “You are here with the
others and, since you are here, this is your role and these are the rules, and the same
role and rules apply to all”.
An individualised care plan may not by definition be formulated before any
assessment of the needs of the individual contacting the mental health services sys-
tem. Hereat lies perhaps the likelihood of a conceptual confusion. An individualised
plan does not exclude the central planning of services to meet the needs of specific
population groups. Indeed, the success of the former is directly related to the suc-
cess of the latter.
258 A. Krokidas et al.

On a practical/organisational level, the model works with each individualised

plan co-ordinator being responsible for the co-ordination of the various interven-
tions mutually agreed as necessary on a case-by-case basis. However, the co-
ordinator is not just an intermediary (broker). Building a therapeutic relationship
initially between the co-ordinator and the user is an integral part of this approach.
This, however, is the greatest challenge as this relationship does not follow the rules
and methodology of a specific psychotherapeutic model, although, naturally, it may
and usually does draw on various models and approaches depending on the prefer-
ences and training of the mental health professional. And this is the particularity of
this type of therapeutic relationship which is developed and evolves not on the
couch or in some practitioner’s clinic or office but “out there”, at home, in a café, in
the street or such other place where the mental health profession must go to meet the
patient. A relationship which, naturally, does not stop however much it is tested
when the patient is hospitalised.
In practice, the care co-ordinator/case manager is responsible for a specific num-
ber of “cases”. At this point, it should be pointed out that the rather unfortunate
English term “caseload” may refer to the burden or workload assigned to each co-
ordinator. Of course, when the number of cases assigned to members of the team
places is heavy, the term is rather apt.
Contact with the patient takes place mainly at home. This is a fundamental prin-
ciple of the care in the community approach. The frequency of visits is subject to
negotiation and agreement but in fact they rarely take place more than once a week.
If the need arises for more intensive support in order to avert a crisis which could
lead to an admission, then the crisis team which is able to offer daily support for a
short time period intervenes.
Such interventions may include the administration of medication, psychological
treatment and support, family support, psychoeducation, support and advocacy and
support in matters relating to benefits, housing, rights, support in the development
of social networks, employment, education, cooperation and interconnection with
other service structures. In summary, they cater to a broad range of needs related to
psychosocial rehabilitation. The fact that such interventions are not limited to
administering medication is an important and key component of the psychosocial
rehabilitation philosophy and approach.
The progress of any individualised plan is monitored/assessed at regular inter-
vals and provided for under the institutional/legislative framework [at least since
1990 with the introduction of the Care Programme Approach (CPA)]. The teams
operate within strictly specified geographical boundaries (sectorisation), while in
terms of caseload, staff and composition of the teams, the relevant guide of the
Ministry of Health [Mental Health Policy Implementation Guide (PIG) for CMHTs,
Department of Health, 2002a] recommends the following:

Each team can handle a population of 10,000–60,000 persons, depending on local

morbidity levels and distances travelled by the members of the team when they
visit patients.
13 Assertive Community Treatment 259

Each team, according to the guide, should be composed by eight full-time care co-
ordinators, each being responsible for a maximum 35 cases, as well as 1
consultant psychiatrist, 1-1,5 clinical psychologist(s), 1-3 support staff, 1-1,5
other medical staff and 1-1,5 secretarial support staff.

An indicative estimate is 4½ CMHTs for a population of 250,000 persons

(Boardman and Parsonage 2007). The recommended number of staff (WTO =
whole time equivalent) per team and cumulatively is set out in detail in the table
below.

Requisite full time staff for a population of 250,000 persons – Community Mental Health Teams
(CMHTs)
Total number of staff for a population
of 250,000 persons (i.e. for 4,5
Staff Full time ratio per team teams)
For continuous care Total = 9,5 Total = 42,75
Community psychiatric 5 22,5
nurses
Social workers 2,8 12,6
Occupational therapists 1,7 7,65
For assessment of needs Total = 5 Total = 22,5
Community psychiatric 3 13,5
nurses
Social workers 2 9
Other professionals Total = 8,5 Total = 38,25
Psychiatrists (consultants) 1 4,5
Other medical staff 2 9
Clinical psychologists 1 4,5
Team supervisors 1 4,5
Pharmacists 0,5 2,25
Professionals for dual 1 4,5
diagnosis
Professionals for mental 1 4,5
disability
Supervisors for work 1 4,5
rehabilitation
Non-professional staff Total = 7,44 Total = 33,5
Pharmacy technicians 0,44 2,0
Trainee psychologists 1 4,5
Support staff Not taken into
consideration
Qualified vocational 1 4,5
rehabilitation staff
Staff for ethnic minorities 1 4,5
Secretarial support 4 18,0
Total staff 30,44 137,0
260 A. Krokidas et al.

So, what are the differences introduced in the ACT model and Assertive Outreach
Teams? Initially, the assumption/promise put forward was that, with the reduction
of admissions as the primary indicator, these would be more efficient and cost-
effective. However, how can one justify the emergence of specialised AOT teams in
the UK scene, insofar as both their structure and their operation are actually similar,
if not identical, to that of CMHTs? One difference was that, by design, AOTs would
have a significantly smaller clinical work volume (caseloads), 12–15 per team mem-
ber, compared to 35 per each CMHT member. It was deemed almost axiomatic that
the smaller caseloads would translate into more intensive work with each patient
and, therefore, better outcomes. The answer at this juncture, i.e. after years of paral-
lel and supplementary operation to the CMHTs, and following a number of surveys,
is that there were no changes, or at least no radical changes (Burns 2010; Stull et al.
2010).
The initial assumption/promise did not come to pass, as established by Burns
(2010): “The small volume of cases and specific ACT team staffing model did not
result in any difference in term of outcomes. The organisational structure of habit-
ual/traditional CMHTs is mainly similar to that of ACT’s and indications are that
they provide identical outcomes with much fewer resources. Consequently, the
value of any investment on resources to create highly conforming ACTs can only be
called into question”.
The reply to the legitimate question why, therefore, do they still exist and operate
today in the UK could perhaps be given to some extent using systemic terms. The
evolutionary tendency of the mental health services system over the last 25 years or
so followed the direction of an ever-increasing specialisation of structures and ser-
vices. Traditional CMHTs have ceased to exist as such (and, furthermore, the name
has ceased to exist) or were transformed into specialised teams serving patients who
are categorised and regrouped on the basis of a complex methodology which
includes diagnosis, needs, functionality and type of intervention. This is the famous
HoNOS, the pivotal tool of the PbR or Payment by Result system implemented in
the UK National Health System in recent years.
The following are a few examples of the specialised teams which have emerged
and introduced in an increasingly complex structured system:

Assessment and Brief Treatment or Referral Teams. Multidisciplinary teams spe-

cialising in new cases entering the system. To a large extent, referrals originate
from primary healthcare, i.e. the GPs. Depending on the assessment, they either
refer the patient to other teams or provide brief support and treatment (up to
6 months) and refer the patient back to primary healthcare.
Recovery and Rehabilitation Teams. Perhaps the closest offspring of traditional
CMHTs. These are multidisciplinary teams providing support and rehabilitation
services only to individuals with psychosis. They operate with approximately 40
cases per care co-ordinator. They, as all other teams, follow the classic individual
care plan methodology and approach, as institutionally established within the
CPA (Care Programme Approach) framework. As of the introduction of the
13 Assertive Community Treatment 261

Payment by Result system 2–4 years ago and the HoNOS patients clustering
tool, such patients are exclusively those who fall under the clusters 13, 14 and 15.
Crisis Teams, or as they are now called Crisis Resolution and Home Treatment
Teams. Institutionally, the gatekeepers of involuntary admissions. They intervene
when patients who are under the care of other teams experience a severe relapse
and face the risk of being hospitalised. For example, they provide intensive, daily
and brief (up to 2 weeks) home support and treatment in order to prevent hospi-
talisation. They operate 24/7, 365 days a year (at least, theoretically, but in prac-
tice they rarely visit patients after 10 pm but there is always a member of the
team on call).
Emergency Duty Teams or Out of Hours Teams. They operate from 5 pm to 8 am and
their role is to intervene in emergency cases, wherever they come from. If neces-
sary, they arrange admission in hospital.
Early Intervention Psychosis Teams. Multidisciplinary teams providing services
exclusively to individuals experiencing their first psychotic episode. The main
theoretical operational principal is the DUP (duration of untreated psychosis)
which is defined as the time between the manifestation of the first psychotic
symptom and the initiation of drug treatment. The shorter the time, the better the
outcome. This is, in simplified terms, the concept of such teams. Initially, the
model was similar to the AOT model, at least with respect to the number of cases
per team member, about 12 to 1, i.e. small caseloads and intensive intervention.
However, gradually, caseloads rose to the level of 30 to1. In addition, the age
limits were 18–35, but very recently the age limit of 35 was eliminated and only
a minimum limit persists, since all cases under 18 are taken care by child psychi-
atric services.
Assertive Outreach Teams. These are, of course, multidisciplinary teams based on
the US ACT model, which we have already mentioned. These teams target a
specific patient population who refuse or are unable to contact mental health
services (difficult to engage patients) with multiple involuntary admissions
(revolving door patients). The theoretical model calls for small caseloads,
approximately 12 to 1, and is based on team approach, i.e. although a care co-
ordinator is assigned, he/she is not the only one visiting the patient but all the
members of the team (not at the same time). It was deemed almost axiomatic that
smaller caseloads would translate into more intensive work with each patient
and, therefore, better outcomes and, at least, a reduction in duration and fre-
quency of admissions. Studies do not appear to confirm this initial assumption/
promise.
Fixated Threat Assessment Teams. A very particular English “innovation”. The sole
purpose of such teams is to assess and respond to incidents where members of
the royal family, politicians and celebrities are threatened. A relevant study
showed that 83 % of those likely to threaten, in one way or another, members of
the royal family suffered from psychosis (James et al. 2009).
Forensic Mental Health Teams. Multidisciplinary teams for individuals who have
committed criminal offences in a setting of mental illness. Likewise, they operate
according to the classic individual care plan methodology and approach, with a
262 A. Krokidas et al.

clear emphasis on preventing the further involvement of patients in punishable

criminal acts.
Homeless Outreach Teams. Multidisciplinary teams specialising in psychosocial
interventions intended for homeless people with mental illnesses. They operate
with the same philosophy based on the individual care plan. Clear emphasis is
placed on helping users find suitable accommodation

One can easily guess the patients’ path from team to team, through a complex
referral system, which is by no means unusual in the way the system operates in the
UK.
Our objective, as already mentioned above, was not to carry out an overall assess-
ment and evaluation of the mental health system in the UK. We simply tried to
outline a single category of the mental health services system, the home interven-
tion teams. It is unavoidably an imperfect and incomplete picture since we did not
examine how such teams are structurally integrated into the overall system which
includes inpatient treatment services, daily services and accommodation structures.
Historically and gradually, the centre of gravity may have shifted from hospital/
asylum structures; however, this does not naturally mean that hospital admissions
have disappeared. In fact, recently and, despite all the specialised services provided
in the community, we observe an increase in involuntary admissions in the UK, an
increase of 12 % over the last 5 years, where 17,000 individuals are “detained”
under the Mental Health Act according to the annual Quality Care Commission
2012/2013 report.

Greece

In Greece, in the late 1960s, a team of psychiatrists at the Aiginiteio Hospital led by
Professor P. Sakellaropoulos promoted care in the community for individuals with
psychoses in an effort to avoid relapses and mandatory admissions. This was a first
pilot project confined to the geographical limits of Attica.
The purpose of the first core teams established under the acronym “PCHP”
(Psychiatric Care at the Home of the Patient) was to intervene in a crisis and keep
the patient at home and in the community. Even though the teams providing psychi-
atric care at the home of the patient operated for many years targeting individuals
with psychosis in an acute phase of the disease through interventions for the pur-
pose of managing any relapses and to keep the patient at home and in the commu-
nity, they subsequently also provided care to individuals with psychomotor problems
(e.g. CNS problems) who developed an associated mental disorder and individuals
who, for various reasons, were unable to contact the community and request the
provision of mental health services.
However, a key finding was that due to the relative cumbersome nature of psy-
chiatric reforms in Greece, home intervention teams with the structural
13 Assertive Community Treatment 263

characteristics of such intervention teams have not yet been established in Greece.
With the exception, for specific methodological reasons, of mobile mental health
units operating in many Greek regions, the provision of home intervention services
to individuals with severe psychopathologies is limited largely to visits by mental
health professionals (social workers and carers) from the local municipalities.
However, this approach does not provide a methodologically integrated care plan
and is often inconsistent in the continuity of care.
Mobile mental health units are community intervention teams with a struc-
tural characteristic which differentiates them from PCHP teams and ACT teams.
Such mobile mental health units provide their services to both children and
adults (see relevant chapters). Their key objective is to intervene on a primary
prevention level mainly in geographically remote areas and provide a broad
range of psychosocial rehabilitation and psychiatric care services to patients
and their families.
A targeted and methodical cooperation is required between all available health
services, such as health centres, hospitals, rural clinics and local authorities in order
to achieve the above objectives.

The Assertive Community Treatment Team of the “Franco Basaglia”

Psychosocial Intervention Centre of the Association for Regional
Development and Mental Health (EPAPSY)
In January 2013, the first Assertive Community Treatment team was founded with a
view to reinforce the already existing day centre of the Association for Regional
Development and for the purpose of providing services in the fifth ToPSY (psychiatric
sector in terms of sectorisation) which includes the following municipalities in Attica:

326.000 κάτοικοι.
Agios Stefanos, Amaroussio, Anoixi, Afidnes, Varnavas, Vrilissia, Grammatico,
Polydendrio, Dionyssos, Drossia, Ekali, Kalamos, Kapandritis, Avlona, Kifissia,
Kouvaras, Kryoneri, Lykovryssi, Malakassa, Marathonas, Markopoulo, Melissia,
Nea Erythraia, Nea Makri, Nea Palatia, Nea Penteli, Pefki, Pikermi, Rafina,
Rodopolis, Oropos, Spata, Artemida, Stamata, Sykaminos.
The team was staffed by two psychologists, one psychiatric nurse and one social
worker.

According to the Mental Health Policy Implementation Guide (PIG) for

Community Mental Health Teams in the UK (Boardman and Parsonage 2007), a
home intervention team covers an area with a population of 10,000–60,000 inhabit-
ants, and this is dependent on local mortality rates and distances travelled by the
members of the team to carry out such visits. In light of the above, we propose to
establish a team consisting of eight full-time members. We propose that each mem-
ber of the team be assigned a load of 35 clinical cases of a total of about 300–350
cases. More specifically, the team shall consist of the following:
264 A. Krokidas et al.

Three to four community psychiatric nurses

Two to three social workers
1-1,5 occupational therapists
1-1,5 clinical psychologists
One psychiatrist
1-1,5 other medical disciplines
One to three support workers
1-1,5 secretaries
Receptionists

At first glance it is clear that the day centre ACT is trying to cover an area with a
quintuple population with no community mental health services provided other than
by the psychiatric department of the general hospital which operates as a satellite
hospital for this specific area and with one fifth of the necessary personnel. Another
paradox affecting the ontological aspect of this team is that the Ministry of Health
does not officially recognise this specific service as a home intervention unit, at least
until the time of writing this document, although it does recognise the services
provided.
Therefore, in an effort to design the characteristics of a model taking into consid-
eration the socioeconomic conditions in our country (Stylianidis 2003), we were
influenced mainly by the English model with the following specificities: the model
being formulated combines elements from various specialised teams outlined above.
More specifically, it operates up to a certain extent as a crisis intervention team,
intensifying its interventions in the event of a serious threat of relapse and hospitali-
sation or other serious risks. It responds, as necessary, on the same day to cases
where the threat is assessed as immediate, e.g. someone calls and reports suicidal
thoughts – within 20 min from the call two members of the team depart and visit the
caller. In this specific case, and after investing many hours in exploring and assess-
ing the situation, they avert the crisis and evaluate the need to take on the case or to
refer it to a more appropriate service, reinforcing thereby a process of interconnec-
tion and ongoing treatment for the patient.
Then, the Day Center ACT team integrates elements of early interventioning
psychosis, in cooperation with the Adolescent Psychiatry Services and intervening
in cases of early occurrence of the disease, either on a secondary prevention level
(when the patient has already been hospitalised) or even on a primary level (see
relevant vignette at the end of this chapter). In such cases, the services provided
include medication support and psychiatric monitoring, psychoeducation and fam-
ily therapy.
Another operational aspect of the Day Center ACT team includes intervention to
revolving door patients, individuals with many admissions and great difficulty to
commit to any form of therapy.

Services Provided
The services provided by the ACT team are as follows:
13 Assertive Community Treatment 265

Access to mental and general health services

Psychological support
Resolution of practical and social issues, claims for benefits and pensions
Settlement of bills and outstanding financial obligations
Intervention to improve residential premises
Development of daily living and socialisation skills
Psychoeducation
Family counselling and family therapy
Prescription of medication
Psychiatric monitoring

Other than designing individual plans, the team develops demand conditions,
which is something new in the current referral system, by appealing to mental hos-
pitals and general hospital psychiatric departments and trying to educate mental
health professionals to refer individuals who could receive the services of an ACT
team in a timely manner.
The methodological tools used are:

PANSS (Positive and Negative Syndrome Scale): the results for each patient will
allow us to identify each patient’s position on the quality of symptoms axis and,
consequently, the type of intervention required according to the ACT programme.
This scale is administered during the first meeting with the patient (intake), if
feasible, and then again 6 months later.
GAF (Global Assessment of Functioning): the aim is to explore the overall func-
tionality of an individual, in terms of life in the community.
Comprehensive individual care plan with re-evaluation of needs and objectives
every 6 months.

Certain initial outcome indices concern the reduction of the number of admis-
sions and the avoidance of relapses for individuals receiving the services of the
ACT team during the period of commitment to the programme and compared –
based on their track record – against the previous number of relapses/admissions.
Specifically:

Vignette of ACT Team Case

Siblings D.P. and I.P.

I. Referral
D.P. and I.P. are two 55- and 53-year-old siblings, respectively. They were
referred to us by the social services department of their municipality of resi-
dence in the Northern Suburbs. The reason for this referral was twofold: first, D.
had caused serious problems to all the services of the municipality as he was
aggressive and offensive towards all employees and the local community over
the last 10 years and was stigmatised as the region’s “madman”. Second, the
266 A. Krokidas et al.

Αριθμός νοσηλειών ανά έτος = Number of admissions per year

lack of any municipal specialised mental health professional staff did not facili-
tate the provision of ongoing care.
II. Psychosocial history
D. mentions domestic violence during their childhood from a very stern and
overbearing father, who worked as a builder and an alcohol abuser. The mother
is depicted as a passive and busy housewife. The first signs of the disease
appeared around the age of 19 when he was involuntarily hospitalised for the
first time. At the same time, he began taking on occasional jobs but stopped at
the age of 27 and received a disability pension because of his health problems
and recurrent hospitalisations. He describes his hospitalisations as traumatic
and abusive experiences. On the average, over the last 30 years, he has been
involuntarily hospitalised twice every year.
Ι. attended high school up to the last grade. She managed to complete a
hairdresser course and worked for 2–3 years as a hairdresser, but because of
the deterioration of her condition she stopped working. The onset of the dis-
ease occurred at the age of 19. Since then, she has been hospitalised about ten
times. She very often talks about her unfortunate engagement and her wish to
marry and have a family, a wish which is very often a structural component
of an erotic delirium. The information provided by colleagues from the
13 Assertive Community Treatment 267

municipal social services is that, perhaps, the two siblings have a sexual
relationship.
The father passed away in 1983 and the mother in 2009. For several years,
the mother was bedridden due to serious health problems. The first serious com-
plaints from the neighbourhood received by the municipality referred to the
inadequate care provided to the elderly mother by the siblings and the likeli-
hood that she was being physically and verbally abused. However, after the
death of her husband, D. and I. were placed under her guardianship.
ΙΙΙ. Clinical picture
D. has been diagnosed on the axis as F30-39 – bipolar disorder with psychotic
features (ideas of grandeur, auditory and visual hallucinations). In 2009, D.
attempted to commit suicide. He has not provided any information on any other
attempt. His sister I. has been diagnosed with F20 schizophrenia.
For a period of 3–4 months since the team’s intervention, D. and I. have no
insight. D. speaks mainly of his “sufferings”, referring to his hospitalisations as
“the will of God”, who will “elevate” him. Ι. wonders what’s wrong with them
which leads to their hospitalisation. A working assumption for both siblings is
that this is a case of a folie a deux (shared psychosis), where D. exhibits a preva-
lent delirium. It is typical that for several months they spoke roughly at the same
time about what has happened to them using much the same common experi-
ences, with D. leading I., permitting her to talk or not. After several months of
intervention they talk about their “small problem” and about experiencing
“great stress”.
ΙV. ACT team intervention
The ACT team took charge of the two siblings at the end of August 2013. Their
living conditions were appalling. They lived in a house with the bare necessi-
ties, inadequate water supply because the plumbing network was damaged, full
of animal faeces, piles of dirty clothes scattered on the floor, many broken appli-
ances and lots of junk, mouldy dishes and food in the sink and their many debts
and unpaid bills (electricity and water supply, taxes, etc.) and virtually without
heat. They got their meals from the municipal soup kitchen and, at the same
time, they spent both their pensions to buy ready meals.
During the first meeting, D. was suspicious, irritable and resented our pres-
ence in his home. He felt that the neighbours would suspect he was being visited
by mental health professionals and that he would be stigmatised, even though
the neighbourhood was already aware of him. He also said that he was ashamed
of the conditions in his house.
Three days after our first meeting, he visited the offices of the municipality
in a frantic condition and verbally attacked the employees. The municipality
initiated immediately the process for his involuntary admission and D. was
admitted to a psychiatric clinic. It should be noted that at that time he had not
been taking his medication for 3 months.
We started treating D. at the hospital and I. at home. In the hospital, D. com-
plained about the conditions, was worried about his sister and was anxiously
waiting to be discharged. We began discussing and preparing a care and support
268 A. Krokidas et al.

plan. It should be noted that he expressed his gratitude regarding our visit dur-
ing his stay at the hospital. This was the first time any service such as ours was
involved in the difficult transition from the hospital to the community.
During the first 2 months after being discharged from the hospital, the dis-
cussion regarding his medication plan and the preparation of a care plan were
completed. The siblings are visited at home twice a week mainly by the psy-
chologist, the nurse and the psychiatrist and, in addition, there was frequent
telephone contact. D. showed signs of a relapse, given his refusal to take his
medication for a long period. Visits were intensified. The main medical objec-
tive was to convince D. to commit to a minimum medication regimen in order
to avoid a new relapse and prevent the likelihood of a new admission, something
which was achieved and resulted in avoiding a new involuntary admission.
During this 10-month intervention, D. and I. have not been hospitalised.
V. Main axes of work
During this 10-month intervention by the team, the two siblings have joined a
personal care plan.
The following objectives were achieved under the main axes of work undertaken
by the ACT team:
1. Frequency of visits
The visits were scheduled to once a week and there is also frequent telephone
contact with the case manager.
2. Practical help with daily life skills activities
(a) A money management plan was set in place, given that both siblings
receive pensions which are sufficient to cover their needs.
(b) The house was cleaned by members of the team as well as with the help of
both siblings. A member of the team is responsible for the weekly visit to
the house during which daily chores (home care, preparation of meals,
etc.) are carried out according to a specific plan. All home supplies are
also purchased once a week, with the cooperation of D. and I. In addition,
we contacted voluntary charity organisations which offered furniture and
kitchen utensils.
3. Medication regimen
The ACT team has also undertaken to provide both siblings their injectable
medication. At the same time, the team has undertaken to accompany the
siblings during medical visits (pathologist, endocrinologist, dentist). Finally,
the team psychiatrist has undertaken the psychiatric follow-up care and the
prescription of medication.
4. Help with social welfare benefits and financial aid
The team has tried to accumulate the siblings’ debts and make arrange-
ments with public authorities as well as settle any outstanding bills. Actions
were taken to integrate them as vulnerable people into the social residential
tariff of the power supplier in order to secure a significant reduction in power
consumption and claim all the rights and benefits to which they are entitled to
as disabled persons.
5. Interconnection of services
Throughout the intervention, the team maintains an interconnection with
all the municipal services and the welfare department in order to ensure a
13 Assertive Community Treatment 269

greater flow of resources from the community to the two siblings as well as to
monitor the case in the best possible way.
6. Accommodation and rehabilitation of accommodation facilities
For D., rehabilitation will be achieved – as he himself says – through the
settlement of his debts and improved living conditions. Therefore, in strict
recovery terms, through the beneficiary’s perspective, this is now being
achieved.
Concerning the house where the two siblings live, efforts have been made
to repair damages and secure new electrical appliances and furniture.
7. Work with the family
This is a rather difficult part of the job considering the previously strained
relations with the family as well as D.’s disdain mainly for his relatives.
However, as they refer frequently to one to three relatives (cousins) with
whom they would like to reconnect, the team has tried to locate them and
establish a new relationship with them. An interesting fact is D’s now dimin-
ished insight relating to his “behaviour issues” – as he says – that led relatives
to keep their distance.
8. Commitment
A structural element of the work of the ACT team with the siblings on
which all the aforementioned axes of intervention are based is the sibling’s
extent of commitment to the treatment plan and cooperation with the team.
Two key elements contributed to this effect: first, our visits at the hospital
when D. was admitted when we began working with him. He felt, as he him-
self says, the “companionship” offered by the members of the team during
one of his many admissions and that someone cared for him. Second is the
fact that the members of the team were not judgmental about his living condi-
tions. This intervention was established on the basis of a fine and fragile line
between a specific methodological approach by the professionals and dealing
with the siblings under their own “terms”: the permission to enter their home
as well as accept their hospitality terms – sit with them on dirty furniture and
accept their treats and the acceptance of their diversity and their different liv-
ing conditions.

Outcomes (D)
Tools
GAF on the first intake: 15
GAF – currently (10 months later): 35

PANNS on the first intake:

Positive: 34
Negative: 30
Overall: 75

PANNS – currently (10 months later):

Positive: 26
Negative: 23
Overall: 60
270 A. Krokidas et al.

ACT Team Case Vignette

Y.L.

I. Psychosocial background facts

Y is a young 24-year-old man, the son of a family of four. He has a brother who
is 3 years older. His father is a retired civil servant and his mother a hairdresser.
He lives with his family in a privately owned house in the North Suburbs.
II. Clinical facts
Y’s parents visited us in January 2014. They described the change in their son’s
condition over the last months. About a year before our meeting with the par-
ents, Y was a particularly sociable young man, with many friends, who very
went out often during the week to have fun with his friends and was meticulous
about his appearance.
Since Christmas 2012, Y began withdrawing, had no telephone contact with
his friends and avoids meeting them. The parents refer to a period when he
often went to the bathroom and they worried that he suffered from some kind of
renal disease.
He is described as a bad student and quite highly strung, irritable. A year ago
he was quite a drinker. Now he doesn’t drink or smoke. Over the last few months
he refuses to cut his hair, shave or take a bath and does so only after being
encouraged by his mother and, then, only once every 3 weeks.
His parents described in detail Y’s rituals. He spends a long time in the bath-
room (approximately 50 min every time and as frequently as two to three times
a day) and cleans it meticulously. Because there is only one bathroom in the
house, if any other member of the family needs to use it, Y agrees to come out
with some difficulty but goes back in to “finish” what he was doing. He doesn’t
drink water, only juices. He washes his face thoroughly, refuses to use the toilet
soap and prefers to use the kitchen soap.
Other rituals include the use of objects such as, for example, opening and
closing his mobile phone, counting coins and stacking them up and placing them
in a particular way. All these activities may last for about an hour. After some
months, he refused to sleep in his bed and instead sleeps sitting up on the sofa.
Y began quarrelling with his parents who were unable to understand the
“meaning” of all these rituals. The only thing giving the impression that he is
relatively able to function as a healthy person is his work. He works with his
brothers in a technical company which manufactures signs and unfailingly asks
his mother every day to wake him up to go to work.
In autumn 2013, the parents tried to bring Y into contact with a private psy-
chiatrist, who after one session prescribed an antidepressant. Y refused to take
it. The quarrels at home persisted, there was no follow up from the psychiatrist
and the parents decided to contact another practitioner in parallel with our own
intervention.
A key factor of the intervention is that the parents are seeking a specific
medication solution for Y, even if he is unaware of this (covert administration
of medication), while the ACT team intervention moves in a completely
13 Assertive Community Treatment 271

opposite direction. The private psychiatrist prescribed risperidone in liquid

form and advised them to administer it covertly in water or juice. The parents
employed this “method” for a week; however, the ACT team’s intervention
includes two points which convinced them to stop:
First, Y must first understand through our meetings what is happening to him,
trust the members of the team and build a therapeutic relationship with us.
The covert administration of medication and the resulting recession of the
symptoms would not help him in the process of understanding, gaining
insight and taking responsibility for his health condition and treatment.
Second, morally, the covert administration of medication violates Y’s rights
as a patient.
ΙΙΙ. Interventions
We started seeing Y in February 2014. He showed up about 50 min late as he first
had to complete his rituals. He was guarded, aloof and wary. The first meetings were
of a psychoeducational nature for him and his parents in an effort to alleviate their
anxiety and Y’s wariness as to who we are. The first two to three times he asked us
to not visit him again. At that time and while Y’s verbal abuse of his parents
increased, his father informed us that he had initiated the process of involuntary
admission (by court order). We urged him to “freeze” the process and return to the
team and work with Y. Along with the meetings and a psychoeducational process to
inform Y on the use of medication, their potential adverse effects as well as how this
medication could help him, the team psychiatrist prescribed overtly risperidone in
liquid form. Y was convinced and has ever since been taking his medication and is
monitored on regular basis by the psychiatrist. Y’s diagnosis moves along the F20–
29 axis with an estimation of initial occurrence of the disease.
At the same time, we initiated a structured family therapy intervention by
family therapists at the day centre in which Y now participates. In addition, the
psychiatric monitoring takes place in the day centre during meetings which Y
attends unfailingly.
IV. Axes of work
The following objectives were achieved under the main axes of work in coop-
eration with the ACT team:
1. Frequency of visits
The visits are scheduled to once a week in the form of socialisation out-
ings and there is also frequent telephone contact with the case manager. Y is
now open to outings and also plans activities outside the home without the
members of the team.
2. Practical help with daily life skills activities
Support in self-care to which Y responds very successfully (he showers
often, cuts his hair and shaves regularly).
3. Medication
He now takes his medication on his own. His clinical picture shows some
signs of depression. This is an expected outcome given that Y is now gaining
insight, is becoming connected with his history, started giving again thought
to his health condition and identifying problems in his relations with others.
272 A. Krokidas et al.

At the same time, a significant reduction in active symptoms and rituals has
been observed while he no longer sleeps on the sofa.
4. Help with social welfare benefits and financial aid
Y communicated his desire to change his job and work voluntarily in
various activities. The team supports him in these areas.
5. Accommodation and rehabilitation of accommodation facilities
He expressed the need to live alone at some point and this is a significant
item in his personal care plan and assertive recovery process.
6. Work with the family
The family therapy sessions where all participate are ongoing. Y is thinking
of reuniting with his old friends and the team is encouraging him in this effort.
7. Commitment
During this 4-month intervention, Y and the other members of the family
participate actively in setting up and implementing his personal care plan.

Outcomes
Tools
GAF: on the first intake, 42
GAF: currently (four months later), 61
PANNS: on the first intake:
Positive: 23
Negative: 36
Overall: 67
PANNS – currently (4 months later):
Positive: 16
Negative: 24
Overall: 44

In Lieu of Conclusion: Findings, Outlook and Concerns

As we have already indicated, any efforts to establish home intervention teams in
Greece have never been included in the strategic plan for psychiatric reform. Any
individual efforts which may have been pockets of good practice, though never
assessed, remained just that, i.e. pockets within an institutional framework that did
not envisage and still does not envisage the establishment of such teams and their
systemic integration with other mental health services structures. The national
action plan at this stage of psychiatric reform in Greece leaves little doubt about
this. The mobile units are a special case only for remote areas.
The question is why reform in Greece bypasses what is possibly the quintessen-
tial psychosocial rehabilitation community structure which is the home intervention
teams. We use intentionally the designation “quintessential”, in the sense that the
interventions by home intervention teams are not provided within any structures
(pre-)designed by mental health professionals but at the users’ home, i.e. in a space
that does not belong to and was not designed by mental health professionals.
Contrary to this, all community services (other than the limited liability social coop-
erative [LLSC – KoiSPE] and, of course, the mobile units) are patient “reception”
13 Assertive Community Treatment 273

structures, e.g. day centres, mental health centres, residential units, boarding houses,
sheltered residential accommodation, etc. Of course, we are not suggesting that
such structures are less useful, but we are just highlighting, at least in our opinion,
one interesting difference with symbolic, moral as well as therapeutic/rehabilitation
aspects and consequences.
Our initial question remains unanswered but let’s not rush to engage in worn-out
and off-the-shelf criticisms “against any person responsible”. We choose to put it
forward as an issue for further discussion and analysis, not only for Greece but also
for other countries. Moreover, as regards the home intervention model in particular,
Greece does not fall short compared to other countries. The World Health
Organisation report (2008), Policies and Practices for Mental Health in Europe:
Meeting the challenges, states indicatively that only in the UK (England and Wales
but not Scotland) all patients with chronic and serious mental illnesses have access
to Assertive Outreach Teams. In 16 of the 42 countries covered by the report, e.g. a
percentage of 38 %, do not have access to such services (WHO 2008). For example,
in Italy the percentage of patients with access is between 1 % and 20 %, in Germany
51–80 % and in Switzerland 1–20 % (Table 6.12). In terms of home intervention
teams for the treatment of a first psychotic episode (early intervention psychosis),
80–100 % have access to such services in three countries only (Germany, UK and
Luxembourg). In Italy and Switzerland the percentage is between 51 % and 80 %
(Table 6.14).
We could say then, by way of a provisional conclusion, that, Greece is not exactly
an exception as regards the existence and operation of home intervention teams. Of
course, this doesn’t mean that we must accept this situation as is. The subject of
psychiatric reform remains open.

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Brief Psychotherapy in a Community
Framework 14
Marina Skourteli and Stelios Stylianidis

Abstract
This chapter addresses the need to integrate brief psychotherapy as the most
appropriate model for the provision of psychotherapeutic intervention in a public
or community framework. The discussion begins with a historical overview of
the development of brief psychotherapy starting from psychoanalysis and goes
on to point out the key principles highlighting the differences between brief psy-
chotherapy and open psychoanalytic treatment, particularly within the context
the modern socioeconomic challenges governing the provision of mental health.
It also addresses the psychodynamic approach in brief psychotherapy and pres-
ents research findings with regard to its effectiveness. Common factors with
regard to the effectiveness of brief psychotherapy are highlighted with the main
focus on the therapeutic alliance and the therapist’s role; these are shown through
a clinical example of brief psychotherapy in the community. Finally, the pressing
need is highlighted for intensive training and supervision for psychotherapists
working in a intensive, brief therapeutic framework.

M. Skourteli (*)
CPsychol Specialising in Psychotherapy, DPsych., AFBPsS, HCPC Reg.,
Head of Psychotherapy Service, ‘Franco Basaglia’ Day Centre, EPAPSY, Athens, Greece
e-mail: [email protected]
S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 277

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_14
278 M. Skourteli and S. Stylianidis

14.1 Introduction

This chapter tries to point out the necessity of integrating and utilising brief
psychotherapy in a public mental health framework, in particular that of the reality
in Greece, given the socioeconomic crisis conditions. Although the authors are
trained in psychodynamics/psychoanalysis, they make a conscious choice to adapt
psychodynamic/psychoanalytical principles, approaches and techniques into a pub-
lic mental health framework. In a public system with its accompanying socioeco-
nomic challenges, the target of this standpoint is not the full understanding of the
patient’s unconscious outside the boundaries of time, but the recognition of a limit
that ensures the immediate therapeutic benefit of both the patient and the therapist,
meeting in a public framework of mental health provision (Gillieron 1994, 1997;
Despland et al. 2010). The work begins with a historical overview of brief psycho-
therapy development from Freud and his followers extending to the current socio-
economic background and the contemporary challenges surrounding their
implementation in public mental health frameworks. The significance of the initial
case estimates during the first interview is set out as an integral part of the therapeu-
tic process in brief psychotherapy, followed by the basic therapeutic principles gov-
erning the practice of brief psychotherapy, which are radically different to those of
“open” psychotherapy. Due to the limited space, the chapter addresses only the
psychodynamic approach to brief psychotherapy, which is supported by research
regarding its effectiveness relative to corresponding “open” psychotherapy treat-
ments. In conclusion, the importance of the therapeutic alliance and the therapist’s
role in brief psychotherapy is showcased, as well as the imperative need for inten-
sive training and supervision of the therapists working in a fast-paced, brief thera-
peutic framework. Finally, the Greek example of brief psychotherapy in a public
framework is put forth as well as a clinical vignette from the Psychosocial
Intervention Day Centre of EPAPSY.

14.2 Historical Overview

According to many, it was Freud who first used brief psychotherapy. According to
Freud, the patient’s symptoms were due to unconscious, traumatic but regressed
memories, which, once recalled, together with their emotional foundation, and
made conscious, led to symptom elimination (Symington 1986; Mander 2000;
Coren 2001). Recognising, however, that not all patients were eligible for hypnosis,
the classic method used to recall regressed memories from the unconscious, Freud,
during the pre-analytical period, developed the “cathartic” method, a process
whereby the patient lays on the divan bed and, with the help of the analyst, who
applied gentle pressure on the patient’s forehead and actively encouraged him to
remember, the regressed memories were recalled and the conflicting emotions were
experienced, resulting in the restoration of mental health. Despite the fact that these
early therapeutic approaches and techniques were experimental and were later mod-
ified (e.g. after this first technique of the cathartic method, Freud went on to the free
14 Brief Psychotherapy in a Community Framework 279

association method), they were in essence brief, specific symptom oriented and
significantly based on the therapist’s active participation (Freud 1893, 1895, 1905).
In that sense, these first psychoanalytical approaches were the same or similar to
contemporary brief psychotherapeutic approaches, where the clarity, the active
therapeutic attitude and the focus on a specific therapeutic planning are important
elements (Mander 2000; Coren 2001).
During this early period, the analyst maintained an active or even guiding
attitude, whereby he often encouraged the recall of regressed memories from the
unconscious, while supporting as well as updating the patient regarding the process
and course of analysis, through an active therapeutic practice. Later, especially in
the context of his disputes with his followers, Freud abandoned this position, in
order to defend the clarity of psychoanalysis as an inclusive model for the deeper
and fuller understanding of the individual’s psycho-cognitive function (Freud 1917,
1920, 1923). Even so, the early psychoanalytical attitude made the patient more of
a collaborator that is a passive recipient of the analyst’s interpretations. Here, it is
worth mentioning that transference became the central and most important element
of psychoanalysis much later. Freud initially believed that psychoanalysis was not
indicated for people with major pathology and that, on the contrary, it was appropri-
ate for the lighter cases. It is interesting that today, many psychoanalysts, as well as
some researchers, maintain the exact opposite, namely, that psychoanalysis is also
indicated for major psychopathology cases (Mander 2000; Coren 2001; de Maat
et al. 2009).
The first treatments Freud gave were exceptionally brief and lasted just a few
weeks or months. For example, Gustav Mahler and Katharina’s analysis (Jones
1956; Kuehn 1965) was conducted over the duration of a walk, while Bruno Walter
and Lucy R.’s analyses lasted six sessions and 9 weeks respectively (Freud 1893;
Walter 1947; Sterba 1951; Coren 2001). As we said before, and particularly within
the context of Freud’s attempt to ensure the clarity of psychoanalysis as a robust
therapeutic model for the in-depth understanding of the individual’s psycho-
cognitive system, the cathartic method was finally replaced by that of free associa-
tion, which required therapeutic neutrality, and correspondingly increased the
possibility of the patient’s regression from the therapeutic process. The concepts of
resistance, defence, character analysis and the in-depth working through as well as
the issue of the end of therapy may be considered as the natural aftermath of this
new technique, which inevitably made treatment duration a lot longer. At the same
time, analysts became less active, supportive or “challenging” in their attitude, while
the interpretation (mainly of patient transference) became the tool for analysis and
therapeutic change. Gradually, treatments lost the boundaries of time and acquired
a quality of timelessness. Consequently, the need to focus on specific therapeutic
targets or symptomatic relief ceased to be a therapeutic priority (Coren 2001).
Freud’s theory was actually based on a purely intrapsychic, solitary supposition
of the psyche that paid scant attention to the role or participation of others. Also in
the context of therapy, the analyst remains a distant observer to the therapeutic
process. Many of Freud’s followers, such as Otto Rank, Sandor Ferenczi and later
Alexander and French, Michael Balint and David Malan, adopted a critical stance
280 M. Skourteli and S. Stylianidis

to the scientific positions and clinical applications of the theory of psychoanalysis

and proposed instead clinical approaches based on an intersubjective background
that continue to influence the development of brief psychotherapy to this day. For
Rank (1929), for example, therapy (much as life) must have an end, and issues
such as separation, dependence and differentiation emerge in each therapy ses-
sion. Acceptance of the reality of the end, according to Rank (1929), can be seen
as the dominant characteristic of any “successful” treatment, while the determina-
tion of a clear end date and the investigation of the reactions relating to it would
make it a therapeutic priority. Rank’s theory on brief psychotherapy (the ideal
duration was considered to be a period of 7–9 months, symbolic of the gestation
period) is what led to the final rupture of his relationship with Freud in 1926
(Lieberman et al. 2012).
Just like Rank, Ferenczi (Ferenczi and Rank 1925) was also concerned with the
increasing inactivity, passivity and a tendency to intellectualise (he thought that
psychoanalysis became a chiefly academic exercise that benefited the analyst more
than the patient), as well as the lack of emotional reciprocity between the analyst
and the patient. Ferenczi believed that by emphasising the most important dimen-
sion of the therapeutic relationship, namely, the emotional interaction between
patient and analyst, the duration of therapy would become briefer. He also ques-
tioned the axiom of therapeutic neutrality, as he believed that a scientific, objective
interpretation did not help vulnerable patients as much as a supportive therapeutic
attitude. Many of the therapeutic interventions suggested by Ferenczi (e.g. hugging
his patients for comfort, or his attempts at “mutual” analysis) were particularly con-
troversial, and his name never recovered in psychoanalytical circles. Even so, some-
thing worth retaining from his theory is the emphasis and weight attributed to the
dynamics of the therapeutic relationship and the need for flexibility and adaptation
of the therapeutic framework to the needs of the patient (Symington 1986;·Stanton
1990;·Mander 2000;·Coren 2001).
Alexander and French (1946) considered their work a natural extension of the
early relational models introduced by Rank and Ferenczi. According to Alexander
and French, the purpose of therapy was not so much the recall of regressed memo-
ries, the historical reconstruction and correctness of interpretations, but the direct
emotional experience of the patient within the session, which had to be brief and
intense in order to be transformative. The “corrective emotional experience” actu-
ally referred to a new iteration of an old conflict; the tendency of the patient to
repeat past trauma in the context of analysis had to be dealt with a new, different
therapeutic response, and it was this “discrepancy” that was considered restorative.
Again, Alexander and French identify the concept of therapeutic flexibility as key;
they maintained that the analyst ought to adapt the therapeutic framework to the
patient’s needs and not the reverse. Recognising the risk of dependence of vulnera-
ble patients from analysis, Alexander and French (1946) believed that breaks and
short separations during therapy (such as extraordinary absence due to illness or
scheduled vacations) helped rather than disrupting the analytical process, thus sug-
gesting that therapy was not just limited to the context of the session but rather
extended between sessions too.
14 Brief Psychotherapy in a Community Framework 281

Alexander and French (1946) were particularly criticised with regard to the
concept of “corrective emotional experience”, which was characterised as a
manipulation of transference. Their assistance, however, as well as that of Rank
and Ferenczi, contributed significantly to the implementation of psychoanalytical
concepts in treatments of shorter duration and in the differentiation of psycho-
analysis as a separate therapeutic approach, as well as the term “psychoanalytical”
as a concept that may enrich different theoretical frameworks (Lemma 2014;
Gillieron 1991, 1994). Even more significant is the fact that these new trends pro-
pelled the move from a solitary, biological view of the psyche to a modern object-
oriented relational theory taking the therapeutic relation to a dynamic process,
where the one side affects and is affected by the other (Mander 2000; Coren 2001;
Mitchell 1988, 2000).

14.3 The Socioeconomic Framework of Brief Psychotherapy

Besides the theoretical and clinical factors governing the principles of brief psycho-
therapy, the discussion of its development as a separate therapeutic model would be
incomplete if it didn’t also establish the role of the wider socioeconomic framework
of the provision of mental health. Particularly within the past two decades there is
wide, international recognition of the financial cost, mainly of “common” mental
disorders, such as anxiety and depression (Murray and Lopez 1997; Laylard 2006;
WHO 2008). Although these common disorders are not as serious compared to
chronic disorders, such as schizophrenia, their total cost with regard to “disability”
and the economic burden they cause is clearly bigger (Andrews and Henderson
2000; Gillieron 1994; Gask et al. 2009a, b; Sartorius 2009).
For many years, the impact of mental disorders at public health level was
extremely difficult to quantify, as most international research used mortality as a
comparative indicator between various medical disorders. The World Bank intro-
duced a new methodology for calculating “disability” resulting from the various
disorders. It is calculated that neuropsychiatric disorders are responsible for 8 % of
the total economic burden, measured by the number of work years lost due to the
disability they cause. Specifically, in ages between 15 and 44, mental disorders are
responsible for 12 % of the total economic burden, while if we include self-
destructive behaviours (e.g. the use of alcohol as self-medication), this rate rises to
15.1 % for women and 16.1 % for men. On the basis of the above, it is forecast that
by 2020, mental disorders will be responsible for 15 % of the total economic bur-
den, while depression will come second after ischemic heart disease, regarding the
cost of the disability it causes. These rates of disability (from the point of view of
diminished capability to work) may be even higher if we include the phenomenon
of somatisation or medically unexplainable symptoms, whereby patients present
physical problems that have no organic aetiology (Thomas and Lewis 2009).
One economic analysis in Great Britain (Laylard 2006) maintains that the new
“psychological technologies” have the capability of resolving long-term unemploy-
ment due to a mental disorder, for example, through the implementation of a small
282 M. Skourteli and S. Stylianidis

number of sessions of cognitive-behavioural therapy, which may actually be

administered with the help of a computer or by untrained “psychological thera-
pists”. These suppositions are particularly problematic not just from a scientific and
ethical viewpoint but also because they include the risk of poorly thought-out neo-
liberal policies, where each attempt to shorten therapy may be seen as a managed
care technique and the provision of brief psychotherapy in a public context as a
consumable product. On the other hand, full understanding of the patient, unhin-
dered by the limits of time, cannot be ensured within the context of a public system
and under the conditions of a socioeconomic crisis. Although these phenomena
indicate the socioeconomic parameters of public psychiatric treatment and the risks
they pose, it is important to point out the need for increased availability and acces-
sibility of brief psychological treatment for “common” mental health problems in a
community or primary context (Stylianidis 1995).

14.4 Initial Assessment of the Case in Brief Psychotherapy

Initial assessment with regard to patient eligibility for brief psychotherapy during
the first interview differs significantly from that of “open” psychotherapies. At first,
the development of the object-oriented relationship led to identification of the
duality governing the therapeutic relationship, while the emergence of intersubjec-
tivity as a scientific framework (Mitchell 1988, 2000) respectively places the issue
of the initial assessment in a more interactive, bidirectional and flexible framework
of reciprocity (Symington 1986; Mander 2000; Coren 2001). Gillieron (1994)
points out the significance of the patient’s initial assessment during the first session
even within the context of a treatment of four sessions’ duration.
The meaning of the initial assessment during the first interview consists of three
main fields: purpose, target and procedure. As these priorities may often differ
between patient and therapist, an important element during the assessment process
is the establishment of a therapeutic cooperation (or alliance), which, on the one
hand, is an integral part of any effective treatment and, on the other, facilitates tak-
ing the patient’s history, which in turn allows the psychological expression of his
difficulties and the selection of the brief therapy model (Dewan et al. 2009;
Leichsenring 2009). A key question of the initial assessment is “why now” – the
reason why the patient is seeking psychotherapeutic assistance at this precise time
forms the specific framework. Often, the need to seek assistance at a specific time is
motivated by an external factor, indirectly related to the patient’s history, as in the
example that follows:
Anna, survivor of a particularly aggressive form of breast cancer that necessitated a double
mastectomy, presented with major symptoms of depression, when a colleague was diag-
nosed with breast cancer two years later.

Upon the initial assessment, it is a good idea for the patient to receive some basic
information about the treatment he will follow, particularly regarding its structure,
purpose and method, in order to ensure transparency and convergence but also a
particular therapeutic contract that specifies mutual expectations and obligations.
14 Brief Psychotherapy in a Community Framework 283

This is of use mainly for patients from different cultural backgrounds that may have
a different concept and expectations with regard to what constitutes psychotherapy.
This attitude of participation and cooperation is a key difference between brief and
open psychotherapy, as the latter argues that the clarification of the therapeutic
framework may affect patient transference and by extension compromise treatment
quality (Mander 2000; Coren 2001).
Careful clinical listening of the patient regarding the difficulties he is facing (not
only what is being said but also what is not being said) is an extremely important
element of the assessment, as the narrative style and the emerging repeated interper-
sonal motifs (e.g. “I’m not making myself understood”) are directly linked to the
therapeutic framework.

Peter, 36 years old, with chronic depression, difficulty in forming interpersonal relations
and intense schizoid elements, arrives at the assessment session and states during his
narration that ‘he doesn’t get on well with women’. The therapist, pointing out her gender,
wonders what this means to Peter and how it can affect their possible cooperation.

This way, the patient gets a first taste of therapy, while the therapist assesses the
form that the therapy may take (Tantum 1995; Dewan et al. 2009). Any form of
assessment ought to include the current problem; the presence of possible co-
morbidity (especially behaviours used as self-medicating means, such as eating dis-
orders, substance or alcohol abuse); history of significant interpersonal relationships,
including therapeutic ones; and existence of physical or mental diseases, as well as
expectations, previous experiences or fears with regard to therapy and the therapist
(pre-transference is an equally important assessment element to the content of the
initial assessment). The therapist ought to remember that the initial assessment is
not a monodimensional, static, diagnostic position of observation and collection of
information, but a dynamic, developing process, directly related to the therapeutic
one (Mander 2000; Coren 2001; Dewan et al. 2009). The initial assessment proce-
dure on the one hand needs to be based on scientifically documented criteria and on
the other to remain flexible and sensitive to new data as this emerges in the course
of treatment.
Although the selection criteria differ depending on the theoretical approach, in
general terms, brief psychotherapy is indicated for persons with specific problems,
sufficient motivation, the capability to form interpersonal relations and containment
of impulses and frustrations, while also establishing intrapsychic, physical and
social aspects of the human experience. Vaslamatzis and Verveniotis (1985) men-
tion that patients who stayed and completed a course of brief psychodynamic psy-
chotherapy in a psychiatric hospital psychotherapy department were highly
motivated, brought a specific problem and were in “crisis”. Correspondingly, part of
the literature maintains that brief therapy is contraindicated for patients with diffi-
culty in dealing with separation, intense acting-out and excessive use of early
defence mechanisms (Coren 2001; Dewan et al. 2009). In all this, however, there is
extensive literature maintaining that even the most difficult, borderline patients may
benefit from brief psychotherapeutic intervention [e.g. the synthetic approaches of
mentalisation-based treatment, rational-emotive therapy and dialectical-behaviour
therapy are mentioned (Fonagy 1991; Allen and Fonagy 2006; Ryle 1998; Koerner
284 M. Skourteli and S. Stylianidis

and Linehan 2003; Gabbard 2009)]. Even within a brief psychotherapeutic

framework, the earliest the trauma is developmentally, the longer-term therapy is
indicated.
The focus of brief psychotherapy is not so much the patient’s behavioural “cor-
rection” as the investigation of peripheral difficulties or problems, which are directly
linked to his behavioural structure. We point out again that the “ideal” and “clarity”
of full and in-depth understanding of the individual’s psycho-cognitive instrument,
as it emerges through psychoanalysis, are not feasible or advisable in the context of
brief psychotherapy, particularly when the provision of the latter is carried out in a
public framework. Due to the limits in time and the focused therapeutic approach,
the priority of the initial assessment includes the establishment of the therapeutic
alliance from the first session and the immediate identification of possible negative
emotions to therapy (Leichsenring 2009), and those two elements are connected
with a more active therapeutic position. The issue of initial assessment during the
first interview has less to do with treatment duration or number of sessions (e.g. a
therapeutic intervention of 1 year is considered brief if its end has been determined
from the outset) and more with the most appropriate type of therapy (interpretative,
investigative, supportive, oriented towards the resolution of specific difficulties/
symptoms, etc.). The attitude of the therapist as to brief psychotherapy, including
the capability of frustration containment and the management of frequent and mul-
tiple separations, is also a significant criterion in the provision of brief psychother-
apy (Messer and Warren 1995; Vaslamatzis et al. 1986, 1989; Gillieron 1994).

14.5 Therapeutic Principles in Brief Psychotherapy

In brief psychotherapy, the establishment of a specific therapeutic target is the most

important element from the point of view of technique. As to the technique, the
ensuing fields are the therapeutic focus, the therapist’s attitude and the end of the
psychotherapy.

The Therapeutic Focus

Contrary to “open” psychotherapeutic approaches, where the entire clinical material

the patient brings is addressed as important and directly linked to current symptom-
atology, brief psychotherapy requires the identification of one core target. In this
sense, the clinical material produced by the patient is addressed as more or less
relevant to the core target, while clinical listening requires a stance of selective
neglect of the material. Identification of the core target in brief psychotherapy serves
to maintain narrative cohesion and continuity, which interweaves sessions and orga-
nises the therapeutic process, while also reducing the risk of “pointless wandering”
in fields that do not comprise therapeutic priority within the limited time frame. In
psychodynamic approach and brief psychotherapy in particular (but not exclu-
sively), the core target refers to repeated interpersonal or relational motifs, which
14 Brief Psychotherapy in a Community Framework 285

occur again and again in various aspects of the patient’s life (Mander 2000; Coren
2001; Dewan et al. 2009; Leichsenring 2009). Identification of the core target is a
mutual process while the target of the therapy must remain flexible, more as a guide
than a destination, and expedient to the patient’s actual, latent needs. Expressing the
core target requires on the part of the therapist the attitude of a conscious observer,
with full knowledge of theory and, more importantly, creativity and freedom from
traditional ways of thinking, where the patient has to “fit” into predetermined diag-
nostic categories and by extension to be treated with stereotyped therapeutic inter-
ventions (Balint et al. 1972; Coren 2001).

The Therapist’s Attitude

The concept of therapeutic activity is contrary to the image of the more neutral, less
active analytical stance that dominates open psychotherapies. In brief psychother-
apy, the therapeutic activity serves to maintain the core target, the ideal levels of the
patient’s thymic stimulation during therapy (Fonagy et al. 2008; Dewan et al. 2009),
but also to avoid the patient’s dependence from the therapist. The therapist’s attitude
differs significantly in brief psychotherapy. The concept of therapeutic neutrality
and detachment (which possibly reflect the need of psychoanalysis to be as distant
as possible from the early methods of catharsis and hypnosis) has been questioned
mainly by Mitchell (1997), who believes that even analytical neutrality is, in
essence, a kind of participation (Gill 1994). From this intersubjective viewpoint, the
analyst’s silence is potentially as harmful as activity, especially when addressed
without thinking and with a lack of reflection regarding its effects in the therapeutic
process. In order to showcase the problem of analytical neutrality, Mitchell gives the
following clinical example:

A psychotherapist adopts a strictly silent attitude in therapy, but her chair creaks (as the
patient finds out) each time she refers to a specific clinical material. The patient senses that
the creak in the chair communicates some sort of malaise on the therapist’s part, but despite
this eminently significant material, namely the therapist’s participation in the dynamic pro-
cess and the (non-) response to it by the patient, it is never mentioned and analysed.
(Mitchell 1997, p. 13, in Coren 2001)

In brief psychotherapy, the therapist’s attitude becomes the objective of reflec-

tion always in reference to the patient’s core conflict and the therapeutic focus. In
the context of the time limitations governing brief psychotherapy, the therapist’s
neutrality or silence includes the risk of increasing the patient’s anxiety to a degree
threatening the therapeutic alliance, particularly in patients with more serious psy-
chopathology. The attitude of therapeutic neutrality as well as that of activity must
be addressed in relation to how much they contribute to the service of therapeutic
focus or in respect to the patient’s relational difficulties (Mander 2000; Coren 2001;
Dewan et al. 2009).
Here we should clarify that the therapeutic activity is not tantamount to the
provision of advice or directivity. The concept of activity refers to the direct shift in
286 M. Skourteli and S. Stylianidis

focus from the “out there” to the “here and now” of therapy. Direct identification
and investigation of the patient’s negative emotions of resistance from as early as
the first session seem to cement the therapeutic alliance. In the research of
Vaslamatzis and Verveniotis (1985), the processing of translatif reactions of patients
towards their therapist early in treatment increased the probability that they might
remain and complete their brief psychodynamic therapy and not leave early. The
active therapeutic attitude in brief psychotherapy communicates the openness of the
therapeutic framework to acquit and contain difficult emotions of diversity or
ambivalence, probably contrary to other relationships that the patient experiences
(Mander 2000; Coren 2001; Gabbard 2009).

The End of Psychotherapy

The core dilemma governing brief psychotherapy is the question of the end: specifi-
cally whether the end of the treatment must be determined precisely prior to its start
or whether the clinical contract may allow supplementary or follow-up sessions
after the end of the treatment. In any case, what must be avoided and is clearly a bad
practice in the context of brief therapy is an unclear stance with regard to the end,
which results in an unstable, uncertain and noninclusive therapeutic framework.
The availability of supplementary sessions includes the risk of denial of the reality
of the end as a general concept (e.g. as a symbolism of death) and is generally con-
sidered to be unhelpful, as the ambivalent management of the end may cancel the
effectiveness of therapy in its entirety (Mann 1973; Coren 2001). Furthermore, the
availability of supplementary sessions (which may communicate difficulties with
regard to the end both on the part of the therapist and that of the patient) may uncon-
sciously reflect a therapeutic doubt or uncertainty related to the patient’s readiness
to stop (making him seem fragile or dependent). Management of the end, besides
being real, is also symbolic and reflects the patient’s psychic representation and
containment by the therapist. The end (in its physical as well as symbolic dimen-
sion) is the most important element of brief psychotherapy and must be set from the
start of treatment. The thematic of end, loss and separation must be interwoven with
the therapy’s narrative fabric from the start and throughout its duration and not
investigated when treatment is approaching its end. The end of psychotherapy
brings to the forefront issues of loss, separation or mourning (Holmes 2001), while
the manner in which the patient is related to the end reflects motifs of forming and
ending interpersonal relations:
Vicky, an intergenerationally traumatised patient (her father was a war veteran and suffered
with PTSD) comes to therapy with depression and a history of self-injury. Although the
therapeutic contract provides from the start 20 sessions and despite all references to the end
of treatment throughout its duration, Vicky “forgets” the end, consequently experiencing it
violently and angrily as a traumatic abandonment. The interpretation of Vicky’s repeated
unconscious tendency to (re-)injure herself, avoiding or “forgetting” the mental processing
of the end, relieves the patient and allows her to contain and reflect on the feelings of loss
and anger related to the end of treatment.
14 Brief Psychotherapy in a Community Framework 287

It appears that the patient’s transference with regard to the non-infinite

dimension of time is directly linked to his relational history and core focus, so the
time constraints set by the institutional framework, the patient’s mental function
and his acting-out in the transference/countertransference dynamic meet in the
“here and now” of treatment with regard to the theme of its end (Gillieron 1991,
1994). Also, the therapist’s history related to loss and separation appears to be
activated and become involved in the therapeutic dyad dynamic with regard to the
end (Vaslamatzis et al. 1986; Boyer and Hoffman 1993). Vaslamatzis et al. (1989)
state that the less certain therapists declared they were regarding the end of brief
psychodynamic psychotherapy management, the more probable it became for
patients to withdraw from the treatment prematurely. One can get a taste of the end
of psychotherapy by observing how each patient manages the end of each thera-
peutic session. Some patients are punctual as to the start and end of sessions, while
others find separation hard and try to avoid the end, presenting important material
during the last minutes of the session. The end of the therapy session reflects a
microcosm of the end of treatment reminding the significance of separation in
therapy on a weekly basis (Mander 2000; Coren 2001; Holmes 2001).
Although the issues of therapeutic focus, therapeutic activity and the end of ther-
apy comprise basic characteristics of all brief psychotherapies, the individual fields
that therapy focuses on differ depending in the therapist’s theoretical model.
Therefore, the target may be set relative to the symptomatology or some specific
problem, or it can focus on the patient’s structural or behavioural details. The thera-
peutic view should also include a developmental aspect as to the patient’s issues, as
the same event or symptom may have a different meaning or significance when
occurring at a different age or stage of his life. Due to the limited space, this chapter
addresses only the psychodynamic approach in brief psychotherapy, while it pro-
vides suggested literature references for other, equally important brief therapeutic
approaches widely applied in a public framework (Gabbard 2009).

14.6 The Psychodynamic School in Brief Psychotherapy

The term “psychodynamic” suggests that psychism is not a static field; on the con-
trary, it includes powers that seek expression, release or satisfaction. According to
Freud, the impulse refers to a dynamic process and to a “push” that forces the indi-
vidual to abolish this internal status of intensity and physical stimulation through an
object (LaPlanche and Pontalis 1986). With the development of the school of object-
oriented relations, the concept of the impulse acquires an interpersonal existence
and interpretation, where this intrapsychic intensity is the need of the subject to
relate to the object rather than being just a biological function of release. The activ-
ity of psychism is not limited only to external relations but essentially to relations
between objects. The concept of the self as an observer of internal processes sug-
gests that the dynamic psychic activity takes place both intra-psychically and inter-
personally (Symington 1986; Jacobs 2001; Nelson-Jones 2001; Maroda 2010). The
psychodynamic theories say that the first years in the life of an infant and its
288 M. Skourteli and S. Stylianidis

relationship with its mother and father have a determining effect on personality and
mental health development in adult life (Slade 2008; Cassidy and Shaver 2008). The
psychodynamic school believes that the real, repeated interpersonal interactions
between mother and infant are introjected and become psycho-cognitive representa-
tions [in a process where the interpersonal becomes intrapsychic (Maroda 2010;
Gabbard 2009)]. These representations or internal work models describe the rela-
tions between different aspects or dimensions of the self, while they are directly
involved in thymic stimulation and regulation (Goldberg 2000), defence mecha-
nisms (Holmes 1997; Bifulco 2002; Hesse 2008; Gabbard 2009), memory and
attention processes (Coan 2008), cognitive structures (Lopez and Brennan 2000;
Holmes 2001) and the function of reflection (Main 1991, 1993; Fonagy 2004; Allen
and Fonagy 2006; Schore 1994, 2003; Coan 2008) of the adult. The latest research
from the field of neuropsychology showcases the role of early bonds and trauma in
the formation of the brain, particularly with regard to impulse control, empathy,
thymic stimulation and self-regulation (Schore 1994, 2003; Fonagy et al. 2008;
Greene 2011).
Psychic representations created in childhood are maintained with relative stabil-
ity in adulthood, where they contribute significantly in psychopathology adaptation
and development (Mallinckrodt 2000; Feeney and Collins 2001; Bateman and
Fonagy 2004; Mikulincer and Shaver 2008; Dozier et al. 2008). Psychic representa-
tions are activated particularly in the context of interpersonal relations including the
therapeutic relationship. Just like a parent, the therapist provides availability,
responsiveness, stability and security, thymic regulation and relief, a basis of con-
tainment and reflection from where the patient can investigate internal and external
reality and “play” on his own, in the presence of the therapist (Farber et al. 1995;
Holmes 1997, 1999; Mander 2000; Wallin 2007). Accordingly, the manner in which
the therapist is being experienced, his perception, the cognitive and emotional
response towards him (the transference) are influenced by the patient’s uncon-
scious, early psychic representations, often irrespectively of the therapist’s behav-
iour (Mallinckrodt et al. 1995; Mallinckrodt 2000; Malan 2001; Westen and
Gabbard 2002; Slade 2008; Mallinckrodt and Jeong 2015), often irrespectively of
the therapist’s behaviour (Goldman and Anderson 2007).
Malan (1979, 2001) linked the elements of psychic representations and rela-
tional motifs formed during early life, to the patient’s interpersonal relationships in
adulthood and transference with the “here and now” of therapy. The “triangle of
insight” suggested by Malan (1979, 2001) shapes the threefold connection between
transference, the patient’s current relationships outside of therapy and the relation-
ships with significant others in the past. The triangle of insight is connected with
another psychoanalytic triangle, the triangle of conflict, which consists of the secret
emotion or impulse, the patient’s defences and the problem or symptom he pres-
ents. The therapist works methodically with the objective of linking the two trian-
gles, pointing out the coherence between the points within but also between the
triangles (e.g. how transference, defences, core conflict, as they emerge in the ther-
apeutic relationship, re-emerge in the patient’s current and past relationships)
(Malan 1976, 1979, 2001; Coren 2001; Dewan et al. 2009). With regard to
14 Brief Psychotherapy in a Community Framework 289

transference, the technique in brief therapy differs radically from that in open
therapies; emphasis is given less in the achievement of transference awareness on
the part of the patient and more on how transference is used actively in relation to
core focus. The manner in which the patient is related to the interpretation reveals
significant information on the repeated relational motifs, the thymic background of
interactions as well as the attempts to deregulate the thymic stimulation that ther-
apy may possibly activate (Mander 2000; Coren 2001). For example, if a pertinent
or misguided interpretation causes anger, how does the patient manage this con-
flict: Does he fight with the therapist, withdraw emotionally and act out passively
and aggressively through self-destructive behaviours? Does he begin to miss or
cancel sessions? And finally, how does this information relate to the patient’s other
relationships outside of therapy?
Malan’s technique, although arising from psychoanalysis, effectively adapts to
brief psychodynamic psychotherapy in relation to the core target and the patient’s
relational motifs, in particular with regard to ending and separation (Coren 2001).
Once more, we point out that Malan’s (1979, 2001) technique does not aspire to
fully understand the patient’s unconscious in its entirety outside the boundaries of
time, but aims at an in-depth understanding of current issues that he brings and their
composition within the immediate, intersubjective as well as institutional frame-
work of psychotherapy.
Randomised control trials (RCTs) have shown brief psychodynamic
psychotherapy to be effective for patients with major depression, emotional and
stress disorders (Knekt et al. 2008, 2011), somatisation disorders, psychogenetic
bulimia and cluster C personality disorders (Leichsenring 2009; Vinnars et al.
2005), while its effectiveness is increased in combination with pharmacotherapy
(Kay 2009). Synthetic representations of brief psychoanalytical psychotherapy with
a good and documented basis as to its effectiveness are the mentalisation-based
treatment (Bateman and Fonagy 2004; Allen and Fonagy 2006; Fonagy et al. 2008)
and the dynamic interpersonal psychotherapy (Lemma et al. 2011).

14.7 The Effectiveness of Brief Psychotherapy

In the past, the relationship between psychotherapy and psychiatry has been tense.
Research development in the fields of neuroscience, genetics and psycho-
pharmacology (Gabbard 2009) emphasises the use of pharmacology and fast solu-
tions to the detriment of traditional psychological treatments. Within this biomedical
field of knowledge, Kandel (1998) has noted the plasticity of synaptic connectivity
in the brain, which can be modified through good psychotherapeutic practice. In
fact, Goldapple and his associates (2004) have begun mapping the areas of the brain
that are modified as a result of psychotherapy (anterior cingulate και hippocampus),
in contrast to the ones that are modified through medication (prefrontal cortex). The
combination of neuroscience with psychotherapy is one of the fastest developing
and exciting fields of research, as it finally appears to be bridging the void between
psychological treatment and biological function.
290 M. Skourteli and S. Stylianidis

In general terms, psychotherapy has been proven effective with positive results
for various theoretical approaches and technical interventions (Lambert et al. 1986;
Smith et al. 1980; Andrews and Harvey 1981; Shapiro and Shapiro 1982; Lambert
and Bergin 1994). Specifically, at the end of treatment, the average patient makes up
to 80 % improvement compared to the control groups that do not receive psycho-
therapy. The effectiveness of psychotherapy is comparable with that of pharmaco-
therapy, while in many cases their combination promotes the effectiveness of the
treatment (Friedman and Thase 2009; Kay 2009). The extent of the effect produced
by psychotherapy is commensurate or higher in duration or depth to that produced
by the administration of psychoactive substances (Andrews 1982, 1983; Lambert
2003; Friedman and Thase 2009; Kay 2009). The increased recognition of the neu-
roscientific existence of psychotherapy in conjunction with the long-term absence
of a substantial empirical basis makes the need for the systematic evaluation imper-
ative with regard to the effectiveness and efficiency of psychotherapy.
As to the effectiveness of brief psychotherapy compared to that of the open alter-
native approaches that are not time limited (and given the small empirical basis with
regard to the latter), it is argued that short-term, brief psychotherapy is just as effec-
tive with the longer-term approaches (Garfield 1998; Coren 2001; Leichsenring
et al. 2004; Lewis et al. 2008). A new research trend regarding the effectiveness of
brief psychodynamic therapy also supports its efficiency in the long term, after the
end of treatment (Gelso and Johnson 1983; Lemma et al. 2011; Lemma 2014).
Vinnars and his associates (2005) compared the effectiveness of an open, nonstruc-
tured psychodynamic psychotherapy with that of a brief structured psychodynamic
psychotherapy [based on the protocol of Crits-Christoph et al. (1988, 1991) that
focuses on the immediate interpretation of translatif, core interpersonal motifs] for
156 patients with personality disorder. The differences between open and brief
interventions with regard to their effectiveness (reduced personality disorder char-
acteristics, psychiatric symptoms, improved general interpersonal function and
reduced requests for help by the mental health services) are reported as minimal
after 1 year of treatment, when both interventions are provided by experienced,
well-qualified therapists (Vinnars et al. 2005). Also, Knekt and his associates (2011)
compared the effectiveness of brief and open psychodynamic psychotherapies and
psychoanalysis for 326 patients with anxiety and affective disorders. All psycho-
therapeutic approaches were effective in reducing the patients’ psychiatric symp-
toms and general functioning 5 years after the start of treatment. During the first
year, brief psychotherapies were more effective than psychoanalysis, while open
psychodynamic psychotherapies were more effective after 3 years. Psychoanalysis
seemed to be more effective after 5 years of therapy. The authors conclude that
while psychotherapies of brief and middle duration produced faster results than
psychoanalysis, the latter appeared to produce more established and long-term ben-
efits (Knekt et al. 2008, 2011; de Maat et al. 2009). Cumulatively, it seems that
although the effectiveness of open psychodynamic psychotherapies produces
longer-term benefits through structural, behavioural changes, the effectiveness of
the corresponding brief approaches is more direct and therefore implementable in a
public or community framework; these findings place open and brief
14 Brief Psychotherapy in a Community Framework 291

psychotherapies in a complementarity range that can be exploited depending on the

patient’s needs and the capabilities of the institutional framework (Leichsenring
2009). On the other hand, the belief that the therapeutic depth is achieved only in a
long-term context is not empirically supported; on the contrary, research proves that
the patient’s core interpersonal motifs emerge very soon in treatment (Crits-
Christoph et al. 1988; Luborsky and Crits-Cristoph 1998; Mallinckrodt 2000), sup-
porting in this sense Winnicott’s view that the depth of therapy is not related to
intensity or duration.
Extensive literature reviews and research efficiency post-analyses bring out a
plethora of therapeutic and para-therapeutic variables in psychotherapy patient
improvement. These include factors outside of therapy (the patient’s behavioural
characteristics, the quality of his support network, accessibility to self-help sources,
disorder chronicity, gravity and complexity, etc.) that correspond to 40 % of the
improvement as well as the effect of the patient’s expectations with regard to the
help he expects from treatment (placebo effect), corresponding to 15 % of the
improvement (Lambert and Barley 2002; Garfield 2003; Lambert 2003;
Papadopoulos 2007). In an important research comparing cognitive-behavioural
treatment and interpersonal psychotherapy (IPT) to a control group only taking
imipramine, the slight superiority highlighting the interpersonal approach for the
more disturbed patients disappeared when factors outside of therapy and the
patients’ expectations were checked with regard to the effectiveness of treatment
(both psychotherapeutic and pharmaceutical) (Elkin et al. 1989; Ahn and Wampold
2001; Arnkoff et al. 2002). A plethora of factors common to all psychotherapies
irrespective of theoretical approach have been flagged as being involved in 30 % of
the improvement; these include, among others, empathy, the therapist’s respect and
authenticity towards the patient and therapeutic allegiance quality that favours the
patient’s integration and signification difficulties as a start for the exploration of
internal and external conflicts (Lambert 2003; Norcross 2002; Holmes 2001; Wallin
2007; Rosenfeld 2009).
The common factors for therapeutic change refer in theory at least to the neces-
sary and sufficient conditions introduced by Rogers (1957). Although the literature
is unanimous as to the necessity of these conditions being present in any therapeutic
relationship (even between psychiatrist and patient, in order to maximise the latter’s
response to adherence to the pharmaceutical treatment), the different theoretical
schools disagree with regard to their sufficiency as unique factors of change. For
example, Miller et al. (1980) note the significance of the therapist’s empathy even
in uniquely behavioural treatments. Correspondingly, Lafferty et al. (1991) and
Elliott et al. (1991) point out the central role of empathy in the effectiveness of psy-
chotherapy, with the less effective therapists in their sample being characterised by
the lowest levels of empathy and understanding with regard to the patient. At the
same time, therapist evaluation with regard to the effectiveness of treatment does
not seem to correspond (it is systematically lower) with the patient’s subjective
evaluation (Cooley and LaJoy 1980).
Despite this, newer research from the field of neuroscience demonstrates that
empathy, although necessary as a condition, is not sufficient for the therapeutic
292 M. Skourteli and S. Stylianidis

change. Comparing purely personality-centred treatments with synthetic approaches

that harmonise basic Rogerian conditions with Gestalt experiential techniques,
Greenberg and Watson (1998) point out that the most “energetic” approaches were
effective faster in patients with major depression, especially with regard to interper-
sonal difficulties and the levels of anguish related to the end of psychotherapy.
Correspondingly, in their extensive research with regard to mentalisation treatment,
Fonagy et al. (2004) and neuroscientist Schore (1994, 2003) mention that empathy
alone is not sufficient for therapeutic change, as the solidifying of insight requires a
ground of ideal thymic stimulation levels from the patient, something that results
from the therapist’s active attitude. The significance of the therapist’s active and
lively attitude in brief psychotherapy is noted also by Roth and Fonagy (2005), who
point out that non-specific, unclear approaches (from a theoretical and technical
aspect) are less effective in more serious pathologies.
Conventional evaluation methods that compare different theoretical psychother-
apeutic approaches in the wide range of emotional and interpersonal disorders have
not culminated in clear conclusions showcasing a specific school as superior to
another. The absence of essential differences with regard to the effectiveness further
supports the effect of common factors in psychotherapy (Lambert 2003; Luborsky
et al. 1975; Bergin and Lambert 1978; Elkin et al. 1989; Lambert and Barley 2002;
Meltzoff and Kornreich 1970), while the small differences distinguished for certain
techniques implemented in specific diagnostic categories and symptomatologies
beg the question “What works for whom in psychotherapy?” (Quality Assurance
Project 1983; Robinson et al. 1990; Norcross 2002; Lambert 2003; Lewis et al.
2008; Rosenfeld 2009; Gabbard 2009). In this sense, the theoretical and clinical
field of knowledge with regard to the effectiveness of different approaches is shown
to be localised and not global. The methodological limitations often involved in the
“artificial” status of the findings with regard to the effectiveness of different theo-
retical approaches in brief psychotherapy point out the need for careful and critical
implementation in clinical practice (Allen et al. 2008).
In any case, the general finding of non-difference with regard to effectiveness
refers to the conclusion that the different theoretical approaches conquer similar
targets through different procedures or methods and through the presence of thera-
peutic factors, common to all psychotherapies, dominated by the therapeutic alli-
ance (Lambert 2003; Lambert and Barley 2002).

14.8 The Therapeutic Alliance

The concept of the therapeutic alliance has attracted particular interest with regard
to its role in the effectiveness of psychotherapy, although it is accepted that the alli-
ance is only one aspect of the therapeutic relationship (Clarkson 2003). It is widely
accepted that the alliance includes both the therapist’s and the patient’s variables
and consists of the characteristics of the therapeutic purpose, the targets and the
bond between therapist and client. The therapist’s contribution to the alliance
includes the capability to provide the aforementioned code conditions, the ability to
14 Brief Psychotherapy in a Community Framework 293

resolve conflict within the alliance and mutual cooperation with regard to the
purpose and the target of the treatment (Hovarth and Bedi 2002; Lambert and Barley
2002; Gabbard 2009). The patient’s contribution to the alliance refers to his ability
to create an emotional bond with the therapist and to be able to participate in the
treatment with purpose (Luborsky and Luborsky 2006; Gabbard 2009). The contri-
bution of the therapeutic alliance in the effectiveness of treatment is transtheoreti-
cally recognised, as its components (both the patient’s and the therapist’s
characteristics) are common in all psychotherapies, irrespective of theoretical
approach (Horvath 2005; Horvath and Luborsky 1993; Norcross and Goldfried
2003). Research in the therapeutic alliance put it forth as a factor that is not just
ahead of therapeutic change but is also an active ingredient of psychotherapy. For
example, Safran και Wallner (1991) say that mutual evaluation of the alliance (by
the therapist and the patient) already after the third brief cognitive psychotherapy
session forecasts its effectiveness after its completion; other research supports these
findings (Martin et al. 2000; Horvath 2005). Also, Gaston et al. (2002) mention that
the contribution of the alliance accounted for 36–57 % of patient improvement in
their research irrespective of the theoretical or technical approach. Castonguay and
his associates (1996) compared the role of the alliance in two groups of patients
with major depression, who were following brief cognitive therapy or its combina-
tion with pharmacotherapy. In their attempt to minimise the contribution of thera-
pist characteristics, the therapists followed a strict protocol in the provision of
treatment, while the alliance evaluation was conducted by the patients and indepen-
dent judges. The two variables related to therapy effectiveness and the patients’
symptom improvement were the therapeutic alliance and the therapist’s emotional
participation in the therapeutic relationship. Finally, in the big research of the
NIMH, Krupnick and his associates (1996) showed the role of the therapeutic alli-
ance in the effectiveness if treatment for patients with major depression is an active
common factor in psychotherapeutic, pharmaceutical and pseudo-pharmaceutical
interventions.
In general terms, what emerges from the literature is that some therapists are bet-
ter than others in the provision of the interpersonal conditions that forecast the
improvement of the patient’s symptoms and the effectiveness of the treatment. The
therapist’s characteristics as variables clearly involved in the effectiveness of the
treatment have attracted particular research interest, especially from the aspect of
the attachment theory, as can be seen below.

14.9 The Therapist’s Role

The attempts to evaluate effectiveness communicate an ethical, professional attitude

to show that psychotherapy is a worthwhile, empirically documented and reliable
therapeutic method, which supplements biomedical approaches in mental health. A
significant limitation of existing literature is that the therapist is illustrated as a
depersonalised sponsor of standardised therapeutic interventions. In its implemen-
tation, effectiveness and efficiency research appears to systematically attempt to
294 M. Skourteli and S. Stylianidis

minimise or isolate the personality of the therapist as a core change factor and the
interpersonal dimension of psychotherapy as one of deeply restorative process
(Coren 2001). However, a number of converging instances of research show that the
therapist is a therapeutic factor directly linked to the effectiveness of brief psycho-
therapy. Luborsky and his associates (1986) mention that the differences due to the
therapist’s personality significantly exceeded those that were due to specific techni-
cal interventions. These results have been confirmed recently by Crits-Christoph
et al. (1991), Wampold (2001), Huppert et al. (2001) and Project MATCH Research
Group (1998). It is strange then that while the literature points to the significance of
the therapeutic relationship, there are few clear instructions given with regard to the
therapist’s attitude. Instead, all instructions accompanying clinical practice with no
exception refer to purely diagnostic categories (DSM-V 2014).
Although specific techniques have been proven effective for specific disorders
(Lambert 2003; Lilienfield 2005; Rosenfeld 2009; Allen et al. 2008), the question
that emerges is to what extent do psychological treatments adapt to the patient’s
person, the stage of change and his behavioural characteristics and not exclusively
to his diagnosis. Clinical practice shows that different patients respond better to dif-
ferent approaches, while recent research (especially in the areas of the therapist’s
countertransference and attachment) brings up the issue of client-therapist match
(Norcross 2002). For example, Hayes (1995) and Rosenberg and Hayes (2002)
developed a structural theory of countertransference that includes notions of ori-
gins, triggers, manifestations, effects and management. According to it, the thera-
pist’s relational characteristics or conflicts are activated by the client’s characteristics
or behaviours and are manifested with emotional, cognitive and behavioural reac-
tions, which affect not only therapeutic interaction quality but also the outcome and
effectiveness of treatment (Vaslamatzis et al. 1986).
The systematic research into countertransference allows a deeper understand-
ing of the dynamic, the therapeutic “use” of self by the therapist and what com-
prises “corrective emotional experience” (Friedman and Gelso 2000; Bernier and
Dozier 2002; Bridges 2006). For example, Hardy and his associates (1999) say
that psychodynamic therapists working in a brief 16-week framework tended to
respond with “mirroring” and an inclusive attitude to anxious-“preoccupied”
patients and with interpretive interventions to more avoidant patients. Rubino and
his associates (2000) report that therapists with insecure attachment respond with
less empathy and depth to patients with similar attachment characteristics to their
own; similar findings are also reported by Mohr et al. (2005). In an important
research, Dozier et al. (1994) investigated the therapist’s attachment role in his
therapeutic interventions towards patients with serious psychiatric disorders. It is
said that therapists with more secure attachment tended to trace the deeper, less
distinguishable (unconscious) patient needs while less secure therapists, the more
obvious, conscious patient needs, thus showcasing the role of the therapists’ intra-
psychic characteristics in the choice of their therapeutic interventions. The con-
cept of asymmetry or dissimilarity between the therapist-client relational
structures was also investigated by Tyrell and his associates (1999), who report
that the relational structure disparity in the therapeutic dyad was related to higher
14 Brief Psychotherapy in a Community Framework 295

evaluations (on the part of the clients) of the treatment effectiveness with regard
to their mental, social and professional functioning; the therapist-client matching
appears to help the therapeutic process “revising” the patient’s internal working
models (Tyrell et al. 1999). It total, these findings showcase the interaction of the
therapist-client relational structures in the dynamic and by extension the effec-
tiveness of the therapeutic relationship, thus underlining the therapist’s role (Gelso
and Hayes 2007; Vaslamatzis et al. 1986).

14.10 Training and Supervision in Brief Psychotherapy

One of the problems with brief psychotherapy is that it is mistakenly thought of as

a condensed form of psychoanalysis; although its theoretical basis results from psy-
choanalytical thinking, its clinical implementation requires specialised training,
therapeutic flexibility and pluralism and does not seek full understanding of the
unconscious in its timeless entirety. Despite its documented effectiveness for spe-
cific clinical populations and symptomatologies, brief psychotherapy is often
addressed as a lesser psychotherapeutic alternative solution, which is necessary in
view of a lack of long-term or open therapy availability in a community or primary
context. During their first interview, many patients react with doubt or disbelief to
the “brevity” of the offered treatment (although the time frame of brief psycho-
therapy differs depending on the institutional framework: treatment predetermining
its end from the start, with an average duration of 4–6 months, is considered brief in
literature). At the same time, many therapists working within a brief framework also
agree with the belief or fear that brief psychotherapy is no more that the “poor rela-
tion” of “pure bred” open psychotherapies (Coren 2001).
The therapist’s attitude, values and beliefs with regard to the brevity of the frame-
work significantly affect the therapeutic relationship’s dynamics, while it is possible
that it may bring forth personal and professional issues for the therapist, such as
guilt and frustration regarding the patient’s treatment or abandonment, anger against
the system that does not allow more sessions or a feeling of professional inade-
quacy, a “not good enough therapist” (Vaslamatzis et al. 1989). Such therapeutic
reactions include the risk of the patient as well as the therapist acting out this ambiv-
alence. Many therapists deal with brief therapy as an introduction to a longer-term
treatment rather than a stand-alone area of knowledge with essential and sufficient
existence. The therapist’s occupation with the possibility of future treatment dis-
tracts focus from the therapeutic core and the “here and now”, something that may
reflect a defensive denial of the end on the therapist’s part (Mander 2000; Coren
2001; Gelso and Hayes 2007).
The non-timeless time frame of brief approaches is psychically and mentally
demanding for therapists. Clinical work includes the frequent alternation of start-
ing and ending therapeutic relationships, a large number of patients per week and
the need for awareness, focus and activation with regard to the therapeutic target.
Due to these conditions, therapists may become vulnerable to professional exhaus-
tion syndrome, which is manifested with loss of empathy or psychic co-ordination
296 M. Skourteli and S. Stylianidis

with the patient or with raised emphasis in technique or theory and, at the same
time, loss in reflective function on clinical practice (Coren 2001; Hawkins and
Shohet 2006).
These issues bring to the forefront the need for regular supervision and personal
analysis for therapists (both trainees and experienced professionals) who work in
the fast-paced and demanding brief psychotherapy framework. Supervision offers a
context for reflection, a safe basis from where the therapist may deconstruct and
investigate aspects of the therapeutic process, identify blind spots or conflicts,
remain clinically aware and ensure an ethical practice (Hawkins and Shohet 2006).
Perhaps, the most significant aspect of supervision is the reflexive function condi-
tioning, namely, the capability of objectifying and observing the dynamics in ther-
apy and the therapist’s intrapsychic processes, for the purpose of better understanding
the clinical material and the flexible maintenance of the “ideal” emotional therapeu-
tic distance, depending on the patient’s needs (Symington 1986; Casement 1991;
Meszaros 2004; Allen and Fonagy 2006; Gelso and Hayes 2007; Mander 2000).
The institutional framework and its capability to respond to the challenges of brief
therapy also affect the therapeutic process and the dynamics among the staff. The
administration of institutions implementing brief therapy should recognise the pres-
sure weighing on therapists, who see more and more cases, as well as the risk of
professional exhaustion, by providing support and regular supervision for the entire
cross-sector group (Coren 2001; Hawkins and Shohet 2006).

14.11 A Greek Experience: The EPAPSY Day Centre

This discussion should not exclude the significant contribution of Greek scientists,
who have tried to implement and utilise the theoretical and clinical knowledge
regarding the provision of brief psychotherapy in a public framework. In Greece,
from as early as the 1980s, the Psychotherapy Department of the Eginitio Hospital
has integrated brief psychodynamic psychotherapy [specifically the approach by
Malan (1979) and Sifneos (1979) in the services it provides] and has produced a
wealth of research material with regard to both the client and the therapist’s param-
eters contributing to its effectiveness (Vaslamatzis and Verveniotis 1985; Vaslamatzis
et al. 1986, 1989). As well, the Fokis and Evia Mobile Mental Health Units have
been providing brief psychotherapy services since 1990, responding to the popula-
tion’s increased need and demand for realistic and accessible mental healthcare in
the community (Stylianidis 1995).
The Psychosocial Intervention Day Centre in the “Franco Basaglia” community
is a “hybrid”, atypical mental health structure, among the first in Greece, which
combines elements of day hospital and mental health centre in an attempt to bridge
the gap between secondary care and (non-existent in our country) organised primary
care. The day centre consists of a cross-sector group of psychiatrists, psychologists,
social workers and psychiatric nurses and provides, among others, psychiatric mon-
itoring and prescription, brief individual and group psychotherapy, home interven-
tion and psychosocial rehabilitation services.
14 Brief Psychotherapy in a Community Framework 297

The psychotherapy service is staffed by psychologists-therapists from various

approaches (three psychodynamic-psychoanalytical psychotherapists, one
cognitive-behavioural psychotherapist, one cognitive-analytical psychotherapist
and five art therapists working under the supervision of more experienced thera-
pists), while it responds to a wide range of psychic disorders, such as emotional
disorders (50 %), personality disorders (25 %), psychotic disorders (5 %) and neu-
rotic and somatoform disorders (20 %). Fifteen percent of referrals for the psycho-
therapy service come from general psychiatric hospitals, 41 % from mental health
centres and 44 % corresponds to self-referrals or referrals from private individuals.
The psychotherapy service is evaluated with regard to its effectiveness, while the
theoretical approach option is evaluated on the basis of patient needs. The average
duration of psychotherapy varies from 15 to 24 sessions, while for major patholo-
gies the duration is extended to 52 sessions. The day centre splits the psychothera-
peutic and pharmaceutical care it provided to psychotherapy patients (split
treatment) (namely, the two are provided by different professionals), in order to
protect the therapeutic boundaries, to generate “pure” translatif reactions towards
the psychotherapist and to prevent the patient from dedicating the session to phar-
macology issues to the detriment of psychological issues. The pros and cons of split
and combined care are put forth by Kay (2009). The psychotherapy group attends
group supervision twice a week as well as a monthly psychoanalytical approach
supervision with an external supervisor. The following clinical vignette is set out as
an example of implementation of 9-month brief psychotherapy at the day centre.

Dimosthenis is a 45-year old single man, who has been diagnosed with bipolar disorder
with psychotic elements. He comes to therapy with a persistent depression complaint, at the
prompting of his private psychiatrist after a suicide attempt a few months earlier. His medi-
cation regimen includes an anticonvulsant factor, two mood adjusters (one of them lithium),
two antidepressants (SSRI and SSNRI), two antipsychotics (one typical and one atypical
and, from time to time, a sedative. Dimosthenis arrives punctually at the initial evaluation,
is neat and clean, but his monotonous voice and expressionless face project a mournful and
heavy quality. During the first session, Dimosthenis appears particularly cautious, passive
as well as aggressive as to his expectations (pre-transference) and challenges the therapist
asking her how she can believe that “someone in his condition” can be helped by psycho-
therapy. Dimosthenis identifies in particular with his bipolar diagnosis and refers to his
“disease” in a riveting and unwavering manner. He has a history of three previous attempts
at psychotherapy (two instances of cognitive-behavioural therapy and one of psychoanaly-
sis) about which he says that despite his therapists well-meaning motivation, were not par-
ticularly helpful. The therapist directly realises Dimosthenis’s challenge to prove and
defend the value of the “objective” (the treatment) she will offer and makes a mental note
of her counter-transference) defensive position, rejection anxiety but also empathy for his
fear) as a significant element of the patient’s transference and his interpersonal motifs in the
“here and now” as well as in other relationships. The psychotherapist wonders if
Dimosthenis believes he can be helped and what moves him to seek help this time, given the
disappointment that accompanies the previous psychotherapeutic attempts.
Dimosthenis comes from a well-to-do family and has an older brother, with whom he
describes his relationship as one of conflict. His father was a successful businessman, a
perfectionist, strict and frugal with his emotions. Dimosthenis’s mother died of cancer
when the patient was 17 years old, three years after her diagnosis; Dimosthenis has very
few memories from his childhood (which he describes as “foggy”) and describes his
298 M. Skourteli and S. Stylianidis

mother as a saint, a feature that attributes to her the quality of an idealised, elusive,
unreachable and frustrating object. In general terms, the patient’s family background
stressed power, success, conquest and strongly rejected any semblance of vulnerability,
fear or anguish. As a child, Dimosthenis was an excellent student, and a perfectionist in
all his occupations. He remembers himself as independent and unconnected and as not
having particular need of connection, despite being popular at school. The start and diag-
nosis of the disorder at the age of 17 coincides with the mother’s death; the family does
not seem to have processed mourning and while the father and the brother went on with
their career, Dimosthenis broke down, almost as though permitting the others to continue.
Despite Dimosthenis’s attempts to go on with his studies and succeed his father in busi-
ness (like his brother), none of his efforts bore fruit and Dimosthenis has been unem-
ployed for the last 10 years. Upon referral, Dimosthenis shows he has a reduced support
network; he has very few friends whom he believes he is a burden to and has had one love
affair at the age of 18.
The first concern of the treatment is to establish a strong therapeutic alliance, a safe
basis from which Dimosthenis can explore aspects of his psyche. The end of the treatment
is set from the beginning, but Dimosthenis minimises its significance, saying it is still too
far off for him to be concerned about it (largely as he has minimised the effect of his
mother’s death on him). During the first sessions, the therapist realises and “hosts”
Dimosthenis’s need for psychic distance and the therapeutic relationship develops slowly
but steadily; when nearness becomes threatening for Dimosthenis, he cancels sessions,
which is interpreted right away as a distance-nearness regulator. Dimosthenis’s ego strength
at the start of treatment appears vulnerable in containing internal conflict and the defences
he uses include splitting, projective identification and primary projection, denial, emotional
isolation, repression and intellectualisation. These principally early defences indicate a pre-
Oedipal trauma, which deteriorates with the loss of the mother at a vulnerable age.
Dimosthenis’s object oriented relationships are played out through his repeated interper-
sonal motifs and transference towards the therapist; one of these is that he is a burden and
is undesirable to his friends as well as her. During a specific session, Dimosthenis arrives
very frightened and tells the therapist that during his last visit to his psychiatrist, she warned
him against psychotherapy, telling him that raking up the past will not help him. The imme-
diate counter-transference felt by the therapist was intense anxiety that the treatment was
“hurting” the patient and would lead him to a relapse. The institutional supervision helps
the therapist to contain this excessive, almost paranoid anxiety and explain it as an attempt
at splitting between the two professionals involved in the patient’s care. During the next
session, after divulging to the therapist some innermost, persisting paranoid thoughts,
Dimosthenis confides to her that now, he is very worried about her; that he is putting her at
risk and may have “harmed” her. Looking into these two events together with Dimosthenis,
a second interpersonal model begins to appear in the opposing pair “I harm others – others
harm me,” which appears to be related to his unconscious, core conflict. Dimosthenis’s
childhood wish to “conquer” and connect with his elusive mother is futile, forbidden, dirty,
bad, causes shame and rage and is thus suppressed; her death causes her further idealisation
and even sainthood. Denial and splitting allow Dimosthenis to insulate the “bad” emotions
of shame and anger, so that they will not infect the idealised ones, while projection and
projective identification (which includes the therapist’s psychic “preparedness” to receive
his projection) allows him to unload them on those around him. The treatment is organised
around Malan’s two triangles; interpretation and signification of these defences related to
chronic depression with paranoid elements and the core conflict improves the dynamics of
the therapeutic relationship. Dimosthenis’s therapy is in progress, while 5 months of treat-
ment still remain; in the latest session, Dimosthenis was able to say that the treatment is
important to him and that he feels closer to this therapist. Particular attention is given to the
end of the treatment so the motif of avoiding the end is not repeated resulting in the patient
not speaking of his emotions as to the loss of the therapeutic relationship.
14 Brief Psychotherapy in a Community Framework 299

14.12 In Conclusion

Brief psychotherapy appears to comprise a significant part of applied psychiatric

care globally in a primary and community framework (Gabbard 2009; Gask et al.
2009a, b; Sartorius 2009). This tendency projects both the capability of developing
new ethical and scientific positions and significant challenges with regard to their
implementation. On the one hand, generalised and vague, idiosyncratic or unstruc-
tured clinical estimations without the will to make assessments no longer seem to
have a place in the clinical environment. On the other, this new reality includes the
risk of making psychotherapy one more product for consumption, by losing its
intersubjective background (Stylianidis 1995; Coren 2001). Placing emphasis upon
standardised, undifferentiated techniques, treatment contains the risk of clinical and
professional alienation, denial of the complexity of mental anguish and restriction
of therapeutic freedom, whilst the significance of the reflexive, exploratory and per-
sonal aspects of treatment may be sacrificed in the name of functionality and strat-
egy; institutional and economic pressure for fast and effective treatment must be the
objective of reflection of the cross-sector group. Brief psychotherapy is not a pana-
cea for all patients. On the contrary, it must be part of a wide range of provision of
mental health services, including long-term treatment, critically implemented
depending on each patient’s needs. This chapter attempted to showcase the signifi-
cance of brief psychotherapy with regard to its accessibility and effectiveness in a
public framework, in full awareness of this choice and its limitations. The therapist
working in a short-term framework must have achieved a sound, long psychody-
namic/psychoanalytical education (supplementary to the briefness of the treatment
he provides), which will integrate and also differentiate elements of the brief and the
open approach in psychotherapy. The need for a pluralistic approach is therefore
pointed out that may listen to and respond more to the patient’s rather than the thera-
pist’s needs or those of the institutional framework that provides mental health ser-
vices in a public framework (Stylianidis 1995; Coren 2001; Norcross and Goldfried
2003; Lemma 2014).

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Community Mental Healthcare
for Migrants 15
Nikos Gionakis and Stelios Stylianidis

Abstract
This chapter discusses the relationship between migration and mental health, as
it is illustrated in the way trends are formulated, in the field of relevant research
on the one hand and, on the other, in the recommendations offered for the mental
health of migrants on the other. The second part deals with the basic organisa-
tional and operational aspects of a mental health unit for migrants, the Babel Day
Centre (Athens, Greece), and presents the challenges that its multidisciplinary
team faces along with the ways it attempts to manage them. Upon completion of
this chapter, the reader will have received ample stimuli for reflection on the
important issue of service provision to migrants.

15.1 Introduction

The period from the middle of the twentieth century to date has been defined as the
age of migration (Watters 2007). In fact, humans have always been on the move (the
history of humanity is a history of peoples’ movements and the meeting between

“χαῖρε, ξεῖνε, παρ’ ἄμμι φιλήσεαι· αὐτὰρ ἔπειτα δείπνου πασσάμενος μυθήσεαι ὅττεό σε
χρή.”
(“Greetings, stranger. You are welcome here.
After you’ve had dinner, you can tell us what you need”.)
(Homer, Odyssey, A, 123–124, English translation by S. Lombardo)

N. Gionakis (*)
Psychlogist, Scientific Responsible, Day Centre Babel, Athens, Greece
e-mail: [email protected]
S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 309

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_15
310 N. Gionakis and S. Stylianidis

them); however the migratory flows of our time, in terms of scale, globalisation and
social/economic consequences, have no precedent.
Migration is defined as a process of social change during which an individual
moves from one cultural framework to another for the purpose of settling – per-
manently or temporarily (Bhugra and Jones 2001). This change may be due to
different reasons, usually social/economic, political, educational and environmen-
tal (idem). Travel duration to the country of settlement varies and depends upon
different factors; movement may be conducted individually or in groups (factors
such as the reason for departure play an important role in this), while, after settle-
ment in a country, a significant number of the migrants will form ethnic
minorities.
In the last 40 years, migratory flows have doubled compared to the past;
recently the number of people forced to abandon their countries of origin for
another country (refugees), or their homes for other regions within their country
(internally displaced), has risen dramatically. According to UNHCR, in 2013 the
number of refugees internally displaced throughout the world was calculated at
51,2 million, 86 % of which have sought refuge in developing countries (http://
unhcr.org/trends2013/). It is expected that by 2050, 150,000,000 people will have
migrated, not because of economic reasons but because of the climate changes
observed on the planet.
The presence of migrants in a country triggers phenomena related to the social
and individual changes emerging from coexistence with the natives [see, e.g. accul-
turation, namely, the mutual changes arising when individuals or groups from dif-
ferent cultural backgrounds come into direct and constant contact], creating the
need for integration policies, namely, relevant to the migrants exercising their rights
in the country of settlement.
Featuring highly among these rights is access to health and mental health ser-
vices. Health is a fundamental human and social right. It also is, at the same time,
an important factor in the life of migrants, directly linked to integration: “Migrants
whose health condition is poor or who cannot move due to health problems, are
obstructed in the efforts for integration. […] Disease accentuates marginalisation
and marginalisation accentuates disease, creating the conditions for a gradual
decline. At the same time, integration is a prerequisite for the provision of effective
health care, which is often impeded by inadequate accessibility. Access to effective
health care must be viewed as equally important as housing and education for living
and by extension the migrants’ integration” (Ingleby et al. 2005).

15.2 Migration and Mental Health

The relation between migration and mental health has been the objective of study
since the 1930s. Ødegaard’s (1932) paper on the prevalence of schizophrenia among
Norwegian migrants in the USA is known; the paper was the start of a series of
research efforts, the objective of which was the effect of migration on mental health
and the reverse. In this section, we will present some findings as they have been
described in published meta-analyses.
15 Community Mental Healthcare for Migrants 311

According to Kirmayer and his associates (2011), the prevalence of common

mental disorders among migrants is initially lower than in the general population
and increases with the passage of time until it becomes equal to that of the general
population. As to the refugees, those among them that have been exposed to vio-
lence often suffer from higher rates of disorders related to trauma, including post-
traumatic stress disorder (PTSD) and chronic pain or other physical syndromes. In
Fazel’s and his associates’ meta-analysis, about 1 in 10 adult refugees in high-
income Western countries suffers from PTSD, 1 in 20 from major depression and
approximately 1 in 25 from general anxiety disorder. In many cases these disorders
coexist. With regard to children, the same meta-analysis has shown that approxi-
mately one in ten children presented with PTSD (Fazel et al. 2005).
The research questions changed in 1960. Instead of seeking why the migrants
had higher (or lower) rates of mental disorders, researchers began wondering under
what conditions migrants present higher rates of disease (Murphy 1977).
The overview by Zissi (2006) concludes with the finding that the studies and the
research trying to associate the migration condition with bad mental health have
given varied, often conflicting, results, while there are more than a few ensuing
methodological difficulties (most of the overviews have reached the same findings).
Therefore, the requirement is to study the factors that make migration a negative
experience causing an adverse impact on mental health, as well as the factors that
are protective for migrants against the new challenges and requirements in the
receiving country. According to the author, it is therefore possible to arrive at the
identification of three groups of factors, the presence of which may play a protective
role in the migration process, while their absence may be related to a negative
impact. These factors refer to:

(a) The migrant’s personal characteristics, whether these are premigration ones
(gender, age, education level) or they emerge during migration (internal
resources, search skills, acculturation tactics).
(b) Social interaction characteristics, in the migrant’s immediate environment (e.g.
family) as well as that of the community where he belongs (e.g. diaspora com-
munity, neighbourhood, school). Networks consisting of relatives that ensure
positive reciprocity, exchange of information and practical support favourably
influence the migrant’s psychosocial adjustment, while, on the contrary, the
dense, traditional orientation networks of relatives have a negative impact,
especially on women migrants.
(c) Characteristics of the receiving country’s wider political and socioeconomic
framework, such as multiculturalism, unemployment levels and the implemen-
tation of migration policy measures, intercultural education programmes and
health services recognising cultural peculiarities. According to Zissis, empirical
findings show that migrant rejection by native residents, unemployment, high
levels of bureaucracy and the lack of culturally sensitive policy implementation
constitute threatening conditions for their adjustment. The author, however,
ascertains that this group of factors has been studied less in social sciences, and
therefore, our knowledge regarding the role they play in the migrants’ individ-
ual biographies is not enriched.
312 N. Gionakis and S. Stylianidis

Specialists draw attention to the need of looking into the conditions that pertain
to the mental health of special groups among migrants, such as minors and, in par-
ticular, unaccompanied minors, victims of trafficking, the elderly, refugees, survi-
vors of torture and abuse, heads of single-parent families and different sexual
orientation individuals. For example, it has been found that exposure to violence is
linked to the appearance of post-traumatic stress disorder, that the adverse experi-
ences children live through during the trip or after arrival at the receiving country
play a significant role in the manifestation of psychic disorder symptoms and also
that children separated very young from their parents due to migration run a greater
risk of presenting with such symptoms (Bhugra et al. 2011).
Discussion has recently begun on the consequences of migration in the reception
areas of health system, as well as the consequences of the lack of accessibility to the
health system (mental health, in our case) on migrants. The relevant questions
mainly pertain (1) to the level of which health and mental health policy is formu-
lated (by governments, healthcare authorities or individual service provision) and
(2) the level of service provision (by health professionals and services). The aim is
that health and mental health professionals may be informed with regard to the
migrants’ special needs and may be trained so that they can offer more effective
care. It is necessary to pay particular attention to these and other similar questions
as it is now clear that even if the “healthy migrant phenomenon” is valid at the time
of arrival, most migrants will obtain a lower socioeconomic position in the receiving
country, which alone will undermine the possibility of their maintaining a positive
health status. We should recall that relating migrants to “special health problems”
refers to long-gone eras and in particular to the time of the colonies, when the
migrant was seen as “inappropriate” or “exotic”. In fact, the health problems for
which migrants often seek help are common, usual diseases that anyone could suffer
from (Ingleby 2008).
Further issues concerning the specialists pertain to (a) the effect of conditions
prevailing in the transit countries and the receiving countries on the mental health of
migrants and (b) the way that the receiving countries’ agencies should be organised
in order to provide the appropriate answers on the migrants’ mental health prob-
lems. As to the first question, researchers usually refer to conditions such as con-
finement and the threat of extradition, limited access to employment, housing,
education and social benefits as well as the consequences of boredom, isolation and
discrimination. In these cases, more and more researchers are documenting the
manifestation of post-migration stress and the weight it adds on pre-existing disor-
ders (Silove et al. 2000). As to the second question, it is interesting to examine the
extended directives and recommendations as well as the characteristics that good
practices should have in the context of migration and refugee mental healthcare.
Directives have been issued by the World Psychiatric Association (Bhugra et al.
2011) and the European Office of the World Health Organisation (Gionakis 2009),
while on the matter of good practices, the points made by Watters and Ingleby
(2004) and Watters (2010) are interesting.
The common point in all the aforementioned is identifying the need to (a) take
measures to ensure migrant access to the appropriate, integrated and culturally
15 Community Mental Healthcare for Migrants 313

sensitive agencies equipped with sufficient resources; (b) pay particular attention to
extroversion and the mobility of community resources, as well as the promotion of
migrant participation in management/administration of such agencies; (c) achieve
agency co-ordination and cooperation with them to ensure care continuity; (d) retain
awareness of the political dimension of the agencies and have professionals engage
in their activities accordingly (see advocacy) and have clear relevant policies taking
into consideration the migrants’, refugees’ and asylum seekers’ human rights; (e)
operate continuous training programmes, so that human resources can be supported
in order to acquire cultural adequacy and apply it to daily practice and also to
develop knowledge and training networks for the identification and dissemination
of good practices; and (f) to organise registration and monitoring systems for the
agencies’ control and evaluation.

15.3 Mental Health Agencies for Migrants Internationally:

Theoretical and Practical Approaches

In some countries, such as France, Italy, Spain, the United Kingdom and Australia,
there has been a notable development of organising and providing specialised
services to migrants and, in several cases, to special categories of individuals,
such as, for example, survivors of torture, trafficking victims, children and adoles-
cents, etc. Some of these agencies are the Centre Minkowska in Paris, continuing
the French tradition in ethnopsychiatry; the Centro Franz Fanon in Turin; the
Transcultural Psychiatry Unit in Victoria, Australia; the Freedom from Torture
Foundation in London, which specialises in the rehabilitation of survivors of tor-
ture, as does the Dignity Institute in Copenhagen; the Psychopathological and
Psychosocial Support Service for Immigrants and Refugees (SAPPIR) in the Sant
Pere Claver Hospital in Barcelona; and others. Each team follows its own
approach, both on theoretical and practical-operational level. We could say that,
irrespective of the approach each of them has adopted, they are all facing similar
challenges which they try to manage utilising specific – and appropriately
adapted – tools and strategies. Here we will examine the main among these
challenges.

Cultural Competence

Culture affects the way in which “people relate to disease, manifest symptoms,
organise search for help behaviour, make decisions on who is normal or not,
approach therapists (and therapists clients) and understand ethics and the changing
stages of conscience” (Ridley et al. 1998).
Particular emphasis has been given in recent years to the demands of clinical
work with people from different ethnocultural origins. Cultural sensitivity, cultural
awareness, cultural adequacy and cultural proficiency are abilities that a health/
mental health agency must have, among others, in order to competently receive and
314 N. Gionakis and S. Stylianidis

respond to requests from migrants, namely, from clients who differ by ethnoculture
and language.
Cultural competence is defined by the US Department of Health and Human
Services as “a set of cultural behaviours, attitudes and policies within a system that
enables its professionals to work effectively in cross cultural situations”. The term
refers to the professional’s capability to honour and respect the beliefs, the lan-
guage, the manners of interpersonal communication and the behaviours of individu-
als and families receiving the services as well as the staff providing these services.
Another common definition widely used in mental health considers cultural skill as
“a set of congruent behaviors, attitudes, and policies that come together in a system,
agency, or among professionals that enable them to work effectively in cross-
cultural situations” (Cross et al. 1989).
In this sense, the health practitioner must, among other things, respect the differ-
ent language, the values and customs of a social group, know the main points of the
individual’s cultural framework and have the will to explore his/her own beliefs and
prejudices. She/he must also integrate the individual’s culture in health provision
and be open to the various ways that the patient participates in his/her treatment.
Cultural competence allows the professional (better yet the multidisciplinary
team and the institution in its totality) to conduct assessments of the migrants’ psy-
chosocial needs. Doing this takes into consideration their triple “diversity”: cultural
background, migration condition and mental (ill) health. In addition, it facilitates
the professional’s approach to the individual in such a way as to make the assess-
ment of his/her needs be the result of a process. In such a process, needs are not
determined by the professional alone but are conjointly identified. In this sense,
meeting the needs is the result of negotiation between the individual (who then is
raised to a subject) and the agency or rather the network of agencies. Through this
process, unique for each person, the network becomes a set of places and moments
that receives them as subjects with respect and dignity, without conditions and
prerequisites.
The establishment of an effective relationship with the beneficiary implies a
negotiation process between the two sides. This will lead to the development of
culturally appropriate management and treatment plans. The professional should
become aware of the explanatory model the beneficiary uses in order to manage his/
her disease. This negotiation will include the following steps (Seah et al. 2002,
p. 30–31):

1. “Eliciting the client’s explanatory model

2. Outlining the practitioner’s explanatory model
3. Comparing the models
4. Conceptually translating and negotiating an understanding and acceptance of
one model with the other
5. Developing a mutually acceptable treatment plan”

In some cases it may be feasible to utilise different methods, such as “Western”

drug treatment, cultural mediation and other traditional therapeutic means.
15 Community Mental Healthcare for Migrants 315

Cultural Mediation

The major issue during communication between people with different ethnocultural
origins is to ensure that what one person says coincides with what the other is hear-
ing. It is also important to take into consideration that communication consists both
of verbal and nonverbal transfer of valuable information and that – as a rule – more
than one message is communicated at the same time.
In many cultures, terms such as “mental” “mood”, “anxiety”, etc. have different
meanings or do not exist at all in different cultures than the Western one. Moreover,
the request for assistance follows different routes, the provision of help has specific
codes and daily living routine unfolds differently. The role of the mediator is critical
in order to bridge these and other differences.
The language/cultural mediator helps by explaining to the professional how to
address problems that are presented during the session in the context of the patient’s
culture of origin. She/he does not just explain the context of the specific culture;
she/he discusses it with the health professional. In other approaches, the mediator is
a regular member of the team receiving the request and manages the case therapeuti-
cally. The mediator will participate in the creation of a common language in the
team, a language that keeps the team together. The mediator is therefore not a neu-
tral “tool” facilitating the comprehension of the language’s precoded meanings but
rather a determining factor in building a common ground for communication.
The role of the mediator is not limited in facilitating the therapist to approach the
patient but also to assist the patient in finding his/her way in the new living environ-
ment. Thus, it is important to accompany the migrant patient to the various agencies
that offer him/her support so that she/he may learn to use them effectively.

Ethnopsychiatry and Moving Population Care in the Community:

Querying an Example

According to Stylianidis and Bagourdis (2008), the definitions that have been used
from time to time to determine the trend promoting the enrichment if the psychiatric
view with cultural elements (cultural relativism) vary depending with each research-
er’s research and scientific interests.
The term transcultural psychiatry is controversial. Whether it is appropriate or
not is questioned by many experts, as besides transcultural psychiatry, other terms
such as comparative, ecological, prescientific, ethnopsychiatry or just cultural psy-
chiatry are used as well. It is possible that the different approaches of the term
showcase the multifaceted nature of the researched objective, as anthropology, med-
ical history, psychology, sociology and social work as well as nursing are used
besides psychiatry and medicine.
Kraepelin (1904) used the term comparative psychiatry. The same term was used
by Yap (1974) and Murphy (1982), subsequently (Litllewood 1990). In the USA,
psychiatrists began using the term transcultural psychiatry introduced by Wittkower
in the 1950s. Wittkower clarifies that the concept of transcultural psychiatry is
316 N. Gionakis and S. Stylianidis

determined by five targets: (1) exploring the similarities and differences in the
manifestation of mental disease in different countries, (2) identifying the cultural
factors indicating a predisposition for mental disease and mental health, (3) assess-
ing the effect of cultural factors in the prevalence of mental disorders and the nature
of mental disease, (4) studying the kind of interventions preferred to be used in dif-
ferent cultural frameworks and (5) comparing the different attitudes against mental
disease in different civilisations and cultures (Wittkower 1966, p. 228). Okpaku
(1998) proceeded along the same lines. In 1988, Kleinman introduced the term
“new transcultural psychiatry”, in order to determine the new trend prevailing at the
time in the USA, which then became more widely known as “cultural psychiatry”
or the “psychiatry of culture” (Favazza and Oman 1978).
The massive scale and complexity of the migration phenomenon places the field
of ethnopsychiatry into radical restructuring, at least in the way this had been
defined by colonial psychiatry. Theoretical examples that emerged from the 1960s
despite the increasing number of ethnopsychiatric studies remain anchored to date
in their majority on old stereotypes and antiquated interpretation models of the rela-
tionship between culture and mental disorder: these stereotypes are characterised by
strong prejudice, a vague definition of culture and mainly by a constant interest for
classification of Western psychiatry in the emergence of new clinical categories,
techniques and knowledge, which, however, did not show the required careful and
in-depth analysis of the political and social framework where these psychopatholo-
gies flourished (Beneduce 2007). In other words, psychiatry that meant to consider
the patients’ “culture” or the different forms of social or family structure as param-
eters to be taken into consideration in the diagnostic and therapeutic process
remained inaccessible, not comprehending the economic contrast that causes migra-
tion, the correlation of forces between the involved parties, the moral conflict, as
well as the set of consequences that the daily actual and symbolic violence causes
to the populations of the colonies.
The examples in literature on this type of violence on populations that, according
to Balandier (1955) acquired a form of social surgery, are numerous and indicative
of this positivistic trend in psychiatry (Cartwright 1851 – drapetomania or patho-
logical indifference “dysaesthesia aethiopica” (Vaughan 1991; Morrison 1988;
Garrigues 2003).
Bourdieu (2003) spoke of “symbolic violence”, of a “sweet and invisible” vio-
lence, wishing to determine specific relations in the area of pedagogy, sexism and
racism. This formulation by Bourdieu could reliably define the type of relation-
ships that were established between colonising and local populations and to a great
extent “dressed up the correlation of power”. The symbolic power is the power of
acting on the world, by acting on the representation of this world (Bourdieu and
Wacquant 1992).
The challenge of the meeting and therapy with the other, when the other is part
of an increasing number of moving populations in the world, is a complex scientific,
political and cultural problem. How could we consider the role of cultural identity
in clinical narratives of foreign citizens who cannot accept what we as Western
societies call “social integration”? What kind of dialogue can be conducted with
15 Community Mental Healthcare for Migrants 317

therapeutic techniques that are formed within completely different fields and
horizons, where the interpretation of effectiveness is completely different to that of
traditional Western psychiatry? Perhaps the time has come to explore not just the
function of the symbols originating from a different cultural framework or their
effectiveness (Levi-Strauss 1978) but also their power to cause disease or even
death. Recent social anthropology, ethnology and critical psychiatry literature
underline the scientific fragility of ethnopsychiatry or transcultural psychiatry:
terms such as “invention of culture”, “mixed identities” (métis), “construction of
authenticity” and “invention of tradition” are serious indications of the scientific
identity of other terms, such as ethnos (a people), culture, tradition or identity, and
underline the risks deriving from the attempt of objectification, according to the
classification of Western tradition or their political manipulation.
Therefore, the challenge of meeting and caring for moving populations requires
us to redetermine the basic concepts that had supported the scientific edifice of eth-
nopsychiatry. As Hannerz (1998) says: “each complex culture must be seen as a
moving set of connections. The connections we see are those between signifiers and
forms that transport them, but at the same time, connections between individuals are
established through the social organisation of the signifier”.
The reception, understanding, meeting and mental healthcare of the other lead us
to look differently at the “cultural identity” in the current context of globalisation.
In this multifaceted meeting with “the other”, there cannot exist mutually accept-
able lines of interpretation of the unconscious in individuals or groups, irrespective
of the framework in which they live, exist and relate to others.
The recent genocides, the responsibility of the West in feeding and reproducing
pre-existing ethnic tension differences and the conflict to conquer wealth-producing
resources of developing countries in the geopolitical sphere give us the general con-
text and cause to reflect first on our own clinical view and our own ambivalence in
view of the complexity of these individuals’ requests and needs.
If anthropology is the search between individual freedom and social meaning
(Augé 2009), ethnopsychiatry of moving populations must be referred to the under-
standing of this fluidity, these tensions and our own structural ambivalence in the
context of our meeting with them.

15.4 One Example of Organising Migrants’ Mental

Healthcare in the Community: Babel Day Centre
in Athens

Let us begin with three stories:

When she arrived in Greece from Sierra Leone, Georgetta was impressed to find people
who were in their 40s and their parents were still alive. She had lost hers in the civil war;
she didn’t even have time to bury them. It weighs on her; not burying your parents is a grave
sin. She can’t sleep at night; the spirits keep her awake, reminding her of her duty.
Nazrul did not want to leave his country, Bangladesh. He wanted to stay there, study
business administration and find a job in that field. But he was the one, together with his
318 N. Gionakis and S. Stylianidis

brother, selected by the family to immigrate and help the rest of them survive. Shortly after
arriving in Greece (where he found a tailor’s job and worked for twelve hours a day) he
started seeing things that others did not see, he began wandering, fearing for his life.
The family of 13-year old Faroul was forced to leave Afghanistan because of her father’s
political beliefs. Before they were able to leave, Faroul and her sister were kidnapped. The
kidnappers demanded ransom. The family collected the money with help from others, but not
the full amount. The uncle who went to the negotiation (to hand the money over and get the
children back) was murdered by the kidnappers because he didn’t have the full ransom amount.
Faroul has trouble sleeping at night and has difficulty remembering. As does her mother…

The Babel Day Centre started its operation in November 2007 in Kypseli, a mul-
ticultural Athenian district. It is a mental health unit that provides services to
migrants. Priority is given to those who have difficulty accessing or are banned from
mental health services, either because they are illegal aliens or they have yet to
achieve adequate knowledge of Greek, so that they may communicate with the pro-
fessionals in mainstream mental health agencies. However, since Babel operates in
the context of public mental health and there is no other unit like in throughout
Athens, it has no exclusion criteria for requests addressed to it. Each request receives
an answer, even if it is a referral to another unit (only people with substance and
alcohol abuse/addiction are not taken in charge; instead, they are referred to special-
ised units).
An extensive information campaign was implemented for organisations address-
ing migrants’ (a) mental health needs, (b) physical health needs and (c) social needs
and mainstream organisations where migrants could apply, in order to make Babel
known and build a cooperation and referral network. Through this ongoing cam-
paign, it has been possible to inform a wide range of organisations about Babel, the
services it provides and the ways in which someone may apply to it. Also, a media
campaign was designed, mainly for the migration mass media, in order to make its
operation directly known to potential interested parties; an effort has been made to
approach representatives of the so-called migration communities.
Babel receives requests from anyone irrespective of age, gender, ethnicity, reli-
gion and residence status (legal or not) in our country. It also receives requests
pertaining to couples and families. Since January 2008, when the clinical work
began, till December 2013, Babel had received 2,210 requests of which 1,256 were
undertaken as “cases”. These people came from 74 different countries. Of the
“cases”, 55.4 % did not understand Greek, while 18.75 % had problems with legal
stay in Greece.
Access to Babel is not subject to specific rules. Anyone can apply in the most
expedient way to them: by phone, in person or through another professional. The
request is received by a member of the multidisciplinary team and the first clinical
meeting is then scheduled. Both on reception of the request and on the first clinical
meeting, the aim is for the applicant to establish a contact with the unit. In order to
achieve this aim, an attempt is made to help the applicant understand that at Babel
there is someone available to listen to him/her. This is made possible as there are no
formalities upon reception, communication is done in his/her own language and the
staff allows the expression of the challenges she/he is facing in his daily living.
15 Community Mental Healthcare for Migrants 319

Many migrants find it hard to trust easily. In most cases they are referred to Babel
without an explanation as to the reason, or the kind of provided services and what
to expect from them, making contact even more difficult.
Starting from the premise that migrants and refugees with mental health issues
and/or mental disorders (namely, ones that can also be distinguished by their triple
otherness: the migration condition, different ethnic-cultural origins, mental disorder
experience) are in particularly vulnerable positions while they also have sufficient
reserves of mental resilience, the overall goal of Babel is to provide the appropriate
care and support services to underpin their resilience. In order to achieve this, an
attempt is made to create a home (see below) able to actively listen, understand and
support any person (individual, couple, family, group) addressing a request to Babel
related to mental health. In this space, besides having the mental disorder symptoms
treated, it is possible for the applicant to establish the meaning of the loss of country
has for them as well as the expectations of a new life on an individual, family and
social/cultural level. Emphasis is given to the individualised approach, while the
individual care plan prepared and implemented is the result of negotiation between
the framework and the person to whom the service is provided. This means that
there is no previously set “service menu”; depending on the negotiation and the
needs that will emerge, services may be “invented” that have not been offered to
another applicant before and may not be offered to anyone in the future, as they are
appropriate to the specific person, the specific family and so on.
As mental health is favourably or adversely affected by a multitude of factors
(risk and protection), the Babel multidisciplinary team tries to maintain its readiness
in order to trace (in the context of the “assessment”) the existence of such factors
and take action (by applying the principles of promoting mental health). So to make
the assessment, it is of essential significance to acquire information regarding the
applicant’s quality of life and the degree of his integration (particularly if he wishes
to remain in the country). This information pertains to the status and capability of
caring for physical health, covering basic needs (housing, clothing, nutrition),
employment, the existence of a support network, knowledge of Greek, legal or not
residence in the country, integration into education (for children and adolescents)
and similar “non-clinical variables”. Addressing the needs linked to these variables
is a priority for the Babel team, and to this end, a client-centred network is convened
each time to undertake the planning and implementation/assessment of the indi-
vidual treatment and rehabilitation. This includes interventions on all aspects of an
individual’s or a family’s life (by the end of 2013, Babel had developed coopera-
tions with more than 200 entities – state, local government, non-profit, volunteer, as
well as informal active citizen networks). The cooperation is necessary to address
the needs of the beneficiaries in terms of health and mental health, social care,
employment, education, recreation, culture, legal aid, etc. As a result, the benefi-
ciary becomes a “client” of a network and not of a unit, and each unit has to operate
as an “open system” in constant communication with the community. In such a way,
the unit makes an effort to “correct” its own imperfections by making use of
resources available in other institutions. In order for the network (or rather for the
multiple networks) to operate successfully, constant communication is necessary
320 N. Gionakis and S. Stylianidis

between the professionals of the participating organisations. This communication

takes place using any possible form (face-to-face meetings, telephone contact, tele-
conference, e-mail, etc.). Communication is effective and cooperation becomes effi-
cient under certain preconditions. For example, the cultivation of a common
language between professionals, compliance to specific and mutually acceptable
principles and the will to cooperate (therefore also to compromise and everything
else that cooperation involves) can contribute to this end.

Clinical Approach

Clinical work at Babel is based in many respects on the theoretical approach of

R. K. Papadopoulos (see Papadopoulos 1997, 2000, 2001, 2002, 2007, 2011), direc-
tor of the Essex University Centre for Trauma, Asylum and Refugees, concerning
refugees who constitute the majority of Babel beneficiaries (such approach can be
also used with other migrants, adapted accordingly). Central concept to
Papadopoulos’ theoretical approach is that of psycho-ecological settledness (more
recently, the “psycho-” component has been replaced by “onto-”). Psycho-ecological
settledness is the product of a unique combination of the “tangible” and “intangi-
ble” elements of our identity: “tangible” elements include gender, age, physical and
psychological characteristics, profession, family status, political and ideological
affiliation, religious beliefs, activities and hobbies, culture, nationality, family,
body, etc., while the “intangible” elements (the term “intangible elements” signifies
the sensory data related to home and the sense of “belonging”) comprise the basis
on which we build the tangible elements. According to Papadopoulos this set of
“intangible” elements of our identity form a mosaic substrate of identity because
“each element on its own may not be of relevance but in combination with the oth-
ers, much like a mosaic, form a coherent pattern, a design that accommodates all the
elements which are part of our identity but which we become aware of usually when
they are absent, when we lose them” (Papadopoulos 2011, p. 20). He proposes that
involuntary loss of home refugees experience is not only about the conscious loss of
the family home with all its material, sentimental and psychological values, but it
creates a more fundamental psychological disturbance of their whole sense of
“psycho-ecological settledness”; this, in turn, activates a nostalgic disorientation
(the term refers to the unique psychological experience of migrants and refugees in
particular, which is not a psychiatric disorder; actually, all those who have lost –
refugees against their will – their hearth, namely, their home with all its dimensions,
share a deep sense of nostalgic longing to restore this type of loss) which is a much
more fundamental and primary disturbance than the sense of losing tangible posses-
sions or social positions – “it is a loss that affects refugees deeply yet in an way that
is difficult to grasp clearly its nature” (ibidem).
Those who lose their home involuntarily and are dislocated, says Papadopoulos,
experience the effects of a multidimensional, deep and permanent loss and feel dis-
oriented because they have a hard time accurately identifying the source and exact
nature of loss of home. The loss creates a void that makes migrants – and even more
15 Community Mental Healthcare for Migrants 321

so refugees, people who left their homes because they were in danger – feel that
they have no space, that they do not belong and that nothing contains them (with
regard to this, Losi (2000) says that migrants are balancing between two worlds,
unable to feel that they belong to either one).
Also central to Papadopoulos’ approach is the view that, paradoxically, despite
their adverse nature, the devastating events linked to the migration condition (irre-
spective of the degree of their toughness and the adversity of their consequences, as
in the case of refugees) can also help people reorganise their life, to regroup it and
give it new meaning. Exposure to adversity can (a) lead to negative consequences
(mental disorder), (b) have no effect on the person’s resilience and (c) have positive
consequences, namely, cause new skills to be born that the person did not have pre-
viously, precisely because of their exposure to adversity (adversity-activated
development).
The assessment of the status of a person appealing or being referred to Babel
adopts the guidelines that are born from the aforementioned theoretical approaches.
Although in their first iteration they pertain to asylum seekers, with small adjust-
ments they may be used for the different migrant categories. According to them, the
assessment process looks for (a) the positions where an individual is vulnerable and
those where he appears to have maintained his resilience, (b) the factors responsible
for this situation (individual, familial, environmental, contextual) and (c) the miss-
ing information necessary for the completion of as full and dynamic image as pos-
sible of the individual and his interactions.
The process suggested by the specific methodology tends to avoid turning the
migration experience into “pathology” and instead valorises its positive characteris-
tics. Following Papadopoulos’ theoretical approach, the assessment (which is not
separate from the therapeutic intervention) investigates the adverse consequences of
the migration experience, the neutral ones (namely, the individual’s characteristics
that remained untouched after the migration experience) and the positive (in which
positive characteristics that the individual did not possess previously were activated
due to his exposure to the specific adversity).
The explored indicators are the following:

(A) External circumstances: Adverse and facilitative circumstances pertaining to

the categories below. It is of essential significance to check if the migrant
enjoys the benefit of basic rights: (a) physical safety, (b) financial security to
enable at least survival (benefits/employment), (c) education, (d) housing and
(e) avoidance of exposure to discrimination (gender, racial, ethnic, religious,
sexual orientation, etc.).
(B) Family constellation: Adverse and facilitative circumstances regarding the fol-
lowing categories: (a) age, (b) gender, (c) family composition (e.g. divorced,
reconstituted, active links with the extended family) and (d) family role (e.g.
single mother, single head of a household, unaccompanied minor, isolated
elderly person, etc.).
(C) Physical health: Adverse and facilitative conditions (e.g. good health, medical
problems, disability, etc.).
322 N. Gionakis and S. Stylianidis

(D) Psychological/psychiatric state: Adverse and facilitative circumstances and

responses to adversity: negative (mental disorder, distressful psychological
reactions), resilience functions and adversity-activated development functions.
(E) Links with the community: Participation and/or isolation relevant to their
preferred community with regard to the following categories: (a) ethnic,
(b) racial, (c) political, (d) religious, (e) ideological, (f) cultural, (g) local
(geographical), etc.
Isolation may be due either to the actual absence of the specific category in
the receiving country or to their inability to have access to it for any reason.
(F) Links with the wider society: Participation and/or isolation with regard to the
wider society.
(G) Degree of difference: Difference between home and receiving country with
regard to the following categories: (a) language, (b) educational system (in
relation to functioning in the current context, e.g. not just the education level
attained but also whether one’s qualifications are recognised in the receiving
country), (c) cultural norms and practices, (d) urban/rural living context and (e)
general life style.
This dimension does not correspond only to the actual degree of difference
but also to the extent to which the applicant is capable of handling these differ-
ences. Category: “duration of stay at the receiving country” is of particular
significance as to this point.
(H) Type of journey: Degree of hardship endured in reaching the receiving country
and/or positive experiences gained along the journey. For example, were they
smuggled, trafficked, followed a long and arduous journey through many other
countries or did they arrive directly and with fewer hardships?
(I) Legal position: Degree of current legal complications. Is their legal case simple
or is it complicated by specific factors?
(J) Daily routine: The degree to which the migrant is able to engage in life and lead
a fulfilling life with a daily routine that reflects his active involvement, e.g.
visiting friends, attending classes, engaging in sport activities, etc.
(Papadopoulos 2011, p. 51).

The reception process, the assessment with the active participation of the benefi-
ciary and the activation of resources in the community which address an individu-
al’s or a family’s basic needs, all these components contribute to the creation of a
“home”. This is where the beneficiary can feel safe and protected. Such feelings are
considered necessary for the beginning of the therapeutic process. B. Cyrulnik
states that “psycho-traumatic experiences are almost the same, no matter the cul-
tural context… Each culture, however, provides the expression capability of the
trauma in the post-traumatic phase that either allows re-processing leading to resil-
ience or it impedes it” (Cyrulnik 2011, p. 16). So, “home” plays precisely this role:
it provides the possibility to express the trauma, hence permitting its reprocessing
that will lead to a new resilience state. It also uses all the skills and other positive
elements that were activated by the adversity. This is a process that requires time,
patience, endurance and respect of one’s pace. Disbelief, cautiousness, the
15 Community Mental Healthcare for Migrants 323

experience of abuse in the receiving country, racist behaviours and the obstacles
placed before access to rights and the feeling of unfairness and disappointment, all
those are factors impeding the therapeutic process. The latter is frequently chal-
lenged as it collides against obstacles related to new adversities faced by the
beneficiary in his daily, “ordinary” life.

The Challenges of Clinical Work with Migrant Populations

Migrants’ mental healthcare constitutes a challenge for mental health professionals

and services (Gionakis 2013). The following factors contribute to this:

• Identity. In one of the first scenes of Costa-Gavras’ film Eden à l’ Ouest, (Paradise
in the West), the migrants, who are in a boat, are asked to get rid of their identity
cards and passports, when a boat makes its appearance. They tear them apart and
throw them in the sea. A gesture showing that entrance into Europe requires the
denial of one’s own identity. The loss of one’s country, the separation from one’s
family, the length of the journey and the payment of the smugglers, all have pre-
ceded this. Subsequently, without identity, like Pirandello’s Mattia Pascal, they
discover that at least in the Western World, entry in an actual reality is a prereq-
uisite so that someone can exist.
• Who are the migrants? Some of them went to a country as tourists, liked it and
stayed. Others are migrant workers. Some of them are EU nationals who move in
other EU states, others originate from countries that until recently were not (but
now are) EU members and others come from “third countries” (outside the EU).
Many are seeking asylum and have been waiting (for years) for their request to
be examined. Among them there are people with specific features needing par-
ticular attention (unaccompanied minors, survivors of torture, victims of traffick-
ing and so on). Others were identified as refugees or granted with humanitarian
protection status. Many wish to request asylum, but not in the country they have
arrived in; for this reason they do not apply for it and therefore remain in the
country illegally. Some are not refugees, but as there are no other ways for them
to obtain legal residence status, they claim that they are. Many have arrived to
stay and others, perhaps the majority, to leave but are unable to do so. As a result,
they continue their journey illegally as they do not possess the necessary travel
documents. Finally, some have arrived and are willing to stay, but they soon dis-
cover that things are not as they expected them to be and realise they must either
go back or proceed to another destination.
• The therapeutic alliance. The therapeutic approach implies challenges too. The
beneficiary is confronted to a different language, a different culture, a different
world view and a different signification system. Furthermore, the reception and
living conditions in the country create frustration, thus leading to the feeling of
disbelief and, often, to hostility. Many of the beneficiaries may not agree with the
way Westerners perceive and live their life. On the contrary, they may regard
psychological, social, political and physical issues as an integral whole that
324 N. Gionakis and S. Stylianidis

cannot be separated in different components (i.e., “inside/outside”, “mental/

somatic”, “political/social”, cfr. Ingleby and Watters, 2005). As a result, they
may not recognise the problems “within” the individual or have a different view
as to what is the priority or the best intervention to carry out. As per Arthur
Kleinman’s idea, the “explanatory models” of the person seeking assistance may
not match those of the professional they meet (Kleinman 1980).
• Much has been written about the features of the professional’s “cultural sensitiv-
ity”, “cultural awareness” and “cultural competency” (Seah et al. op.cit; Saldaña
2001). The personal history of each individual, the acculturation strategy she/he
adopts and one’s own expectations are elements shaping the uniqueness of the
“suffering subject”. To approach this uniqueness, the mental health staff is helped
by his/her own culture and world view, his/her own technical training and his/her
own availability. Staff should accept that cultural sensitivity, awareness, compe-
tency and proficiency pertain to diversity in all its representations and forms and
not just to the ethno-cultural one.
• Access to rights. In many countries there is a significant gap between the legal
recognition of rights and the possibility to practice them in a concrete way. Such
conditions permit the ascertainment of an “as if” function of the institutions.
Especially regarding people coming from different countries, cultures and back-
grounds, the manifest or underlying racism has the function of a meta-context.
The latter undermines any attempt to establish a relationship of trust and create a
safe framework between the service personnel and the “beneficiaries”, namely, a
framework that will permit (and will be facilitated by) the exercise of such rights.
Discrimination is the ground for the lack of access to rights. This is the case of
people who are “different”, such as those with a mental disorder. The institu-
tional history of psychiatric care in many countries is full of examples of viola-
tions of rights. This occurs despite lawmakers’ efforts, such as the ones regarding
involuntary care, which are not applied.
• Inadequacy of Resources. There is a lack of resources that discourages profes-
sionals to meet the complex and multiple needs of migrants with mental disor-
ders. The lack of resources does not just affect migrants, but in their case this
lack creates unsustainable situations. A simple example related to service acces-
sibility arises from the need to make communication possible with the patients.
In the case of people who do not speak the local language, the cooperation with
language or cultural mediators is a prerequisite in order to facilitate communica-
tion. Indeed, the appropriate training (of the people taking on the role of the
mediator as well as of the mental health professionals working with the aliens) is
necessary in the cooperation. Despite that fact, such resources are lacking in the
psychiatric care system in many countries and in many cases are considered to be
an unnecessary luxury. To the insufficiency of resources, one must also add the
insufficiency of rehabilitation initiatives (such as, for instance, the case of voca-
tional rehabilitation, which is almost prohibitive in some categories – see asylum
seekers – integration in the education system, which is not supported, etc.). It is
obvious that the relevant conditions (to the context of life) raise significant obsta-
cles to a person’s attempts for social and economic integration.
15 Community Mental Healthcare for Migrants 325

• The risk of victimisation. As it has become almost a stereotype, it is very easy for
someone to fall into the trap of seeing a person traumatised by the adverse condi-
tion they have lived through in every migrant, especially in the case of refugees.
In reality, as repeatedly discussed in this chapter, many do not just survive intact
to a significant extent despite all they have experienced under inhuman and tough
conditions; they are empowered further from their exposure to adversity, finding
a meaning in their pain and are in a position to turn their experiences into positive
ones, drawing new strength and experiencing a transformative renewal
(Papadopoulos 2007). This means that a mental health service must take seri-
ously into consideration this position and act accordingly. The modern
approaches, post-traumatic growth (Calhoun and Tedeschi 2006) and positive
transformation following trauma (Herold et al. 2008) (just like everything dis-
cussed in this chapter on adversity-activated development), could possibly con-
tribute to the formulation of this position.

In order to address these challenges, a mental health unit should benefit from the
professional knowledge and skills of the multidisciplinary team, as well as continu-
ous training and supervision. It can also depend on the resources outside the unit,
namely, the network of cooperating bodies, institutions and volunteers. All of these
together – and not separately – stand out as requirements for feasible effectiveness
of the clinical services.

Other Aspects of the Work of Babel

Clinical work is the main activity that Babel chiefly engages in. However, the unit
is also active in other areas, the most important of which are:

• Networking. Babel’s networking with other institutions (state, local government

and non-profit sector units) allows the achievement of a critical range of targets
linked to the centre’s mission. These targets include the efforts to plan and imple-
ment integrated interventions in the community, raising awareness/training pro-
fessionals and the community, agreeing on joint political action (advocating in
favour of integration and anti-discriminatory policies, etc.) and, last but not least,
participating in peer consultations.
• Education. Education and continuous training are components of the operation
of Babel. This includes organising internal training programmes for Babel staff,
interns and volunteers; initial/continuous training of professionals, the main job
objective of whom is either working with migrants (security forces, holding cen-
tres, hosting units, health institutions, asylum seeker support organisations) or
coming into contact with migrants in the course of their work (teachers, civil
servants, others); pre- and post-degree level education (through participation in
courses and internships) for domestic and foreign students; training package
preparation (the training packages compiled by Babel pertain to areas such as
effective cooperation with interpreters, integration of foreign pupils at school,
326 N. Gionakis and S. Stylianidis

migrant mental healthcare); and publications aiming at continuous improvement

of the skills of professionals in the field. An important field of education is the
one pertaining to the training of language facilitators on the basis of specific
guidelines (Miletic et al. 2006).
• Volunteering. A large part of the activities of Babel is carried out by people
offering their services voluntarily. In most cases they are mental health profes-
sionals who wish to contribute to the work done by Babel, and they operate on
humanitarian, political and social motivations. Their work is varied; they con-
duct specialised individual and group therapeutic or rehabilitation activities,
accompany, provide training and address the needs of everyday life of the
beneficiaries. The volunteer work is contracted through an individual agreement
for the provision of services, which describes the purpose, duration, frequency
and other commitments by Babel volunteers.

In conclusion, one could say that Babel does not operate as a “traditional” day
centre, in order to provide effective mental healthcare to migrants. “Provision of
effective mental health services” in this case means taking into account the com-
plexity of these peoples’ situation, the vulnerable positions they may be in, as well
as the resilience they have developed, the need to actively approach them supporting
the potential of communication in a language they understand, through the creation
of a framework they can perceive as familiar and within which they can gradually
feel safety and trust. This framework must direct its (manifold) activities not just
towards migrants but also towards a wide range of stakeholders, who participate –
each from his/her own vantage point – in the formulation of facilitative or adverse
integration conditions.

15.5 In Conclusion

The migration condition is closely related to the history of humans. The history of
humans is a history of movements, meetings and encounters. There is a plethora of
different reasons for these movements; they can be coercive or mass movements (as
in the case of refugees). The migration condition comprises a reality of particular
complexity; therefore, the approach that will explore and intervene must be of cor-
responding complexity. The migrants themselves create categories that are internally
very different, and it would be extremely risky to voice general and generalised
determinations on their behalf. As stated elsewhere, not identifying these peculiari-
ties has turned ineffective many of the interventions designed for this purpose, result-
ing in totally controversial results, far from what had been expected (Gionakis 2008).
The situation becomes even more complex when the attempt is related to explor-
ing the relationship between migration and mental health. It appears, at least insofar
as what is currently acceptable, that it is important to identify the consequences of
the conditions under which migrants live in the countries where they settle on men-
tal health and not just those related to what they “bring along” from their countries
of origin. In this sense, emphasis is given to the principles and the manner of
15 Community Mental Healthcare for Migrants 327

organising the framework of mental health in the countries of settlement, so that it

may be in a position to provide the appropriate services.
The framework that will receive and support migrants with mental health
problems and mental disorders must have the capability to negotiate with the person
the creation of a new “home” within which it will be possible to lay the foundations
to develop a relationship of trust. This will allow the person’s subjectification,
namely, the capability for them and others to recognise oneself as the producer of
significance, a significance which, to begin with, can be expressed within a hospi-
table framework of services, so that he may then seek a connection with others,
“attempt emotional and material transactions, learn to interact” (Saraceno 2010).
This, continues Saraceno, “requires mutual adjustments between the subject and the
environment: more capable subjects and more tolerant environments”. Of course,
the necessary condition is the availability of services that accept to play this role, to
experiment with new ways of approaching the potential beneficiaries, to “open up”
to other services, to question themselves, to seek new intervention objectives and to
accept the complexity of reality and that of mental suffering, namely, in terms of
social psychiatry, to become deinstitutionalised.

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Modern Technologies and Applications
and Community Psychiatry 16
Orestis Giotakos

Abstract
The provision of remote psychological support services was initiated in the
1970s with the psychological support helplines. Such services are a continuously
growing field of mental healthcare, given that many mental healthcare units are
located in remote areas and unable to provide immediate psychological and coun-
selling services in response to crisis situations. Other support services, such as
online counselling and teleconferencing services in a telepsychiatry context, may
also contribute significantly in an integrated crisis intervention system aiming to
prevent the effects of psychological trauma and regain an individual’s functional-
ity. Online support is provided in the form of information guides and self-help
groups or online counselling services, as the process involving two persons has
been defined, the therapist and the client, in verbal or written communication via
an Internet connection. The benefits of this specific practice, such as accessibil-
ity, comfort, anonymity, facilitation of face-to-face psychotherapy and low cost,
make, in specific cases, online counselling the therapy of choice. Although the
use of the Internet seems promising for the treatment of psychiatric disorders,
specialists disagree on the ethical practice of psychotherapy in an interactive,
digital environment. Issues such as know-how and the management of technical
problems, difficulties in the diagnostic process, verbal and nonverbal cues, crisis
management, preservation of therapeutic alliance, protection of personal infor-
mation, age limitations and respect of boundaries in terms of space, time and the
dynamics of the therapeutic relationship and, finally, the training and supervisory
process of online therapists are some of the issues to be addressed.

O. Giotakos, MD, MSc, PhD

Director, Psychiatric Department, 414 Army Hospital, Athens, Greece
2 Erifilis, 11634 Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 331

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_16
332 O. Giotakos

16.1 Introduction

The spread of the use of the telephone and the Internet has led to the potential to
provide additional health services and information. The term “e-mental health”
comprises a wide range of interactions, such relationships between service users
and scientists (via email, live online counselling and searching for information)
or specialist-to-specialist or specialist-to-trainee communication (supervision,
evaluation of subordinates, specialised counselling-diagnosis, assessment of
information, ongoing training through two-way systems). E-mental health
includes the following general counselling services: information (information
transmitted over the Internet or by electronic means, client records and advice),
recommendation and advocacy (through referral to other service providers and
the establishment of relationships [in the form of documents forwarded to mail
lists and chat groups]) and direct relationships between consultants and clients
(by e-mail or live chat). The benefits of online counselling, such as accessibility,
commuting, comfort, anonymity, facilitation of face-to-face psychotherapy and
low cost, may make, in certain cases, online counselling the main therapy of
choice (APA 1997; Giotakos 2008).

16.2 Psychological Support Over the Phone

Objectives, Promotion and Assessment

The objective of a support helpline varies according to the type of services provided.
All policies, procedures and objectives must be written and disclosed to both the
helpline workers and the general public. The manner in which a helpline is pro-
moted should accurately reflect its purpose so that it is clear for whom it is intended
and the type of requests the specialists working at the helpline are able to handle. In
addition, a clear staff selection and training plan should be in place and available to
the supervisory committee or anyone assuming the overall responsibility for the
management of the helpline. The methods used to select, train, supervise and sup-
port the helpline staff are monitored, reviewed, modified and improved through
designated meetings between helpline supervisors and workers. The recording and
compilation of call statistics are considered useful for the better and more efficient
management of the helpline. Monitoring the manner in which such services are
provided, recording the number of calls and classifying them according to type of
request and intervention determine the needs that the helpline staff is called to meet,
the requirements of the population for which it is intended and any likely shortcom-
ings and deficiencies of the service. The promotion of a psychological support
helpline must be clear as to the type of help offered and the subjects covered as well
as how callers may contact them, i.e. helpline operating hours, address, e-mail or
website. This enables the public to use the helpline by whatever means they prefer
and are available to them. The impact and effectiveness of the promotion must be
frequently reassessed (Giotakos and Triantafyllou 2006; Sanders 1993).
16 Modern Technologies and Applications and Community Psychiatry 333

Many terms, such as review, monitoring, determination, assessment, evaluation,

performance indices, qualitative and quantitative measurements, procedures, con-
clusions and impact, are used in the appraisal process of the services provided by
the psychological support helpline. This appraisal may be internal or external. A
self-appraisal is an internal organisational procedure which enables a concise review
of any action on a personal or organisational level. Some psychological support
helplines employ external appraisers. This appraisal is linked to accreditation. Any
accreditation process must include an external organisation, acknowledged for the
quality of its services, to carry out the appraisal based on specific criteria. The nec-
essary information to be collected regarding the effectiveness of the helpline varies
according to its purpose. The appraisal of a psychiatric support helpline aiming to
provide information or advice differs and may often be carried out more easily than
the appraisal of helplines focusing on emotional support. On the whole, however, the
key information for each appraisal includes quantitative information about incoming
calls, unanswered calls and information about the quality of responses to such calls.

Type of Services Provided

Counselling Over-the-phone counselling may be defined as a service during which

a trainee consultant works with a client or a group of clients, over the phone, to
enable the client (service user) to explore and process personal situations, problems
or crises in a single session, a short-term or long-term therapeutic relationship. In
the latter two cases, a type of contract is established between the client and the con-
sultant and this may also include a financial relationship between the two parties.

Information During this individual function of the service, specific information is

provided in response to specific requests and the reported circumstances. Although
a friendly tone of voice is deemed useful and advantageous, an in-depth discussion
is not mandatory unless further clarification is needed on the issue concerned. The
person answering the phone must be able to provide immediate information on the
issue. In this context, issues relating to social welfare may also be resolved.

Support Insight is a prerequisite skill on the part of the consultant for over-the-
phone support. This skill is inherent in some people and whether it may be acquired
and effective in a counselling context is disputed by many.

Management of Call by a Person in Crisis

Every call to the psychiatric support helpline is expected to have a specific structure.
The same rules, certainly, apply to all tele-applications, such as teleconferencing in
the context of telepsychiatry. Such contacts always have a beginning, a middle and
an end as well as the following distinct stages (Giotakos and Triantafyllou 2006;
Sanders 1993).
334 O. Giotakos

Establishment of the relationship The helpline must be located in an environment

which allows the consultant to focus on the reason of the call. This requires an
environment free of any likely and unnecessary distraction, such as background
noise. If this is feasible, it would be advisable for the consultant to let the phone ring
two or three times so that he/she may focus on the caller and give him/her time to
prepare. For many callers, the manner of answering their call will define whether
they will stay on the line. The caller’s greeting must be in line with the policy of the
helpline.

Exploration of content This stage covers the main part of the call. The consultant
needs to be particularly careful so as to “follow” rather than lead or guide the caller.
While dialling the number, many callers have not yet organised their thoughts about
what they actually want to say. They may, perhaps, need to be listened to more
attentively so that they may understand what is happening to them and what is their
actual requirement from the helpline. The consultant must continue listening and
responding in a way that helps the caller explain their situation and needs as well as
their feelings with respect to the situation and assure them about their emotional
support and insight for their needs, i.e. their willingness to see things from their side
and stand by them through this hardship. Therefore, a consultant’s basic training
should include the development of active listening as well as the development of
call handling skills.

Clarification of basic issues This stage may not be necessary but could, however,
become more relevant if one of the most important objectives of the helpline is
emotional support. Consultants should be sensitive to the reactions of the callers so
that they can “read” when they need to move in this or that direction and, at the same
time, “perceive” the feelings of the callers and avoid pressuring them to continue
beyond their point of endurance at this stage.

Closure Each call must certainly come to an end and the manner in which it will
come to an end often determines whether the caller will feel comfortable to use the
support or information offered to them. It may also affect their feelings and prompt
them to call again. A “good closure” may include a summary or a recap of the call
by the consultant which includes acceptance and acknowledgement of the caller’s
feelings.

After the call This is an important part of the call, just as important as the actual
communication with caller. Time should be dedicated to review how the call was
handled. There is no such thing as a “perfect” call and depending on how willing
someone is to assess their performance and accept their colleagues’ support and
feedback, the more effective they will be in the future. It is advisable for the
workers to take the opportunity to review the last call and “recover” before
proceeding to the next call. An “internal supervision” of the call by the consultant
or, even better, discussing the call with a colleague could facilitate this process.
16 Modern Technologies and Applications and Community Psychiatry 335

The consultant must not feel obliged to proceed to the next call, especially if they
are still affected or preoccupied with their feelings for the previous caller. Also, it
is preferable that they complete as soon as possible the relevant call paperwork.
The more they put off this to a later time, the more difficult it will be to recollect
the details of the call.

“Difficult” Calls

Many psychological support helplines receive calls which, for whatever reason, are
considered “difficult”. Such calls may affect the specialist answering the call and/or
the entire service. In cases where the psychological support helpline consultant is
affected by the caller, they must first become aware of this and then request support,
supervision and, perhaps, additional training. A psychological support helpline may
employ external consultants to supervise and counsel the staff.
“Difficult” calls are extremely angry calls, calls from people threatening to
commit suicide, sexually inappropriate calls, hoax calls, calls by people who are
intoxicated, racists, homophobes or calls of a threatening nature and repeated calls.
The specialists employed by psychological support helplines must be trained in order
to be able to handle such so-called “difficult” calls within the boundaries set by the
service where they work. Many psychological support helplines deem it useful to
incorporate a separate “suicide call” service which forms part of their confidentiality
policy. Likewise, a specific way could be developed to answer calls of an abusive,
sexual, racist or homophobic nature. The specialists providing psychological support
services over the phone cannot be left to manage such calls on their own and without
support. Certain callers, such as repeat callers, may cause problems to the entire ser-
vice as they overstep the specific boundaries of the psychological support helpline.
They could even cause anger. It is, therefore, necessary to develop specific ways for
all the helpline workers to manage such calls, even preplanned written replies.
The following strategies have often proved to be particularly helpful in cases of
“difficult” calls:

Keeping written confidential records accessible to all other helpline workers and
supervisors. Such records must be checked at regular intervals.
Agreeing upon an action plan with the caller which should be added to the record.
If the caller does not agree, such refusal must be recorded. The staff that will
subsequently contact, directly or indirectly, the caller must be familiar with this
plan and follow it.
Involving other specialists in this action plan. The counselling process must be
ongoing as the plan develops.
The personal safety of the caller and any persons contacting them as well as the
personal safety of all helpline workers must also be taken into consideration.
In certain cases it may be necessary to involve the police or other services
(Giotakos and Triantafyllou 2006; Sanders 1993).
336 O. Giotakos

16.3 Psychological Support via Teleconferencing

(Telepsychiatry)

Determination of Needs

Telepsychiatry is defined as the application of modern telecommunication

technologies to mental health services. Telepsychiatry is one of the most dynami-
cally growing fields of telemedicine today. The capability of modern telecommuni-
cation systems to transmit audio and video provides the basic tool for remote mental
health services, i.e. verbal and nonverbal communication. With the help of modern
IT systems, any information of interest to any mental health services user is trans-
mitted remotely and readily accessible to the examiner, the therapist or other spe-
cialist. Furthermore, the accelerated growth of telepsychiatry services addresses
two modern trends in the field of mental health: on the one hand, the increasing need
for mental health services which often exceeds the capacity of available human
resources and, on the other hand, the contemporary need to provide healthcare ser-
vices and psychosocial support at a regional level. Generally, we could talk about
three integral parts: videoconferencing (bidirectional transmission of digital images
in real time between two or more positions), the electronic psychiatric file (software
used to save, edit and transfer patient information) and online services (such as
e-therapy, e-learning, etc.). The clinical and other applications of such systems are
able to support basic operational needs of the mental health services in our country
(Rees and Stone 2005; Giotakos 2008).

Services Provided

The services provided through such telepsychiatry systems can be classified under
the following categories:

Services requiring direct communication between the user and a specific scientist
(psychiatrist, psychologist, social worker), i.e. interviews, sessions, application
of various tests or questionnaires. Such services include the examination and
monitoring of patients as well as various psychotherapies.
Services requiring cooperation between mental health professionals, such as, for
example, direct consultation with a specialist in relation to cases (e.g. between
psychiatrist and general practitioner), discussions between scientists from differ-
ent fields to manage cases and the operation of the “therapeutic team”.
User information services, such as special assistance, support and information
through dedicated webpages (information on mental health, queries to
specialists).
e-learning services. Particularly in the mental health field, this may include a live or
recorded demonstration of an interview (via teleconferencing or online) or the
direct supervision by the trainer during the session conducted by the trainee.
These also include the general forms, such as online courses in the form of
webinars, scientific debates and lectures via teleconferencing.
16 Modern Technologies and Applications and Community Psychiatry 337

Web-based management services. Teleconferencing and the transmission of data

(documents, information, etc.) allow managers to participate remotely in
administrative functions. The “users” (users) of telepsychiatry services may be
primary healthcare units (psychosocial care groups located in remote areas or
regional clinics) and secondary healthcare units (healthcare centres lacking men-
tal health services or various other community structures, such as day centres
and/or correctional facilities). The “provider” of such services is usually the cen-
tral Tertiary Mental Health Unit (psychiatric hospital or psychiatry department
of any general hospital). Special applications for the provision of specialised
services and training (special centres, universities, etc.) may also involve work-
ing together with other bodies.

16.4 Online Psychological Support

Determination of Needs

In 1997, the American Psychological Association and, in 2001, the British

Psychological Society established rules of conduct relating to ethical practice and
online counselling. The Internet offers users more than one platforms to commu-
nicate and as a means of prevention in mental health, this takes various forms. The
specialist-therapist may be actively present and involved in the session with the ben-
eficiary (counselling via e-mail, teleconferencing, videoconferencing). Individuals
may also look for ways to help themselves, with online support groups or self-help
literature and counselling. In this field, we come across the terms online counselling
or online therapy (the corresponding terms in international bibliography are online
counselling/online therapy/Internet-delivered psychotherapy/web-based therapy/
cyber counselling/e-therapy). In general, this is a process involving two parties, the
therapist and the client, in a verbal or written communication via an Internet connec-
tion, using a PC, or via e-mail (Andersson et al. 2009, 2011; Carlbring et al. 2005;
Haberstroh et al. 2007; Moritz et al. 2011; Murphy et al. 2011; Oravec 2000; Skinner
and Latchford 2006; Liebert et al. 2006; Suler 2000; Sucala et al. 2012; Titov 2011).

Services Provided

Counselling via e-mail The exchange of e-mails is considered the most common
way of communication over the Internet. Counselling by e-mail is now an outdated
form of support as the discussion between the therapist and the client does not occur
in real time.

Counselling via live chat Counselling via live chat is a form of support occurring
in real time, as the therapist and the client are able to converse by typing.

Counselling via video conferencing using a camera Video conferencing is mainly

based on free software, such as Skype, which enable users to chat while maintaining
338 O. Giotakos

visual contact. The use of a camera, which is either built in the PC or attached to it,
is necessary for the visualisation of the dialogue. The ability to exchange further
information for the counselling process is achieved through video recording using a
camera. The specific communication platform is more complex than the above
mentioned as it requires additional equipment and a faster Internet connection.

Online support groups Online self-help/support groups allow users to expose

themselves anonymously in a group, exchange experiences with people facing the
same problem and provide mutual support. Registered members post topics for dis-
cussion with other members facing the same problem and are able to reply at any
time of the day, free of charge. Confidentiality in such groups is not ensured as the
flow of new members entering the group and older members leaving it is ongoing.
The type of interventions used in online counselling is clearly influenced by the
social learning theory and cognitive behavioural therapy. This therapy aims to reduce
the reported symptoms, change dysfunctional behaviours and prevent future relapses.

The Benefits

Accessibility Direct and easy access to support services via the Internet is one of the
benefits of this practice for individuals who, otherwise, would not be able to seek ther-
apy. Individuals residing in remote areas lacking an organised framework or a men-
tal health specialist, individuals with reduced mobility, indigent individuals without
health insurance and victims of intimate partner violence who don’t want to draw the
attention of their partners, are able to search for assistance services via the Internet.

Anonymity Individuals from a closed social system may perhaps find it difficult to
seek help from a local mental health service because they fear social stigmatisation.
Furthermore, clients concerned about being criticised by the specialist seek online
support to express their thoughts and feelings from a more detached position.

Low cost The cost of online counselling is much lower than that of face-to-face ther-
apy. A videoconference session using a camera and a live teleconference is usually paid
for by credit card, and payment is effected on the date of the next session. Counselling
via e-mail may be free of charge or not, and such fees may correspond to an amount
charged on an e-mail basis or a larger amount for an unlimited number of e-mails.

Ethical Considerations

In general, specialists disagree on the ability to provide support to any individual

within the infinite environment of the World Wide Web (Welfel 2013; Lee 2010;
Giotakos 2008). Other than the rules of conduct governing the practice of psycho-
therapy, additional ethical practice concerns are raised relating exclusively to online
counselling:
16 Modern Technologies and Applications and Community Psychiatry 339

Know -how and management of technical problems A therapist practising online

counselling, other than being well trained, must also have practical knowledge on
the use of PCs and surfing on the Internet. At the same time, it is necessary to assess
whether the client is eligible for online counselling: Does this specific client possess
the necessary know-how? How experienced is he/she in the use of the Internet? How
developed are his/her writing and typing skills in terms of speed, adequacy and
content? From which location will the client be communicating online with the ther-
apist? Are there any risks of disclosure of personal data?

Initial assessment A careful assessment may reveal that someone is not eligible for
this type of intervention. The problem being reported, the client’s request, any prior
counselling experiences, current therapy expectations and the reason for which he
chose the Internet as a means should be thoroughly examined. The likelihood that
the beneficiary may have an audio-visual or mobility problem, a chronic physical
condition or any other particular condition should also be examined. During the first
phase of the therapy and for a more qualified assessment of the needs of any indi-
vidual, it is recommended to hold a face-to-face meeting or a telephone conversa-
tion and to dispatch electronically self-reference questionnaires for completion – a
method which is as reliable as the completion of questionnaires in printed form.

Verbal vs. nonverbal communication A disadvantage of online counselling is the

fact that nonverbal cues are not perceptible. The written word is not the same as the
spoken word, either in terms of content, quantity or style. For example, sarcasm is
difficult to perceive in a text, a fact which may lead to a significant misinterpretation
from the part of the therapist. It is recommended that the therapist encourage the
clients to mention any likely difficulties so as to minimise this possibility. Contrary
to written communication, counselling via video recording allows the observation
of facial expressions.

Therapeutic relationship A safe and trustful therapeutic relationship, characterised

by insight, authenticity and unconditional acceptance, is a necessary condition for
the psychotherapy to be effective. It is, however, possible to establish a therapeutic
relationship via the Internet. Studies on the therapeutic alliance associate its exis-
tence with a positive therapeutic result, recognising its value as equivalent to that of
face-to-face counselling.

Personal information When a user decides to reveal any personal information on

the Internet, it is impossible to guarantee completely its secure path. A breach may
be caused by a hacker or due to user error. The password must be codified and
strictly personal and the name of the sender should be carefully verified before
sending an email. Sending messages via an encrypted web page reduces the dis-
semination of information. Moreover, the use of a public PC, at home, in the work-
place, in an Internet café or a library, could compromise the personal information of
an individual. Both e-mails and chat could come into the possession of third parties.
In order to protect written sessions with therapists, it is recommended that the indi-
340 O. Giotakos

vidual delete their browsing history when using a public PC and create a new
account which will not be shared. Safeguarding the therapy is equally important as
protecting the client’s privacy. In written session via live teleconferencing or email,
there is always the possibility that a client will use the sessions’ texts for legal pur-
poses, e.g. in child custody cases. Therefore, the therapists must also be particularly
careful with the content of their reports.

Age Older people may find it difficult to respond to the condition of online
counselling. On the other hand, a therapist should not accept to treat minors
without a signed and duly certified declaration from the parent or legal guardian
of the minor.

Training of the therapist In the case of counselling only services, it is difficult to

verify any training, specialisation and professional qualifications of a therapist, psy-
chologist or psychiatrist. To enable an interested party to obtain the necessary infor-
mation regarding the training of the specialist, it is proposed that their curriculum
vitae be published together with certain contact details of their training bodies.
Supervision, a necessary process for the ethical practice of counselling, may be car-
ried out by a certified, well versed in online support matters, as employing a super-
visor with considerable experience in online support is rather difficult.

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Assessment and Management
of Domestic Violence Cases Within 17
a Community Mental Health Services
Framework

Stella Pantelidou, Athina Vakalopoulou,

and Stelios Stylianidis

Abstract
This chapter describes the phenomenon of domestic violence, its rise over recent
years in Greece and abroad and its consequences, placing emphasis mainly on
the way that cases of child abuse and abuse of adults are assessed and managed
by community mental health services. In addition, it presents a guideline for the
detection of domestic violence as well as the proposed therapeutic approaches
based on existing literature. Reference is also made to the management of a child
abuse case and the therapeutic plan implemented, in cooperation with all
community actors, in the course of the operation of the Mental Health Mobile
Unit for Northeast Cyclades. Finally, it highlights the importance of developing
actions to prevent domestic violence.

17.1 Introduction

The phenomenon of domestic violence has been, and still is, for most societies a
taboo subject: frequently, any reference to violence in a family on the one hand,
appeared only in mythology and literature, or in police reports as to certain of its

S. Pantelidou (*) • A. Vakalopoulou

Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]
S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 343

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_17
344 S. Pantelidou et al.

aspects while, on the other hand, idealisation of the family, particularly in Greece,
casts a veil of silent complicity and tolerance with respect to this threat against the
family ideal. The first objective of this chapter is not just to explain terms and con-
cepts theoretically but to also describe the extent of this phenomenon in our coun-
try, in Europe and the rest of the world.
The working assumption of the issues discussed is to examine violence not as
something external to us but as a phenomenon growing within us and in our inter-
personal relationship, within the families which may be both warm and supportive
as well as dangerous and which, under the current “fluid circumstances”, are threat-
ened by extinction or radical changes.
The second objective of this chapter, building on such issues, is to develop pro-
grammes and action plans at the community level to manage domestic violence in
the most effective manner possible.
However, the phenomena of unravelling social ties, the vicious cycle of lack of
financial resources, social exclusion and mental disorders, cultural admixtures and
migration, revolutionary progress in the health sciences through new assisted repro-
ductive technologies, gave rise to new forms of familial organisation, and parental
roles. New phenomena which could constitute sources of instability, uncertainty
and risk, therefore, support the prevalence of domestic violence.
How can we manage this violence which stems from a pathologically structured
family modus operandi, through the understanding of intrapsychic, group and inter-
generational dynamics? Conflict, trauma, unexpressed, hatred, envy and neglect
could result into incapacitating and dysfunctional situations, inasmuch as they are
developing within an environment of social disgrace and cover-up of such cata-
strophic phenomena by the local society’s own defensive mechanisms. The “unex-
pressed” grows in an insidious, slow and silent, however, often unanticipated and
violent, manner. The mental health interdisciplinary team working in the commu-
nity has a therapeutic, ethical and social responsibility to intervene, acting as a cata-
lyst, and eliminate this collective denial and collective cover-up of such phenomena
by the local society itself.

17.2 Definition of Concepts and Terms

Different definitions have been attributed to the term “domestic violence”. It refers
mainly to any form of violence (physical, sexual or psychological) exerted against a
member or members of the family. The forms of power and control exercised
include threats, verbal abuse, breaking objects, torture of animals, emotional abuse
(humiliation, contempt), financial abuse (prohibition of work, withholding of finan-
cial resources), isolation, displays of extreme jealousy etc.
In summary, the main forms of violence include the following:

Psychological violence (verbal abuse, humiliation, threats, swearing, prohibition to

leave the house, etc.)
Sexual violence (rape and attempt to rape, sexual humiliation, sexual exploitation)
17 Assessment and Management of Domestic Violence Cases 345

Financial violence (lack of financial freedom)

Physical violence (punching, slapping, shoving, injuring etc.)
Stalking

The victims of domestic violence could be men, women and children. According
to the “UN Declaration on the Elimination of Violence Against Women” (CEDAW,
as adopted by the Word Conference on Human Rights in Vienna, in 1993), vio-
lence is defined as “any act of gender-based violence that results in, or is likely to
result in, physical, sexual or psychological harm or suffering to women, including
threats of such acts, coercion or arbitrary deprivations of liberty, whether occur-
ring in public or in private life”. Τhe term “violence against women” may refer
to physical or psychological assaults, emotional and psychological abuse, rape
and sexual abuse/harassment, incest, “honour” crimes etc. Social class, gender,
nationality, race and religion may affect the likelihood of someone experiencing
violence.

Child Abuse

Child abuse and neglect refer to “any recent act or failure to act from the part of a
parent or caretaker of a child, which results in death, serious physical or emotional
harm, sexual abuse or exploitation, or an act or failure to act which presents an
imminent risk of serious harm” (Child Abuse Prevention and Treatment Act,
CAPTA, 93-247).
The primary types of child abuse are physical, emotional and sexual. Physical
abuse of a child is defined as the deliberate use of force against a child, which results
in harm to the child’s health, survival, development or dignity. It includes behav-
iours such as beating, kicking, shaking, biting, choking, burning, poisoning and
causing asphyxia. Emotional abuse includes acts or omissions on the part of the
parents or caretakers of a child which have caused or could cause behavioural, cog-
nitive, emotional or mental disorders (Covell and Howe 2009). Finally, sexual abuse
refers to engaging, exploiting, soliciting, inducing, grooming, persuading or coerc-
ing a child to participate or cause others to participate in any sexual behaviour or
imitation of such behaviour for the purpose of producing a visual representation of
this behaviour (NCCAN 2005, p. 3).

17.3 Historical Background

The first studies on understanding the phenomenon of domestic violence were con-
ducted in the 1960s, a period during which the extent of child abuse was initially
established (Gil 1970). In 1970, mainly as a result of the feminist movement,
researchers focused their interest both on spousal violence and child abuse (Gelles
1974). Abuse of elders attracted particular attention around 1980 (Steinmetz 1978).
Towards the end of 1970, a rise was observed in child sexual abuse cases (Finkelhor
346 S. Pantelidou et al.

1979, 1984), while research data confirmed cases of beatings in spousal relation-
ships (Russell 1982; Shields et al. 1990).
Feminist theory has undoubtedly been the cornerstone in encouraging research-
ers, and every society, to study the roles of both genders and the circumstances
which may lead to value systems that justify sexism, the prerogatives of men against
women and the socialisation of both genders (Healey et al. 1998). Such value sys-
tems appear to reflect the patriarchal structure of societies where the man is consid-
ered all-powerful (Ahmad et al. 2004). Therefore, despite its long history and
prevalence in every society, domestic violence has been part of an overarching femi-
nist stand against patriarchal structures towards the end of 1960, while in early
1970, when the feminist movement of abused women was introduced in Britain, it
also assumed political dimensions resulting in the establishment of the first com-
munity support centre for battered women and their children in 1971, the Chiswick
Women’s Aid. So, gradually, domestic violence became one of the major basic
human rights violation issues and a major threat to the health and integrity of the
members of a family (Ellsberg and Heise 2005).
All the above resulted in raising public awareness and aroused the researchers’
interest in the different forms of domestic violence and their consequences (Dobash
and Dobash 1979). In the absence of any investigation of this phenomenon over the
past decades, one of the major research questions raised in 1970 related to its extent.
In Greece, the changing socioeconomic circumstances together with the redistri-
bution of roles between the two genders and the different perception as to the role
of each family member resulted in mobilising international organisations and the
enactment of law 3500/2006 (Government Gazette Α΄ 2006 Issue No. 232), entitled
“On combating domestic violence and other provisions”. The purpose of this law is
to combat the phenomenon of domestic violence according to the principles of free-
dom, self-determination and human dignity and enhance the harmonious cohabita-
tion family members. During the meeting of the UN Experts Group on 24/01/2007,
the Greek Delegation presented law 3500/2006, which underlined the obligation of
the state to adopt measures for gender equality, by providing protection and assis-
tance to victims, training public stakeholders and creating a database to monitor this
phenomenon. In addition, the law focused specifically on criminal mediation,
according to which the rights of victims are fully protected and women are, at the
same time, encouraged to seek help from public authorities (Stefanidou 2010).
According to Tomaras (2008), “this new law is a significant step forward in Greek
legal culture as it makes, more than sufficiently, clear that the family is not a vacuum
and that its behavioural values, rules and standards must comply with those of the
social hypersystem to which it belongs and with which it interacts”. However, sev-
eral difficulties and problems were encountered on the way forward to implement-
ing the above law and the institution of criminal mediation.

17.4 Extent of the Phenomenon

Studies over the last decades established that the phenomenon of domestic violence
is global. Comparing the frequency of cases in various countries, the transnational
study conducted by the World Health Organisation (WHO) (Garcia-Moreno et al.
17 Assessment and Management of Domestic Violence Cases 347

2005) concluded that physical and/or sexual violence varies from 15 % in Japan up
to 70 % in Ethiopia and Peru. 21 % of the women interviewed in the USA reported
that they have been physically or sexually assaulted and/or both by their partners,
while it is estimated that 37 % of the women in maternity wards have been abused
(Garcia-Moreno et al. 2005). Furthermore, 13–16 % of respondents reported that
they have experienced violence at some point up to age of 49.
Almost in every country included in the survey, approximately 50 % of the
women experience violence in the family and, in fact, the first incident occurs in the
age group 15–24.
Studies conducted in EU countries confirm that women are the primary victims
of domestic violence, in the form of physical, psychological, emotional and/or sex-
ual violence. A study conducted by the Council of Europe (Fact Sheet, Council of
Europe Campaign to Combat Violence against Women, including Domestic
Violence 2012) concluded that one in four women experience such violence at least
once in their life and 6–10 % of women are reported to be victims of violence during
any year. However, several studies indicate that men are also victims of domestic
violence, although to a lesser extent than women (one man out of ten women vic-
tims) (Walby and Myhill 2001). The research data on violence exerted by members
of the family other than the husband is limited. Therefore, further research is
required as regards the detection and identification of the needs of different victim
types.
In Greece, research on the phenomenon of domestic violence only started in the
1990s. The majority of information as to the frequency of domestic violence cases
is obtained from the General Secretariat for Gender Equality. According to data col-
lected from women victims who contacted the counselling services in the period
2002–2005, the first incident of violence usually occurs after the marriage (56.06 %),
and women, despite their spouse’s violent behaviour (80 %), continue to live with
them (65.22 %). The most common form of violence is psychological and emo-
tional violence, whereas psychological violence is less frequently reported. Based
on the first Panhellenic study on the extent, the nature and the aspects of violence
against women in Greek families (Artinopoulou and Farsedakis 2003), 56 % of the
women interviewed experienced verbal and/or psychological violence, the most
common form of which was contempt (19 %), insults (16.40 %), restrictions
(10.90 %), isolation from friends and family (5.5 %) and threats (4.30 %) Another
study concerning a population of 1122 adults, in the 18–64 age group, residing in
Greek urban areas (Tzamalouka et al. 2007), concluded that emotional violence was
the most common form of violence in the family (27 %), whereas physical violence
amounted to 18.7 %. Finally, a recent study on the detection of emotional and physi-
cal abuse of women after childbirth indicated that 35.6 % of the mothers inter-
viewed had experienced spousal violence.
Recent studies associate the Greek financial crisis with the crisis in relations
within the family. The new socioeconomic circumstances often lead to changes in
familial role patterns, the change of balances in family structures, tensions and con-
flicts between family members (Anagnostopoulos and Soumaki 2011). Moreover,
this new situation is likely to make it more difficult for a member of the family who
is being abused to break the pattern and leave the relationship because of their finan-
cial dependency. A study conducted by the Hellenic Society for the Study of Human
348 S. Pantelidou et al.

Sexuality (EMAS) and the Andrology Institute with the title “Greece in the crisis
and the MoU” (Kallidonis 2013) indicated that cases of violence (physical, sexual,
verbal) in our country increased by 47 % over the last months, with one out of three
women being beaten. The most prevalent forms of violence exerted by men are
verbal violence (72 %), followed by financial blackmail (59 %), sexual humiliation
(55 %), beatings (23 %) and rapes (18 %). As to the economic profile of men who
exert violence against their partners, 44 % were unemployed, 39 % in poor financial
situation and only 17 % were financially sound.
Traditional family norms are considered sacred and impervious to external fac-
tors which, considered in conjunction with the personal nature of the crime of vio-
lence between its members, make domestic violence “sinister” at every level
(Kilpatrick 2004). Victims, mainly women, hesitate to report exactly what happened
to them because they fear being re-victimised by police and judicial authorities
(Panoussis 1994). A typical example of this is the fact that the first epidemiological
survey conducted in our country in 2003 (Artinopoulou and Farsedakis 2003)
revealed that a large proportion of women did not identify the behaviours they expe-
rience in their family environment as being tantamount to abuse and within the con-
cept of violence. Ethnic minorities and female migrants are more likely to postpone
reporting such incidents than other women, either because of the fear of deportation
or because the norms of a society prohibit the disclosure of negative incidents in
most cases (Farah et al. 2004). Therefore, the private nature of the phenomenon of
violence in the family and the victims’ predominant reluctance to self-report assaults
present a challenge in mapping precisely the prevalence of this phenomenon.
The frequency of physical abuse is estimated to approximately 2 % of the child
population (Akmatov 2010). According to the World Health Organisation, it is esti-
mated that 1 in 5000–10,000 children under the age of 5 dies every year as a result
of physical abuse, and 1 in 180–1000 are referred to a health or social protection
service as a result of abuse. In Europe, the prevalence of physical violence is
between 5 % and 50 % (Lampe 2002).
A recent study by the Directorate for Mental Health and Social Welfare of the
Child Health Institute on child abuse (Petroulaki et al. 2013) indicated that one in
two elementary, junior high and high school pupils in Athens, Thessaloniki and
Crete has experienced physical violence, one in ten children has experienced sexual
violence over the last year alone and 76 % of children reported they had fallen vic-
tim to physical violence at some point during their childhood, whereas the corre-
sponding figure of those reporting sexual violence stands at 16.2 %.
In 2012, the Smile of the Child SOS Helpline received 366 reports of cases of
abuse concerning 691 children in total (Klontza 2012). Specifically, the reports con-
cerned the abuse of children in the 0–6 age group (43 %), while this figure for chil-
dren in the 7–12 age group is 32.5 %. As to the forms of abuse, the reports for 331
children (48 %) concerned neglect or abandonment, followed immediately by phys-
ical abuse (i.e. 41 %, 283 children). This is followed by coercion to beggary (4 %),
psychological abuse and sexual abuse (3 %) and, last, forced child prostitution
(1 %). Compared to 2012, the reports for child abuse submitted to the organisation
rose by 66 %.
17 Assessment and Management of Domestic Violence Cases 349

17.5 Male Victims of Domestic Violence

A “silent” and not so recognisable form of domestic violence is also that exerted by
women against their partners. According to a study, male victims of domestic violence
usually are emotionally dependent on their partners, show a clear lack of self-
confidence, consider that this violence is their own fault and don’t believe that they
would be better off in another relationship (Migliaccio 2002). And, in case children
are involved, men worry that they will be unable to remain in contact with them and
are, therefore, compelled to remain in the problematic relationship, often to protect the
children, given that women who exert violence against their spouses are very likely to
abuse their children too (Margolin et al. 2003; Straus 1990). Finally, a man’s need to
suppress pain and appear strong and in control also inhibits their ability to leave the
relationship, admit they have been victimised and seek support (Fontes et al. 2003).
Violence among same-sex couples is a complex phenomenon and as frequent as
violence between different-sex couples (McClennen 2005). However, the services
available to deal with such cases are almost non-existent. And here too, this form of
violence is to a large extent “silent” (Turell 2000).
Τhe effects of domestic violence are summarised in Table 17.1.

Table 17.1 The effects of domestic violence

Effects of domestic violence against adults
The adverse effects of domestic violence are derived from research findings over the last
decades. The basic types of this phenomenon are inextricably linked to serious (Coker et al.
2000) physical and mental health implications (Coker et al. 2000)
Physical abuse can cause injuries and persistent illnesses, such as chronic pain, irritable bowel
syndrome, backaches and headaches (Ratner 1993). Female domestic violence victims may
experience a greater number of unwanted pregnancies, miscarriages and premature births
(Sullivan and Knutson 2000). In addition, they show high levels of sexually transmitted
diseases, including AIDS (Walker 2000)
Several studies confirm that domestic violence is also linked with the onset of mental
disorders, such as depression, anxiety, post-traumatic stress (Wolfe et al. 1985; McCauley
et al. 1995; Houskamp and Foy 1991)
Effects of domestic violence against children
It has been found that children who have been exposed to violence in the home may show
signs and symptoms of:
Low self-confidence, anxiety, post-traumatic stress, depression
Increased risk of substance-related disorders
Hyperactivity, concentration problems
Antisocial behaviour
Guilt, anger, fear
Poor school performance
Emotional instability
Behavioural problems
Passivity
Wolfe and Birt (1997), Prekaté (2008), Giotakos (2004)
350 S. Pantelidou et al.

17.6 Identification and Assessment of Domestic

Violence Cases

It is important for mental health professional to include in their daily routine

domestic violence assessment practices and to be able to identify any signs and
symptoms implying abuse (Warshaw 1996; Appelt and Kaselitz 2000).
Adults may show the following:

Physical signs
Frequent physical injuries (bruises, fractures, cuts) and the explanations for how
they occurred may be inconsistent or vague. Typically, they most frequently
occur to the head, the face, the neck and parts of the body which they usually
cover with clothes, such as the chest, breasts and abdomen.
Hearing problems.
Complications during pregnancy or gynaecological problems; any injury,
inexplicable pain, mental disorder, suicide attempt and substance abuse during
pregnancy may be related to violence in the family.
Psychosomatic symptoms
Signs of fear (tachycardia, hypertension, fremitus, perspiration, nausea, stomach
pain, pains around the heart, breathlessness)
Signs of weakness (sense of weakness, depression, fatigue)
Signs of stress (headaches, sleep disorders, stomach pains, menstrual disorders)
Psychological symptoms
Anxiety, depression
Withdrawal/social isolation
Suicidal tendency, self-destructive behaviour
Low self-esteem
Fear
Sense of guilt and shame
Post-traumatic stress disorder symptoms
Substance abuse

In order to detect domestic violence, particularly where the victims are women
and children, the scientific team participating in the implementation of the
EMPOWER_W (Daphne Project) translated into Greek the handbook used by
mental health services and social services in London (Barnet Multi-Agency
Domestic Violence Identification Flow Chart – Bell).
By way of example, we list a few introductory questions for adults on the subject
of domestic violence (Bell et al. 2007; Roberts 2002; Warshaw 1996):

Do you experience problems in your relationship with your partner? Do you

sometimes disagree or fight? Do your fights ever get violent? Did you ever feel
fearful? Were you ever injured?
You seem to be scared of your partner. Could you talk to us about this? Does he ever
behave in a way that frightens you?
You mentioned that your husband loses his temper with the children. Could you tell
us more about this? Has he ever hit or threatened you or your children?
17 Assessment and Management of Domestic Violence Cases 351

Is your partner ever jealous? How does he react when he feels jealous?
Have your children ever been injured during violent incidents between you and your
husband? Do they often witness such incidents?
Has your partner ever tried to control you by threatening to hit you or your
family?
Has he ever tried to restrict your freedom, control or keep you from doing things
which are important to you (such as work, see your friends or family)?
Does your partner often humiliate, insult or blame you?
Do you fear your partner? Do you feel you are in danger? Is it safe for you to go
home?
Does your partner have any alcohol- or drug-related problems and/or psychological
issues? How does he behave in such circumstances? Do you need specific sup-
port with respect to any such issues?

As regards the detection of child abuse, it is essential to take into account and
assess any risk factors as well as any of the following signs (Prekaté and Giotakos
2005; WHO 2006):

Denial or delay in providing medical care to a child for health-related

problems
Failure to provide for a child’s daily needs and hygiene (clothing, food, assistance
in studying at home)
Frequent accidents
Frequent absences from school
Lack of emotional support from the parents
Threats, underestimation of the child and his/her abilities
Unreasonable prohibitions and control
Social isolation of the child and the family
Marks on the body, such as bruises and burns which the child may possibly try to
cover them with clothes
Stunted growth
Sexualised behaviour
Fear/reaction of the child to any physical contact

17.7 Management of Domestic Violence Cases with Adult

Victims

Managing domestic violence cases with adult victims includes primarily (a) the
risk assessment and development of a safety plan for the abused adult and any
minor family members (if any), (b) the assessment and management of vio-
lence-related physical health problems (acute or chronic), (c) evaluation and
treatment of any likely mental disorder and disorder related to the victim’s or
the perpetrator’s drug abuse and (d) the provision of psychotherapy services
including counselling, individual psychotherapy, couple and family therapy
(where appropriate) and referring the perpetrator to a therapeutic programme
(Table 17.2).
352 S. Pantelidou et al.

Table 17.2 Management of domestic violence cases

Risk assessment and safety plan
Risk assessment refers to an abused individual’s perception of the dangers associated with an
abusive relationship: whether remaining in the relationship or trying to leave increases or
reduces the risk to the individual and perhaps the children
The specialist should help the victim recognise such behaviours and the characteristics of a
perpetrator associated with such violent behaviour
A number of factors which have been acknowledged as crucial in assessing the level of risk
associated with serious cases of violence are set out below (Schechter 1982):
Background of the perpetrator
Previous aggression against the victim or others
Suicide attempts or threats
Threats, attempts or ideations to commit homicide
Use of weapons in the past
History of victimisation during childhood or of witnessing violent acts against his mother or
their siblings
Behaviour of the perpetrator
Substance or alcohol abuse
Stalking or persecussion behaviour
Threatening and sadistic sexual behaviour
Escalating frequency and intensity of aggressive behaviour
Physical and sexual abuse of children
Abuse during pregnancy
Personality of the perpetrator
Paranoid, jealous
Dismissive of others’ feelings or lack of insight
Serious mental disorder
Possessiveness
Setting
Divorce
Availability of weapons
Losses: professional, death, illnesses
Suicide attempts on the part of the victim
Poor social support on the part of victim
Substance abuse on the part of the victim
Safety plan
Whenever someone works with domestic violence victims, it is essential to develop an
action – safety plan. The specialist should discuss with the victim the following possibilities
(Warshaw 1996; Roberts 2002):
A. If they leave the home
Can they stay for a while with friends or family?
Can they stay for a while in a shelter for domestic violence victims?
Can they move to another community?
Discuss matters concerning financial resources and means of transportation
Discuss the necessary documents and items they must carry with them in case they need to
leave the home urgently (ID cards, passports, birth certificates, other important
documents, papers, medication, money, credit cards etc.)
17 Assessment and Management of Domestic Violence Cases 353

Table 17.2 (continued)

If they have to meet the perpetrator after leaving the home, this meeting should take place in
a public place
The special conditions associated with nonurban areas (social exclusion, lack of services
and lack of transportation) should be taken into consideration
B. If they remain at home
The specialist should discuss any actions and situations which have proven to be supportive in
the past and reduced the risk or likelihood of injuries in time of crisis:
Mobilisation of social network for emotional and practical support
Calling the police or a neighbour who is able to recognise an emergency situation
Initiation of legal procedures when deemed necessary (reporting the incident to police,
protective measures etc.)
Prepare to remove the victim and the children from the home in case of escalating violence
in order to protect them
Removal of weapons
Prepare the children for any eventual removal from the home together with the victim.
Explain that the children are not to blame for the situation they are experiencing
Encourage them to begin thinking of a more independent life in case the situation does not
change
Encourage them to discuss the situation with people they trust so as to alleviate the sense of
isolation experienced

Basic Principles of Counselling Women Who Have Suffered

Domestic Violence

In principle, a professional needs to present a calm, neutral and supportive attitude.

It is useful to draw the attention of the individual who has experienced a serious
mental trauma that this does not rule out the possibility of returning to a normal and
functional life (Roberts 2002). More specifically:

The session must be held in a quiet place, without the presence of other parties, and
always in a climate of safety and trust.
A mental health professional must show insight, respect and understanding and
reassure the domestic violence victim that the feelings they express are normal
and expected due to their circumstances (Safta et al. 2010).
Some basic information on domestic violence, the forms, the dynamics, the conse-
quences of violent acts and the specialised bodies that provide assistance on a
social, psychological and legal level should be provided.
The specialist must help the victim understand that all forms of violence (physical,
sexual, psychological) have consequences and that they should never be accepted
or tolerated. Moreover, the responsibility for any violent behaviour rests with the
perpetrator, and such behaviour represents a means of control and manipulation
on their part.
The safety of the victim and their charges are the most important element that a
specialist must ensure during each session. This concern must be expressed
openly, in a direct and clear manner (Safta et al. 2010).
354 S. Pantelidou et al.

The limits of confidentiality in the therapeutic relationship must be clearly defined.

It is important from the outset to stress that the mental health specialist is obliged
to report to the authorities any potential abuse – neglect of any minor family
members.
From the outset, the main goal is to promote self-control and empowerment by:
• Stressing their character strengths, their abilities and sources of support
available to them
• Stressing the victim’s right to have an opinion and be the “specialist” in their
own life in order to make the appropriate choices
• Identifying social support resources

The professional needs to discuss with the victim some ways to manage the situ-
ation, encourage them to propose solutions to the problem and respect any decisions
(Safta et al. 2010).
It is essential to take cultural differences into account. A specialised interpreter
must be present when this is required for the purpose of communication.
The community where the victim resides must also be taken into account, i.e. the
differences, for example, when their permanent place of residence is a small provin-
cial town, a small village or a large rural centre.
The professional must be aware of his own attitudes, experiences and reactions
towards violence by:

• Recognising his limits in terms of time and energy.

• Recognising and managing with supervisory assistance (and personal therapy)
his need to be an “omnipotent” specialist.
• Realising to the extent possible his own preconceptions and beliefs on the sub-
ject of violence.
• Accepting, without expressing any dissatisfaction, the wish of an individual to
remain in an abusive relationship.
• Acknowledging that he/she is probably one of the few people in the life of the
individual who has suffered domestic violence who has treated them with respect
and understanding (Nelson 2002).
• Having realistic expectations as to the goals of the therapeutic intervention so as
not to become controlling, stressed or disappointed.
• Always bearing in mind that they need to protect themselves. If, for some reason,
they feel that their safety is threatened, the competent authorities need to be
informed.

Other than the level of counselling, it is essential to help the individual who has
suffered domestic violence by providing psychotherapy on a personal or group
level. Psychotherapeutic interventions must be carried out by professionals with
specific training in psychotherapy.
Any short-term cognitive-behavioural therapy could be useful in approaching
any cognitive aspects of functionality and decision taken on financial, legal, inter-
personal and training matters. Training in problem-solving techniques (D’Zurilla
and Nezu 1999) can enhance their decision-making capability. With the support of
17 Assessment and Management of Domestic Violence Cases 355

the problem-solving model, the patient is empowered to maintain control over the
decisions they take in their lives. Moreover, the therapy aims to develop assertive-
ness, enhance self-respect, manage stress and anger, improve communication etc.
Geffner and Mantooth (2000) propose a psychoeducational model for individuals
and couples, with a focus on the areas identified above.
Longer- or short-term psychodynamic type interventions are also recommended
to facilitate processing and managing the trauma, feelings of guilt and self-blame,
dysfunctional and violent interpersonal relationships and also to mitigate the impact
and consequences of this fatal cycle within the family system (Despland et al. 2010).
Psychodynamic interventions in a major system crisis situation require the thera-
peutic team to formulate and define-submit to the family a “psychodynamic hypoth-
esis for the crisis” and an integrated intervention plan to manage this situation.
The common overall objective of such interventions is to develop a subjectifica-
tion process for each individual member of the family and as the family as a group.
When the mental and, often, the physical death invades and occupies the therapeutic
setting, one fundamental, clinical question remains: how can we, as therapists, gain
access to this symbolic-subjective aspect, without concealing the fact that the mem-
bers of the family have become actual objects of abuse by their environment?
“Every individualisation-subjectification mental process is a “betrayal”: Either a
“betrayal” of the individual-father, whose tyranny must cease, or of the ‘body-
mother’ from which we must break away” (Scarfone 1999, page 108).
The therapeutic approach should ensure an intermediary space, where it is pos-
sible to imagine and process the function of the family group and its history. The
multiple traumas, expectations, secrets, disagreements, complaints, violent out-
bursts and incestual environment, according to Racamier (1995), should be the
object of new significations. The fundamental paradox lurks throughout the treat-
ment period: “Living together kills us, but separation could be fatal” (Pozzi 1999).
Finally, it has been debated at length, with conflicting views, whether couple
therapy is recommended in cases of interpersonal violence. There are criticisms, on
the basis of which couple therapy is not recommended in cases of abuse of one
partner by the other, as such an approach could result in the re-victimisation of the
abused partner and allow the perpetrator to justify their violent acts (Avis 1992;
Gondolf 1995; Kaufman 1992). On the other hand, based on various models set
forth in literature, there are indications that couple therapy in cases of interpersonal
violence may be effective (Bentovim 1995; Goldner 1998; Hammel 2008; Caplan
2008). An initial assessment of certain factors, such as the safety of the children and
the adult who has suffered violence, the couple’s motivation for therapy and coexist-
ing problems requiring additional therapeutic interventions (e.g. substance depen-
dence), is essential before making a decision for couple therapy. A couple therapy
model, which is focused on matters relating to the relationship, dynamics and inter-
action between the couple, trauma management, the meaning attributed to violence
by each member of the couple and in deconstructing the violent moment, is pro-
posed by Goldner (1998). At the same time, it is based on the principle that vio-
lence, abuse and inequality are not morally acceptable in any form, highlighting the
perpetrator’s responsibility for such violent acts and the victim’s responsibility to
safeguard their safety.
356 S. Pantelidou et al.

Support Groups

Group therapy is effective for domestic violence victims (Tutty et al. 1993). Such
groups are usually psychoeducational type groups and provide a framework in
which the members can work on matters relating to the dynamics of abusive rela-
tionships, communication skills and management of emotions (Dutton 1992). While
therapeutic models vary, some general objectives are common and include:

Ensuring the future safety of the woman

Processing feelings of guilt and self-blame
Enhancing self-esteem
Understanding the dynamics associated with domestic violence
Expressing anger at and bereavement for the above relationship
Developing support networks and reducing social isolation

The EU Project EMPOWER_W (www.empowerw.eu), implemented in the

period 2011–2013, aimed to evaluate the impact of a number of funded interven-
tions in the light of the EU Daphne Programme (Pantelidou et al. 2011). Specifically,
women who have suffered domestic violence, but also mental health problems, par-
ticipated in a psychoeducational group which sought to bolster their self-esteem and
increase control over their life. A special training programme was also developed
for women who had suffered domestic violence in the past so that they could, in
turn, become self-help group co-ordinators. At the same time, mental health profes-
sionals had the opportunity to participate in a training programme intended to
improve their ability to identify and manage cases of domestic violence. Services
specialising in the management of domestic violence cases and academic institu-
tions from the UK, Italy, Poland and Slovenia also participated in this programme.
In Greece, in an attempt to address this phenomenon in the islands, where social
services are underdeveloped or inexistent, and the existing problems in healthcare
services often make it impossible to deal with such cases, the programme was
developed and implemented by the EPAPSY Mental Health Mobile Unit for
Northeast Cyclades.
The positive findings for the women who participated in the programme confirm
its effectiveness: It seemed that any abuse-related emotions (anger, guilt, fear) had
receded, their self-esteem was improved, they now managed stress effectively and
they had developed a more assertive attitude. On the other hand, after the end of the
training programme, mental health professionals expressed their satisfaction with
the intervention and the need for similar interventions in the future, and it seemed
that management of domestic violence skills had improved.
At the same time, in cases of domestic violence, the perpetrator should also be
referred for treatment. His psychological assessment is also important so as to
address any coexisting mental disorder. Various approaches based on specialised
programmes including mainly psychoeducational groups have been put forward in
literature (Mills 2003; Braithwaite and Strang 2002). Individual therapy models
include cognitive-behavioural therapy approaches, with a focus on changing beliefs
on violence, the perpetrator’s responsibility, and non-acceptance of violence, the
17 Assessment and Management of Domestic Violence Cases 357

development of communication and anger and stress management skills

(Dutton 2003; Babcock et al. 2004). However, models combining psychodynamic
techniques in interventions are also put forward as effective (Lawson et al. 2012).

17.8 Management of Domestic Violence Cases with Minor

Victims

The management of domestic violence cases with minor victims by a community

mental health service includes psychosocial interventions on many levels; hence
cooperation with social services, health services, legal services and other commu-
nity services is essential. More generally, the role of the competent services’ profes-
sionals is to provide care with a view to mitigate the impact of abuse and prevent the
continued exposure of the child to abusive acts. The timely detection of abuse and
immediate intervention help in reducing the long-term adverse effects for the child.
On a first level, in cases of suspected abuse or when the mental health specialist
receives information regarding the possible abuse of a minor, the competent authori-
ties, i.e. the Public Prosecutor, should be notified. Under law 3500 (article 23), in
cases of suspected abuse, teachers should take the same action. Based on the infor-
mation provided, the Public Prosecutor calls for a social investigation to be carried
out by a social worker from the competent social services. The social investigation
is carried out, and if deemed necessary, a child psychiatric expert evaluation, a med-
icolegal examination of the child and a psychiatric examination of the parents-
guardians (where appropriate) may also be requested. Furthermore, any emergency
medical situation is addressed immediately when necessary (paediatric examination
and treatment). Upon completion of the social investigation and the examinations
deemed necessary, the services need to cooperate to prepare a therapeutic plan for
the child and the other members of the family.
It is necessary to ensure the protection of the child and to assess whether the
child can remain in the family and receive support by the competent services or
whether the child must be removed from the home and the person who exercised
violence (and whether legal action is required). It may be necessary to admit the
child to a paediatric or child psychiatric hospital until the requisite assessments have
been carried out and a decision is taken as to whether the child can go back to the
family environment or whether they should be placed in a child protection institu-
tion. If the child remains in the family, social support must be provided to the family
and it should be supervised with regard to childcare and the non-use of violence. At
the same time, psychiatric follow-up care and psychotherapy are provided to the
child, and the other members of the family are monitored. In certain cases, family
therapy is also recommended to manage domestic violence with child victims. This
may be achieved under the following conditions (Bentovim 1995):

(a) The protection and safety of the child has been ensured and the competent
services have decided that the child may remain in the family environment.
(b) The perpetrator has assumed and accepted the responsibility for the violent acts
he has committed.
358 S. Pantelidou et al.

(c) The family has acknowledged the victim’s needs and is able to make them a
priority.
(d) The perpetrator has acknowledged he needs help (on a personal and family
level) to deal with his psychosocial difficulties and commits to the therapeutic
plan recommended (both for him and for the entire family).

Another important issue for professionals is the appropriate response when it is

established that a child has been abused. Usually, children don’t know how this infor-
mation will be construed, whether they will be believed, supported or blamed for
something. Clinical therapists stress that a negative response from the family or local
society could have a detrimental effect on the child/victim and this effect could be as
harmful as the abuse itself. Generally, a professional should remain calm, maintain a
neutral and investigatory stance, avoid expressing strong feelings of anger/surprise/
revulsion, avoid making assumptions about the perpetrator’s identity, allow the child
to express their feelings and reassure them saying that he must act in the interest and
for the protection of the child by informing other professionals as well as the compe-
tent services (WHO 2006; Giotakos et al. 2011; Cooper and Vetere 2005).
In therapeutic work with children who have been exposed to violent behaviour,
the professionals aim to (a) deal with the crushing thoughts and feelings of the chil-
dren surrounding the traumatic experiences and losses they have suffered (expres-
sion of feelings, stress management, treatment of metal trauma), (b) provide the
parents with support (if the child remains with the family) in terms of childcare and
the non-use of violence, (c) provide social support to the child through their partici-
pation in activities which facilitate their psychosocial development and (d) cooper-
ate with the school to provide further support to the child. At the same time, it is
essential to cooperate with people who are able to provide social support to the
family (friends or relatives).
Therapeutic interventions are adapted taking into account the age, mental and
emotional development, difficulties and needs of the child and may include the use
of various techniques. Several professionals have adapted some of the narrative
treatment techniques to the particular circumstances of the children experiencing
domestic violence. They develop other ways of expressing their dilemmas and skills
such as, for example, letter writing, scrapbooks and painting while trying to improve
the child’s social support in the community (Cooper and Vetere 2005).

17.9 Example of Addressing a Case of Child Abuse

by a Mental Health Community Service

In order to describe more candidly the role of mental health community services
when addressing cases of child abuse, we will briefly refer to a similar case man-
aged by the Mental Health Mobile Unit for Northeast Cyclades (Pantelidou et al.
2011; Pantelidou and Stylianidis 2010).
Following an anonymous complaint for physical violence and neglect of E., a
10-year-old minor, by her mother, the Public Prosecutor called for a social
17 Assessment and Management of Domestic Violence Cases 359

investigation to be carried out by one of the Mobile Unit social workers. E. and her
mother live in a small island, in the Cyclades. This investigation revealed that the
minor’s 43-year-old mother has psychosocial problems (suffers from mild mental
retardation, exhibits symptoms of mild depression, has financial problems and is
socially isolated), which result in making it harder for her to exercise her parental
role. According to information provided mainly by the school and by relatives, the
child showed signs of neglect (poor hygiene, many absences from school, learning
difficulties which have not been diagnosed and taken care of, spending long hours
alone both at home and outside the home, numerous accidents, inadequate medical
treatment of health problems she had developed over the last year). It was also
established that the mother used physical violence “… when E. does not obey me”,
in her own words. At school, E. presented the image of an isolated child with emo-
tional difficulties. She lives with her mother since her father passed away 4 years
ago. The problems in the care of the child and the use of physical violence by the
mother seem to have begun after her husband passed away.
An intervention plan based on both the child’s and the mother’s needs was devel-
oped in cooperation with the local authorities and services available in the commu-
nity. This plan included:

The provision of psychiatric follow-up care to the child by a child psychiatrist of the
Mobile Unit on a bi-weekly basis (frequency of visits of the Mobile Unit Team
mental health specialists to the particular island).
The provision of psychological and counselling support to the mother by a psychia-
trist of the Mobile Unit on a bi-weekly basis intended, among others, to strengthen
her parental role and to cease using physical and verbal violence.
Home interventions on a weekly basis by a social worker and a nurse from the
“Help at Home” programme in order to provide assistance in practical matters.
Holding regular meetings between the Mobile Unit’s mental health specialists and
E.’s teacher, for updates on her image at school and to draw up a common plan
for the child’s socialisation and support on a learning and emotional level.
The provision of support to the mother preparative to carrying out to necessary
medical examinations and to address E.’s health problems.
The diagnostic assessment of learning difficulties at the Syros KEDDY (Centre for
Differential Diagnosis, Diagnosis and Support) (help the mother accompany E.,
finding suitable accommodation for them in Syros).
Encouraging E. to participate in extracurricular activities (painting group, volleyball
team).
The provision of support to the family by relatives in the island who began visiting
and helping the family in practical matters.
The provision of financial support to the family (through the provision of goods) by
island’s Women’s Association.
The systematic supervision of the family by the Mobile Unit’s social worker to
ensure a stable environment for the minor and to eliminate further incidents of
violence and neglect. The Public Prosecutor in Syros was updated in writing on
a semi-annual basis with respect to above actions and the progress of the case.
360 S. Pantelidou et al.

Through these interventions and the proper co-ordination of the relevant bodies
and persons, E.’s psychosocial condition as well as her mother’s improved
significantly, and no further incidents of violence were reported.

Conclusions
Among other challenges, the current systemic socioeconomic crisis places the
interdisciplinary therapeutic team working in the community before the thera-
peutic, legal and social responsibility to deal with ever-increasing numbers of
domestic violence cases.
The implementation of interventions for the prevention and management of
such complex phenomena in a community framework presents three levels of
difficulty:

(a) The clinical, therapeutic and anthropological – in the sense of a deeper

understanding of the community – expertise of the team to diagnose and
make decisions in a relatively short time and under pressing conditions.
(b) The team’s resilience as well as countertransference interactions to phenom-
ena of abuse and violence, which is unable to comprehend and process both
mentally and intellectually. Consequently, the need for constant external
supervision, particularly in such cases, is a sine qua non requirement for the
continuation of such strenuous, intrapsychically and socially, work.
(c) The very culture, attitude and preconception of the community vis-à-vis
such phenomena, often latent and persistent, through mechanisms of sup-
pression, tacit tolerance and denial of such phenomena when they come to
light. It has been established that a simple complaint from leaders of the
community involved in such incidents is not useful, if not combined with
other intervention mechanisms and programmes, such as the ones described
in more detail below.

The dramatic lack of specialised mental health services for children and
adolescents in our country makes lobbying, together with the local communities
and bodies, for the creation and consistent operation of therapeutic teams with
ongoing training, supervision and material support, an absolute priority.
Therefore, it is essential to develop on national and local level actions to
prevent domestic violence and violence in general. Such actions must include the
following (WHO 2006, 2010):

Programmes for the prevention of violence against primary and secondary

education schoolchildren; such programmes should focus on attitudes and
information relating the subject of domestic violence, reducing violence
tolerance and promoting non-violent ways of communication/alternative
conflict resolutions techniques.
Interventions through the media: limit the presentation of violence in the media,
campaigns to inform victims of the need to seek help and the support services
available.
17 Assessment and Management of Domestic Violence Cases 361

Campaigns to inform the general population on the promotion of information on

the subject of abuse and overcoming stereotypes and myths surrounding
violence.
Specialised interventions for migrants, based on their cultural diversities and
needs, intended to help them develop nonabusive communication skills and to
promote their social integration.
Systematic training of mental health and social services staff in the detection and
management of domestic violence cases and development of domestic
violence management protocols to be used by the services.
Teacher groups with the view to inform them on children abuse issues (identifi-
cation and management at school).
Training of police officers on the management of domestic violence cases.
Preventive interventions with regard to the perpetrators (on the predisposing
factors associated with violence).
Development of services offering home visits and providing social support to
families.

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Sexuality of Patients with Serious
Psychiatric Disorders in Psychosocial 18
Rehabilitation Units

Stelios Stylianidis, Pepi Belecou, and Stelios Farsaliotis

Abstract
This chapter attempts a systematic theoretical and clinical study of the sexuality
of psychotic patients in psychiatric institutions, in particular in those the stated
objective and vision of which is to create an alternative therapeutic culture and
practice. It examines the determining role and the various aspects of sexuality
in the field of psychotic disorders, with particular emphasis on highlighting the
role of the therapeutic team and countertransference work in psychiatric institu-
tions, with respect to better understanding and managing the expression of sexu-
ality of patients. This debate is highlighted through the clinical material content
from a psychosocial rehabilitation unit. Commitment to thinking and hoping is
a strong protection of therapeutic teams against the anxiety related to the break-
down of institutions as well as their psychosis generating and neo-institutional
functioning.

For the meaning of a statement is not exhausted in what is stated. It can be disclosed only if one
traces the history of its motivation and looks ahead to its implications.
Hans-Georg Gadamer

S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
P. Belecou
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]
S. Farsaliotis
Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 365

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_18
366 S. Stylianidis et al.

18.1 Introduction

“Sexuality and psychiatric institutions” is a challenging subject to even attempt to

define, as we consider the complexity and resilience of applying the principles of
deinstitutionalisation, institutional psychotherapy (psychothérapie institutionnelle;
Oury 1976), psychoanalytical thought in the field of psychosis and the application
of the principles of recovery as a dynamic process of recovery-cure-empowerment
of speech, life and gender, therefore a carrier of sexual drives, of the patient.
Several issues relating to the day-to-day living of subjects with a psychotic
pathology in psychiatric institutions have occupied more or less systematically the
minds of clinicians and specialised literature. It seems, however, that we dwell less
frequently on the complex, practical, clinical, theoretical and ethical questions
raised by the sexuality of the mentally ill in an institutional framework (psychiat-
ric hospital, psychiatric departments of general hospitals, psychosocial rehabilita-
tion housing structures). The limited number of writings on the specific topic
could, in fact, be seen – at least this is our assumption – as an indication of the
existence of a “pact of denial” (Kaës 2011), a form of collective repression, around
these points.
What is, in general, the place of sexuality in an institution? Is human sexuality
characterised by certain unique features when examined in terms of psychosis and
schizophrenia in particular? What is the significance of sexuality in relation to such
disorders? What about the sexuality of psychiatric patients in an institutional frame-
work and, more specifically, the users of mental health services in psychosocial
rehabilitation structures? What is the position of professionals on sexuality? In
other words, what representations and practices do they have in this regard? What is
the role of the therapeutic team members’ position and, specifically, any counter-
transference work in terms of understanding and managing sexuality within the
institution? What are the complex dynamics emerging between the therapist-
reference person of the psychotic patient and the overall multidisciplinary therapeu-
tic team? Certain aspects of the above-mentioned problems are set out below.
Sexuality and the interest in it did not wait for the nineteenth century or psycho-
analysis to emerge. They were always present for mankind, and there have always
been codes of sexual behaviour which were defined by the specific historical, social
and cultural context of each community at that time (Foucault 1976–1984; Mead
1963). However, with psychoanalysis, sexuality emerged for the first time as a
reflection of an entire era (Sullivan 2001), as an instrument of understanding the
human world and psyche. Present in all expressions of human existence in the form
of a fundamental psychic energy investment, sexuality is no longer limited to its
strictly carnal, hedonistic aspect.
Prior to its psychoanalytical development of its definition, for a long time, the
term “sexuality” referred almost exclusively to activities, behaviours and pleasures
associated directly with the function of the genital organs. According to this strict
sense of the term – which also prevails in daily speech – sexuality refers to acts and
pleasures involving essentially gender, the model of which is mainly sexual inter-
course. For its contemporaries, however, the advent of psychoanalysis will succeed
18 Sexuality of Patients with Serious Psychiatric Disorders 367

in refuting a number of more or less established perceptions about sexuality.

S. Freud and his associates will discover gradually, or rather will take a fresh look
at, various previously “unknown” aspects of sexuality, as well as its key role in the
human mental function.
The Three Essays on the Theory of Sexuality (1905), one of the cornerstones of
the theory of psychoanalysis, illustrates perhaps outstandingly this effort to put
forward a new approach and a wider definition of sexuality. In this paper, Freud
examines infantile sexuality as the first stage of the dual-phase human sexuality
development and identifies its presence from the very first moments of life. As to
the adult sexual activity, due to the complex mental processes it involves, it is mani-
fested more as a conquest of the subject and not as a given: procreation is the happy
result of the progressive transformation of infantile sexuality, which it replaces and
covers to a smaller or larger extent. We will also discuss in passing that in the heart
of this view of psychosexual development is the concept of drive (Freud 1915a;
Laplanche 2008), indissolubly linked to the object, which – although partly gener-
ated by it – is always the condition of its disclosure, as aptly highlighted by
A. Green (1993).
Now, in the course of time and the vulgarisations of certain psychoanalytical
discoveries, the Three Essays scandal seems to have lost something of its original
subversive dimension. Still, the new representations of resistance manifested in the
modern social and cultural landscape (Schaeffer 2008) are a reminder of the fact
that the forms of repression are, in fact, unlimited, as are the faces of sexuality
(McDougall 1995). In the sexual revolution of the current “liquid” social reality
(Bauman 2003), together with the impressive rise of narcissism in the area of ethics
(De Gaulejac 1996), the diversity of sexual practices appears to be at consensual
level and transient arousal increasingly becomes a substitute of the subject’s emo-
tional and mental life. Together with N. Zaltzman (2011), we could wonder at this
point, to what extent would the mass cultural spread of psychoanalysis in the mod-
ern work have contributed to modifications between the ego and the unconscious
mind, affecting the psychic institutions of censorship and transferring repressions?
Be it as it may, the Freudian discovery of the sexual foundations of our psychic life
permits us first and foremost to understand and approach mental diseases therapeu-
tically – at the end of the day – as sexuality disorders.

18.2 Sexuality and Psychotic Disorders

In order to better process the multiple questions on the sexuality of subjects afflicted
with a mental disorder within an institutional framework, we must first turn to the
significance and specific aspects of sexuality in the area of psychoses, from a
psychopathological view.
Psychoanalytical literature has a wealth of tradition with regard to the quest of a
cause in the area of psychoses and the attempt to present a significance, a reasoning
even in the strangest among their symptomatic derivatives. This meaning – today
we would say to be found and to be created – is closely related to the subject’s
368 S. Stylianidis et al.

history and in particular to its psychosexual history. Early fixations, cancellation of

latent homosexual desire sublimations, narcissistic regression, delusional recon-
struction and externalisation of instinctual danger through mass projections – these
are, in summary, the most important points of the schema “mined” by Freud (1911)
from his reading of Schreber’s memoirs (Denkwürdigkeiten eines Nervenkranken)
in his first systematic study of psychosis. Significant contribution from M. Klein,
her students and other analysts, who dedicated a large part of their efforts in treating
psychotic patients, extended in their turn the capability to approach certain archaic
parts of mental life. According to the most traditional belief, the common denomi-
nator of various psychoses can be identified in a primary disorder of the libidinal
relationship with reality, a disorder that may be compensated on a secondary level
by creating a neo-reality (delusion as an attempt at recovery; Freud 1911, 1914;
Laplanche and Pontalis 1967).
In an attempt to understand what happens with sexuality in the field of psychotic
disorders, we will focus at this point on the mental processes that take place in
schizophrenia and in particular at its beginning. We will use schizophrenia as prin-
cipal, clinical reference, taking it as a psychotic function model. As we know,
schizophrenia is a disease either gradually and softly established or manifested from
the start with extremely noisy delusional symptoms, usually during adolescence and
up to the first years of adult life. This extremely costly solution for the ego is a psy-
chopathological eventuality more frequent during this period of life compared to
other ages. Indeed, schizophrenia is considered specifically a disease of adoles-
cence – provided that we accept the nosographic distinction between schizophrenia
and chronic systematic psychoses (Ey et al. 1960). Acknowledging the above, how-
ever, gives us a significant premise with regard to the place of sexuality within the
explanatory understanding of schizophrenia, as well as a lot of information to reflect
on for its treatment.
More specifically, schizophrenia expresses a difficulty in accessing procreation,
namely, an adult sexuality structured on the primacy of the genitality erogenous
zones, which takes into consideration the difference and complementarity of the two
sexes, for the purpose of the sexual contact. Although on the cognitive level, the
anatomical difference between the two sexes seems more or less obvious, on a psy-
chological level, sexuality as well as the wider sense of the world is not organised on
the basis of the genital distinction between male and female; instead they are based
mainly on pregenital fantasising. “Man” and “woman” and “penis” and “vagina” are
often caught into paradoxical forms of thought, which acknowledge and at the same
time deny their difference. This significant burden within the psycho-mental function
of forms of reasoning and mechanisms that belong to earlier libidinal stages related
to procreation is not, however, synonymous with the total absence of the latter –
as would be maintained by a structural formulation (Lacan 1956; Bergeret 1974)
that would make the Oedipus complex a kind of exclusive privilege of the neurotic
economy. Present, therefore, in primary, raw forms, unaccompanied by the funda-
mental parameters of neurosis (intrapsychic conflict between desire and prohibition,
integrated superego, castration anxiety, authentic triangulation, etc.), the Oedipal and
progenital components cannot function as basic organisational poles of mental life.
18 Sexuality of Patients with Serious Psychiatric Disorders 369

The role of adolescence is decisive here as gender signification, namely, the

subjective appropriation of genitality is the core of the internal work that the ado-
lescent is required to carry out. This pivotal period of development requires of
everyone a multifaceted reorganisation process of the ego and sexuality, starting
from the reality of the radical physical changes in puberty. Therefore, the fact that
schizophrenia begins where, in theory, the psychological work of adolescence
should be completed, expresses an inability to process these changes, resulting in
the emergence of a serious difficulty in the formation of a solid sexual identity –
male or female. In other words, the anxiety of forming an identity and the fragility
of schizophrenia is closely linked to the failure of the representation integration in
the self-image of a biologically mature, sexually capable body. Referring to this
significant difficulty that the adolescent encounters to make his body and the meta-
morphosis it is going through his own, English analysts M. and E. Laufer (1984)
suggest the concept of a “developmental breakdown” to describe the unconscious
rejection of the adolescent body’s sexual identity; however, they point out the dif-
ference between natural forms of such breakdowns as the expected passing moments
of crisis in adolescence and the establishment of psychotic quagmires. In such
cases, if an adolescent falls victim to this kind of pathology, it can be considered a
costly outcome of the work of adolescence and its insufficiencies, while entry into
psychosis marks the rupture of the subjectification process (Cahn 2002).
A significant number of clinical manifestations of the psychotic range may there-
fore be comprehended on the basis of the issue of sexuality and the massive negative
defences it motivates in the adolescent and/or the young adult. For example, the
start of the psychotic process often corresponds to a painful depersonalization expe-
rience, whereby the person is under the impression that their body does not belong
to them. The subject experiences its body and sexuality as foreign and extremely
alarming. The body’s sexual identity turns into a persecuting object, causing intense
archaic anxieties to flare up. Unable to recognise himself, the patient gradually loses
the feeling of cohesion of his existence. The delusional ideas he is suffering from
are presented in a painful attempt to redetermine his relationship with sexuality.
They therefore refer to self-image adjustments (e.g. loss of physical integrity, uncer-
tainty as to gender, a firm belief of pregnancy), as well to origins, cancelling the
difference between sexes and generations through fantasies – non-fantasies – of
self-generation (auto-engendrement) (Racamier 1978).
Despite all this, “psychosis” does not signify a break or a permanent end to the
function and development of a subject. The majority of sufferers from schizophre-
nia, or other forms of chronic psychotic pathology, live in society, work and pos-
sibly even have a family. Clinical experience in mental healthcare institutions daily
confirms that the timelier the therapeutic response and the more it takes into con-
sideration the patient’s personal characteristics and history, the better it permits
him to unfold his resources and his hidden capabilities and invest in hope, in order
to address effectively his difficulties. The target of institutional intervention, of
course, is to soothe mental anguish and help the subject to experience a more sat-
isfactory relationship with the world and himself; therefore also with his
sexuality.
370 S. Stylianidis et al.

If the mission of the psychiatric institutions, in particular those that are considered
places of living, is the contribution to the laborious subjectification process, it is rea-
sonable to think that the interdisciplinary therapeutic team working in the institution
is the catalyst of this subjectification process, the lost signification of the subject’s
life, as well as its registration in everyday social reality. However, how is institutional
work to permit the subject to progressively renegotiate the issue of sexuality in a
more favourable way? How ready are the therapeutic team members and the team as
a “mental institution” to contain and process not just the archaic forms of psychotic
patients’ expression of sexuality but also their own deficits related to a subsequent
developmental breakdown of their own that may transform to a fear of breakdown as
per Winnicott, namely, the threat of a break in the therapist’s mental function and that
of the extended therapeutic team within the institution?

18.3 Therapeutic Team and Countertransference

Particularities in the Work with Psychotic Patients

The Therapeutic Team

The daily life of persons with psychotic disorders within psychiatric institutions and
the management of their sexuality are indissolubly linked with the capability and
cohesion of the interdisciplinary therapeutic team, its dynamics as well as its resil-
ience and creativity to implement a range of principles, tasks, positions and thoughts
of community based mental healthcare, deinstitutionalisation and recovery
(Thornicrοft and Tansella 2010; Anthony 1993, 2007; Farkas 2007; Deegan 1992,
1997).
The concept of a team within an institutional framework refers to all its mem-
bers, which are linked on the basis of a plan and through a network of mental and
emotional codes, formal or informal. This is the theoretical assumption of
J. Hochman (1982) regarding the “mental institution” (institution mentale), which
establishes a special meeting location and composition of all the team members’
mental function, capable of containing and transforming psychotic psychopathol-
ogy (Stylianidis 2008).
It is a fact that there is a dual reference to this conceptual context: on the one
hand, it determines the significance of these live interactions for the team’s indi-
vidual members with regard to the satisfaction they may draw from it; on the other
hand, it formulates the outcome of the patients’ treatment plan. Foulkes (1964)
describes this communication and relationship network as a “group matrix” which
defines the meaning of all events that take place. This network described by Foulkes,
as it develops, also includes the nonconscious reality of the teams. D. Anzieu (1975)
talks about the requirement for a team to have previously existed as a fantasy, as a
collective defence system against many sources of threat. R. Kaës (2011), with the
“group mental apparatus”, suggests approaching the team in the light of the connec-
tion and transformation processes and also highlights (1993) the collective ideal or
the “group illusion” (Anzieu, as above) that unconsciously organise the teams’
functioning.
18 Sexuality of Patients with Serious Psychiatric Disorders 371

The understanding of this meeting place of the TT (therapeutic team) has been
greatly aided by (Bion’s 1961, 1962) contribution: the concept of “containment”.
This last one permits the establishment of a containing space of reflection suggested
by the therapeutic teams to patients with mental disorders, in order to co-give mean-
ing to daily mediations (Stylianidis 2008). The therapeutic actions helping the
recovery-healing process are conducted within this intermediate space, liberating
the therapist from the dyadic relationship which is the main reason a psychotic
patient feels threatened.
While discussing the concept of framework and communication, we could not
leave out the contribution of anthropologist G. Bateson and the famous Palo Alto
School. Bateson worked to surmount the partition between the individual and the
context, which he actually called “counterfeit” (Bateson 1972, 1979). Highlighting
the concept on interdependence, he placed communication in a network of relation-
ships that individuals and their actions create, which remains in constant flux. The
messages generated gain significance due to the context, as this places them in a
specific space-time and gives “instructions” for their comprehension to the users. In
his description about the “double bind”, where two entirely opposing and mutually
exclusive things are asked of the individual and their incompatibility, the first
researchers said that a situation such as this would lead thinking into a complete
impasse, in a nonsolution, as occurs in schizophrenia (Navridis 2005).
The basic idea of systemic thinking relevant to the context and the principles-axioms
of human communication (see Watzlawick et al. 1967) are being reread in recent
decades, in the light of an intersubjective dynamic. The relational model in contempo-
rary psychoanalysis, fundamentally alternative as to the classical drive theory
(Greenberg and Mitchell 1983), invites us to comprehend the therapeutic relation as the
process of co-construction of a new narrative through the emergence of a common
affective and symbolic meaning between the two subjects. The meeting between indi-
viduals that always takes place in a specific historical, social and cultural setting creates
a special, unique intersubjective relationship, transcending any form of preconstruced
reality.
Utilising the post-modern narrative thinking (Bertrando 2000; Bruner 1986,
1990; Gergen 1982, 1985; Hoffman 1990; Watzlawick 1984; Welsch 2006), we can
but speak of co-development and co-construction of meanings. It is important that
the stories shared between the members of a TT within the setting of a psychosocial
rehabilitation institution are included in a discussion that remains “open” (Anderson
and Goolishian 1988) so that the production of new meanings towards a coherent-
joint narrative may become possible. Only shared meanings make interaction and
communication possible (Luhmann 1995).
The “meeting” that takes place here is twofold: on the one hand, this multilevel
reading framework encounters the conceptual framework of the dynamic process of
recovery from mental illness, which is what we focus and work on with the patients’
histories, so that they may build meaningful lives within the community. On the
other hand, a meeting takes place between contemporary systemic post-modern
thinking and the contemporary trends of psychoanalysis (integration; see Evans and
Gilbert 2005; Holmes and Batman 2002; Lancer 2000; Pocock 1995), where the
interpersonal is a pivotal point of reference and concern.
372 S. Stylianidis et al.

In fact, we comprehend here the complexity and the multiple levels of

communication in the TT’s “relational network”. Functional teams are established
on a joint project with rules, boundaries and culture that formulate their identity. Due
to the inability of processing their own vital function, dysfunctional teams break up
and are unable to provide meaning to the contradictions and difficulties establish-
ing a resilient network of relationships: at the end of the day, they are unable to
contain the patient. Contradicting messages boost the early defence mechanisms of
the patients’ psychotic functioning. Elements that are not processed mentally, persis-
tently and covertly interfere, are indirectly disseminated within the therapeutic space,
hampering the growth of the TT’s cohesion, effectiveness and resilience. In this case,
“attraction” towards the team as a factor of cohesion is limited (Yalom 1995).
Such a team process, however, towards the quest of a cohesive discourse and
practice against the chaos and archaic defence mechanisms of psychosis, forces us
to address the countertransference movements of the team, the psychiatric institu-
tion, the external supervisor as well as each therapist-member of the team sepa-
rately. In other words, the pressing question is how to help our colleagues, who are
not and will not all become psychoanalysts (and why would they?), use their coun-
tertransference in their difficult daily work with patients afflicted with a wide range
of psychotic disorders.

Countertransference Particularities in Work with Psychotic Patients

The term countertransference appears relatively late in Freud’s writings, specifi-
cally in his correspondence with Jung. Jung addresses the teacher as though he were
a confessor, saying that he has “sinned”, succumbing to the seduction of one of his
patients. Freud “absolves” him, saying that the patient’s transference may generate
a countertransference in the analyst, a countertransference that the latter should
control to the greatest possible extent through his self-analysis.
Therefore, countertransference is considered here through a dual point of view:
it is primarily an erotic move. It is also an “enemy”, a “parasite”, the pathological
effect of which we must limit (Freud 1910, 1915b). For precisely this reason, Freud
later established personal analysis as a necessary stage in the analysts’ training pro-
cess. Later papers will enrich the concept of countertransference, adding its aggres-
sive dimension.
In any case, CT (countertransference) remained the enemy, a “blot” on the clarity
of the psychoanalytical process. Mainly two authors lead us to a CT revision. One
of them is J. Lacan with his famous phrase: “There is no transference, only counter-
transference”, which opens the debate that, looking at the big picture, CT is a cre-
ation of the psychoanalytical process. S. Viderman (1982) is close to this
co-construction, with his classic The Construction of the Psychoanalytical Space, as
is R. Diatkine, when he says that transference is not an accurate new version of the
past, but rather a construction, a radically new way of thinking that the patient expe-
riences for the first time. In this sense, CT is not a reaction to transference; it comes
before it to a certain extent, or, if we wish, it exercises a certain seduction on the
patient, attracting transference like a magnet attracts metal.
18 Sexuality of Patients with Serious Psychiatric Disorders 373

The other one is M. Klein, who remains closer to the Freudian concept, in the
sense that CT is a result of transference. She does, however, introduce the concept
of projective identification, insisting that this is not just a defence mechanism, but
also an archaic way of relating which means that the individual “places or projects”
parts of his inner world in the inner world of the other. So Klein believes that CT is
a direct reaction of the analyst to the integration inside him of parts from his patient
that continues to have an independent life in his own inner reality. In other words,
CT, in cases of individuals mentally functioning in an archaic manner, becomes a
true case of taking over the therapist’s space. W. Bion pushed this premise by Klein
to its extreme, showing that at certain particularly intense times with psychotic
patients, the therapist (or the analyst) hosts feelings, emotions and even fantasies
inside him that the patient is unable to contain, rejecting all these annoying elements
and projecting them on the other.
These two views, however, according to which, on the one hand, CT structures
transference and on the other, whereby CT becomes a simulation of transference
through the projective identification process, are not necessarily opposed. Currently,
within the context of modern psychotherapy and psychiatric care of psychotic
patients, we can say that the transference-CT interplay is an interrelated, comple-
mentary process, where one refers to the other and the reverse. In conclusion, we
tend to view CT not as the “enemy”, but as a tool of knowledge that we are obligated
to process.
When working in a psychiatric institution, countertransference on the patient
becomes complicated due to “lateral” countertransferences. The most important one
is the CT on the team. The team can be an ally or an enemy for the therapist of the
psychotic. The person of reference, the therapist of the specific psychotic patient,
may have the tendency to become dispersed in the team, to refuse to be differenti-
ated from it, to feel that he is constantly under its control and to withdraw or waive
any personal responsibility, taking cover behind the team decisions, as though he
had no personal presence. Conversely, he can often voice intense opposition to the
team, ignore both it and the therapeutic framework and believe that he is the only
one able to help the patient, becoming trapped in what Michael Woodbury once
called “paranoid duo”, which J. Hochman called “autism for two”.
It is true that psychotic patients have a tendency to blend the space and people
around them, to turn it into magma, a chaos, where information is cancelled and all
individuals are smelted into an “undifferentiated space”. The therapists’ tendency to
succumb to the pressure exerted on them and to imagine themselves completely
“interchangeable” with their colleague, without their personality, also comes from
this premise. Psychotic patients split the objects they invest in pieces unrelated
between them; they deconstruct their world into disconnected parts, isolated from
each other. Often subjected to this process of splitting, the team can develop destruc-
tive tensions among its members (including the management-therapeutic position
with regard to a patient’s sexuality), as certain members of it may imagine that they
are committed to the “saviour syndrome” alone, standing against the thirst and the
fusing demand of those patients.
374 S. Stylianidis et al.

The CT of the therapist’s team is often involved with the entire team’s CT. This
is collectively trapped into the embodiment of the patient’s difficult situations and
is transformed into a theatre of confrontationalism, which the patient cannot process
either around him or with his family. For example, if his mother or father are par-
ticularly forbidding in the expression of the patient’s sexuality during his adoles-
cence, the team may develop extreme permitting positions for his sexuality within
the psychiatric institution, thus believing (or creating another illusion) that it is
repairing the basic lack of care the patient did not receive when he should have. This
process of splitting of the therapeutic team, within which one side embodies a good
repairing object and the other an evil persecuting object, was masterfully described
by P. C. Racamier.
Collateral CT can also occur in the family. For example, when conflict between
the team and the psychotic patient become intense and raw, when the reference
therapist becomes an object of rejection or destruction by his patient, one way for
him and his team to recover the missing balance is to shift its aggression to the fam-
ily and not the patient, especially if these emotions cannot be mentaly processed.
Therefore the family becomes the absolute bad object, and the therapist feels uncon-
sciously reinforced in his internalised “saviour syndrome”.
Collateral CT may also occur on the framework and the theory that supports
the framework’s function. We may consider that it represents, to a certain extent,
the balance of therapist-analyst transference on his analyst and his own analysis.
What the patients make us experience reactivates this transference on the frame-
work, to the extent that the projective identification dominates in our relationship
with them. Specifically, it makes us experience mainly two painful emotions:
that of emotional discharge, the emotional emptiness of any kind of meaning
from our therapeutic practice, and the feeling that our inner space has been
invaded.
Perhaps we may be permitted here a wider observation on how fragile the psy-
chiatric institutions staff can become in relation to the prevailing economic, moral,
cultural and political crisis: When a therapist is frustrated, deprived, abused and
unfulfilled by the health system for many months, when he experiences daily an
uncanny, incomprehensible and repulsive semantic, symbolic and moral void, how
is it possible for him to have the mental and intellectual resilience to process the raw
fragments and detritus of the derivatives of projective identification? Perhaps the
most mentally economical solution he has left is to withdraw into a depressive posi-
tion, to disinvest the “mental institution” that can no longer offer sufficient multiple
support to his psyche, as aptly noted by R. Kaës. Otherwise, he may easily slide into
the position of a persecuted person or that of the victim of vampirism from the
unsatisfied voraciousness of the psychotic functioning or to feel literally emptied,
immobilised by feelings of incapacity and helplessness, thus finally becoming
attuned to the unconscious wish of the psychotic functioning: the destruction of
social bonds and the inability to transform libidinal moves to sublimation. The psy-
chotic subject’s sexual drive then easily transforms into a simple autoerotic or allo-
erotic functioning of discharge.
18 Sexuality of Patients with Serious Psychiatric Disorders 375

Another CT defence may be the reaction of the team or the therapist with anti-
projective moves, in response to the projective attacks it is subjected to. For exam-
ple, let us reflect for a while on our reactions in times of crisis and tension; we might
say to the patient or think something like the following: “Who do you think I am?
What do you think you are, compared to me? A poor psychotic, a nobody compared
to me, a professor, who knows what is good for you and how to treat you. You owe
me your respect and thanks for everything that I am doing for you”. We can easily
understand that even if something like this is not said verbatim, it is important to
bear in mind the extent to which thoughts of this kind can deconstruct the edifice of
the therapeutic/rehabilitation work with the specific psychotic patient, if we are
overwhelmed with such an experience of perverse countertransference reaction.
These reactions of excessive presence and giving (réactions de prestance) that
J. Hochman describes may take the form of a therapeutic activism on all levels:
medicinal, special intensive care measures, security measures, special welfare inter-
vention, social activism of activities, uncoordinated barrage of various psychothera-
peutic interventions or even interpretative activism. This is the moment when what
P.C. Racamier called “omnipotence inanitaire” occurs, namely, the schizophrenic’s
boundless power that can make us feel as though we are nothing, throw us in com-
plete despair and make us a wreck. There are, however, moments when the under-
standing of CT, the better comprehension and explanation of these archaic mental
phenomena, through supervision and theory, helps us to make progress in the diffi-
cult work of caring for psychotic patients.
Our effort to keep our capability of thinking untouched, to support the theoretical
and institutional framework that surrounds us, our potential to understand after-
wards the meaning of what was “performed as a play” on the mental stage, all this
is our identity as professionals, therapists as well as social subjects that can with-
stand situations without succumbing to the temptation of therapeutic omniscience
or the hypomanic defence for new, utopian therapeutic targets. The value of the
framework and the containing function of the team are invaluable at those moments
or periods without, however, slipping towards turning psychoanalytical theory and
the therapeutic framework into a fetish. It is true we need a theory in order to treat,
to understand and to care for. The mental institution that functions satisfactorily
gives us the capability to emotionally and mentally invest theory, transforming the
institution to a space that according to Winnicott is intermediate, transitional and on
the borderline of the ego and the non-ego. This space is cathexed with libidinal and
narcissistic elements that can permit us to turn the CT’s acting-out, the experience
of emotional emptiness and lack of meaning, to a new narrative with new links and
opening capabilities.
When, however, for obvious defensive reasons, theory is fetishized, each theo-
retical construction loses its vitality and creativity and is repeated stereotypically as
the one and only truth, like an autoerotic intellectual game, then it means that the
psychotic processes and the expressions of archaic sexuality have also gained the
ground of our own psyche and the framework in which we work. It is important to
use the CT as a tool of knowledge ancillary to the care of psychotics in psychiatric
376 S. Stylianidis et al.

institutions. The psychotic patient’s disease is chronic in nature; he pushes us to

consider him the object of an unwholesome process that is outside of him (neuro-
chemical, genetic disorder, etc.). He consequently forces us to unconsciously deny
him the position of subject and all the conflictuality connected to this position. If we
become aware of this unconscious movement of aggression to subjectification, we
may better define the boundaries and negotiate his sexuality both within and outside
psychiatric institutions, understanding better at CT level our own representations
and projections with regard to our own sexuality as therapists.

18.4 Clinical Cases

The Clinical Field

In an attempt to answer the questions that have been asked as well as those that
arise in our daily practice as mental health professionals, we present the clinical
material below; it comes from a psychosocial rehabilitation unit, a boarding house
in the environs of Athens. The selection of the specific material is the result of the
attempt to showcase the complexity of the issue through the viewpoint of a holistic
approach.
The boarding house as a “living place” for patients with psychiatric disorders is
an institution that aims at psychosocial rehabilitation, within the context of psychi-
atric reform (Madianos 2009; Stylianidis 2009 and Chondros 2010). The boarding
house operates on the basis of the principles of community psychiatry, as an inter-
mediate structure between the asylum and life as an independent individual in the
community and is required to provide such a climate as to promote human relations
that both patients and professionals will commit to (Stylianidis and Chondros 2008).
The main factors ensuring the successful operation of the boarding house are the
staff’s team work, the complementarity of roles and the intersection of compe-
tences, going beyond traditional asylum-type mentalities.
The institutional framework in which the events took place, the specific psycho-
social rehabilitation unit, was mired in an extended crisis for at least 5 years. It
began its operations in 2006, within the context of the PSYCHARGOS 2nd phase
for psychiatric reform. This unit in particular was licenced and operated given the
continuity of discontinuity with regard to the commitments and the consistency of
the Hellenic State, both vis-a-vis the EU as well as the parties involved, patients and
mental health professionals. Therefore, the lack of scientific adequacy, know-how,
adherence to internal regulations and conceptual framework relevant to psychoso-
cial rehabilitation was almost self-evident.
The unit hired untrained and unmotivated staff and without internal regulations
and regulatory rules, soon found itself in full confusion with regard to the employ-
ees’ duties and roles. Members of the TT describe their experience like: “everyone
did what they wanted” and “we did not know what to do and what was right”. The
constant staff turnover was unprecedented (at least 100 individuals went through the
unit in the first 18 months) creating discontinuity and chaos. Staff conflict at vertical
18 Sexuality of Patients with Serious Psychiatric Disorders 377

and horizontal level was intense and the unit operated with competitive polarities
that kept being recycled; there was always an “enemy”. In practice we have the
deconstruction of the mental institution and the “creation” of a psychotogenic insti-
tution, an institution that produces “madness” at the time when it is called upon to
manage the patients’ psychotic manifestations as well as the chronic nature of
psychosis.
My first contact with the specific context was practically “chilling”, uncanny.
Everything was in confusion, nothing was clear. There was always a patient that
“created” a crisis every day and the staff team was absent; however the first reaction
to any communication or new stimulus was determined from a paranoid position. It
seemed that everyone was under an imperceptible threat and each one was “fight-
ing” for survival. Someone had to be blamed for everything that was happening;
there were no boundaries at any level, and wherever they existed, they were con-
stantly breached. On the part of the staff, there was no difference between the indi-
vidual level and the professional role (Agazarian 2004). Each one acted purely
“empirically” (with whatever consequences this might entail) and on the basis of
their own perceptions and prejudices. For example, there were members of the staff
who spoke to the patients from their personal phones at a time when they were out-
side the unit.
The undifferentiated TT meets the internal “chaos” and “confusion” of the psy-
chotic patients, with the result that these spread and “infect” (Miller and Gwynne
1972; Main 1989) the unit. The concept of “defensive care systems” (Foster and
Roberts 1998) refers to the community mental healthcare systems that, through the
concepts of splitting and projection, can become harmful/unhealthy both for
employees and patients. In these ways, the TT defends itself, on the one hand against
the anxiety arising from the target’s difficulty and anguish, and on the other, against
the strong and conflicting emotions that arise in our work with the patients. The
result is that the TT members do not relate with patients as “whole individuals”.
This process may reduce the TT’s anxiety; however, it also diminishes the significa-
tion of its therapeutic work.
I immediately saw that I had to read all these symptoms through the history of
the unit and the TT dynamics.

The Story of One Couple

This is the story of Maria, a 44-year-old woman, and Costas, a 52-year-old man,
whom I began to get to know when I first took over the unit’s scientific responsibil-
ity. From as early as our first meeting in January of 2012, they came to the office
together, both stating that they were a couple, that they are engaged. They even
asked me if I wished to see the “rings” and expressly stated that they “would con-
tinue being a couple”. At the end of this sentence statement, which was more press-
ing from the part of M., they seemed to attach an imperceptible question mark, an
anxiety: would I make this legitimate? I assumed it might be coming also from their
need for a clear message, about what would apply going forward.
378 S. Stylianidis et al.

The first reaction was “anger” with what I had to “fight”. The issues that had to
be resolved, to bring some order in the chaos, were too many for this to also exist,
which was even more complicated. The question that kept going around in my
mind was “how can this be happening in a housing structure, under what rules?”
The way their identity was stated to me was also particular; it was as though they
did not exist as independent subjects… On a first level, my internal dialogue
focused on the institutional framework and all the difficulties that a sexual relation-
ship might create within a community structure. Of course, a love relationship
might comprise a therapeutic factor and help promote subjectification in the con-
text of the recovery process; however, what about the history of their difficulties? It
was obvious that this was a relationship that was born and was “permitted” by
precisely this psychotogenic and undifferentiated function of previous years. How
could future changes contain this relationship so that it might acquire a functioning
existence and help it have functional elements? Things appeared even more diffi-
cult as I was experiencing a contradiction through a big countertransference func-
tion: I had been called to support the relationship product of a context that I was
required to change.
Initially I agreed to leave the discussion “open”, implying that it would be some-
thing we would discuss further down the road. In essence it was a first manoeuvre;
this relationship seemed to be a fabrication of the “prevailing illness” and I needed
time. The position of the team at the time was total acceptance of this relationship,
which worried me even more. While I was trying to take in all the questions that
needed to be answered, I immediately began obtaining information from various
sides, in an attempt to construct my own narrative.
M. is a plump woman of medium height and with pronounced female character-
istics and a strong personality. Her attitude is intensely provocative and without
boundaries on all levels. She was born in Athens, is a twin and is described in her
history as a special and charismatic child. She completed her schooling up to the
first grade of secondary school and worked in the family business until she reached
the age of 17. She then presented the first problems that were manifested with an
“acute psychotic episode” – mention is made of obsessions – and she started to ask
for help on her own. At the age of 25, she had a love affair; when it did not go well,
M. requested admission to emergency hospitals. After 9 years, at the age of 34, she
attempted suicide trying to fall under a train, due to a disappointment in love. After
that came 4 years of continuous hospital admissions in psychiatric facilities. She has
been a resident at the boarding house since 2006. Her current diagnosis is schizoaf-
fective disorder with elements of hysteric personality disorder. We also know that
she had relationships and sexual affairs in preadolescence and that during her hos-
pitalisations, she had two pregnancy terminations. Upon her arrival at the unit, M.
had great difficulty with boundaries and manifested uncontrollable sexual behav-
iour. She masturbated, also using objects to do so, and many times tried to do it in
public. At the same time, she made constant attempts to have sexual relationships
with male patients. The staff tried to enforce boundaries and the instructions to the
team at the time were that “sexual relationships are not permitted”.
Costas was born in Chios and is a graduate of the second grade of elementary
school. Following that he worked in various professions to earn a living. He
18 Sexuality of Patients with Serious Psychiatric Disorders 379

completed his military service normally and presented the disease at the age of 29 in
Boston, where he was living with his family; he was admitted to hospital with a
diagnosis of “acute psychotic episode”. Immediately afterwards he returned to
Greece with his mother. At the age of 46, and after beating his mother up in an
attempt to “exorcise” her, he was hospitalised and then moved to the unit (2006). At
the time, he was described as a “very reserved and private person”. No information
appears in his history regarding any previous sexual behaviour. What we know is
the fusing and undifferentiated relationship with his mother, with manifestations
throughout the entire time they lived together. Since the episode, his mother has
been living in the USA; she does not communicate with him; his sisters say “she is
afraid of him”. He is experiencing it as abandonment. At the same time, he blames
himself for the violent incident. His current diagnosis is residual schizophrenia.
M. and C. came to the unit within just a few months of each other. When they
met, M. approached him and they started spending time together. A member of the
staff said that “he began to open up more, we thought that it might be good for him,
there was disagreement in the team, some said that it was good for him, others not;
the psychologist continued to say that these relationships should not be permitted”.
Then, C’s roommate told the staff that he saw them having sex in the room. The
intervention from the unit’s administration at the time was “they are people and they
have rights, let’s allow them to do what they want…” “then we tried to set the
boundary that they should use the room and not have sex in the common areas”.
During the same period, M. also had relations with other patients; C. found out or
saw it; he put up with it. They said they wanted to marry; it is not certain that it was
their own decision/wish or if they heard it from the staff or if, even further, they
listened to the need of the framework for meaning. The staff were divided; some
were happy and the administration, encouraging them, chose to hold an engagement
[gathering]. The prospect of a wedding had given everyone joy (“let’s give them a
wedding”). The engagement took place; the staff arranged for rings to be
purchased.
However, M. also continued to try to have sexual relationships with other patients
at times, mainly those who suffered from schizophrenia. She usually picked persons
who were not well, who were in relapse or in extreme difficulties. She complained
that C. did not satisfy her sexually. Subsequently, C. had a very serious relapse, dur-
ing which he tried to strangle her in order to “exorcise” her. In the time leading up
to the incident, he kept telling her she was “a sinner”, she “needed God to forgive
her” and various other delusional “comments” of religious content. He was admit-
ted to hospital and as soon as he returned, a member of the team says, “the famous
shifts began”. There had been a patient suicide and the staff and mainly the admin-
istration were afraid of “some other bad things occurring”. It is worth mentioning
here that at this point almost the entire staff resigned. Following that and in the
context of this monitoring, the instructions on the floor were that whenever they
have sex, they should leave “the door a little open”, and a member of the staff must
supervise discreetly. It is also important to mention that during this hospitalisation,
a new cycle of relapses began for C. in the time period that followed.
The puzzle was beginning to make sense. It was obvious that the team was
unable to “contain” M., who continued to provoke with hysterical symptoms. The
380 S. Stylianidis et al.

patient’s constant acting-out was in continuous oscillation with the acting-out of the
TT. Most of the team members were permanently angry with her, but were unable
to get her to respect boundaries. Her sexuality was chaotic, with casual [sexual]
relations and a lack of respect for any boundary and prohibition. At the same time,
C. seemed to be reproducing the uncomfortable fusing relationship with his
mother – where M. “is in control” – and which in the past was a factor of release of
his relapses.
In a flat and “arid” landscape, where there was no vital differentiation between
“in” and “out” on all levels, the function of this couple brought to the surface all of
the context’s contradictions. It was established through a desperate attempt of the
team to hold on to some kind of live objective, in a unit that was functioning psy-
chotogenically and where nothing was actually committed to. The TT was trying to
draw pleasure, to recommit and create meaning through “interventions” that were
aimless timewise, awkward, undifferentiated and partly “violent”. It gave contradic-
tory messages (permitted-not permitted, happy-angry, love-hate). Besides, its entire
functioning was generating inconsistency, a stalemate in its communication with the
patients that swung from “everything allowed” to “nothing permitted”. The actions
that the team resorted to were either therapeutic “activism” (Stylianidis 2002a, b) or
intensely prohibitive, autocratic and often suppressive, as is common in asylum-
type psychiatric institutions. Functioning defensively and completely denying real-
ity, the TT acted towards them as though they were an independent couple, living
within the structure, separately and self-sufficiently. Even the so-called manage-
ment of C’s relapse by the TT is a voyeuristic act, one more entry in the perversion
of the said psychiatric institution’s functioning.
Fantasies of the team members were projected on the forefront in this manner,
mainly serving a process of release. The institution’s as if (Deutsch 1942) function-
ing varied between a tendency for fusing with the psychotic and perverted psycho-
pathology of the couple and the mass denial of this relationship.

Yanni’s Story

Yanni is a 46-year-old man with schizophrenia range problems. He was born in

Volos and has three more older siblings. His history shows that his father was an
alcoholic, with an addiction to gambling, and that he was often violent in his behav-
iour towards his family. His mother, whom Y. loved dearly, died of cancer a few
years ago. He presents himself as a very reserved and lonely child. He is an upper
secondary school graduate and is single. His problems began after his military ser-
vice, with an “acute psychotic episode”. Repeated hospitalisations followed, mainly
due to his discontinuing his medication and his alcohol use; some of the hospitalisa-
tions were by order of the public prosecutor. There are no sexual relationships men-
tioned in his history.
He has been in the unit since 2006. At the time he was a neglected overweight
man, who seemed older than his age, although he was highly functional on day-to-
day level. His current diagnosis is residual schizophrenia. From the time he arrived
18 Sexuality of Patients with Serious Psychiatric Disorders 381

at the unit, he displayed an intense and frequent sexual self-gratification behaviour,

previously, even with his roommate present. This became a serious problem, since
the two roommates had a major disagreement and no longer wished to share a room.
His roommate stated that he was unable to tolerate this behaviour. It was compulsive
behaviour of discharge that was not accompanied by any sexual pleasure. He was a
particularly regressed patient.
Some of the TT’s narratives were “in the beginning, he would do it three to four
times a day; at the time, the instruction given was not to disturb his roommate”,
“these discussions were taboo, they were not to be conducted with the patients”,
“we did not talk to them about sex because we also had the precedent, the couple”
and “he didn’t want to go with a woman; he always had at the back of his mind that
he would recover and be able to find a partner and build a life”.
Due to its distress at being unable to remodel Y’s repeated masturbating behav-
iour towards the direction of its therapeutic ideal, the TT chose the “solution” of
mass withdrawal. They left him alone in his room for a long time, to find his own
discharge.
Furthermore, the team’s perception or fantasy about this patient had a fundamen-
tal contradiction: on the one hand it believed Y. to be the most “functional” resident
in the structure but, on the other hand, “able” to have a love affair only with a patient
“from inside”, namely, a woman resident of the facility. Each time a female patient
was scheduled to arrive, the event received great importance. Y. was very anxious as
to what she would be like, if he would like her or if he would be able to have a rela-
tionship with her. It appears that each time he, as well as the team, was disappointed.
It is clearly a psychotic oscillation: The team’s unconscious expectation of mating
was transferred to the patient, who anxiously awaited the next arrival of female resi-
dents at the boarding house. The TT unconsciously enforced its own ideal on Y.,
through this collective fantasy.
Afterwards – and as the “prospective partner” was not found within the unit – it
was suggested by the TT that he have sex with a prostitute, which happened twice.
However, Y. did not ask for it again, saying “I used to go before, now I don’t need
it, women are trouble”. Obviously, using the word “trouble” refers to “trouble” on
all levels, as he experienced it: trouble with his psychotic experiences, trouble with
the TT’s chaotic functioning and trouble with the ambivalence before the female
object of his desire.

18.5 Challenges

Talking about psychotics is easier than talking to psychotics. In other words, the last
but not the least issue is how we can help on a practical level the teams both in the
process of establishing and managing this complex network of transactions, as well
as that of managing countertransference when working in psychiatric institutions
and in particular insofar as pertains to the sexuality of psychotic patients.
The first principle is to understand that we have to work with the therapists we
have, with the level of training and skills they have, in respect of each one’s
382 S. Stylianidis et al.

professional experience. There is no point “prescribing” guidelines for the

management of the psychotic patients’ sexuality or the professionals’ burnout
through cognitive behavioural techniques, when facing such complexity. There is
also no point adopting a pseudo-analytical position and stance, whereby the thera-
pist avoids, almost in fear, any physical or emotive and affective interaction with
psychotic patients. The caricature of supposed “interpretations” or supposed “con-
nections” hiding behind a “malignant” psychoanalytical silence of a supposed lis-
tening must be avoided at all cost.
What we must ask of the therapeutic team, besides the careful observation and
listening of what the other is saying or not, is the adoption of a spontaneous and
genuine position towards the patients. This position must use the therapist’s truly
familiar mediations towards the patient (e.g. athletic activities, narration group,
music, painting, etc.), avoiding two obstacles: boring repetition and boredom and
excessive stimulation of the psychotic subject’s psyche. Being able to wait without
denying the sexual dimension of the life of psychotic patients, but also suggesting
another space or context of activities, creates a friendly, warm atmosphere that is not
intrusive to the other’s psyche and is of primary significance in the adequately good
functioning of a unit. A good service is one that can change and adapt its principles
and theoretical framework to the patients’ changing needs and consequently to be
surprised by and process the various aspects of their sexuality in relation to the
external reality (socio-economic conditions, resources, networks, stigma, resis-
tance, etc.).
At the same time, the team must be capable of distancing itself from what it is
doing; processing psychically, mentally and emotionally what it experiences; using
transference, symbolisation, communication and playing; and taking pleasure from
this distance that on the one hand organises and on the other permits it to turn its
experience into theory. Invoking “belonging” in community psychiatry, psycho-
analysis and psychiatric reform is not capable of protecting us from the eroding
psychotic function.
The ruptures, the cracks, the silences, the boredom, the occasional breaches of
the framework and the rules occasioned by the management of the sexuality of
patients, the small errors and the unforeseen incidents in the life of an institution are
just as important objects of observation as the observations of an external supervi-
sor. The questioning vis-a-vis the immobility of psychosis and the mechanisms of
neo-institutionalisation, even in community housing structures aiming at psychoso-
cial rehabilitation and recovery, cannot be implemented through the fatal idealisa-
tion of the “ideal” theory (psychoanalytical, systemic, cognitive, etc.) nor through
an equally fatal social activism, as defence against psychosis. As mental health
professionals, we often come face to face with this paradox: although we accept the
principles of community psychiatry and the model of the recovery process respect-
ing the individuality of the patient and his personal history, at the same time we
panic before the emerging complexity, finding safe “refuge” behind a single
theory.
On the opposite side of this imaginary safe “refuge” that can be misleading, and
respecting the emerging complexity, we place the concept of supervision. We
18 Sexuality of Patients with Serious Psychiatric Disorders 383

mention it as a “continuous relationship” between the framework and its dynamics

with the supervisor, who helps the TT members develop therapeutic skills, under-
stand the dynamics produced at all levels (patient – therapist – TT – hyper-context),
resolve conflict and process what is experienced, utilising their own resources. The
process of the supervision to include more than one scientific field and scientific
theories is a call and a challenge, as just one point of view cannot have perceptions
on everything that is happening. Experience shows that the coupling of psychoana-
lytical and systemic supervision within a context of connection and integration
helps us understand the intrapsychic, the interaction and the family history, provid-
ing us with a safer framework of understanding and utilising information.
Committing to multiple audiences strengthens the “mental institution” and opens
the way to meaning and to transformation of the psychotic functioning.

Conclusions
This chapter attempted a systematic theoretical and clinical study of the sexuality
of psychotic patients in psychiatric institutions, in particular in those the stated
objective and vision of which is to create an alternative therapeutic culture and
practice. It examined the determining role and the various aspects of sexuality
in the field of psychotic disorders, with particular emphasis on highlighting the
role of the therapeutic team and countertransference work in psychiatric institu-
tions, with respect to better understanding and managing the expression of sexu-
ality of patients. This debate is highlighted through the clinical material content
from a psychosocial rehabilitation unit. Commitment to thinking and hoping is
a strong protection of therapeutic teams against the anxiety related to the break-
down of institutions as well as their psychosis generating and neo-institutional
functioning.
Still, the systematic theoretical and clinical processing of sexuality in psychi-
atric institutions, in particular in those the stated objective and vision of which is
to create an alternative therapeutic culture and practice, should become the objec-
tive of future research, particularly in view of the current conditions of the fragil-
ity of links and the cohesion of therapeutic teams in the midst of the socio-economic
crisis. Besides, commitment to thinking and hoping is a strong protection of TTs
against the anxiety related to the breakdown of institutions as well as their psycho-
sis generating and neo-institutional functioning. The quest for solutions in the
direction of the transformation of psychotic functioning must take the form of
“open” dialogues, including that of scientific theories in dialectic relationship.

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 Part III
Evaluation
Evaluation of Social Psychiatry Services
19
Stelios Stylianidis, Petros Skapinakis, Venetsanos Mavreas,
and Michael Lavdas

Abstract
The provision of mental health services is a field that is linked more and more
with issues concerning the quality of care, its evaluation as well as its quality
assurance. Linking evaluation and quality of care to mental health is directly
related to the shift towards a community-oriented service system. In this chapter,
we will analyse concepts related to the public mental health system in Greece,
quoting contemporary literature and linking it with the main concerns of
psychiatric reform and the function of a community-oriented mental health
system. Following this, we will present the clinical approach with the
administrative-management approach relative to the evaluation and record
the basic requirements for the proper collection and use of clinical information
in the health systems. Finally, we will refer to the obstacles in the implementa-
tion of evaluation in the Greek mental health system with one implementation
example and will underline the significance of evaluation for the protection of
the users of mental health services as the direct beneficiaries of the provided
services, as well as the parties involved in mental healthcare.

S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
P. Skapinakis • V. Mavreas
Department of Psychiatry, School of Medicine, University of Ioannina, Ioannina, Greece
e-mail: [email protected]; [email protected]
M. Lavdas
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 389

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_19
390 S. Stylianidis et al.

19.1 Introduction

The practice of evaluation involves the systematic collection of information about the
activities, characteristics and outcomes of programmes, services, principles or pro-
cesses to improve effectiveness and make decisions with regard to the programmes/
processes for future growth (Patton 1997). Evaluation in the field of health includes
two areas of implementation: the evaluation of clinical-therapeutic programmes and
the evaluation of services or the extended health system. The evaluation of health
services and systems is defined by Tountas and Economou (2007) as the assessment
of operation of a health system or the individual health services on the basis of certain
criteria, according to the standards formulated either theoretically or empirically.
Generally speaking we believe that the term “evaluation” is the common denom-
inator for a wide range of approaches that “… include the assessment of user needs
and the planning of services, national health policy directions, specialised response
and programme assessment studies, methodological proposals and practices,
research on the users’ views and satisfaction and specialists’ attitudes, ways of clini-
cal activity documentation, expenses and, finally, the rehabilitation activity assess-
ment” (Rossi 1994).
At this point, it is important to see that care in the area of mental health is a con-
cept with fairly different content than that regarding physical health: The problems
that mental disorders and psychoses in particular cause are more complex than those
caused by physical diseases, while this difference becomes bigger and reality
becomes more complex if we go from the aspect of the disease to that of the patient,
the issues of mental anguish, the grid of social relationships and the quality of life
(Gionakis and Stylianidis 1995). We therefore understand that mental health evalu-
ation clearly has particular characteristics, adapted to the field’s particular needs.
Continuous evaluation is an important means for the implementation of commu-
nity mental health service goals and the decision-making process for intervention,
organisation and improvement (Tansella and Thornicroft 2001; Thornicroft and
Tansella 1999). The main areas where the evaluation activities are focused are the
following:

Incident outcome at psychopathology, functionality and quality of life level

Effect of mental disorders on the family
User and family’s expectations and satisfaction of the provided services
Quality of provided services on the basis of the WHO criteria
Effectiveness of community actions and actions to promote mental health
Needs and effectiveness of educational interventions in professionals’ teams in the
community
Staff development
Needs and effectiveness of in-house training seminars for the therapeutic team
members
Administrative procedures and outcomes (effectiveness on the financial level is
assessed in this context – the provision of best quality services at the lowest
possible cost/cost-effectiveness)
19 Evaluation of Social Psychiatry Services 391

Orley (1989) identified structure with quality of service: “Service quality refers
to a more general view of all aspects and resources of the service and includes levels
such as the natural environment, the service’s procedures, the administrative-
management systems, the care practices and personal growth”.
Health economist Donabedian (1978, 1988), who has been particularly focused
on the definition of quality in the provision of health services, perceives quality “as
the component of a given healthcare provision unit, but also as a value judgement
on the provision of such care that can be distinguished into two kinds, technical and
interpersonal”. With regard to the term technical quality, Donabedian refers to the
application of specific medical interventions that aim at maximising health benefits.
The interpersonal component refers to the roles and functions of individuals partici-
pating in the care process. According to the same author, a useful distinction in the
components of the health service provision sector is the following:

(a) The system’s structural elements, which refer to those elements of the health
system that generally remain fixed and do not change dynamically
(b) The system processes that refer to actions and effects with a dynamic-changing
character
(c) The outcome, namely, the final result of the actions taken previously

Saraceno and Bolongaro (1988) believe that concepts structure-process-outcome

have a completely different meaning and significance in psychiatry than in other
areas of health and that the attempt for an accurate distinction between them is often
artificial, giving few results. McGlynn and his associates (1988) agree with this,
pointing out that the structural characteristics of the spaces there psychiatric care is
provided are instrumental in determining both the procedure and the outcome. They
continue, saying that in psychiatry, one cannot take into consideration just the
administrative aspect; insofar as the procedure and the outcome, they believe that
due to the absence of any studies on the experimental effectiveness of various forms
of interventions, an agreement could be adopted around practices and outcomes that
are not acceptable (e.g. adverse effects from psychotropic drugs, long-term uncon-
trolled benzodiazepine prescribing, patient abandonment in the community, long-
term hospitalisation with no plans for discharge and post-hospital care, etc.).
From the foregoing, it follows that the provision of high-quality services requires,
on the one hand, creating outcome standards and indices and, on the other, assessing
and monitoring their adherence on the part of the agencies, improving conditions
and avoiding unwanted incidents that could occur. Instituting such criteria is usually
implemented at national or regional level, while monitoring agency operation and
compliance at local level. The role of international and national associations of
mental health professionals in the process of establishing criteria is structured on
two interlinked levels: (a) the definition of certification criteria that reflect in a spe-
cific manner the formulation of the criteria, the indices and criteria for which there
is consent and that can also be used in evaluation activities, aiming at recognising
the proper operational quality of hospitals or services and (b) processing guidelines
relevant to the treatments that meet the need, especially significant in the psychiatric
392 S. Stylianidis et al.

field, of arriving at agreement regarding the indications relevant to the approach for
the various needs and pathologies, before even getting to the formulation of good
quality criteria for each therapeutic approach. There are currently several quality
assurance efforts and applications in mental health (WHO, national standards) used
in several countries.
If we wish to evaluate the quality of an intervention implemented by an agency,
we need to see which dimension of quality we are interested in. Saraceno and
Bolongaro (1988) believe that we must distinguish three quality dimensions:

• Social quality, which we can measure in terms of accessibility to the provision of

the services, not just from the viewpoint of work organising but also from that of
the cost of the accessibility for the user: emotional, cultural and financial cost.
We can also measure it in terms of acceptability of the provision, namely, the
degree of user satisfaction.
• Financial quality, which can be defined in terms of efficiency, measurable as a
correlation between the total expenditure and the kind of service provided.
• Medical quality, which we can measure in terms of the provided services’ cor-
rectness and appropriateness (Saraceno and Bolongaro 1988).

The objective of the quality of care evaluation studies is the description of the
way in which the available knowledge and resources that can be used in a specific
care facility are, in fact, being used to address health problems at individual or entire
community level.
Within the issues of Health Services Research, the core issue is the difference
between the experimentally proven efficacy and the effectiveness in everyday prac-
tice. Researchers that belong to this group maintain that significance must be given
to the efficacy epidemiology and that the relationship between efficacy and effec-
tiveness is not one of hierarchy, because it often happens that we are not sure about
the effectiveness of an intervention in practice even if its effectiveness has been
verified under ideal experimental conditions (Brook and Lohr 1985).
The efficiency of a service can be measured many times in terms of figure absorp-
tion (and the absorption always has time constraints, irrespective of the service’s
goals, insofar as the extent of the therapeutic team maturity with the correspondence
of the financial resources offered and the actual needs of the people responsible or
the staff). At best, the investigation of effectiveness is exhausted in the description
of programmes and the number of patients who have participated in them.
In the handbook Better Mental Health Care, Thornicroft and Tansella (2010) say
that the improvement of mental health services must rely on an ethical basis, the
practice based on documentation and the collection of experiences obtained through
the years. In the same sense, the same researchers believe that for the mental health
service development and improvement to be continuous, a charter must be estab-
lished that will contribute to the formulation of the services’ targets and provide
guidance for the steps towards this implementation. Relying on the dimensions of
19 Evaluation of Social Psychiatry Services 393

place and time, they suggest using the matrix model; its goal is to contribute to the
overall evaluation of the strong and weak points of the local services and to the
creation of an action plan for the improvement of the services. Also, this model can
indicate the interdependencies between levels and phases that do not directly
communicate with each other, such as between the outcome at service level and the
funding at country or region level.

The matrix model

The dimension of time
The dimension of place (Α) Data entry phase (Β) Procedure phase (C) Outcome phase
(1) Country/region level 1A 1B 1C
(2) Local level 2A 2B 2C
(3) Individual level 3A 3B 3C

19.2 Evaluation of Mental Health Services in the Community:

Psychiatric Reform Questions

Quality assurance of the provided services in conjunction with the establishment of

assessment indices and treatment protocols comprises a continuous evaluation
mechanism, which aims at achieving optimal system performance and sensitivity in
changing needs.
Criteria are usually set out with the help of the literature, through consensus
conferences, which are conducted in the spaces comprising the evaluation objective
and, finally, with the help of recognised experts. In the second case, the criteria are
implied as the responsibility of setting out the criteria is left to the expert(s), while
in the first case, the criteria are evident because they are set out in writing and are
acceptable to all participants in the procedure (Gionakis and Stylianidis 1995).
The main questions of psychiatric reform and operation of a mental health sys-
tem are the following:

1. Who are the services for? The question pertains to the population of individu-
als with a need for psychiatric care. This information comes from epidemio-
logical research among the general population recording both the obvious
(individuals with psychiatric disorders using psychiatric services) and hidden
morbidity (individuals with psychiatric problems who do not use psychiatric
services). In Greece, the only countrywide general population research of this
kind was conducted in 2009, and its first results have already been published
(Skapinakis et al. 2013).
2. Who provides the services? This pertains to the bodies and institutions providing
psychiatric services. They have to be standardised and codified, as do “user
definitions” with the philosophy, structure, goals and the type of services
394 S. Stylianidis et al.

provided by the various mental health units (MHUs) and the therapeutic and
administrative procedures followed by them (internal regulations), namely, the
following units:
• Psychiatric hospitals
• General hospital psychiatric departments
• Community mental health centres
• Hospital outpatient clinics (psychiatric hospitals, general hospital psychiatric
departments)
• Chronic mental patient rehabilitation units
• Chronic mental patient hostels and boarding houses
• Special programmes and services (special clinics, mobile units, special
treatment programmes, etc.)
3. How are the services provided? This pertains to the available effective interven-
tions by the MHUs. The main questions seeking answers are:
(a) What are the necessary interventions for mental health problems? In this
case, the answer requires the presence or establishment of clinical guidelines
on the basis of indications of their effectiveness, using the documented
medicine criteria.
(b) Which interventions are available from psychiatric services? The necessary
data pertain to information on staff training and skills, as well as the use of
interventions provided by the MHUs.
(c) How satisfactorily are patient needs covered by the services? The answer to
this question requires the definition of the concept of “need”, with regard to
health problems. According to Stevens and Gabbay (1991), “need is the
capability of a population to benefit from their health care”. Depending on
the degree of cover of needs by the service, we have:
• Needs that are not covered: These are needs for which there are effective
interventions, but that the MHU is unable to cover for various reasons
(lack of training, specialised staff, lack of time, etc.).
• Needs that are covered: These are the needs that the service covers satis-
factorily, either in full or in part. In the case of a need covered in part, the
ensuing questions pertain to the capability of full cover and the reasons
and shortcomings on which the part cover is due.
• Needs that are covered in excess: These are needs that do not exist, but may
have existed in the past and which the MHU continues to provide cover for,
whereas it should have either discontinued or stopped the provision (e.g.
maintaining the administration of a high neuroleptic medication dosage for
patients over long time periods without due reason, providing housing to
individuals who can be accepted back into the family home, etc.).
4. How effectively are the services provided? This pertains to the evaluation of ser-
vices and interventions. The question above refers to the regular maintenance of
information about the patient and the therapeutic interventions. Such informa-
tion includes:
• Personal details (personal and family history, history of the disease, psycho-
pathology and functionality)
19 Evaluation of Social Psychiatry Services 395

• Socio-demographic details
• Basic details on the patient’s treatment or intervention and follow-up
5. What is the quality of the provided services? The question pertains to the ser-
vices’ quality assurance. As there are no criteria pertaining to conditions in
Greece, a study needs to be made of the international criteria, which can be
adapted to the reality in Greece with the appropriate methodology.
6. How satisfactorily are the services provided? This pertains to the satisfaction of
users and their families as well as adherence to the stipulated therapeutic, admin-
istrative and legal processes. Research on matters of satisfaction of the users and
their families with regard to the services is a parameter that is often overlooked
in the evaluation of services; it is, however, significant for the reason that it illus-
trates how acceptable the service is by the directly involved parties, while it is
very important at this point in time, when their participation in the planning and
decision-making is viewed as essential and necessary. With regard to compliance
with legal procedures, the evaluation pertains to the security and confidentiality
of files and records, in protecting the rights of the mentally ill and adhering to the
procedures related to involuntary hospitalisation.
7. What is the position of the population about the services? Investigation of the
greater community’s positions is deemed necessary as the success of the mental
health system depends on them, as well as its acceptability by the general public,
and it gives important information with regard to the planning of community
treatment interventions.
8. How economically are the services being provided? This pertains to the so-called
financial evaluation that is related to the efficiency of the service (or the health
system). Efficiency is the quotient of the theoretically minimum expenses
required to achieve the objectives by those that were actually spent and includes:
(a) Net cost analysis: Cost is calculated in the monetary units that a disease or
group of diseases (e.g. mental diseases) has for society. Direct costs (public or
individual), loss of resources (for the society, the individual and the family)
and the transfer of resources from other sectors are also taken into account.
(b) Cost/benefit analysis: It is the systematic comparison in monetary units of
all costs and the benefit of suggested alternative schemas, with a final inves-
tigation – first, of the degree to which this combination of schemas will
achieve their set targets with a set financial investment and, second, the
extent of the benefit that arises from the schemas (programmes, services,
treatments) requiring a minimum investment.
(c) Cost/effectiveness analysis: It is the same as the one above, except it mea-
sures the benefit in achieved results (e.g. days of work in rehabilitation pro-
gramme, days of stay in the community without hospitalisation, etc.).

Questions on the Mental Health System Evaluation

The questions that arise from evaluating the mental health system are not indepen-
dent from epidemiology and the conditions it studies, as we have discussed above.
396 S. Stylianidis et al.

Questions related to the evaluation of the system both on local and on national level
are the following:

1. How frequent is the problem? The question pertains to the information

resulting from the descriptive epidemiological research. In particular, the
sub-questions are:
• Description of “at-risk” population
• Prevalence and consequences of mental disorders
• Assessment of risk factors related to mental disorders, namely:
– Relative risk
– Attributable risk
• Determination of cases and syndromes in the community (study of the repre-
sentativeness of observed cases)
2. How serious is the problem? This pertains to the consequences and the aftermath
of the problem on the individual and the micro-social and macro-social environ-
ment. More specifically, the questions pertain to:
• The “objective” classification and assessment of the problem’s seriousness
• The “subjective” assessment of malaise and quality of life caused by the
health problem
• The effect of the problem on the immediate family and other relatives of the
patient
• The socioeconomic aspects of the problem
3. Are the interventions acceptable (to the patients, the population, the other state
agencies)? The answers to these questions may be given by collecting informa-
tion on a local level (qualitative and quantitative) or by accumulating data col-
lected by local services.
4. Does the problem seem to be increasing, stabilising or reducing? Monitoring
epidemiological trends, with repetitions of the epidemiological research at regu-
lar periods (at least every 10 years or even better every five), can yield data with
regard to how the system corresponds to changing needs.

Evaluation of the health services is based on collection and use of valid and
reliable information. Evaluation is an administrative process, the goal of which
is to check the system’s operation as to the set purposes and the intended results
from it. As far as the clinician is concerned, the (clinical) information is impor-
tant for the following reasons: (a) the reminder of the diagnosis and differential
diagnosis criteria (use of uniform classification system such as ICD-10 and
DSM-IV, use of standardised psychiatric interviews and psychiatric question-
naires), (b) the reminder of the appropriate treatments (clinical and therapeutic
instructions) and (c) assessment of the outcome (symptomatology and disability
before and after the intervention, indications of effectiveness of the treatment
and the service, scales and questionnaires). For completely different reasons, and
in the case of the administration of health services, the evaluation is based on the
19 Evaluation of Social Psychiatry Services 397

collection of information in the field, namely, during the provision of services to

the patient. However, the evaluation process follows the opposite course to that
of clinical work insofar as the collection and use of information, even though this
information comes from it. According to Wing (1994), this course is as follows:

Clinical approach (bottom-top) Administrative approach (top-bottom)

1. Clinical work with patients 1. Data collection from the clinical units
2. Clinical audit: problem assessment, 2. Epidemiology of use of the services (mental
treatment, audit, outcome assessment, health units) by the population
re-evaluation
3. Clinical audit of files 3. Assessment of the population’s needs
4. Mental health clinical data and information 4. Planning, staff hiring, new services creation,
system resource management
5. History and file confidentiality and security 5. Measuring the progress of health services
and outcome
6. Data collection for the administration of 6. Public health policy
health services 7. Collection of data on the health of the entire
population

The basic requirements for the proper collection and use of clinical information
in the health systems are the following:

To be based on the unit-individual: The collection of detailed information on every

patient in touch with the MHUs is necessary to gather the data illustrating the
socio-demographic profile of the services’ users, the diagnosis and psychopa-
thology, their personal and family history, their functionality, the interventions
conducted and their result, as well as patient follow-up by the mental health
service system.
To be entered only once: This means that there should be a unique, uniform record
of the patient in the mental health system that will be updated by the different
MHUs that the individual visits during his care by the mental health sector of the
mental health system. Past difficulties that existed in the maintenance of such
records as well as their use by the various MHUs, which created multiple prob-
lems of communication and data collection, may be easily overcome today with
the development of software applications (patient electronic file).
To come from the MHU clinical staff: Gathering the regularly collected clinical data
is among the duties of the units’ clinical staff. Information about special ques-
tions may come from special research in the context of the system, where both
clinical and non-clinical (trained) staff may be used.
To ensure the collected data security and confidentiality: The laws pertaining to
personal data collection and use must be respected. Therefore, the data collected
by the staff of the units must be usable in clinical practice, with the breach of
their secrecy fully prohibited, while the cumulative data must not show patient
398 S. Stylianidis et al.

names, or show information in a way that may permit their identification.

Furthermore, full security and protection of the record systems (electronic or
not) must be ensured from potential outside interventions.
To use common standards permitting communication within the framework of the
health system: Their reliability and validity requires their classification and codi-
fication and the generation of “user definitions” that are acceptable and can be
used by all the staff.
To provide information to the following potential users:
• Mental health service users
• Mental health professionals
• Administrative services

Of course, the type and nature of the information may vary depending on the user
and the purposes of use of the information.
They have to be usable for both clinical and administrative and research
purposes.
In summary, the main research questions on evaluation investigations regarding
mental health are as follows, as determined by Wing (1972):

How many individuals are in touch with existing services? How did they obtain
contact? What kind of use of services do they conduct? What sort of changes in
time is observed?
What are the needs of these individuals and their relatives?
Do current services meet needs effectively and economically?
How many of those who are not in touch with the services have needs? Are those
different to the needs of individuals who are in touch with the services?
What new services or current service modifications are required to cover needs that
are not currently covered?
Can imported innovations really help in need reduction?

The commonly used variables in the evaluation investigation are the following:

Volume of use (individuals, admissions, episodes, visits)

Patient (or consumer/client/user of the services) clinical and socio-demographic
data
Treatment or control methods used
Treatment/hospitalisation/follow-up duration
Outcome measurements (e.g. frequency of relapses/hospitalisations during
follow-up)
“New” morbidity during the service’s operation
Mortality
Effects of the service on families, the staff and other services
Use of the staff and training and use of time by the staff
Patient, family and staff satisfaction
Penetration measurement of the service in the community and other bodies
Monetary and nonmonetary cost
19 Evaluation of Social Psychiatry Services 399

It is also necessary to be able to achieve consent through creative dialogue – at

least for “sentinel events” – so that we may further develop services that truly meet
the needs of mental health. Sentinel events in psychiatry are events that should be
avoided [sentinel events have been described (Morosini and Veltro 1991): new
patient with more than one episode per year, a patient who does not leave his house
for more than a determined period of time, patient follow-up abandoned, patient
incarceration, patient suicide, etc.].

Obstacles in Evaluation Implementation in the Greek Mental

Health System

Significant obstacles in evaluation implementation in the Greek mental health

system are the following shortcomings:

Lack of sectorisation and reference population of the mental health system in still
significant parts of the country
Lack of community involvement principles of the services
The fact that evaluation is not a system element
Lack of a common system of record keeping
Lack of common outcome criteria
Lack of therapeutic intervention standardisation

Pubic Mental Health System Evaluation Implementation

Example

Systematisation of the internal pubic mental health system evaluation begins with
an ex post evaluation (2009–2010) (Ministry of Health and Social Solidarity 2010),
which was ongoing at the time of psychiatric reform (2011–2015) (Ministry of
Health and Social Solidarity 2013).
Indicatively, we show the SWOT analysis below that was published in the report
following quantitative and qualitative evaluation methods:

Capabilities Weaknesses
1. Turn in the provision of mental health 1. Fragmented, non-co-ordinated system that
services towards a contemporary model of often results in the wrong provision of
community psychiatric care services
2. Contraction of the number of beds in 2. Unequal geographic distribution of services
psychiatric hospitals
3. Closure of 5 psychiatric hospitals 3. Significant gaps in mental health services
for children and adolescents and long
waiting lists
4. Gradual acceptance of individuals with 4. Significant gaps in mental health services
mental disorders by local communities for the elderly and dementia patients
400 S. Stylianidis et al.

Capabilities Weaknesses
5. Raising awareness, information and 5. Significant gaps in specialised mental health
promotion of mental health with the services (individuals with the autistic range
support of the media of disorders, mental retardation, eating
disorders)
6. Significant improvements in the context of 6. Significant shortfall in judiciary psychiatric
performance of psychiatric and children’s services and antiquated institutional
psychiatric speciality and increase in the framework
relevant jobs 7. Inability to implement procedures and
quality assurance standards in the
operations of mental health services
8. Lack of epidemiological studies on mental
health
9. Shortages of staff in supporting and
ancillary roles
10. Large number of involuntary
hospitalisations
11. Serious issues with regard to the
protection of the rights of service users
12. Limited involvement by the users
of mental health services (RMHS) and
advocacy
13. Delays in the development of psychiatric
departments in general hospitals
14. Absence of self-help groups, training and
support for dementia and mental health
patient carers
15. Inability of scheduling and funding of
education, training and vocational
rehabilitation programmes for RMHS
16. Inadequate sectorisation implementation
17. Excessively centralised administration
model of the mental health system
18. Lack of a clear business plan for policy
implementation, with policy priorities,
costing and funding

Threats Opportunities
1. Risk of mental health system collapse/ 1. Integration of existing subsystems and
unsustainability if the issue of its funding services
from the state budget is not resolved
2. Existing structure issues may lead to higher 2. Corrective actions for system co-ordination
fragmentation and cause a threat to the with clear structures and competences in the
system’s sustainability context of the PSYCHARGOS 3 proposal
revision
3. Pending issues with regard to compliance 3. Utilisation of the National Strategic
with Spidla accord requirements Reference Framework 2007–2013
19 Evaluation of Social Psychiatry Services 401

Threats Opportunities
4. Further burden on the system from new and 4. Development of new plan for the next
emerging needs due to the consequences of stage of the reform
the financial crisis to mental health (suicide
rate, homelessness, migratory flows, etc.)
5. Significant resistance from the staff with 5. Transfer of know-how capability from the
regard to changes in the system EU and the WHO
6. Staff reductions in legal persons governed 6. Utilisation of public sector property to
by public law due to retirement and new house mental health services
hiring restrictions
7. The transfer of psychiatric departments to 7. Funding improvement for structures of
general hospitals is likely to deprive mental legal persons governed by private law
health from resources that would be used through the funding capability of the
for the benefit of services pertaining to NSRF
general-physical health
8. Significant delay in NSRF available 8. Function of the National Organisation for
resources absorption Healthcare Benefit Provision (EOPYY)
9. Current socioeconomic conditions 9. Integration of mental health services in
primary healthcare
10. Maturity of the institutional framework
with regard to social economy

19.3 Evaluation and Human Rights

Evaluation and improvement of quality and the status of human rights, in both
outpatient and hospital units, are of critical significance. An overall evaluation
of the services helps trace problems within the existing healthcare practises,
while it contributes to the development of effective ways to ensure that the ser-
vices are of good quality and respect human rights, so that they may meet the
requirements of users and promote their independence, their dignity and their
right to self-determination/self-identification. Evaluation is important not just
for reframing old neglect and abuse incidents but also to ensure the development
of efficient and effective services in the future. Furthermore, results and recom-
mendations from quality and human rights evaluation may be invaluable for
enriching the planning of a future reform policy, scheduling and legislating as
well as ensuring that these will be conducted respectfully and will promote
human rights.
In conclusion, we would like to point out that the goal of a service’s evaluation
(and self-evaluation) process is to change its practice. The purpose of quality evalu-
ation is not to add to the knowledge of one aspect of reality but to optimise interven-
tions, gradually granting users and others involved in the provision of mental health
services the right to express views for the continuous improvement of the services
and their effectiveness (Table 19.1).
402 S. Stylianidis et al.

Table 19.1 Evaluation types and areas of questions and definitions relevant to good practices in
the provision of services (Hollander et al. 2010)
Evaluation types and areas of questions Definitions – description
Model planning and application
1. Appropriateness of planning This relates to whether the model is well documented
(evaluation of theoretical and is planned in such a way as to meet the
inclusiveness and model structure) programme’s original goals and purposes, while
remaining consistent with the criteria of good
practice in the field. The reasoning of the model, its
basic characteristics and structure are included and
assessed in this field
2. Efficiency and effectiveness of the This field examines the model’s consistency to its
model’s application (application original planning and the extent to which it was
evaluation) adopted in the way it was planned by the staff of the
institution implementing it or any other key persons
Model functionality (evaluation of the procedure)
3. Appropriate provision of care Refers to the evaluation of whether the staff is
adequate or not for the provision of the care. The
provision of care is conducted on the basis of specific
principles and procedures. The model is “functional”
if the procedure of providing care services is
followed
4. Care continuity and care Ensuring care continuity and co-ordination
co-ordination throughout the range of required services in this field
5. Staff skills This field refers to the professional qualifications and
skills of the individuals in the administration,
management or the provision of services
Model effectiveness (outcome evaluation)
6. Service accessibility The degree of accessibility by the beneficiaries is
evaluated, while parameters such as the following are
examined: answers to questions, operating hours,
easy access to services
7. Service quality The quality of provided services is linked to the
satisfaction of service users, the members of their
families and the persons involved with the provision
of care
8. Cost-effectiveness The institution’s value for money is evaluated and is
directly linked to cost and outcome
9. Effect on health The effect of provided services on the population’s
health in general
10. Model transfer and generalisation The relevance of the model with other frameworks of
capability care or provision of services is evaluated. It pertains
to the extent to which the model can be adopted
throughout the country and the extent to which it can
be adopted by various services, institutions and
frameworks. The capability of transferring
innovation is evaluated
11. Sustainability Sustainability examines how well the model can
continue to function through time with alternative
resources for its support
19 Evaluation of Social Psychiatry Services 403

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Implications of the Socioeconomic Crisis
for Staff in Community PSR Units: 20
The Case of an NGO

Stelios Stylianidis, Klimis Navridis,

and Anna Christopoulou

Abstract
Financial strain, high unemployment rates, institutional inconstancy and job
insecurity in the context of the socioeconomic crisis in Greece affect the work-
force at various levels. This situation in conjunction with the austerity policies
implemented for more than 5 years in the mental health field along with incom-
plete psychiatric reform has multilevel consequences, including severe deteriora-
tion in the quality of medical, psychiatric and social services. For these reasons,
we conducted a qualitative research study, in residential units of a Greek NGO,
in order to investigate the subjective experience of weakening in personnel, on
the institutional group levels in association with the defence mechanisms mobil-
ised in response to the patients’ complex psychological attitudes that personnel
have to manage. Suggestions for further institutional initiatives and for new
themes of future research are also presented.

20.1 Introduction

In the context of the socioeconomic crisis in Greece, the underfunding of the units
of an already malfunctioning “welfare state” (Sakellis 2012), especially the mental
health services network, amplified the systemic structural problems (Loukidou et al.
2012; MHSS 2010, 2012, 2013) in a way that puts in question its survival (“ARGO” –
Network for Psychosocial Rehabilitation and Mental Health 2012; Stylianidis

S. Stylianidis (*)
Department of Psychology,Panteion University, Athens, Greece
e-mail: [email protected]
K. Navridis • A. Christopoulou
National and Kapodistrian University of Athens, Athens, Greece
e-mail: [email protected]; [email protected]

© Springer International Publishing Switzerland 2016 405

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_20
406 S. Stylianidis et al.

2012). The obvious “paradox” experienced by all parties involved (patients, fami-
lies, administrators, mental health professionals, the community) is the govern-
ment’s dismantling of the already malfunctioning network of mental health services,
despite the significant increase in requests for psychiatric care, prevention and early
therapeutic intervention in the general population, especially vulnerable social
groups,
This high degree of institutional and professional insecurity causes a series of
chain reactions in all operating levels of mental health services, such as residential
care, family and community intervention, as well as in personnel responsible for the
scientific, administrative and ethical functioning of the units, who are working to
avoid the return of patients to asylums.

20.2 The Contradictions and Incomprehensible Nature

of Social and Psychic Suffering in Mental Health
Community Units

The theory and practice of deinstitutionalisation and the questioning of the psychi-
atric biomedical paradigm began in Western Europe in the 1960s and after five
decades of reform efforts now stand – at least in terms of stated positions and
targets – as the new example of good and evidence-based practice worldwide
(Thornicroft and Tansella 2010; Basaglia et al. 2000).
One of the key questions, however, which in part concerns us in the analysis of
the interview material of this research, is to what extent such institutional and organ-
isational change succeeded in radically altering key features of the old culture such
as “total institution” (Goffman 1968) and institutionalisation processes (Basaglia
et al. 2000) within the new mental health facilities.
Is it possible to argue, without deforming reality through “ideological glasses”, that
the new “institution mentale” (Hochmann 1982), as it is or should be established, is a
solid container allowing the working through of destructive group dynamics, particu-
larly in the present circumstances? If not, then why have we left the safety of asylum,
perceived through the perspective of the ancient function of shelter and protection?
According to Hinshelwood (2001), following the triumphant illusions of the
anti-asylum movement, wide scepticism prevailed after we noticed serious phenom-
ena of institutionalisation even in small community units. However, these external
and internal factors, leading to a recurrence of such institutionalisation mechanisms,
have not yet been adequately studied in the literature (Racamier 1973; Bion 1952;
Hochmann 1982; Searles 1965; Benedetti and Andreoli 1991; Rosenfeld 2003).

20.3 Research

This qualitative research focused on the impact of the crisis for more than 5 years on
the field of mental health in our country, and in particular, given the already incom-
plete and fragile psychiatric reform process, on the personnel of residential units of a
20 Implications of the Socioeconomic Crisis for Staff in Community PSR Units 407

Greek NGO (Stylianidis and Chondros 2011). The research examined the way the
personnel experiences and addresses – subjectively but also intersubjectively – the
phenomena of weakening, i.e. the external devaluation of their profession, role and
individual status and hence the violent attacks:

• On a personal and psychological level (professional identity and narcissism)

• At the group level (risk of decomposition and disappearance)
• At the institutional level (risk of elimination, death anxiety)

20.4 Method

The method used in this case was that of the clinical psychosocial survey (Revault
d’Allonnes et al. 1989; Blanchet 1989; Trognon 1987). In the first stage, three
90 min focus group interviews were conducted with the scientific coordinators of
the various units of the NGO (Banks 1957; Giami 1985; Trakas 2008) in order to
identify potential main subjects. Then, 17 personal interviews followed with mem-
bers of the staff and the scientific coordinators from units of the major area of
Athens and the countryside. The criteria for choosing the staff members included in
the sample (except for Athens vs. countryside) were (a) specialisation/position/
duties and (b) age (<35, >40)/years of service in the organisation (<5, >10).
This was followed by the analysis of the empirical material. The method used
was a clinical type of interpretative content analysis, which permits investigation of
the subjective experience of the sample in greater depth (Enriquez et al. 1993). This
specific approach highlights the significance of the relationship between researcher
and respondent, requiring post hoc simultaneous evaluation of hearing or reading
the notes and the transcribed interviews later on the one hand and the element of
intersubjective construction, therefore the co-construction of the empirical material
on the other hand, in other words, the transference of the sample participants and the
researcher’s countertransference (Devereux 1980).
Thus, the interviewer addresses the narrative in three ways: by selecting the
theme and topics, by ordering the questions and by phrasing questions in his or her
language (Bauer 1996).
This approach is consistent with the emphasis on reflexivity in the interview,
exploring and combining the psychoanalytic and social aims of this study. It involves
comprehension of people’s subjectivities in the context of the weakening process
and events of external reality which they bring to mind and convey in the intersub-
jective context of the interview.
All interviews, individual and group, were carried out by one of the two co-
researchers in a specially designated room at the headquarters of the NGO. After
each group interview, the interviewer kept detailed notes from memory. Personal
interviews, each one lasting between 30 and 50 min, were recorded with the consent
of the individuals.
The steps of analysing, verifying and reporting followed the seven stages of an
interview inquiry (Kvale and Brinkmann 2009).
408 S. Stylianidis et al.

This was followed by analysis of the transcribed material.

Findings

The material from the interviews has multiple levels, involving issues of personal
survival and psychological processing of breakdown anxiety as well as themes aris-
ing from the intersubjective dynamic between the members of the groups and
between the group’s and the organisation’s management.
The subjects frequently switch from singular to the plural form (Kaës 2009),
from “I” to “we”, not only as an invocation for the group’s support or as reference
in a collective synergy regarding professional duties that are particularly demanding
and difficult but very probably as obfuscation and the intervention of a subjective
insecurity regarding the framework (of the job and the interview itself).
A first observation regarding underfunding or irregularity in state payment of the
specific NGO and the psychological impact on employees is that these phenomena
are not exclusively connected to the time period of this crisis but had also appeared
in the past. Let us see what the participants in the study have to say about this:

This problem always existed. It is not new. Because of the Ministry. Now it’s more.
(Lambros, General Duties in a Residential Unit, 2 years in the job)

It is not something that started recently. For these units […] it started in 2005. That is more
than six-seven years […]. The first time that the staff was not paid was in 2008 […]. From
2008 and onwards, as well as earlier, late 2007 I would say, delays began. In fact then, in
2008, we reached a six-month period without pay. (Nikos, Child psychiatrist, Scientific
Coordinator at a Hostel (13 years in the job))

Thus, ever since, as many mentioned, each time that a person was to be hired, he
was asked during the interview if someone from his environment could support him
financially when his payment was late:

When I was interviewed, the first thing they told me was that, you know, you will be paid
every six months. You won’t lose your money, you’ll get it. But you will get it every six
months. This didn’t bother us at first. (Marina, 51, General Duties in a Hostel)

During the current circumstances, however, the major problem for the NGO’s
staff does not appear to be, as we will go on to see, the possibility of delay in pay-
ment continuing or increasing, but the fact that the employees can no longer predict
when they will or how much they will be paid each time, as well as – the worst
thing – how long they will continue to be paid:

[…]There were cutbacks and so on, but at least the employee’s salary was coming in.
(Nikos)

[…] and the six months that we go unpaid and the like, they will give us, I don’t know, 2
monthly salaries, 1 salary. (Marina)
20 Implications of the Socioeconomic Crisis for Staff in Community PSR Units 409

You don’t know what will happen, when you’ll get paid, if they will fire you, we don’t know
anything, if the structures will close, we didn’t know anything. (Martha 50, General Duties
at a Residential Unit)

With the workers of the NGO, survival anxiety is expressed in correlation with
parameters such as age, locality (the distance between work and place of residence),
the employee’s previous experience of similar crises due to underfunding, their fam-
ily status (existence of children or other family obligations), as well as their man-
agement method by the organisation. In particular, the greatest problem for the
younger ones appears to be their extended dependence on the paternal family, due
to the employment circumstances of the financial crisis, and subsequently the
obstruction of their personal development towards adult life:

Basically, my brother is helping who is in the USA..

It is very hard as young people, because my partner is 26 and I am 28, so we young people
are experiencing it and we are feeling it a great deal… I feel a burden that I cannot start a
family. (Stefania, 28, Nurse in a Residential Unit)

I am from the countryside […]. I have rented a house and certainly now in these circum-
stances I have found it very difficult to meet my obligations. How will I pay the rent. Of
course, OK, my parents are helping me.... They are sending me money.. as if I were still a
student.. (Kyriakos, 29, Social Worker in a Residential Unit & Mobile Unit)

On the other hand, older employees appear to experience feelings of loneliness

and abandonment by the organisation and the state. These feelings are frequently
transformed into a sense of personal and professional devaluation, expressed
together with the patients’ survival anxiety regarding their future outcome and the
now existent possibility of abandonment or mental death as a result of potentially
returning to the asylum. Let’s see what they say themselves:

Recently, to tell you the truth, I am afraid of being unemployed. I am not afraid of anything
else from the crisis. Because if I am unemployed, I cannot make ends meet. (Sotiria, Nurse,
6 years in a Hostel)

[…] when you have something else in the background, you are a bit optimistic. At first I was
worried, but then I got over it. (Martha, 50, General Duties in a Residential Unit)

Things are getting tighter […] Without any help from nowhere […]So I look at what I can
do with my hours, with my shifts, what I can decrease in my budget, what can be left aside,
and what priorities there are, which are first and which are second, to be able to make ends
meet. (Eleni, 42, General Duties in a Residential Unit)

The employees who are parents of young children are naturally experiencing
great anxiety due to their inability to appropriately care for them. Eleni, for exam-
ple, (see above) mentions:
410 S. Stylianidis et al.

My children are 15 and 13 years old. Boys.. OK, things are difficult. I cannot potentially
provide what we would possibly have in other circumstances and without an economic
crisis. To offer as a mother. I am offering nothing to them. I am offering a roof, food, sup-
port. I cannot offer them supplies. So all this, make me feel that I am now an incompetent
mother. (Eleni)

However, in older people, personal experience from past similarly pressing cir-
cumstances can operate protectively at present:

Financial problems are not something new for me. I have experienced in the past such situ-
ations, even worse. (Gianna, 55, Psychologist)

She is referring to the crisis her family faced when her husband’s business went
bankrupt.

Defence Mechanisms
Consequently, the choice to explore inner unconscious movements and defence
mechanisms is based on the assumption that either the subject and/or the group
defend themselves against anxiety and other archaic fantasies. This psychic process
significantly influences people’s actions, lives, relationships and their perception of
the future.
What, however, are the psychological and intersubjective phenomena that emerge
through this multilevel crisis? Many interdependent psychological defence mecha-
nisms are mobilised. In summary, we will refer to:

(a) The idealisation in terms of “family” of the structure and the NGO as a shield
protecting against the external enemy and the paralysing uncertainty, as well as
the intolerable emotions caused by the traumatic memory of a childhood
deprived of affection, parental support and security or against guilt due to sub-
jective inadequacy in fulfilling their parental role

Eleni, in the above excerpt, clearly views herself as an inadequate and incompe-
tent mother. By contrast, she is overly active and hyper-efficient with the “tenants”
of the residential unit: “Vicky can do anything”, the patients say calling her, as she
mentions, by the name of a famous heroine of 1821. The identification with the Ego
ideal (Chasseguet-Smirgel 1973) in this case appears as a last defence against men-
tal pain, fear of breakdown and rage because of the unfairness and lack of care in the
work, personal and family environments. An incompetent mother in her family,
Eleni is transformed into a superhuman “good” mother in her symbolic family, the
residential unit, while, altruism, a result of idealisation, becomes an inexhaustible
source of narcissistic satisfaction for her. Eleni’s professional identity supports her,
simultaneously keeping her psychologically alive. Moreover her professional iden-
tification with an ideal family is a substitute of her deficient maternal function.
She says:
20 Implications of the Socioeconomic Crisis for Staff in Community PSR Units 411

No one ever paid any attention to me. No one ever took care of me, not when I was five, not
when I was twelve – at the age she started working - not now […] I know well what it’s like
not to be taken care of. No one deserves that.

Another employee mentions:

I like this job very much. I like to come in contact with people who I really feel that they
need me.. […]We are a family, this is not just the workplace.. (Marina)

(b) In the extreme primal idealisation of the institution:

This job is for me a life experience. I think that I have nothing more to see than what I saw
already […]. (Anna, 42, General Duties in a Residential Unit)

Or even:

I don’t have enough to get by. I can’t even pay for gas for the car. But I like the job, the
nature of the job, I like the subject matte (Stelios)

The person wastes away if he does not protect the work subject:

At least I have a job, I am not unemployed and I am a step above volunteers. (Stelios)

What we can perhaps hear in this phrase is the echo of an unconscious protective
wish which the individual assigns to his professional identity. This identity appears
to be experienced as that psychological “minimum” that shields the individual in his
imagination from the possibility of complete psychological and social disconnec-
tion and breakdown.
What happens, however, with the same individual’s rage towards this extreme
symbolic social and institutional violence that threatens his psychological integrity
and survival? When the interviewer asks Stelios:

Doesn’t all this enrage you?

He replied:

No, not at all. This has nothing to do with the job. It’s not the fault of the patients. [Small
pause] It’s like someone who is living in a village, who has argued with the neighbour,
and to get revenge he ties the neighbour’s goat to his car and drags it with the rope until
he kills it

Through this excerpt one recognises the brutality of Stelios’ psychological expe-
rience. We are also witnessing the sequence of the psychological transformations of
this experience, starting with denial (“No, not at all”) and going through a process
of displacement and transference, idealisation, projection and identification. We
can also wonder about the origin of all these enigmatic internal objects and the con-
nections between them. In other words, what could the “neighbour” and the
412 S. Stylianidis et al.

“neighbour’s goat” represent in Stelios’ internal world and for what reasons? In this
metaphorical scene, “the neighbour’s goat” suddenly suffers a great injustice and an
extreme, excessive tortuous and deadly violence. The violence of someone, who
instead of addressing the “neighbour” who caused his anger and revenge, turns it
against this innocent, weak little mammal, who only produces “good” milk.

There is some friction with my colleagues – says Stelios – the younger ones sometimes do
not respect the older ones.

Another transference: So who is “not respecting” Stelios? His colleagues at work

or possibly the institution and the state which are literally devaluing him and his
work by not paying him?

(c) In the denial and obfuscation of all negative aspects of the work experience,
with a parallel idealisation of the subject matter of the work and the projection
of the hopes of the individuals into a vague and fantastical future:

I know that what happened to us will not last long. I am an optimist and I say that I am
emotionally and financially investing in this NGO[…] Since I like the subject matter, since
I want to continue, be patient, I say, as long as you last, and find something else to do on the
side. (Vicky)

[…] I think that I am well in the job, I like the subject matter of the job, and I am not doing
it like a … I have not reached yet such a level to say that… (pause) I will look for another
job. I am fighting and I believe that at some point things will get better […]. (Jason, Nurse
in a Residential Unit)

(d) In the omnipotence with which he is invested:

What will happen to these people… Where would they all go? This is not simply a business
that closes down, these are human souls, they are a responsibility. (Kyriakos, 32, Social
Worker in Residential Unit & Mobile Unit)

Or otherwise

(e) In moving to a paranoid position and a diffuse paranoid readiness (“they are
hiding something, they are not talking clearly to us”):

I generally think that all NGOs that were involved with mental health are responsible. This
is indirect privatization. Regardless whether it appears as a non-profit. You cannot not have
profit in capitalism. You are obviously making it somewhere else. (Stefania, 29, nurse in a
Residential Unit)

(f) In the function of the scapegoat mechanism, inside the structure (difficult
patients or problematic employees):

Most are not even wanted by their relatives.. […] I told a lady that she has to find some-
where else to go […]. (Nikos, Child Psychiatrist, Scientific Coordinator in a Hostel)
20 Implications of the Socioeconomic Crisis for Staff in Community PSR Units 413

(g) In the fragmentation of the function of the group

Gianna, 55 years old, a psychologist, has been working at the day centre for the
past 10 years. Throughout the day, she does many creative things with the patients:
she coordinates a social club, reading groups, groups which leaf through and read
newspapers and social skills training groups. But what she describes is a rather per-
sonalised care scheme, unconnected to the activities of the day centre and mainly in
contrast to the fundamental principles of psychiatric reform and the declared goals of
the NGO.

(h) In overinvestment in the work subject matter which sometimes may lead to a
process of merging with the patients therefore their chronification:

If I was working in a factory I would have protested. Here… I feel responsible for the
people I am taking care of. I think that it is a serious job that is worth it […]. (Jason, Nurse
in a Residential Unit)

Gianna also refers to her job with great enthusiasm:

I love this job a great deal. I like working with people who truly need me. It is not an inani-
mate object. We are a family, not only a workplace, she tells us.

Among the different groups coordinated by Gianna, there is one she calls the
“parent or close relative group”. The patients refer to Eleni as a “parent”, despite the
average age of the patients of her service being 65. In her mind, patients appear to
be essentially infantilised, while she adopts an overprotective attitude towards them.
The staff’s overinvestment in the patients therefore appears primarily as a defen-
sive attitude, which expresses great difficulty in parting with patients. We could also
ask whether this is to the ultimate benefit of the patients or if, on the contrary, it is
included in what Racamier has described with the terms “psychotic paradoxicality”.
In reality, patients are permanently “trapped” in a double bind, according to Bateson
et al. (1956), whereas the apparent aim of therapy remains for them to become as
autonomous and independent as possible, the underlying goal appears nevertheless to
be their maintenance in a state of almost permanent merged dependency. Eleni says:

Time is required with psychotics. You can’t hurry.

In reality, perhaps it is she who needs time to psychologically process the “other”
as well as her bereavement for the time (work time? age?) that is passing.

(i) In the projection of the origin of the breakdown anxiety to an external enemy
(the heartless state or the ministry which we must face united with each other
and with management):

[…] the State… doesn’t care… everything is done for show. I am disappointed by the State.
(Jason, Nurse in a Residential Unit)
414 S. Stylianidis et al.

(j) Finally, in the exceptionally adverse circumstances of this economic and socio-
political crisis, the scientific coordinators of the units frequently find themselves
in a difficult position: they are called upon to intermediate between management
and nursing staff:

The greatest difficulty for me, is to manage to achieve balance in my position. That is,
between management and staff. (Natalia, 30, Psychologist, Residential Unit Scientific
Coordinator)

What appears to be happening in this case is schematically the following: on the

one hand, in order to maintain the organisation’s cohesion and on the other for the
employees to maintain their psychological cohesion, their connection to each other
and to not collapse, they collectively project the “bad” object onto the state and its
services and the “good” object to management, with which they identify. Thus, “it
is the ministry’s fault that their salaries are delayed”, whereas on the other hand
“management is on their side, is fighting on their behalf and is protecting their
rights”.
However, someone inside the organisation and at the unit level must do the
“dirty job”, that is, implement the policies of the NGO organisation organisation-
ally and administratively on a daily basis, as they are formulated under pressure
and the general circumstances. This person can be no other than the scientific
coordinator.
The scientific coordinators, who are also personally experiencing the conse-
quences of the crisis on a personal level, appear to be psychologically tried, con-
stantly between two identifications: identification with the staff of the unit they are
responsible for (remaining “good” with the staff but “bad” towards the manage-
ment) and identification with the management and its policies (therefore appearing
“good” towards the management but “bad” towards the staff).

20.5 Discussion

The findings of this qualitative research indicate that the socioeconomic crisis is
consistently related to specific attitudes of personnel in residential units. In this
study, reference is made to the concept of collective mechanisms of defence, a
concept which is associated with a long-standing tradition of the clinical psycho-
social orientation of organisations within the psychoanalytic framework (Jaques
1955; Menzies 1961). More recently, Hollway and Jefferson (2000), starting with
their own experience using and analysing interviews in social research, refer to
the same concept, acknowledging the role of collective defence mechanisms
against anxiety, the significance of unconscious intersubjectivity in investigating
the psychosocial profile of research subjects, as well as the usefulness of more
flexible methods of content analysis which enable access to subjective experience
and meaning.
20 Implications of the Socioeconomic Crisis for Staff in Community PSR Units 415

The main collective defence mechanisms (Jaques 1955; Menzies 1961; Kernberg
1998) that they seem to mobilise in dealing with their personal and professional
devaluation as well as persecutory and depressive anxiety are the idealisation of the
institution and overinvestment in their job. An overprotective and dependent attitude
towards the patients results as a side effect of those mechanisms and paradoxically
leads to the patients’ chronisation rather than empowerment and autonomy. A sig-
nificant issue that arises is that the main defence mechanisms used appear related to
and perhaps enhance the pre-discussed neo-institutionalisation phenomena in com-
munity mental health units.
On the other hand, it would be critical to examine in depth the function, strategy
and management of the board of directors of the NGO towards the personnel in the
current context of uncertainty. A first glance indicates that the administration seems
to find it hard to deal with the dichotomous nature of projective identification
related to the personnel (good vs. bad; good in terms of representing the collective
ideal, bad in terms of a punishing mother) and to create a transitional space for
cooperation and dialogue. These deficit results in the mobilisation of the defence
mechanisms, which in combination with a paranoid environment, contribute to the
weakening of the personnel’s strength and the reinforcement of neo-
institutionalisation phenomena in the community.

Conclusions
The crisis impacts negatively not only on the personal and family level of resi-
dential staff. The continual fluctuation and insecurity also debilitate the core of
psychiatric reform and the new culture of care which this approach promotes.
Thus, psychotherapeutic support, continual training and supervision, aimed at
decreasing the negative consequences of uncertainty and internal pain, are vitally
critical.
In addition the dramatic lack of funding could be dealt with through a process
of empowerment-participation of staff, patients, their families and other com-
munity resources through networking in order to gain their basic rights for care.
Future planning and intervention should take into account local conditions
and historical, socioeconomic and political momentum in order to apply princi-
ples of community psychiatry in order to provide mental health services given
the current situation of poor resources and economic strain.
Future research is called for, using both epidemiological and qualitative meth-
odology on a national scale, in order to further investigate and identify the psy-
chosocial variables which contribute to the weakening of personnel. This
ultimately will lead to significant improvement in the quality of patient care.

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Staff Evaluation and Presentation
of Organisational Culture in Mental 21
Health Structures

Stelios Stylianidis, Meni Koutsosimou, Nikos Symeonidis,

Panagiotis Chondros, and Giorgos Chadoulis

Abstract
Staff evaluation is sub-module in the assessment of mental health services. In the
present chapter, we focus on the creation of a structured staff evaluation system
within the framework of mental health through the presentation of a case study
in Greece and its theoretical background. Theoretical definitions are included
with a focus on the concept of organisational culture. It then goes on to present
how this evaluation is implemented to improve the quality of mental health ser-
vices, its methodology and limitations. The establishment of criteria on the basis
of which the operation of the system will be reviewed is central to this process.
Consequently, the adoption or creation of indicators with good psychometric
properties (validity, reliability, sensitivity to change) is a necessary investment
which contributes in studying the efficiency of the system. A multifaceted meth-
odological approach (use of multiple research tools) and simultaneous imple-
mentation of the results in educational and clinical practice are proposed. The
sections on management intervention and changes focus on the following indi-
vidual areas: commitment to the goals of the organisation, participation in the
work, performance, job satisfaction, psychosomatic-psychological reactions.

S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
M. Koutsosimou • N. Symeonidis • P. Chondros () • G. Chadoulis
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 419

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_21
420 S. Stylianidis et al.

21.1 Introduction

The assessment of health systems and, respectively, the services provided should
form an integral part of their design, organisation and administration and may be
carried out at four levels: inflows (human and material resources), procedures
(organisation and quality of services provided), intermediate outflows (use of ser-
vices and volume of the direct results generated) and effects.
This assessment begins by identifying accurately the breadth of the system and
selecting indicators (e.g. effectiveness, efficiency, equality) associated with specific
performance standards.
Over time, numerous definitions of quality have been put forward. However,
although there is no widely accepted definition, the various definitions put forward
are quite similar. Juran, for example, defines quality as “suitability for use”, which
requires quality of design, quality control, availability and convenience (Berger
et al. 2002). Crosby states that the quality of a product or service means compli-
ance to standards, so that the product or service coincides with the needs of the
client, while Deming defines quality as a constant improvement process, based on
minimising deviations from the desired efficiency of the product (Beckford 2010).
According to Feigenbaum’s definition, “quality is the manner in which a company
is managed so that the product meets the clients’ expectations”, while Ishikawa
emphasises that “quality depends not only on the quality of the product but also on
the staff and management, and their cooperation in solving problems (Berger et al.
2002). Finally, Taguchi considers the quality of a product as the provocation of
minimal losses to society, from the moment the product is released for use
(Beckford 2010).
The implementation of staff evaluation is interpreted in literature as the system-
atic assessment of employees, with respect to their job performance and potential
for development. Historically, the act of evaluation was conceptualised after World
War II, as a technique implemented in the US armed forces, and developed term-
wise in the period between the two World Wars (1920–1930). Today, staff evalua-
tion is a separate sub-module in the assessment of mental health services and may,
for instance, be based on daily performance data, reports, structured internal or
external evaluation, self-evaluation and participation in staff meetings (work
groups).
In the context of adopting the act of evaluation and its implementation in the area
of mental health, its implementation as a substantial part of effective personnel
management contributes in identifying the needs and opportunities for employee
development and growth. Essentially, traditional performance evaluation is nothing
more than a careful completion of forms. The advantage of this approach is that one
gets a full picture of the situation as well as the rational views of both the evaluee
and the evaluator. The graphic rating scale or assessment scale, where a sum of
points is assigned to various characteristics, is a direct and secure way of presenting
specific individual scores for predefined areas which are being evaluated. An inher-
ent difficulty in any evaluation process is, of course, recognised as any valid and
reliable assessment necessitates the evaluees’ subjectivity. To this end, it was
21 Staff Evaluation and Presentation of Organisational Culture 421

deemed necessary to ask the evaluees to score certain quality characteristics and to
also answer open-ended questions where they would have a large amount of space
to provide answers.
Over the last years, interest is focused on assessing but also in improving the
efficiency of health systems. This assessment is implemented by creating compa-
rable indicators and by measuring comparable dimensions, including quality of
care, access to such care and costs (Kostagialas et al. 2008). The design of indica-
tors ensures that control can be exercised over all factors affecting every process of
a mental health service. The selection of such indicators depends on the service, its
objectives and the extent of this evaluation. Such indicators do not ensure quality;
however, they identify areas in need of improvement and confirm the success of the
measures taken (Lazarou and Oikonomopoulou 2007).
It is true that, in recent years, there is an increasing demand for radical changes
in the corporate world, aiming to reshape the working environment. In this context,
it is made clear that the human factor deserves due attention, since it is the main
instrument which drives and determines the dynamic growth of a company.
Accordingly, the need to study how job performance, work psychology and, conse-
quently, organisational culture and the level of job satisfaction of employees are
affected has increased rapidly in recent years.
“Organisational culture refers to the working environment shared by employees
within an organisation, including their shared beliefs, attitudes, values and codes of
conduct”, i.e. the vehicle which, in a clinical context, enables staff to identify cir-
cumstances and events that could contribute, for example, in improving quality,
from a joint, but at the same time different, perspective (Davies 2005). The organ-
isational climate reflects the aura of an organisation and focuses on how it operates
(such as, for example, behavioural norms), while organisational culture focuses on
the concept of organisational operation (e.g. shared objectives) (Schein 2004). In
this respect, climate is the apparent aspect of culture, and for this reason it can be
interpreted through the underlying levels of the latter. In general, it is difficult to
distinguish the one from the other, as culture shapes the climate and the climate
reflects the culture. Hence, it is difficult – if not impossible – to be aware of the
climate without an in-depth approach to the culture.
There are two prevailing views-theories about what triggers organisational
behaviour. The first, the macro-culture theory, assumes that organisational culture
affects the working environment, whereas the microculture theory maintains that
human attributes affect organisational culture. The organisational support theory –
(Eisenberger et al. 1986; Shore and Shore 1995) seems to be a pivotal variable in
understanding organisational culture. According to this theory, employees develop
high levels of perception concerning the extent to which the company-organisation
values their contribution and cares about their well-being. It has been established
that perceived organisational support (POS) is associated with positive employee
attitudes, such as increased performance, job satisfaction, commitment and reduced
turnover (Rhoades and Eisenberger 2002).
The basic principles of a successful organisational culture framework, as
set out below, are laid down in literature: legitimacy (partnership, orientation of
422 S. Stylianidis et al.

acceptance), direction (strategic vision), performance (response, effectiveness and

efficiency), responsibility (accountability, transparency) and fairness (equality,
regulatory framework).
In daily practice, however, when staff relations lose their human character, coer-
cion takes the place of communication and lack of enthusiasm takes the place of
qualitative effort (Halligan 2006). What has now become evident from international
practice and literature is that the greater part of any professional’s job-related obli-
gations cannot be stereotyped in some general fashion. It can only be promoted
when self-monitoring and a climate of inspiration, creativity and readjustment pre-
vails, while the professionals themselves do not react positively to orders and con-
stant management monitoring, when, for example, the prevailing organisational
forms are of a bureaucracy style or exclusively a “top-to-bottom” communication
style.
Taking into consideration the theoretical debate above, it is not surprising that
most foreign organisations which have adopted an organisational culture monitor-
ing system have acquired an organisational conscience largely acknowledged as the
heartbeat of the services offered. And at the level of clinical professionals groups,
it is defined as the organisation/company’s DNA, as it is believed to be what triggers
lifelong learning and motivates employees and what also contributes in the provi-
sion of information to patients and giving them their personal energy and voice, in
order to allow all of them to improve – effectively and consistently – the culture in
which they coexist and interact.
Therefore, using specific definitions/questions, it is possible to capture the organ-
isational climate or, specifically, the climate which is geared towards servicing the
patient in clinical establishments, through employee perceptions, which are reflected
in the patients’ perceptions regarding the overall quality of the services and, ulti-
mately, in their satisfaction with the services received. Thus, by associating the
patients’ perceptions with those of the employees enhances the validity of the
employees’ perceptions regarding the organisational development of the framework
in which they work.
For the most part, however, clinical culture is disparate and inconsistent and is
usually described as differentiated because of the different cultures coexisting
within the working environment, which reflect the individual opinions and attitudes
of many and diverse professional groups (Davies 2005). This results in the develop-
ment, within the same organisation, of different subcultures, misconceptions and
conflicts between such cultures. So, according to studies, the four prevailing subcul-
tures are those of (a) the medical staff, (b) the nursing staff, (c) the administrative/
technical staff and, finally, (d) the management.
At the same time, the factors-variables associated with the emotional intelli-
gence of employees are another theoretical tool which could help understand
organisational culture in organisations. By extension, these are the dimensions
which could determine whether an employee is able to communicate with his/her
colleagues, experience any job-related accomplishments and failures, establish
courses of action and increase his/her performance and remain committed.
Comparably, the feelings of any work group can determine those of the entire
21 Staff Evaluation and Presentation of Organisational Culture 423

organisation. That is, any person able to express his/her feelings and control the
feelings of others is also able to strengthen or weaken the group’s morale and
performance.

21.2 Implementation of Evaluation Towards Improving

the Quality of Mental Health Services

The quality and performance of the health sector in any country and Greece in par-
ticular are increasingly drawing the attention of the state apparatus, including the citi-
zens/patients’ interest. The health sector, which in global literature is defined as the
sector with the greatest range of and concentration of services in any field (clustered
service) (Fitzsimmons and Fitzsimmons 2006), is about satisfying the physical, psy-
chological and social needs of the patient. Healthcare providers in Greece are looking
for new solutions to old problems, such as measuring the effectiveness of an organ-
isation and developing alternative national funding models for the healthcare system,
the quality of medical services, the adoption of new technologies (e.g. information
and communication technologies or ICTs) and issues relating to patient safety.
Health service providers are increasingly confronted with a broad range of social,
economic, political, regulatory and cultural changes (e.g. culture) which, compared
to other humanitarian factors, lead to an increase in demand from all interested par-
ties for greater efficiency, reduced costs and the provision of superior quality
services (Tsiotras 2002).
Organisational culture is fundamental for all interested parties in the political and
business world. The international community, regulatory authorities as well as sev-
eral organisations have expressed views and conducted research on the best imple-
mentation of a common organisational framework in all types of organisations.
Internationally, such proposals highlight the fact that the implementation of such
procedures may lead to an increase in competitiveness and a better corporate image
while improving the reliability of the services provided.

21.3 Presentation of Case Study

Pre-existing Situation

The division of subcultures was initially identified by the management of the

Association for Regional Development and Mental Health (EPAPSY). EPAPSY
was established in 1988, as part of the Leros Psychiatric Hospital deinstitutionalisa-
tion programme (www.me-psyxi.gr). It is a recognised non-governmental organisa-
tion operating in the field of psychosocial rehabilitation and mental health promotion
throughout Greece. During the intervention period, and within the framework of the
National Plan for Mental Health “PSYCHARGOS”, it was responsible for provid-
ing scientific and administrative support to a total of 14 units, including 2 mobile
units. More specifically, its objective is to provide a comprehensive mental
424 S. Stylianidis et al.

healthcare model to the community and to restore the abilities of individuals with
special psychosocial needs, by preparing them appropriately, on a professional and
personal level, to facilitate their reintegration in daily life.
The need to highlight the challenge involved aims to ensure the smooth operation
and to preserve collegiality which, in turn, lead to the creation of a work group, in
order to investigate the organisational culture and identify the individual work
dynamics, attitudes, perceptions and behaviours of its employees, the logic of evalu-
ation and staff development.
Employees are useful sources (resources) of information for the development of
a high-efficiency framework organisation, namely, (a) the satisfaction derived by
patients through their physical and psychological contact with the employees, (b)
the job satisfaction derived by the staff and (c) the organisational development and
evolutionary change of the framework. The patients, on the other hand, are the most
important and reliable judges.
In this particular administrative intervention, it was deemed necessary to estab-
lish sound impact indicators, since as a result of this, we were led to establish crite-
ria on the basis of which the system’s operational impact would be assessed.
Consequently, the adoption or creation of indicators with good psychometric prop-
erties (validity, reliability, sensitivity to change) was a necessary investment which
contributed in studying the efficiency of the system. In this context, it was decided
to adopt and implement a multi-agency evaluation model for continuous quality
improvement, based on the PROJECT method, i.e. a holistic action approach, con-
sidering that:

(a) A new approach to modelling the individual quality criteria is introduced

(Tsirintani et al. 2010), together with assessment of the medical and nursing
staff quality levels, the organisation of processes and the living conditions of
patients.
(b) The manner in which the services are offered to the service users, which also
shapes the final product offered, affects to a considerable extent their percep-
tion and ultimate satisfaction from the services provided (Pierrakis and
Tomaras 2009).

The main objective of organisational culture evaluation is to establish a method-

ological continuous quality improvement (CQI) framework, in the context of “clini-
cal governance” (CG), which is one of the most topical issues in the reorganisation
and adaptation of procedures/processes, as well as all changes at the organisational
culture level. The change in the existing culture is an essential precondition for the
successful implementation of a uniform code of communication and operation. All
employees aspire to work in an organisation with a memory that will provide them
with lifelong learning, recognise their contribution and support their efforts to
improve service quality and view mistakes as opportunities for additional learning
and experience (Xyrotyri-Koufidou 2001).
Accordingly, the management of EPAPSY considers the quality of service
responsiveness a key factor in promoting user satisfaction as well as the satisfaction
21 Staff Evaluation and Presentation of Organisational Culture 425

of staff working in comparable, at the level of supply and professional competency.

It has been established that acceptance of the fact that the patients/relatives’ satis-
faction from the care provided is related to the effectiveness of the therapy
(Henderson et al. 1999), and the fact that dissatisfaction is a significant leakage in
care continuity (Ruggeri 1994), the objective set out for this action was to ensure the
best possible use of the human resources within the structures of the organisation by
evaluating and retraining the existing staff.

Administrative Initiative

The change in EPAPSY’s culture is a further opportunity to identify ways and pos-
sibilities to migrate professionals out of the current clinical culture complacency
zone to a culture of challenge where dynamic learning prevails (Moran 2003).
The initiative taken by the administration is focused on the following:

A. Job satisfaction
B. Job involvement
C. Organisational commitment – dedication

We hope that this so-called shared culture will form part of its defence against
any difficulties encountered, mainly owing to the complexity of the operation of the
health system.
The multifaceted methodological approach (use of multiple tools) proposed,
together with the ability to implement the results both in educational and clinical
practice, as already proposed and supported by international literature and practice,
is an innovative element of this intervention.

Methodology

The steps followed by the project team are described below:

A. The first phase included a review of the literature on the aforementioned fields
in order to lay down in detail the theoretical framework of the research, taking
into consideration the multidimensional approach of the subject matter, using
the input from previous research programme analyses.
B. The second phase included the selection-combination-creation of tools to be
used to identify the reference framework for the therapist staff. To enable the
measurement of concepts associated with specific actions, it was necessary to
record all available information in literature and any external observable behav-
iour, while a question/variable database was created.
C. The third phase included a survey of EPAPSY’s structures which involved issu-
ing a questionnaire to mental health professionals and patient relatives and the
collection of statistical information. The staff completed five questionnaires in
426 S. Stylianidis et al.

total (based on quantitative and qualitative criteria) relating to socio-demographic

characteristics, the needs and attitudes with respect to specific matters and
policies, organisational culture, job satisfaction, mental fatigue/exhaustion,
degree of responsiveness in the provision of mental health services as well as a
self-evaluation. The patients’ relatives also completed questionnaires relating to
their satisfaction from the services provided by the organisation.
The method of reverse measurement (reverse scored) was used in some of the
questions in order to prevent the mechanical completion of these questionnaires.
D. The next phase included the codification and creation of a survey data file in
SPSS.
Ε. This was followed by the analysis of the data collected and comparative presen-
tation of results which included individual corrections and selected modifica-
tions of the research process, based on remarks and comments on the results of
the previous phase.
F. And the final phase, which included an review of the results/findings.

Results

The survey was carried out during the period March–May 2011, on all EPAPSY
structures (14 residential units, 2 mobile units, 1 day centre, central administration)
with 210 participants (N = 210, 79 % women). The average age of employees par-
ticipating in the survey was 35.9, of which 38 % were married and most of them
(96 %) were Greek nationals. In terms of education, 36 % were primary/secondary
education graduates (6–12 years of schooling), 14 % held a postgraduate academic
title and 1.5 % a PhD. Half (51 %) had no prior working experience in the field of
mental health prior to joining the EPAPSY. In terms of work experience, 36 % had
less than 1 year, 28 % 1–4 years and 2 % over 10 years.
Subsequently, a review of any differences between the various specialisations
and the views of employees as to the nature of their duties was carried out. To facili-
tate the analysis process and to enhance its statistical validity, the psychiatrists and
psychologists were grouped in one category, SE and HE nurses in a second category
and professionals in a third category which included physiotherapists, social work-
ers and occupational therapists; a fourth category included all administrative and
technical staff and, finally, a fifth category included all general clerical staff.
Escorting residents/users on outings in the community is recognised as a duty by
all nurses and most of the general clerical staff as well as other mental health profes-
sionals. Most psychiatrists/psychologists and administrative/technical staff did not
consider this one of their duties. Carrying out a diagnostic assessment is recognised
as a duty by most psychiatrists/psychologists and approximately one out of three
nurses. Employees in other work areas do not consider diagnostic assessments part
of their job. The chi-square statistical verification highlighted these differences
between specialties as statistically significant: χ2 (4) =72.48, p = 0.000 (<0.01). Staff
21 Staff Evaluation and Presentation of Organisational Culture 427

training did not seem to be recognised as a duty by the vast majority of the sample
(82 %). The sole exception is perhaps the psychiatrists/psychologists category,
where one out of two considers staff training part of their duties. The chi-square
statistical verification highlighted the presence of a statistically significant interac-
tion between this duty and their work area: χ2 (4) =32.88, p = 0.000 (<0.01). Training
residents in independent living is recognised as one of their duties by the major part
of the sample in general and the nurses and other professional and general clerical
staff in particular. On the other hand, only 47 % of psychiatrists/psychologists and
2 % of administrative and technical staff consider the training of residents in inde-
pendent living one of their duties. The differences identified between specialties/
work areas verge on being statistically significant: χ2 (4) =55.78, p = 0.000 (<0.01).
As to the part that the various parameters played in the participants’ decision to
work for EPAPSY, the results are summarised in the table below. The highest aver-
ages reflect the highest contribution in the decision to work for EPAPSY.
Descriptive results regarding the significance of each parameter in the decision
to work for EPAPSY

Sample Standard
Reasons number Average Median deviation
Descent from the prefecture or the area where the 164 3.43 4 1.58
structure is located
Residence in the area where the structure is located 166 3.13 3 1.56
Existence of substantial structures and specialised 161 2.32 2 0.98
staff
Daily learning and development potential 164 2.07 2 0.95
Existence of an employee in the unit with a positive 168 3.23 3 1.48
influence
Relaxed working conditions 160 4.13 5 1.13
Provision of services to socially vulnerable groups 165 1.83 2 0.87
Provision of services to remote areas 152 3.17 3 1.44
For income-earning purposes 163 1.87 2 0.94

The sample’s most significant incentives were as follows (listed from the most
significant to the less significant):

Working environment (extremely/very significant incentive for 83.6 % of the

sample)
Financial rewards
Intellectual and personal development
Work experience
Recognition by the work environment
Well-organised network
Vacation
Professional development
428 S. Stylianidis et al.

The five areas in which the sample rated performance as high:

I give meaning to the results produced by the therapy (6, 12/7).

I establish trust relationships with the patients.
I have a good relationship with my colleagues.
I communicate smoothly with the patients.
I evaluate myself.
I provide information to patients and caregivers.
I assess the clinical needs of patients.

The five areas in which the sample rated performance as low:

1. I prepare reports on research projects (3.04/7).

2. I have access to research resources (e.g. funds, information and equipment).
3. I research the literature which is relevant to my work.
4. I undertake administrative activities.
5. I take initiatives in community work.

The factorial analysis of the organisational culture questionnaire per factor

identified the following factors as significant (an explanation of their significance is
provided):

Factor Comments
Company profile A high score is interpreted as a positive attitude
towards the profile of the company
Team spirit-collegiality A high score is interpreted as retention of confidence
that collegiality/team spirit within the company/
structure is at a high level
Interpersonal relations with A high score is interpreted as reflecting the
colleagues respondent’s positive interpersonal relations with his/
her colleagues
Interpersonal relations with A high score is interpreted as reflecting the
colleagues respondent’s positive interpersonal relations with his/
her superiors
Job satisfaction A high score is interpreted as higher job satisfaction
Education-training A high score is interpreted as retention of confidence
that the respondent feels he/she has received the
appropriate education and training to perform
efficiently and effectively his/her duties (including the
underlying weight accorded to the importance of
education and training)
Recognition A high score is interpreted as retention of confidence
that EPAPSY acknowledges the efforts, initiatives and
importance of the work of the staff
Evaluation mechanism A high score is interpreted as retention of confidence
that the evaluation mechanism is appropriate and
relevant
21 Staff Evaluation and Presentation of Organisational Culture 429

Rating of structures according to their responses:

Lowest Highest Neutral point Lowest

possible score possible (neither Higher ranking
(total score (total agreement nor ranking place place
Factor disagreement) agreement) disagreement) (median) (median)
Company 14 70 42 Livadia 58 Odysseus
profile 43
Team 7 35 21 Odysseus 34 Penteli 17
spirit-
collegiality
Interpersonal 7 35 21 Odysseus 32.5 Lamia 13
relations with
colleagues
Interpersonal 8 40 24 Livadia 38 Penteli 32
relations with
colleagues
Job 4 20 12 Day Centre HQ 11
satisfaction 20
Education- 4 20 12 Livadia 18 Ariadne 10
Training
Recognition 3 15 9 Livadia 12 Ariadne 9
Evaluation 3 15 9 Livadia 12 HQ 9
mechanism

21.4 Organisational Culture Questionnaire: Overall Score

Based on the 50 entries corresponding to 8 factors

Lowest possible score: 50 (total disagreement)
Highest possible score: 250 (total agreement)
Neutral point: 150 (neither agreement nor disagreement)

EPAPSY structurea Number of respondentsb Median Minimum Maximumc

Livadia 15 219 181 246
Melissia DC 11 210 182 230
Eretria 15 203 170 242
Manikas – Chalkida 22 200.5 160 244
Odysseus 10 200 175 223
N.E. Cyclades 10 198.5 158 227
Lykovrissi 19 197 169 232
Thetis 15 196 139 239
Trikala 15 195 177 244
West Cyclades 10 195 167 199
Residential Unit in Chalkida 8 191.5 172 227
Penteli 17 191 161 220
430 S. Stylianidis et al.

EPAPSY structurea Number of respondentsb Median Minimum Maximumc

Lamia 15 187 146 219
Ariadne 13 185 107 225
HQ 10 170 150 221
a
The structures are set out by ranking order according to each factor score.
b
The number of respondents does not correspond to the number of staff in the structure, but to the
number of respondents in each structure whose responses were taken into account.
c
A high score is interpreted as a positive attitude towards the organisation in general.

The qualitative analysis of the data collected was carried out based on dimen-
sions/factors of the supportive environment found in literature, as set out below:

Emotional commitment to the company (affective organisational commitment)

(Rhoades et al. 2001)
Employee expectations in terms of reward for their work (effort-reward expectan-
cies) (Eisenberger et al. 1990)
Duration of commitment (continuance commitment) (Shore and Tetrick 1991)
Employer-employee conciliation (leader-member exchange) (Wayne et al. 1997)
Supervisor support (Kottke and Sharafinski 2008)
Equal and fair treatment (procedural justice) (Andrews and Kacmar 2001)
Job satisfaction (Aquino and Griffeth 1999)
Burnout syndrome

The review of the results focused on appraising the following points:

1. Fair treatment: refers to the quality of interpersonal treatment in the allocation of

resources, as well as the provision of information to employees on the manner in
which the organisation’s operating procedure is monitored.
2. Supervisor support partly inefficient: wherein the selective inability of the struc-
tures to supervise their clinical work is identified, as opposed to the mobile units
which indicate satisfaction.
3. Rewards-working conditions at a satisfactory level: wherein serious complaints
are expressed by the entire staff, owing to delays in the flow of funding.
4. Education partly inadequate: the structures located outside the prefecture of
Attica are experiencing confusion and give the impression that the organisation
should take additional actions in terms of education and training, by investing in
its human capital.
5. Personal characteristics: the entire staff places particular emphasis and attaches
importance on behaviour between employees, team dynamics and relationships
which are reflected by the patients. Relations between employees are described
as satisfactory.
6. Demographic characteristics: a file was compiled with the employees’ social
profile, interests and needs.
21 Staff Evaluation and Presentation of Organisational Culture 431

Particular attention was also given to the employees’ emotional capacity, since
provision was made for partially completed questionnaires, in order to maintain
anonymity and to ensure that the results of the survey would contribute in their
self-improvement and, consequently, in improving the internal dynamics of
employees.
The results identified during the analysis of qualitative data can be divided up
into sets of interventions and management changes related to the following areas:

A. Commitment to the objectives of the organisation. On the basis of the rule of

mutual cooperation, the employee is obliged to ensure the welfare of the organ-
isation (Eisenberg and Rhoades 2006), thereby enhancing his/her own emo-
tional commitment. At the same time, they intensify their efforts to address their
social and emotional needs (Armeli et al. 1998), thereby creating a strong sense
of belonging to the organisation.
Β. Participation in work. Emphasise each employee’s recognition, interest and
involvement in a specific activity; the recorded lack of incentive signals; the
need to motivate employees, by raising their perception of the commitment to
the objectives of the organisation; and, in general, the field of mental health.
C. Performance. The spontaneous offer of assistance between employees, the pro-
motion of initiatives aimed to protect the organisation against risks, as well as
the development of skills which are beneficial to the organisation can improve
staff performance levels.
D. Job satisfaction. The enhancement of positive thinking, definition of the concept
of individual incentives, consideration of the needs of employees, improvement
of the subjective and objective value of employees and enhancement of job
retention.
Ε. Psychosomatic-psychological reactions. Practical support to the organisation
for the work carried out by its employees, so as to enable them to cope with the
high demands of their work. Emphasis on how to handle stress and exhaustion
caused in similar fields of work.
F. Multivariable as well as exploratory factorial analysis techniques were used to
analyse quantitative data.

Conclusions

According to Mair (2002), the subjective interpretation by employees of the support

environment, their personal characteristics/skills and their self-efficacy beliefs
account for the differences identified at the organisational culture level. For exam-
ple, employees who are treated fairly by the organisation are more likely to become
emotionally committed to it (Mowday et al. 1982; Meyer and Allen 1997), perform
their duties, meet their obligations and respond to problems or any emerging
opportunities.
432 S. Stylianidis et al.

In specific terms, the points of concern are outline below:

(a) Information overload: this is caused by the wealth of existing sources and the
inability to assess and organise the amount of incoming information available to
the organisation.
(b) Inadequate dissemination and processing of knowledge: according to initial
observations, knowledge is not disseminated equally to all structures of the
organisation, mainly owning to their location (topography).
(c) Obstacle-confounding phenomena in horizontal and vertical communication
resulting in the distortion of the initial meaning of the mission and, more gener-
ally, the activities of the organisation.
(d) Evidence of widespread frustration relating to the inability of access of finan-
cial resources, the flow of funding and the proximity between staff and
management.

Mair (2002) underlines also that staff behaviour can be analysed by incorporat-
ing the two dominant theories (macro- and microculture theory) and introducing at
the same time views of the social-cognitive theory (Bandura 1997). According to
this theory, behaviour and factors originating from the environment, personal and
cognitive factors are interrelated. Against this background and the social and job
insecurity conditions prevailing during the period in question, it is possible to inter-
pret the fact that, despite the opportunities provided by the organisation, the employ-
ees are expressing their failure to understand this effort and, at the same time, are
unable to put forward any arguments concerning their wants and needs.

Intervention Limitations

Despite the attempt to define the relationships between concepts measured for the
first time using such methods, this specific intervention presents certain limita-
tions, which do not seem to affect the validity and reliability of the results. It is
initially proposed to introduce additional emotional dimensions reported in litera-
ture. Another limitation is the lack of information on alternative mechanisms
through which awareness of the supportive environment affects corporate behav-
iour such as, for example, the feeling of obligation possibly experienced by
employees which, as emphasised by Eisenberger and Rhoades (2006), mitigates
this relationship.

Conclusion
The assessment of the results constitutes part of the comprehensive overview of
qualitative and quantitative data in any ongoing process. At a later stage, it is
proposed to conduct one-on-one interviews with the staff, as well as focus
groups, in order to examine in depth the gap between the organisation’s stated
objectives and strategies and daily practice, particularly in residential psychoso-
cial rehabilitation.
21 Staff Evaluation and Presentation of Organisational Culture 433

It is important to mention that the human factor is a company’s or organisa-

tion’s greatest and most lucrative asset, and it is certain that in the future, the
needs to support this factor will continue to grow rapidly. In addition, live
organisation should be able to process the continuous inconsistencies arising
from its operation and not to rationalise them through routine or standard proce-
dures, something which is particularly evident in the field of psychiatric reform.
Furthermore, building on the research material provides a safe method of under-
standing the chronicity of staff work patterns and new chronicity patterns of
patients, a finding documented in literature (Stylianidis et al. 2007). Finally, the
key concept reflecting this interest in the human factor, particularly within the
framework of deinstitutionalisation and psychiatric reform, is J. Hochman’s
mental institution. In order to try to understand what happens during a psychotic
situation, this institution does not refer to the hospital but to the ideal space
(Hochmann 2003). The multidisciplinary team protecting the system from the
spread of chaos undertakes to create this transitional space, motivated by the
need to help the service users (Stylianidis 2003). Our primary objective is to act
accordingly in a system that generates contradictions and ambivalent feelings
with apparent deficiencies and gaps in the way in which it operates (Stylianidis
and Chondros 2010). The psychomental institution protects the operation of the
therapeutic team, the user as well as their family member against the as if opera-
tion of the public mental health system (Stylianidis et al. 2009).

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 Part IV
Empowering and Rights in Mental Health
User and Family Participation in Mental
Health Services 22
Panagiotis Chondros, Stelios Stylianidis,
and Michael Lavdas

Abstract
This chapter describes the different areas of user involvement (relevant
interventions, type and quality of provided services, professionals and user
training, research direction and criticism, supporting legal framework
empowerment and implementation), the data on the extent of this involvement on
European and national level and the institutional, clinical and ideological
framework that determines user involvement in the issues that concern this
group. The necessity of extending the debate between the involved parties (users,
professionals, relatives, decision-makers at health policy level, etc.) and the
terms and conditions that will make this debate equal, essential and productive
are the points this chapter is focused on.

22.1 Introduction

The more we examine the different ways users are involved in mental health services
and their aftermath in the process of empowerment of their voice in the improve-
ment of issues of quality, information available and capability of choice, protection,

P. Chondros (*) • M. Lavdas

Association for Regional Development and Mental Health EPAPSY, Athens, Greece
e-mail: [email protected]; [email protected]
S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 437

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_22
438 P. Chondros et al.

rights and obligations advocacy, the more we come face to face with the resistance
both among professionals and the patients to re-negotiate their roles and their rela-
tionship. So, as we look into the often difficult relationship between patients and
mental health professionals and the one between patients and relatives’ associa-
tions, we see two main trends in the patients’ movement: one by the abolitionists,
seeking to abolish psychiatry, and another seeking to reform it, the reformists (Van
Hoorn 1992, p. 30). In this chapter we will describe certain matters of mostly tech-
nical nature, relevant to user participation in mental health services, such as the
institutional framework dictating user involvement in the issues that concern them
or the various areas of user involvement (kind and quality of provided services,
professionals’ and users’ training, research direction and criticism, legal framework
empowerment and implementation). We will, however, also refer to the framework
needed for a consequent step and the establishment of a movement on which all this
will be supported and solidly built. A number of the questions that arise, and we
will attempt to respond to here, are the following: What is the growth process of
such a movement? What will be its social role and position? What are the problems
and resistances in their development? Who can guarantee their autonomy?

22.2 Conceptual and Clinical Clarifications: A Sensitive

Semiology

The term (user, recipient, survivor, consumer, etc.) in each case of involvement con-
tinues to be the main problem; however this does not affect the characteristics of the
social role and identity that the term carries and the interaction with society and the
status quo, the professionals and the services’ system. Of course, the prevailing term
indicates a range of characteristics pertaining to the status quo, the social norms and
the prospects. It follows that the selected terminology is not free of ethical, social
and cultural origins. The user’s position and role may differ to a great extent among
various social groups or individuals. This is due to the representation and the degree
that the specific social identity, selected or not, may causes conflict, constitute the
cause for social support or, conversely, exclusion. The different roles and identities
include a patient, an individual who feels inferior, a disabled person, one who is dif-
ferent or has special skills, a marginalised person, a dangerous person, a creative one
and so on. We must note that in Greece, user and families associations have chosen
the term “Receiver” (λήπτης) as opposed to user because this term, as they believe,
refers in the Greek culture directly to the concept of “drug user”.
The term advocacy, as well, carries enough complexity, as does any term trans-
ferred from different cultural, institutional, historical and scientific conditions.
Advocacy is a way of helping an individual who believes he is victim of a prejudice
or feels that his or her institutional interlocutors do not listen or respect him suffi-
ciently and who encounters big obstacles in the exercise of his rights as a citizen to
express herself or himself through the intervention of a third party.
Advocacy is a social mediation practice introducing a third party, who strength-
ens the request of the patient/user of the services without someone speaking in his
place. Furthermore, it permits the different views to be arranged in a framework of
22 User and Family Participation in Mental Health Services 439

debate that is conducted in mutual respect. As a social mediation function, the advo-
cator covers many of the aspects of advocacy beyond the field of mental health.
Supporting the Other’s word, through an active process of transition from a position
of disdain to a position of dignity, the individual’s empowerment through his active
participation comprises a conceptual framework at the opposite side of a philan-
thropic and welfare ideology (Stylianidis et al. 2011b).
We know that in the cases where asylum-based, closed care has primary respon-
sibility over the individual’s relations with society, the individual remains silent, is
disdained, withdraws and becomes a passive recipient of services and not a citizen
who is seeking his social emancipation. The term “social” includes a mosaic of
levels of a reality, such as the judiciary-legal, the intersubjective, the medical, the
political and the psychological. Each of these levels requires a specific response that
depends on the other responses, aiming at the individual’s holistic support. Accepting
diversity is to open the patient’s social and mental potential so he may experience
what he is, without being limited within a special ghetto, in terms of his difference.
This is a moral, political and social problem, not a technical one. The introduction
of a third party is the necessary condition in the establishment of a place of dia-
logue, conversation and mutual listening: “everything is language”, wrote Françoise
Dolto, in 1980. One thing that is said but not heard, e.g. in the context of a therapeu-
tic relationship of mental health team-patient, is as though it has not been said and
has not been recognised as an expression of the Other.
A final term we often encounter and feel we ought to comment on is empower-
ment. During this process, it is the patient who rediscovers a part of his life and
tries to determine “himself for himself” because the experience of mental illness is
deeply debilitating and a source of self-stigmatisation for the mentally ill patient.
The empowerment process describes the opposite: the recovery of the patient’s
negotiating power, not only with his own support but also that of the mental health
professionals, volunteers, a relationship system and grid motivated by advocacy.
The models to achieve something like it are different: they are related, besides the
political, institutional actors, with the different cultural frameworks and the phi-
losophy of the mental health services, but mostly with the social power of the
users’ movement. The medical and social axis, between which oscillates the prac-
tice of psychiatry, also shows the context in which contrasts are being managed
(Stylianidis et al. 2014).

22.3 The Nature of User Involvement

The forms of participation of users and their families are manifold:

Training of other users or family members or professionals

Informing other users, family members, the general public and the mass media
Support – provision of services
Complaint
Claim
Advocacy
440 P. Chondros et al.

Programme, action and service evaluation

Research
Programme, action and services planning

In most cases, users are involved in the provision of services usually as persons
of reference or case managers. These services differ in comparison with services
that are not provided by individuals who are now or were in the past, users of the
services, as to the time dedicated to supervision, individual sessions with patients or
the work in the community (Simpson and House 2002). Users working in the ser-
vices dedicate more time to them and less to administrative work. There are, how-
ever, cases of users working in services not as therapists, but at administrative or
consultant level related to the actions being implemented. This way, they can work
in the secretariat or at reception, as well as in higher positions, in steering groups or
even boards of directors.
The next level where we encounter user involvement is that of research – given
the fact that in research conducted in recent decades, 95 % of the cases pertain to
objectives and methodologies that are not close to patient’s preferences and priori-
ties. The literature is therefore flooded, with the relevant resources being tied up
there, by research on the effectiveness of psychotropic drugs and on the genetic
factors of mental disease, while users would prefer to know more about the effec-
tiveness of psychotherapy or methods of self-help (Hatcher et al. 2005). Unless the
research agenda changes, user involvement in research increases the possibility of
ensuring ethics and the participation of patients in this area. Users work in research
planning, in data collection as interviewers and in results analysis.
Finally, a significant area of involvement is training. There is significant experi-
ence of good practice in user involvement as trainers, a characteristic example being
the experience of the EMILIA project. Users can train either other users, so that they
may in turn assume active roles or professionals. Having users training profession-
als, particularly young ones, is an emerging request in our country. Our view is that
training is a privileged place for creating an important meeting place on an equal
basis between professionals and users, as the relationship between the trainer and
trainee may be reversed, depending on the objective and the training methodology.
In training objectives, however, such as the concept of the healing and recovery
process, organising and empowering the self-representation groups, there is room to
extend the knowledge and experience of all, irrespective of whether they have been
services users, provided there is structured and clear training philosophy and meth-
odology (Lampaki et al. 2008).

22.4 Data Regarding Participation and Involvement

We must obtain a bigger database of studies about the effect of involvement on users
and the provided services. There are still no sufficient and strong research data
regarding the difference there can be at the level of symptomatology, functionality
22 User and Family Participation in Mental Health Services 441

and quality of life for the user who is involved in mental health services. Other
sources report an improvement in the clinical conditions and outcome on the basis
of measurements related to quality of life (Thornicroft and Tansella 2005). Elsewhere
(Simpson and House 2002), it is mentioned that individuals who receive services
from users show the same or lower level of satisfaction from the provided services,
also depending on the time period the use of the services lasts. There is also less
satisfaction when patients participate in research where users are involved.
According to the systematic review of relevant research, there is positive attitude
with regard to training procedures, where users of the services have an active role.
In the UK, the Ministry of Health has determined an institutional framework
directing all services to promote user involvement (Appleby 2000). Conversely, in
the USA, the discussion differs slightly, as the relationship between users and the
system is one of controversy. Here, the users’ position and role came to the fore-
front, not for actual therapeutic reasons, but as an investigation of their position
versus the services system and the insurance system in particular. This is how the
terms consumer or client prevailed, as the user is the individual who receives or is
entitled to the services, whether he pays or not – subsequently survivor for the
individuals who experienced the adverse consequences of a system with tragic
inequalities in dealing with patients (Andreasen 1995). As to Greece, there is a need
to structure literature on the subject.

22.5 Data at European Level

The first reference to a collective movement on behalf of individuals with mental

health problems was in 1845, with the Alleged Lunatics’ Friend Society. The biggest
growth with regard to the antipsychiatry movement occurred in the 1960s and 1970s.
The oldest reference to associations in the form we currently recognise them by dates
to the 1960s, in Norway and Sweden. As a result, the users’ association in Sweden,
Riksförbundet för Social och Mental Hälsa – Swedish National Association for Social
and Mental Health (RSMH) currently numbers 8000 members. The main character-
istic of the early movements was the fact that they did not stand the test of time.
The establishment and development of associations promoting participation are
related to the transfer of care from asylum structures to community structures. We
have to point out that historical evolution in Central and Eastern Europe was very
different due to its dependence from politics.
As to the number of user associations, seven European countries (including Cyprus
and Turkey) do not have any associations. Ten countries have 1 association each, 15
(with Greece among them) have 2–5, while 7 countries have 6–10 associations.
Austria, Germany, Italy and Switzerland have 11–20 associations and Holland and
Spain have 21–30. France and the UK have the highest number; they each have more
than 30 associations. With regard to the number of family associations, the European
Federation of Families of People with Mental Illness (EUFAMI) reports that its mem-
bers are 37 family associations and 8 other associations from 24 countries (ENUSP).
442 P. Chondros et al.

The European Office of the World Health Organisation (WHO, 2008, 2011)
provides data regarding the extent of user and family involvement and representa-
tion (on the basis of whether there is representation or guidelines):

• In committees relevant to the services (in planning, implementation, review)

• In committees relevant to actions (in stigma, prevention, promotion of mental
health)

In the countries where they exist, family associations participate in the formula-
tion and implementation of legislation in 34 % of cases on a regular basis, in 50 %
on a non-regular basis and in 16 % never or rarely. For the establishment or opera-
tion of associations, there is systematic government financial support in 15 of the 42
countries. Of the EU15 countries, government support is not provided in Finland,
Italy, Greece and Sweden.
Users participate in committees related to the planning of services in 20 of the 42
countries (47.6 %), as do families. In committees for the implementation of plans
related to the services, we have user participation in 15 countries and family partici-
pation in 18 of the 42 (35.7 %). For review, participation in committees exists in 17
countries for users and 17 for families, out of the 42 (40.4 %).
In committees related to actions (stigma, prevention, promotion) there are 12
countries, Greece included, where there is no participation at all. Namely, users and
families are not represented at any action implementation level for mental health
(planning, application, review).
This WHO research for Europe does not, of course, show us the quality of
involvement. However, representation may mean anything from a simple presence
to participation in the decision-making. The actions and services to which we refer
differ to a great extent between and within countries.
From the comparative study of the data, we arrive at a series of conclusions. The
extent of representation and support is consistent with the available resources as
well as each country’s model of services. If there is involvement in an area, there is
increased possibility of it in more areas. Users and families are represented and sup-
ported without big differences. The WHO concludes that what is missing are regula-
tions, specific procedures, study of the involvement and relationship characteristics
between associations and other involved bodies.

22.6 Data on User and Family Involvement in Greece

The law on mental health (2716/99) stipulates the participation of representatives in

the Protection Committee of rights of individuals with mental disorders of the
Ministry of Health. There are also family and user association representatives on the
external evaluation committee established in 2013.
In March 2011, the psychiatric reform intervention implementation evaluation
report for 2000–2009 says that the users’ and families’ views are negative with
regard to the current situation. On the one hand, there has been general
22 User and Family Participation in Mental Health Services 443

improvement, in the relationship between the staff and the users (which was
described as “our voice is now heard”) and the attitudes of society in general; on the
other hand, users refer to the extensive dependence they continue to have on their
families (that are often exhausted), their inability to comprehend the system and
their ignorance with regard to where they should apply to receive information and
help. They also noted the inhuman conditions in various hospitals (patients tied to
the beds), expressed their suspicions with regard to whether the money is spent cor-
rectly, referred to the difficulties many patients experience upon entering the system
(especially insofar as the housing structures) and noted the lack of respect they face
(particular mention was made of the Limited Liability Social Cooperative [LLSC –
KoiSPE], where patients are used as “servants”).
In 2011, representatives of the Associations were included in the PSYCHARGOS
Review Team. Two focus groups were conducted in the context of this team’s work
with the Ombudsman in April of 2012. Nineteen individuals participated in those,
from seven user-family associations and from seven other bodies (e.g. Ministry of
Health, committee of rights, Ombudsman, professional associations) (Stylianidis
et al. 2011b).
Summarising the points recorded during these special meetings of the work
group, the following were recognised as core priorities according to the participat-
ing user and family representatives (Stylianidis et al. 2011a, pp. 33–34):

• Continuing efforts to implement community psychiatry modern principles and

establish psychiatric reform
• Enhancing active user and family association participation and involvement in
policy planning and decision-making in mental health
• Educating psychiatric and legal community on new evaluation tools on human
rights and medical ethics violations in the field of psychiatry
• Pointing out malpractice and basic human rights violations, as well as exhausting
legal means to lodge complaints and seek punishment for them.
• Using evaluation tools for the level of rights and care protection, such as those
advocated by the World Health Organisation
• Establishing Ombudsmen in every Healthcare District, in the context of
sectorisation
• Integrating mental health service users and their families in the functioning of
modern empowerment services

The result of the previous actions is the 10-year growth programme of the
PSYCHARGOS C’ (2011–2020) mental health units and actions, which reports in
Axis 4 as a priority the “Protection of mentally ill patient rights and advocacy for
their mental health, and the promotion of self-representation of mental health ser-
vice users and their families”.
User associations and the Federation of Families’ Associations for mental health
are included in the National Federation of Persons with Disabilities (ESAMEA).
The latter implemented a project in 2011–2014 entitled “Empowerment of Collective
Expression and Advocacy for Persons with Mental Disability”. This project included
444 P. Chondros et al.

organising local meetings in over 20 areas in Greece, for the purpose of informing
users on the ways of organising and defending their rights and training trainers on
objectives such as empowerment, advocacy, support in organising associations and,
finally, user training in the corresponding subjects. The actions by ESAMEA pro-
mote the users’ systematic information, in line with the Convention on the Rights of
Persons with Disabilities.

22.7 The Relationship with the Mental Health Professionals:

The Psychiatrist in the Forefront

In a pair such as the patient and the doctor, which is the focus of our discussion,
each one is determined through their relationship with the other. There are two
trends in this pair. On the one hand, the one fighting for a consensual and comple-
mentary relationship; here the doctor ideally fights to restore the patient’s health and
to protect him, despite the asymmetry in the relationship. According to the social
norms, patients are faced with a socially deviant existence; they have to want to
recover and the doctors are the ones to help. On the other hand, there is a trend
describing the relationship as one of conflict. The perception is that the patient-
doctor relationship, generally and particularly in the area of mental health, appears
to be one of conflict and full of challenges and prevails both in the research literature
and in daily institutional/clinical experience. The constant motif of both the consen-
sual and conflicting approach is that the doctor-patient relationship is asymmetrical.
The professionals obtain their power from their established authority. This in turn
permits them to operate as mediators in social control (Nettleton 2002, pp. 190–1).
However, the extent to which a doctor must exercise his authority remains particu-
larly questionable. Patients have to face a double bond. On the one hand, they
encounter more and more proclamations calling them to claim their rights in infor-
mation and decision-making, to seek information from multiple sources and to have
a say in the quality of the provided services, and on the other hand, they are required
to submit to the doctor’s judgement and expertise.
Let us ponder the area of psychiatry in particular. The development of psychiatry,
closely following what is happening with people in society, is constantly transform-
ing clinical-theoretical models, means of organising services and a relationship with
users and their families. At the one end of the anthropographic spectrum, which is
psychiatric discourse, lies biological determinism and the medicalised view of men-
tal illness, while at the other end lie the ideas of safeguarding human rights, socially
emancipating sufferers, restoring dignity and fully integrating the “patients” of
medical thinking and praxis back into society.
What is the role of psychiatrists in all this? There is intense debate on how much
the developments in psychiatry and its transformations as a cognitive field and as a
scientific and socio-political institution have helped empower the voice of the users.
Psychiatry, full of stories of oppression and abuse of authority (Johnstone 1989),
appears to be evolving. We may not be too far from the times when an insane person
was perceived as a form of evil, which was still true up to the start of the twentieth
22 User and Family Participation in Mental Health Services 445

century, even in Europe and Greece (Stylianoudi and Chondros 2008; Stylianidis
et al. 2007). There is, on the other hand, some evidence of progress: new drugs, new
practices, evolved diagnostic, evaluation and monitoring methods for services and
growing documentation and publications. “A key word in developments in the area
of social revolution in the 20th century is post-. It was used as a prefix of numerous
terms by certain generations trying to define the intellectual territory of life in the
20th century… Just like at funerals, here, these prefixes officially certified death,
without involving any consent or actually certainty with regard to the nature of life
after death” (Hobsbawm 1997, pp. 368–9). We are facing one of the transformations
of psychiatry (Stylianidis 2006). We therefore also come to post-psychiatry. This
emphasises the social and cultural context and prioritises ethics versus technology,
while its purpose is to minimise medical control on interventions that include coer-
cion (Bracken and Thomas 2001). It commands a new agreement between psychia-
trists and users. It is a new trend, an alternative proposal to antipsychiatry, which,
again, is attempting to place the users’ voice and requests firmly in the forefront.
Many fields open up under this perspective and a large number of completely new
concepts and approaches, and it is to be reasonably wondered to what extent we now
know more, also bearing on mind Hobsbawm’s questioning.

22.8 Beyond the patient-doctor conflict: suggestions

for the empowerment of users and the change
in the culture of the services

The omniscience of knowledge organised opposite the ailing Other starts from this
shortfall and this gap in the voice of the other. The asymmetry of the medical-
healing relationship is organised around the knowledge and the know-how, around
the ignorance of the individual’s needs and their wishes. Thus, opinion is legalised
socially and supplies the stereotype dominating relationships between the psychiat-
ric team and patients-users, even if this is conducted in a theoretically “open” com-
munity framework and not within a total psychiatric institution (Stylianidis et al.
2008).
In this asymmetrical game, however, where one “loses” and the other “wins”,
each one is aware of both roles, the one stigmatising and the other being stigma-
tised. But in this game there are those who always loose, those who have been cast
out of the game: they either choose to always loose, be marginalised in a therapeutic
relationship or just leave the stage for good.
In this field, the intervention of advocacy by activating user participation plays a
determining role. It redetermines the rules of the game, integrating those who have
already lost or have been cast out and those who have chosen their place to be
absence from the world. The traditional therapist-client relationship in this confron-
tation without mediation represents an entire closed totalitarian system, with its
rules, rituals, language and codes, a true culture of authority in the psychiatric area.
User participation grants to those specified roles a mental, social and institutional
opening, strengthening, as F. Basaglia said, the negotiating position of the weak.
446 P. Chondros et al.

Against the position-based medical-psychiatric omnipotence of the one side versus

the other in a closed system, the introduction of a third party, an advocacy position,
makes existing prejudice lose ground, divides and transforms the identity of the
involved parties and constantly questions the narcissistic feedback of the powerful
(the members of the therapeutic team), the omnipotence of knowledge, the rigidity
of institutional mechanisms and the basis of the so-called (often complacently)
“therapeutic alliance” with the patient.
In the therapeutic alliance, the institutional framework, transference-counter-
transference movements in a dual relationship, identifications, investments, anti-
investments and dead-ends of the therapeutic process are no longer analysed.
Everything becomes more complex to the extent that the position and audience of
the Other are strengthened through the third party: patients are entered into a trian-
gulated process where the parts of the system are obligated to converse, if they wish
to exist as a system. The basis of common action and transformation of traditional
psychiatric culture towards a collective democracy of health can be established from
such a beginning.
In a statement regarding ethics, P. Ricoeur (1996) describes the doctor-patient
relationship as an agreement of trust, a kind of forged alliance between two people
against a common enemy, disease. However, before an agreement of trust can be
established, there must be a stage of suspicion, embarrassment and reluctance. The
patient expresses a request for treatment, suspicious versus the one who is in theory
the expert, and the doctor who tries to reply the patient’s requests, may, in turn,
become suspicious of the non-compliance to the treatment prescribed by him.
In order for the agreement to be established, Ricoeur (as above) tells us that both
involved parties must recognise the uniqueness of this relationship, the
“non-interchangeable character of one with the other”. Therefore, the only
possibility for this agreement to work is to consider the contracting parties as
partners, which requires the active involvement of the patient in the management
and development of his treatment. Medical secrecy is the legal expression of this
agreement and relationship between the two sides.
We can, however, observe three paradoxes included in this agreement. The first
paradox is that the subject is not an object, but the body is a part of the physical
reality observed and is “objectified” by ethics, the approach and the technical
arsenal of biological medicine-psychiatry. Psychiatry is often on a slippery slope,
following the disconnection of body and souls in a simplistic biological reduction-
ism, obscuring a big part of understanding and consequently the holistic care of the
ailing subject.
The second paradox has to do with the fact that the individual is not a commod-
ity, nor should medicine as a commercial product be subject to the laws of the
market; however, in fact, medicine has a price and a high social cost for public
health and private healthcare.
The last paradox overlaps the previous ones: anguish is private, but health is
public. If all these contradictions generate conflict and if misguided psychiatrisation
and the penalisation of social problems create enormous contrasts, the only possible
22 User and Family Participation in Mental Health Services 447

framework where a possible solution may emerge is the consensual/conflicting pro-

cess of the involved parties. On the basis of a “joint morale”, we are obligated to
discuss collectively and democratically the relations between disease and health and
what we call personalised care, treatment and life plan to showcase a “third way”
where the involved parties, namely, the social groups receiving services, the people
involved in general health and mental health and local communities with their rep-
resentatives, will empower their participative movement and will become involved
in openly processing and evaluating a health system, where all coexist.
Through such a process, new collective responsibility, new representations of
roles and relations of authority, new collective identities and new ways of social
integration may emerge for those that Hanna Arendt (1961) called “useless in this
world”; social practices of exclusion and neoliberal “philanthropy” may be radi-
cally challenged and a new democracy of health may be promoted. A change in the
system is not at all easy. Studies show that it is usually occasional, the exception
rather than the rule, while the parties involved easily return to previous, more con-
servative positions when they consider that the status quo is challenged or if they
feel that their identity is threatened if contested. In order for change to exist, we
must recognise new identity elements or even new identities for the involved parties,
particularly psychiatrists and patients, so that they do not feel that change is threat-
ening them. Up to now, we see movements gaining strength and continuity, seeking
conflict as the means to change, whatever the case. Research experience, however,
shows that decisiveness and will are not enough (Pérez and Mugny 1996). Validity,
clear arguments and stability are also required. A strategy is needed so that there can
be meaningful changes in the system and the resistance from each side can be over-
come. These changes can be about specific issues. In detail:

User involvement should become national policy with a specific framework that
will be structured gradually on the basis of good examples (Appleby 2000).
In cases where users offer services (care, consultancy, participation in research and
research), the relationship with the service or with the action in general must be
remunerated, so that obligations are met on both sides and there are no phenom-
ena of patronising.
Training programmes must be established, structured by users for users and profes-
sionals. Programmes with specific methodology and evaluation system.

These are just some preliminary suggestions. At European level, very few users’
and relatives’ movements are independent and powerful in terms of funding, while
most are supported by a specific few number of people and are vulnerable to crises
(Rose and Lucas 2007). In order for user participation to work properly, there should
be allocation of authority and recognition of user and family associations as institu-
tional interlocutors with validity and arguments (Maza 1996), and users must be
considered active citizens with rights and obligations and not faceless collateral
losses of a dysfunctional system. Provided we continue to recognise the right of
individuals to self-determination, besides any social dictates describing fear of the
448 P. Chondros et al.

unfamiliar and the unwillingness to take on responsibility and to delete whatever is

different, we can continue talking about the non-negotiable dignity inherent in any
individual, irrespective and beyond social, political, financial and cultural crises or
“trends” (Condylis 2003).

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Involuntary Hospitalisation: Legislative
Framework, Epidemiology and Outcome 23
Stelios Stylianidis, Lily Evangelia Peppou,
Nektarios Drakonakis, and Emilia Panagou

Abstract
The involuntary hospitalisation of persons with mental health problems is a
controversial issue in the provision of psychiatric care, mainly because its
application is often coupled with the need to balance controversial interests: the
rights of the patient, public safety and the need for treatment. Over the past few
decades, the patients’ movement, but also transition from asylum-type psychiat-
ric care to community psychiatry, has shifted the focus of compulsory admission
from the dangerousness and social control of the patient to his/her need for treat-
ment. Against this background, reforms were progressively introduced into the
relevant laws of most European countries, which gradually incorporated a num-
ber of texts and conventions. However, despite the similarities between such
laws, there are still significant differences, which also explain to a certain extent
the resulting disparities in the number of involuntary admissions in Europe and
overall epidemiology of this phenomenon. Worldwide, the high rates of
involuntary admissions appear to be more related with certain variables of the

S. Stylianidis (*)
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
L.E. Peppou
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]
N. Drakonakis • E. Panagou
Panteion University, Athens, Greece
e-mail: [email protected]; [email protected]

© Springer International Publishing Switzerland 2016 451

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_23
452 S. Stylianidis et al.

psychiatric care system than with the patients’ characteristics, while the outcome
appears to be satisfactory. So far, in Greece the number of involuntary hospitali-
sations is not recorded nationwide, systematically and reliably. The hitherto
absence of systematic research into the subject of involuntary hospitalisation, as
well as its determinants, also explains the absence of proposals and interventions
to address the problem. However, on the basis of the first results of the Survey of
Involuntary Hospitalisations in Athens and other scientific data, it appears that
compulsory psychiatric treatment constitutes a first-line therapeutic solution,
where the incomplete application of the law and the deficiencies of the mental
health system, including its regulating culture and outlook, play a decisive role
in the emergence of this issue. Therefore, the co-ordination of good practices,
documented experience and ethical standards which should ensure the quality of
services provided in a community framework appears to be at this stage an unre-
alistic endeavour for our country.

23.1 Introduction

The involuntary hospitalisation of persons with mental health problems remains a

controversial issue in the provision of psychiatric care, mainly because of the
restrictions imposed on the freedom and autonomy of such patients. It is set within
the context of adopting coercive measures when practicing psychiatry, a fact which
singularly distinguishes psychiatry from other medical disciplines. Significant
issues arise in the application of such coercive measures owing to the difficulty in
balancing the following controversial interests: (1) the patient’s basic human rights,
(2) public safety and (3) the need for treatment.
The term “compulsory admission or involuntary treatment” is understood to
mean “the admission and detention for treatment of a person suffering from a
mental disorder (hereinafter referred to as the “patient(s)”) in a hospital, other
medical establishment or appropriate place, provided this person is capable of
giving his/her consent for treatment, but refuses to give such consent, or he/she
is not capable of giving such consent and refuses treatment” (Council of
Europe 2004).
Theoretically, compulsory admission is dictated by the principle of parens
patriae (need for treatment) and the principle of responsibility of the state. More
specifically, the principle of parens patriae refers to the obligation of the state to
protect in a paternalistic manner its sick members who are in need of care and treat-
ment and unable to survive without help. On the other hand, the principle of respon-
sibility of the state places the state in the position of the protector of citizens, or
society in general, from its “dangerous mentally ill members”.
Since the eighteenth century, when the measure of involuntary hospitalisation
was first introduced, and until the late 1960s, the predominant criterion was the
principle of responsibility of the state. However, ever since and in parallel with the
progressively increasing interest on human rights (patients’ movement), as well as
23 Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome 453

the transition from an asylum-type psychiatric care to community psychiatry, the

principle of parens patriae gradually prevailed.
In this context, reforms were progressively introduced into the relevant legal
provisions on this procedure in most European countries (Zinkler and Priebe 2002).

23.2 Legislation

Europe

National laws and policies worldwide include a broad range of rules and guarantees
for the involuntary admission of persons with a mental illness. All, without excep-
tion, stipulate minimum criteria which need to be complied with in order to ensure
that involuntary admission is consistent with the law. In chronological order, the
most important and binding instruments are as follows:

• The European Convention for Human Rights (ECHR, 1950)

• The Recommendations of the Committee of Ministers of the Council of Europe
(1983, 2004)
• The Recommendation of the Parliamentary Assembly of the Council of Europe
(1994, 2004)
• The UN International Convention on the Rights of Persons with Disabilities
(2006)

Specific mention is made for the first time regarding the care of the mentally ill
in the European Convention for Human Right (hereinafter ECHR), which was
adopted by the Council of Europe in 1950. The significance of this instrument lies
in the fact that the rulings of the European Court of Human Rights (ECHR) are
based on the content of this provision. The Recommendation of the Committee of
Ministers of the Council of Europe of 1983 refers to the legal protection of persons
suffering from mental disorders who are admitted as involuntary patients, while
the Parliamentary Assembly of the Council of Europe adopted in 1994 the
Recommendation on Psychiatry and Human Rights. However, the most recent
Recommendation of the Committee of Ministers of the Council of Europe (2004)
is the most complete and binding instrument worldwide on the protection of rights
of persons with mental disorders. More specifically, it incorporates the basic prin-
ciples underlying the judicial rulings of the ECHR, while taking into account the
provisions of the Convention on “Human Rights and Biomedicine” of the Council
of Europe, as well as the works of the European Commission for the “Prevention
of Torture and Inhuman or Degrading Treatment or Punishment”. This Convention
includes guidelines to the Member States and calls on them to modernise and
adapt their legislations along these guidelines. Finally, the UN International
Convention on the Rights of Persons with Disabilities (2006) became the most
recent basis for the debates regarding the current legal framework governing invol-
untary hospitalisation. Persons with a mental illness are specifically mentioned for
454 S. Stylianidis et al.

the first time in a UN instrument as persons entitled to all fundamental human

rights.
It is worth noting that instruments such as the Declaration of Hawaii (1977), the
Resolution of the UN General Assembly (1991) and the Recommendations of the
Parliamentary Assembly of the Council of Europe (1976, 1977) reflect the basic
principles governing the protection of persons with a mental illness and the improve-
ment of mental healthcare, without however binding on the Member States.
In this context, over the last decade, an attempt was made to systematically report
the discrepancies between Member States regarding their current legal framework
on involuntary hospitalisation. In a study funded by the EU and conducted in a time
span of two years (2000–2002) with the participation of national expert representa-
tives from every country, it was confirmed that despite the adaptation of the policies
promoted by the aforementioned reports, there are still considerable differences
between the national laws of EU Member States (Salize et al. 2002). The main dif-
ferences are found in the criteria for involuntary hospitalisation, the opinions, the
person making the decision for admission and certain aspects relating to the protec-
tion of the fundamental rights of the patients. With respect to the criteria for com-
pulsory admission, all countries agree on the presence of mental illness, but differ
with respect to the second criterion. It is worth noting that in countries where the
need for treatment is specified as a criterion for involuntary admission, the relevant
legislation in Ireland, Spain, Portugal, Sweden and Finland places further emphasis
on the patient’s lack of insight (Table 23.1).
The person rendering an opinion on the extent to which the involuntary hospitali-
sation criteria are met and for making the decision to admit the patient to hospital
differs from country to country. As far as the former is concerned, the laws in Belgium,
Denmark, Italy and Sweden allow physicians other than trained psychiatrists to make
a decision, which is not the case in countries such as Austria, Greece, Ireland and
Spain, where expert – and not trainee – psychiatrists are solely responsible to make a
decision. As far as the decision-making for admission is concerned, the legal frame-
work in countries such as Austria, Belgium, France, Italy and Greece authorises a
state or administrative authority, such as a public prosecutor or mayor, as responsible,
inter alia, for the decision. Conversely, in countries such as Denmark, Ireland and
Sweden, the decision for admission is exclusively made by a medical obligation.
Finally, as far as the protection of patient rights is concerned, the patient’s right
to resort to appeal to court against an involuntary hospitalisation is included in every

Table 23.1 Criteria for compulsory admission in the EU

Criteria Member states
Mental disorder + danger Austria, Belgium, France, Germany,
Luxembourg, Netherlands
Mental disorder + danger Denmark, Finland, Greece, Ireland, Portugal,
or UK
Mental disorder + need for treatment
Mental disorder + need for treatment Italy, Spain, Sweden
Replicated from Table 1.10, Salize et al. (2002)
23 Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome 455

Member State’s legal framework. However, not every state’s legal framework pro-
vides for the patient’s right to be informed, the inclusion of a legal counsel (social
worker, health professional, advocate, counsellor, etc.) and the provision of legal
support free of charge.
Therefore, despite the efforts made to harmonise the laws of EU states on
involuntary hospitalisation, there are significant differences between such laws.

Greece

From 1862 to 1992, two laws regulated the admission and long-term placement of
patients in psychiatric hospitals in Greece: Law ΨΜB’ of 1862 dating back to the
time of King Otto and Legislative Decree 104/1973 (Bilanakis 2004).
Law ΨΜB’ of 1862 “on the Establishment of Mental Hospitals” was the first
piece of legislation of the Greek state on mental illness. In fact, this law established
and developed the asylum structure in Greece, in the sense that – like all other rel-
evant nineteenth century laws in Europe – the asylum was introduced as a place of
confinement and treatment of mentally ill patients. According to this law, a mentally
ill person could be admitted to a mental hospital in one of two ways: (a) admission
of the patient by means of an application submitted by someone close to the patient
(immediate family or relative) or (b) placement of the patient in a mental hospital by
means of an order issued by a public authority (prefect, district commissioner, chief
of police). In both cases, admission was based on a medical certificate which
included a full description of the illness and concluded that the patient is in need for
therapy and should be admitted to a mental hospital.
Law ΨΜB’ remained in force until 1973, when Legislative Decree 104/1973 “on
mental health and the treatment of the mentally ill” was introduced. According to
the procedure laid down by Legislative Decree 104/1973 and the relevant ministe-
rial decisions of the Ministry of Health adopted for the implementation thereof
(Γ2β/3036/1973 και Α2β/5345/1978), a mental patient could be admitted to a men-
tal hospital in one of three ways: (a) by voluntary admission, (b) by involuntary
admission and (c) by compulsory admission of “dangerous psychiatric patients”,
known as “by order of the Public Prosecutor” under Article 5.
The general principle dictating this law was the complete dependency of the
mental patient on the psychiatrists, since the larger framework/details and duration
of the patients’ treatment were determined by their opinions and decisions. The
patients’ admission to a mental hospital was often tantamount to a placement for an
undefined period, resulting in the mental hospitals being used as custody and social
care units.
The risk of arbitrariness inherent in subjecting hospitalised patients to the abso-
lute judication of psychiatric experts, and their treatment solely as patients pre-
sumed incompetent by law and not as persons presumed competent by law,
necessitated the modernisation of the relevant institutional framework on the sub-
ject of mental health in general and, more specifically, the arrangements for invol-
untary placement.
456 S. Stylianidis et al.

The current institutional framework, and the provisions of the 2071/1992

“Modernisation and Organisation of the Health Care System” law and the 2716/1999
“Development and modernisation of the Mental Health services and other provi-
sions” law aims to protect the individual freedoms of patients. With the provisions
of Law 2071/92, the legislator defines clearly the conditions and regulates in detail
the procedure for involuntary placement (the content of the law is summarised in
Table 23.2).
More specifically, the conditions for involuntary hospitalisation under Law
2071/92 are:

(a) The patient must suffer from a mental disorder and not be in a position to judge
what is best for his/her health, and lack of hospitalisation would result in depriv-
ing him/her of the treatment for his/her condition or would lead to the deteriora-
tion of his/her condition.
(b) The patient’s hospitalisation is necessary in order to prevent acts of violence
against himself or others.

With respect to the procedure of admission to a mental health unit, Article 96 of

Law 2071/1992 stipulates that the involuntary hospitalisation of a person who is
allegedly mentally ill may be initiated by his/her spouse or close relatives by means
of an application to the Public Prosecutor of the Court of First Instance of his/her
place of residence or stay. If such relatives do not exist, as can happen in cases of
emergency, only the Public Prosecutor can request ex officio the patient’s involun-
tary hospitalisation. This application must be justified and describe the patients’
mental illness, his/her previous and current behaviour, any past voluntary assess-
ment interventions, his/her refusal to assessment or if such assessment is proved
impossible, as precisely as possible. This application must be accompanied by two
psychiatrists’ reports selected from the list published every 2 years by the competent
medical association. The psychiatrist should not be related to the applicant, or the
patient and their opinions must be justified, i.e. they should contain the actual facts
(any symptoms of illness, previous acts of violence, previous hospitalisations,
where and why) and reasons why outpatient treatment is not feasible and should
conclude with the diagnosis and scientific basis for such diagnosis. Provided that
the Public Prosecutor determines that the legal requirements are met and that the
two medical reports agree on the need for involuntary hospitalisation, the Public
Prosecutor orders the patient’s admission to a suitable mental health unit. There, the
patient is informed by the Head of the Unit of his/her rights – particularly his/her
right to appeal. A record of the proceedings is drawn up and signed by the Head of
the Unit and the person accompanying the patient.
In case the patient’s assessment is not feasible, because he/she has refused such
assessment, the Public Prosecutor orders for the transference of the individual to a
public mental clinic for assessment and for drawing up the opinions. The individu-
al’s admission is carried out under conditions ensuring the respect of the patients’
personality and dignity and the patient’s stay in the unit for the necessary assess-
ment cannot exceed 48 h.
 23

Table 23.2 Contents of Law 2071/1992

Place/conditions of
Requirements Procedure Result Duration treatment Discharge procedure
Existence of mental Civil court decision Orders the involuntary Six months with the Mental health centres, Ex officio after a period
disorder supported by Possibility to attend placement of patient in possibility of extending day centres, general of 6 months, unless the
two psychiatric with advocate a suitable mental health hospitalisation for hospital psychiatric extension procedure is
opinions Possibility to appoint a unit for treatment another 6 months upon departments, followed
The patient is not in a technical advisor as Possibility to take legal decision of a civil court residential units, At any time after
position to judge what expert witness action against the special psychiatric 6 months if the
is best for his/her decision ordering the hospitals attending physician
health involuntary The conditions must deems that the patient’s
The lack of treatment hospitalisation first serve the condition does not
would lead to the therapeutic needs impose the need for
deterioration of his/her Possibility for leaves, involuntary
condition, or is outings and staying hospitalisation
necessary in order to outside the mental
prevent acts of violence health unit
against himself/herself
or others
Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome
457
458 S. Stylianidis et al.

Within 3 days of the patient’s formal admission, the same Public Prosecutor
brings the case before the Multi-member Court of First Instance. The court sits
within 10 days from the Public Prosecutor’s request, and where appropriate in cam-
era, in order to protect the patient’s private life. It should be noted that 48 h before
the hearing, the patient is invited to attend and he/she has the right to appear with
the aid of a lawyer and a psychiatrist as his/her technical consultant.
If the Public Prosecutor’s request is not accepted, the court shall order the imme-
diate discharge of the patient. If the Court decides that the medical reports are insuf-
ficiently convincing, the Court shall order the assessment of the patient by a third
psychiatrist (preferably an assistant professor or the Chief Scientist of a public men-
tal health unit).
If the Court rules to continue the patient’s compulsory treatment, this ruling must
be based on specific reasons. However, until such judgement is issued, the therapeu-
tic responsibility for the patient lays with the Chief Scientist of the Mental Heal
Unit, who continues to be scientifically and therapeutically responsible should the
court order to continue his/her treatment.
Pursuant to Article 97 of Law 2071/1992, the decision of the Court of First
Instance may be appealed or challenged by the patient, his/her relatives and his/her
guardian in accordance with the provisions of Civil Procedure within 2 months from
the publication of such decision. The appeal is heard in any event in camera within
15 days from lodging the appeal.
Pursuant to Article 98 of Law 2071/1992, the conditions of involuntary admis-
sion must serve the therapeutic needs. The necessary restrictive measures should
not exclude the necessary therapeutic means, such as leaves, organised outings or
staying in supervised spaces outside the closed institutions. In any case and through-
out the placement, the patient should be treated with respect, while any restrictions
imposed on his/her personal freedom are determined solely on the basis of his/her
health condition and therapeutic needs.
Finally, pursuant to Article 99 of Law 2071/1992, the duration of placement may
not exceed 6 months. In special cases, placement may be extended beyond the
6-month period, with the consent of three psychiatrists, one of which is the attend-
ing physician and the other two are appointed by the Public Prosecutor. Placement
may, however, be terminated at any time before the end of the period of 6 months,
if it is found that the conditions that led to the placement no longer apply. In this
case, the Chief Scientist of the mental health unit where the patient is placed must
issue a discharge certificate as well as to forward a report of the case to Public
Prosecutor responsible.
A review of the provisions of Law 2071/1992 referring to the conditions, the
procedure and execution of involuntary hospitalisation leads to positive conclusions
as they significantly differ from the previous regime. On the positive side, the law
includes the establishment of judicial guarantees to verify the legality of involuntary
placement, as well as the establishment of a maximum time frame for such place-
ment. Furthermore, the fact that the primary role of involuntary hospitalisation is
shifted from the custodial to the treatment oriented highlights the explicit
23 Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome 459

requirement of the legislator for respect of the personality of the patient in every
case and throughout the duration of his/her placement – a requirement which, inter
alia, is manifested in the latter’s possibility to receive legal and psychiatric aid from
a lawyer and a psychiatrist as technical consultant and to take legal action.
In addition, the enactment of Law 2716/1999 was a serious step towards improv-
ing the weaknesses of the mental healthcare system in our country. Article 1(2)
(“Mental health services are structured, organised, developed and function under
the provisions of this Law, in line with the principles of sectorisation and commu-
nity psychiatry, the priority of primary care, outpatient care, de-institutionalisation,
psychosocial rehabilitation and social re-integration, continuity of psychiatric care
as well as the provision of information and voluntary assistance to the community
for the purpose of promoting mental health”.) was particularly significant to this
positive change of direction.
The effort made to codevelop primary care coupled with post-discharge care, as
well as harmonising the operation between the various units, as well as the general
spirit of law, is quite clear in certain separate articles (Art. 5, 6, 7 and 8) of the law.
In this respect, national legislation is brought in line (ostensibly, as detailed above)
with the country’s international commitments and the trends prevailing worldwide.
Since then, the law which has now been in force for more than 20 years has been
subject to a number of significant changes and modifications. The competent courts’
ruling on involuntary hospitalisation is no longer the Multi-member Courts of First
Instance but the Single-Member Courts of First Instance. Thus, the procedure is
now swifter and more flexible and, at the same time, requires fewer guarantees for
the protection of the individual and the appropriateness of the decision, since one
vote is now sufficient to order the involuntary admissions of a patient. At the same
time, the Oviedo Convention (Convention on Human Rights and Biomedicine) led
to the revocation of a second pair of conditions for involuntary hospitalisation,
namely, the presence of dangerousness to self or others, a fact which the local public
prosecutor authorities do not seem to be aware of. The amendment of the Civil
Code, with respect to the powers of attorney, but also the introduction of a special
provision according to which the involuntary hospitalisation of any person is
allowed “upon the prior the authorisation of the court…”, revokes the authority of
the Public Prosecutor to order the involuntary placement of a patient and, as a result,
defines that compulsory placement without a court decision – even if it is an interim
order – is illegal (Triantafyllou and Chotamanidou 2005). On the basis of the above
observations, it results that all involuntary admissions ordered by a Public Prosecutor
or hospitalisations decided on the grounds of the patient dangerousness criterion are
against the law. Finally, it is worth noting that the UN International Convention on
the Rights of Persons with Disabilities (2006), mentioned above, has been trans-
posed into the legislation of the Greek state (Law 4074/2012) and its provisions take
precedence over any other Greek law.
However, the implementation of such legislation in Greece is found to be signifi-
cantly deficient. On the international level, this is established by two decisions of
the European Court of Human Rights against Greece – the Venios Case and the
460 S. Stylianidis et al.

Karamanof Case – while on the national level, it is reflected in the ex officio inves-
tigation of the Greek Ombudsman (2007). Specifically, with regard to the second,
following the large number of complaints submitted by citizens to the Ombudsman
office, an ex officio investigation was conducted to verify the extent to which the
rights of involuntarily hospitalised patients are protected. The investigation was
conducted in the two psychiatric hospitals in Attica – the Dromokaiteio Sanitorium
and the “Dafni” Psychiatric Hospital – and included the assessment of a random
sample of 89 patient records (equal representation of both sexes), who were invol-
untarily hospitalised in the last decade. Where the records contained information on
prior involuntary hospitalisations, this information was also taken into account. This
resulted in the overall analysis of 179 compulsory placements. The main deficits
identified in the implementation of the law related to medical opinions, the transfer
and information of the patients as well as the judicial review. Specifically, most
psychiatrists did not provide a detailed explanation and the individual reasons for
which the involuntary hospitalisation criteria are met. Instead, a form was used with
the general preprinted statement “The conditions laid down in Law 2071/1992 are
met”. According to the overwhelming majority of the records (97 %), it was estab-
lished that the transfer of patients was made by police and not the National
Emergency Centre (EKAV), a fact which indicates that the patient is treated as
potentially dangerous. At the same time, it appears that patients are not informed of
their rights and, particularly, their right to take legal action. Finally, while 94 % of
placements were effected in pursuance of a court order, in half of the cases a sum-
mons was not found, and in 84 % of the cases, no court decision for commitment
was found. The patient did not appear in court in almost all cases, while it also
appears that the procedural time frames defined by the law are not complied with.
Similar findings were also observed in Thessaloniki (Kosmatos 2002). In a study
conducted following the ex officio investigation conducted by the Greek Ombudsman
at the “Dafni” Psychiatric Hospital, an improvement was noted as regards the con-
tent of medical opinions; however, no improvement was noted as regards issues
relating to the transfer and information of patients, their appearance in court and the
court decision for involuntary hospitalisation. Consequently, despite the liberal,
innovative and protective nature of law 2071/1992 (Stylianidis et al. 1997), the man-
ner in which it has been implemented in practice reminds one of both the content
and perspective, of previous pieces of legislation.
The differences existing between national legislative frameworks, including
Greece, are of great importance as it has been found that they are linked with the
subjective perception of involuntary placed patients regarding the benefits of the
treatment and of accepting its usefulness. A study carried out under the research
programme EUNOMIA (European Evaluation of Coercion in Psychiatry and
Harmonization of Best Clinical Practice) showed that in countries with more pro-
tective regulations, such as Slovakia and Germany, the patients’ opinions regarding
involuntary hospitalisation were more positive, as opposed to countries such as the
UK, where regulations are less protective. At the same time, it has been suggested
that the differences in legislation also explain the diversity witnessed in the epide-
miological parameters of involuntary hospitalisations in Europe.
23 Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome 461

23.3 Epidemiology

Europe

Traditionally, in the epidemiology of the phenomenon, involuntary hospitalisations

are expressed either as quotas of the total number of hospitalisations or as the num-
ber of hospitalisations in a population of 100,000 persons per year. With respect to
these two measurement indicators, the quotas refer to the mix of patients in hospi-
tals and, therefore, cannot be used to record the frequency of hospitalisations in the
population as such (i.e. the benchmark is the clinical and not the general popula-
tion). However, in most European countries, involuntary hospitalisations are
recorded using both ways – if and when such information is available – although the
reliability and the methods of collecting such information are often being
questioned.
Over the last decade, a couple of efforts have been made in literature to catalogue
findings onto the number of involuntary hospitalisations in Europe (Salize and
Dressing 2004; Zinkler and Priebe 2002). More specifically, contrary to the review
by Zinkler and Priebe (2002), the primary review by Salize and Dressing (2004)
seems more well documented, and for this reason, it will be presented in further
detail; however, the reader can refer to the other source for a more complete picture
of the subject. In a study funded by the European Commission, while investigating
the similarities and differences between the Member States’ current legislative
frameworks on involuntary hospitalisation, the method and the results of which
have been discussed in the relevant subsection, an effort was made to track any
changes in the number of involuntary hospitalisations over the last decade, as well
as the disparities in this number between European countries. Specifically, the
authors report consistent levels of involuntary hospitalisations in the last decade for
Europe as a whole, although in some countries, such as the UK, Germany, France,
Sweden and Finland, the numbers are rising. This result is attributed mainly to a
shorter average duration of hospitalisation which, inevitably, leads to higher hospi-
talisation quotas. At the same time, incorporating the two involuntary hospitalisa-
tion measurement indicators mentioned above, a significant difference is noted
between European countries, both in terms of the number of involuntary hospitalisa-
tions (from 6 per 100,000 in Portugal up to 218 per 100,000 in Finland) and in terms
of quotas (from 3.2 % in Portugal up to 30 % in Sweden). It is worth noting that for
the Mediterranean countries – Greece, Spain and Italy – the data available is incom-
plete, resulting in their not being taken into account in the relevant measurements.
In addition, the profile of persons who are involuntarily hospitalised has been
researched by very few researchers-epidemiologists in an effort to explain the cur-
rent differences between countries, although the results are often heterogeneous. In
terms of socio-demographic variables, involuntarily hospitalised individuals are
usually younger, single, unemployed men from ethnic minority groups, with unsta-
ble residence conditions, low socioeconomic level and low social support levels
(Bindman et al. 2002; Houston and Mariotto 2001; Owens et al. 1991; Salize and
Dressing 2004; Webber and Huxley 2004). In terms of clinical variables, the
462 S. Stylianidis et al.

majority of studies indicate that they suffer from disorders of the schizophrenic
spectrum; their symptomatology is quite severe and has more previous hospitalisa-
tions and in particular involuntary (Houston and Mariotto 2001; Owens et al. 1991;
Salize and Dressing 2004). However, the studies focusing on the socio-demographic
and clinical characteristics of patients place the burden of involuntary hospitalisa-
tion on the patient. While personal variables were found to be linked to a large
extent with involuntary hospitalisation, other parameters – more systemic – seem to
play a more significant role.
At the opposite end of studies exploring the correlations between involuntary
hospitalisation and the patients’ particulars, other studies focus on characteristics
associated with the mental health services. Specifically, a higher incidence of invol-
untary hospitalisations is observed in areas with limited access to such services
(Hansson et al. 1999) or poor networking between such services (Durbin et al. 2006;
Weirdsma and Mulder 2009). At the same time, it has been found that the number
of involuntary hospitalisations is higher in areas with low standards of living, insuf-
ficient resources and poorly organised services (Huxley and Kerfoot 1993).
Furthermore, a study by Bindman and his associates in the UK showed that the
levels of compulsory placements in 34 geographical are linked, on a statistically
significant level, to the quality of service indicators: delays in finding beds in hospi-
tal departments or residential units for acute cases and absence of home visits after
a specific time to patients who are in an acute phase, as well as the standard of living
in the relevant area (Bindman et al. 2002). It is worth noting that in addition to ser-
vice networking, areas with improved community networks, i.e. networks which
include welfare services, accommodation organisations and local police, demon-
strate lower levels of involuntary admissions (Weirdsma et al. 2007).

Greece

In Greece, the number of studies on the epidemiology of involuntary hospitalisation

is very limited. The percentage of involuntary hospitalisations in 1979, and before
the enactment of law 2071/1992, amounted to 97 %. However, the corresponding
percentages after the introduction of this law are not recorded nationwide, although
they are believed to range between 4-% and 50-% (Liakos 2004; Greek Ombudsman
2007) or higher (Livaditis 2010).
In a prospective study conducted by Bozikas and his associates in the 1st
Psychiatric Clinic of the Aristotle University of Thessaloniki, data was obtained
from 204 consecutive admissions (Bozikas et al. 2003). Of these, 54,9 % were
found to be involuntary, while the patients who presented a higher likelihood of
being admitted against their will were single, diagnosed with a psychotic disorder
or bipolar disorder, self-employed and skilled or unskilled workers and had a higher
number of previous involuntary admissions. Variables relating to social support or
mental health services were not examined.
In a more recent prospective study, the court order documents which included the
records kept by police stations nationwide together with special forms created for
23 Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome 463

the purposes of the study and completed by the chief of each police station were
examined (Douzenis et al. 2012). The study covered the conditions of involuntary
assessment of patients, following the initiation of the relevant procedure by a rela-
tive or ex officio, as well as the characteristics of patients whose involuntary assess-
ment led to an involuntary admission. Of the 2,038 files examined, involuntary
assessment led to an involuntary admission in the vast majority of cases (87.5 %). A
cause for apprehension and concern was the finding that in 58.1 % of the cases,
police officers were present, presented a concerning factor, although most patients
did not oppose the procedure in any way. A comparison between patients whose
involuntary assessment led to involuntary admission to those who ultimately were
not admitted did not identify any statistically significant differences in terms of
gender, age or nationality.
In light of the above, Greece appears to have high involuntary hospitalisation
rates; nevertheless, no adequate scientific explanation could be extracted for the
reasons behind this.

23.4 Outcome

The issue of outcome is closely related to the criterion of need for therapy, but also
with the moral justification of involuntary hospitalisation. In other words, persons
suffering from mental illness are deprived of their fundamental freedoms, because
of the expected positive outcome of their placement, which could not have occurred
in any other manner than by their involuntary hospitalisation. This is why the inves-
tigation of the outcome/effectiveness of involuntary admission has drawn such
strong scientific interest over the past years.
International literature on the subject differs methodologically in terms of the out-
come indicators used to assess, readmission, symptomatology, insight, functionality,
adherence to treatment and medication and treatment satisfaction, but also the time of
assessment of the outcome. Discharge and/or follow up assessment may be unavail-
able, make it relatively difficult to reconcile the results and draw conclusions. In this
context, two systematic efforts were made by two teams from the UK (Katsakou and
Priebe 2006) and Germany (Kallert et al. 2008) to review the relevant literature.
The first review attempted to examine the outcome of involuntary hospitalisation
both in terms of clinical indicators as well as in terms of subjective perception of the
patients (Katsakou and Priebe 2006). Subsequently, it attempted to determine the
socio-demographic and clinical characteristics associated with more positive and
more negative outcomes. The primary studies were assessed on the basis of specific
methodological criteria relating to the size of the sample, the cross-sectional or
longitudinal nature of research planning, response rates and the presence of a bias
error, prior to being included in the review. Of the 521 articles identified, only 23
satisfied such criteria and corresponded to 18 international studies. The result of the
review substantiated the clinical effectiveness of involuntary hospitalisation, while
at a later stage most patients were mainly favourably disposed towards hospitalisa-
tion. However, a significant proportion of patients did not feel that their
464 S. Stylianidis et al.

hospitalisation was justified or beneficial. Patients showing a significant clinical

improvement were found to express more positive outlook on involuntary hospitali-
sation (Katsakou and Priebe 2006).
The second review was focused on the outcome of the treatment of involuntarily
hospitalised patients compared to those voluntarily hospitalised (Kallert et al. 2008).
The primary works included in the review were previously evaluated on the basis of
methodological parameters, such as those described above. The analysis of these 17
studies showed that involuntarily hospitalised patients were either highly likely to be
readmitted in the years following their discharge (the reassessment time frames vary
considerably between studies, from 30 days after discharge to 17 years), especially
involuntarily. Concerning the clinical indicators, no differences between the two
teams were identified as far as the degree of general psychopathology and commit-
ment to therapy are concerned, during measurements following discharge. In terms of
social functionality, involuntarily hospitalised patients show lower levels both at the
time of admission and at the time of discharge. However, improvement with regard to
this specific indicator is in the same range and magnitude as that of voluntarily hos-
pitalised patients. Finally, as far as the subjective indicators used to evaluate the treat-
ment are concerned, involuntarily hospitalised patients were found more likely to
consider their hospitalisation unjustified and less satisfied with their treatment.
The low to average quality of most studies on this specific subject and their het-
erogeneity as regards the various methodological aspects highlight and stress the
need to conduct methodologically sound studies under daily clinical routine condi-
tions. The use of weighted outcome tools, enlistment of a sufficient number of
patients and clarity in determining follow-up measurements are key to a good meth-
odological approach in accordance with current literature.
No studies have been conducted in Greece on the outcome of the treatment of
persons with mental disorders.

23.5 Study on Involuntary Hospitalisations in Athens

(ΜΑΝΑ)

Against this background and on the basis of the limited number of studies on the
epidemiology of involuntary hospitalisation in Greece, the Association for Regional
Development and Mental Health (EPAPSY), in cooperation with the Panteion
University, has, since 2011, developed a research programme investigating compul-
sory admissions in Athens area and exploring different facets of the issue in depth.
Through different research questions and by adopting different methodologies, the
programme attempts to give a full picture of involuntary commitment in the “Dafni”
Attica Psychiatric Hospital. The following questions represent some of the main
themes under examination:

• What is the proportion of involuntary hospitalisations in “Dafni” APH and which

socio-demographic and clinical characteristics are associated with the involun-
tary nature of admission?
• What is the cohort outcome of involuntarily hospitalised patients?
23 Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome 465

• What is the subjective opinion of involuntarily hospitalised patients on their

treatment?
• What is the subjective opinion of voluntarily hospitalised patients on their
treatment?
• What is the perspective of relatives of patients who are involuntarily
hospitalised?
• To what extent are the legal requirements concerning the content of medical
opinions complied with?
• To what extent do involuntarily hospitalised patients believe they have benefited
from their hospitalisation and that it was justified? Which factors contribute to
such favourable opinions.
• What proportion of the sample meets the “revolving door” criteria? What are the
characteristics of such patients and what is the outcome of their hospitalisation?
• What are the views of mental health professionals in community structures as
well as the staff working at the “Dafni” APH on mental health and involuntary
hospitalisation?
• Which patients are more likely to become mechanically restrained and what is
the outcome of their hospitalisation?
• What are the views of mental health professionals, patients and their relatives on
mechanical restrain?

A mixed methodology (quantitative and qualitative) is adopted to investigate all

the above questions, depending on the nature of the question and the availability of
current literature on the subject. All the sub-studies are carried out with the help of
undergraduate Psychology students, while the authors of this chapter are the ones
responsible for the overall co-ordination and supervision of the project.
The first results of the study reveal that a large proportion of involuntary hospitali-
sations in the “Dafni” APH is explained by the shortcomings of the mental health
services as a whole. For instance, it is noted that the only forecasting indicator for
involuntary hospitalisation is the previous number of involuntary hospitalisations,
while a large proportion of patients was found to meet the “revolving door” criteria
(36.4 %). On the same note, a large proportion of patients hospitalised in “Dafni”
(about 85–89 %), were referred to the hospital’s outpatient clinic instead of commu-
nity settings after hospitalisation to the hospital’s outpatient clinic and not to com-
munity structures, while focus groups of the hospital’s mental health professionals
stress the obstacles and difficulties in communication between hospital and commu-
nity structures. It is worth noting that, based on the sub-question concerning the view
of mental health professionals working in community structures on mental illness
and involuntary hospitalisation, it appears that elements of the “asylum” culture,
especially as to the dangerousness of mentally ill patients and need for social control,
are also found in community structures.
The aggregation of the findings of this specific programme is expected to result
in an in-depth understanding of the mechanisms promoting the establishment of
involuntary hospitalisation as a routine practice in the mental health system. At a
later stage, the programme aims to link these results to the design and implementa-
tion of tailored interventions for the effective management of the problem.
466 S. Stylianidis et al.

Conclusions
In modern psychiatry, the questions concerning restrictive measures during the
psychiatric hospitalisation of patients remain pressing. This is because the asso-
ciation of mental illness to antisocial behaviour and dangerousness is still domi-
nant. A direct outcome of this standpoint is the tendency to exclude, isolate and
marginalise individuals suffering from mental illnesses, “penalise” mental illness
and, ultimately, stigmatise it, as a solution for preventing possible risks (Gravier
and Eytan 2011). Respectively, mentally ill patients facing social exclusion, and
all the more so assert their self-evident rights.
The involuntary assessment and hospitalisation process is an exceptional – in
the sense of departing from the norm – experience in people’s lives (in modern
societies), in which they undergo the restrictions of their freedoms and are being,
without consenting to either of the two aforementioned procedures. The infre-
quency of this experience, supported by the weight of the resulting threat to their
personal freedom and dignity, calls for the establishment of a very clear legal
framework outlining all authorised or unauthorised implementation procedures,
as well as the operation of a reliable system to record and control the above pro-
cedures (Fytrakis 2007).
The need to comply with the law could be said to be a preoccupation for some
legal practitioners ignoring the reality as well as the individuals being in need of
help. In this respect, psychiatrists working in hospitals often argue that “a person
in crisis cannot be helped with legislative articles but with appropriate therapy”.
Even the Code of Medical Conduct [Law 3418/2005, Art. 28(8)] requires invol-
untary hospitalisation “to comply with the terms and conditions laid down by the
laws in force”. Nevertheless, psychiatrists’ knowledge of involuntarily commit-
ment as well as on the rights of the people suffering from mental illness is in need
of improvement.
Of course, the experience of the members of the prosecution or the judiciary
on the specific subject is rather negligible, since their training and briefing on
the procedure is non-existent, and whatever experience they have is gained in
the field. Thus, Thomas Szasz’s aphorism regarding the threat posed to indi-
vidual freedoms from a conspiracy between state authority and psychiatry no
longer sounds threatening but a tangible reality (Szasz and Kraus 2007). In
Greece, the poor implementation of the law on involuntary hospitalisation in
practice frequently finds health professionals and the judiciary directly involved
in a “silent complicity” against mentally ill persons. At the same time, the
absence of reliable national data on the number of involuntary hospitalisations
in Greece is an additional aspect of this silent complicity, as the magnitude of
the problem is not exposed, the reasons for its existence are not scientifically
substantiated and there are no recognised fields and ways of intervention to deal
with it.
Scientific data on involuntary hospitalisations from studies in Greece, as well
as the evaluation of psychiatric reforms, highlight the many and multilevel short-
comings of the mental health system – which cannot even be classified as a sys-
tem and which, basically, is also accountable for the country’s high involuntary
hospitalisation levels. Social welfare shortcomings, the relief of the family, the
23 Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome 467

fatigue and evasion of responsibility of mental health professionals, the

indifference of judicial authorities and fragmented nature of treating the mental
disease result in transforming involuntary hospitalisation from a measure of last
resort to social automatism.
It appears that the current structure of the mental health services “system”
defines both the procedure and the outcome of the therapy for persons with a
serious mental illness. In this context, social automatism reproduces on all three
levels – structure, procedure, outcome – the aforementioned deficiency and mal-
function of the system, as well as its accompanying ethical deadlocks (Stylianidis
et al. 2014). Therefore, the co-ordination of good practices, documented experi-
ence and ethical standards which should ensure the quality of service in a com-
munity framework seems at this stage unrealistic.

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The Impact of the Economic Crisis
in Greece: Epidemiological Perspective 24
and Community Implications

Marina Economou, Lily Evangelia Peppou,

Kyriakos Souliotis, and Stelios Stylianidis

Abstract
The global financial crisis has triggered a sustained recession in Greece with
wide-ranging socioeconomic consequences. Throughout the 5 years of economic
turmoil in the country, unemployment rates have rocketed, while financial strain
has become omnipresent. As a corollary of these, the population health has
declined, while substantial increases in suicide mortality have been recorded.
A series of repeated nationwide cross-sectional studies by the University Mental
Health Research Institute has corroborated a gradual but steady increment in
1-month prevalence of major depression, while 1-month prevalence of suicidal-
ity was found to be on the rise until 2011. Nonetheless, in spite of the growing

M. Economou (*)
First Department of Psychiatry, Medical School, Eginition Hospital,
National & Kapodistrian University, Athens, Greece
University Mental Health Research Institute (UMHRI), Athens, Greece
e-mail: [email protected]
L.E. Peppou
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]
K. Souliotis
Faculty of Social and Political Sciences, University of Peloponnese, Corinth, Greece
Department of Hygiene, Epidemiology and Medical Statistics,
Centre for Health Services Research, Medical School, National & Kapodistrian University,
Athens, Greece
e-mail: [email protected]
S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 469

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_24
470 M. Economou et al.

mental health needs of the population, the mental healthcare system seems
incapable of fulfilling them, as the economic downturn has also impinged on
healthcare. Different types of interventions have been recommended for offset-
ting the dire impact of the crisis in Greece, including restructuring of mental
health services, enhancing the social capital of the community and implementing
active labour market and debt relief programmes; however, any action along
these lines relies heavily on local initiatives taken by specific service providers.
Concerted efforts for ameliorating the mental health effects of the recession in
Greece are urgently needed, in order to prevent further exacerbation of psychiat-
ric morbidity in the foreseeable future and to avoid a potential outbreak of
suicides.

24.1 Introduction

The global financial crisis is considered to be the worst economic downturn since
the Great Depression in the 1930s. It started off in the US banking sector, when a
rise in interest rates resulted in borrower defaults, which in turn led to bank defaults
and eventually to a crash in the housing and stock markets (Financial Crisis Inquiry
Commission 2011). The turmoil was soon diffused to European banks causing the
vast majority of European countries to fall into deep recessions. In Europe, it was
Ireland and the Mediterranean countries – the so-called PIGS – that were more
strongly hit by the crisis.
In the wake of the crisis, the Greek economy was regarded as the 27th largest
economy in the world by nominal gross domestic product (GDP) with 32,100 USD
GDP per capita (Eurostat 2010). Nonetheless, as a corollary of the global recession
and the local unrelenting spending, the country entered a prolonged and sustained
economic downturn since early 2009.
The GDP in Greece started displaying negligible growth rate since the last
months of 2007 and negative growth rate until 2014, when it reached a positive
0.8 % (World Bank 2015). Concomitantly, the national debt rose from 105.4 % of
GDP in 2007 to 175 % in 2013 and 177.1 % in 2014 (Eurostat 2015). To tackle the
grave financial situation and in an attempt to avoid a potential default that would
further endanger the stability of the global economy, the international community
and the Greek government agreed on two bailout packages – the so-called
Memoranda of Economic and Financial Policies, one amounting to 110 billion
euros in 2010 and another one amounting to 158 billion euros in 2011. In return, the
Greek government was expected to implement large-scale structural reforms and
austerity measures under the close supervision of the European Commission, the
European Central Bank and the International Monetary Fund – collectively known
as “Troika” – while it proceeded to curbing public spending.
The wide-ranging social and health-related consequences of the enduring reces-
sion have now begun to unfold. The present chapter will elaborate on the mental
health effects of the financial crisis in Greece, arguing for a substantial negative
24 The Impact of the Economic Crisis in Greece 471

impact in the form of elevated rates of suicides as well as of major depression.

However, in spite of the growing mental health needs of the population, there has
been no policy framework for offsetting the mental health impact of the recession.

24.2 Socioeconomic Consequences

The hallmark of the social landscape in Greece during the ongoing financial crisis
has been the sharp rises in unemployment rates. Unemployment figures had clus-
tered around the 10 % mark in the first half of the previous decade, while before
May 2008, they were at their lowest level for over a decade, reaching 6.6 % of the
labour force (i.e. 325,000 people). Nonetheless, since then, they started displaying
an upward course, with the number of employed individuals being reduced by 20 %
(i.e. 930,000 people) during the time period 2010–2013. In particular, as a corollary
of the implemented measures that disrupted and dismantled the labour market,
unemployment rates rocketed amid the economic downturn with germane figures
being 7.7 % in 2008, 9.5 % in 2009, 12.6 % in 2010, 17.7 % in 2011, 24.3 % in
2012, 27.5 % in 2013 and 26.5 % in 2014 (Eurostat 2015). It merits noting that in
year 2015, 25.6 % of citizens were found to be unemployed, the highest figure
recorded in the Eurozone (Eurostat 2015). Data emanating from monthly reports of
Manpower Employment Organization provide additional information about the pre-
dicament of unemployment in the country. In the July 2015 report, the number of
registered people seeking for work was found to be 817,787 (Manpower Employment
Organization 2015). Among them, 463,595 individuals (i.e. 56.69 %) were looking
for work for more than a year, underscoring the long duration of unemployment in
Greece. Furthermore, during the particular month only 101,257 citizens (i.e.
12.38 %) received benefits for their status.
According to a report elaborating on the social impact of the Greek crisis, labour
market institutions and norms in Greece protected male breadwinners at the expense
of their wives and grown-up children prior to the outset of the recession (Matsaganis
2013) The rationale for this had been to ensure that unemployment was not trans-
lated into poverty. In other words, unemployed and poor people seemed to corre-
spond to two different population subgroups, with the former category entailing
predominantly wives of employed men and young people living with their parents,
whereas the latter included the elderly and those residing in rural regions (Matsaganis
2013). Nonetheless – in accord to the same report – primary earners were gravely
hit by the crisis. A decrease in employment rate was more pronounced among male
workers aged between 30 and 44 years: from 93.8 % in 2008 to 74.1 % in 2013, a
substantial drop of 21 % in less than 5 years. It is therefore clear that population
subgroups that were protected against the pernicious effects of unemployment dur-
ing the previous decades were also at stake amid the recession with vast implica-
tions for themselves and their families.
The second defining feature of the social landscape in Greece amid the economic
contraction has been the rising rates of poverty. In accordance to data provided by
the Hellenic Statistical Authority, the population who is at risk of poverty or social
472 M. Economou et al.

exclusion was found to rise from 28.1 % in 2008 to 35.7 % in 2013 and 36 % in
2014 (Hellenic Statistical Authority 2015). Moreover, a survey by the Hellenic
Confederation of Professionals, Craftsmen and Merchants (GSEVEE) documented
substantial income loss for 93.7 % of households since the beginning of the crisis
with ensuing reductions in expenses for basic goods and food (GSEEVE 2014).
Furthermore, one out of three households reported being in arrears, while 42.5 % of
respondents were pessimistic about the adequacy of their income to meet upcoming
financial obligations. The negative impact of the financial crisis on Greek house-
holds is also substantiated by reports on the child population. According to data
emanating from UNICEF, a stark increase in child poverty rate from 23 % in 2008
to 40.5 % in 2012 has been recorded (UNICEF 2014). Apart from poverty and
income loss, it merits noting that throughout the recession income inequality has
also widened in Greece and in fact to a larger extent than the one observed in other
European countries (Matsaganis and Leventi 2014).
Therefore, the economic crisis has yielded adverse consequences on the social
landscape in Greece, which in turn have impinged on the health of the population.

24.3 Health Consequences

Reviews on the health effects of the financial crisis in Greece have suggested a
gradual deterioration of public health (Kentikelenis et al. 2014; Simou and
Koutsogeorgou 2014). In a single-country analysis and by employing a difference-
to-difference approach, Vandoros and colleagues have substantiated a negative
impact of the financial crisis on self-rated health in Greece (Vandoros et al. 2013).
In a further study, a difference-to-difference analysis was performed in order to
examine trends in self-rated health in Greece and Ireland as compared to a control
country – Poland (Hessel et al. 2014). Evidence from the particular study suggests
that the financial crisis has resulted in higher prevalence of poor health in Greece
but not in Ireland.
Apart from self-report health indicators, it has been reported that during the time
period 2009–2011, Greece has experienced unevenly high morbidity and mortality
burden of certain large-scale epidemics, including an outbreak of West Nile virus
infections and malaria and a major outbreak of HIV among injected drug users
(Bonovas and Nikolopoulos 2012). Arguably, while most of these outbreaks have
been attributed to environmental triggers, the preventive public health measures that
would have contained the spread of these epidemics were not properly implemented,
most likely due to dismantling of pertinent services (Kondilis et al. 2013).
In a recent article questioning the claim of a “major health tragedy” in Greece
amid the recession, potential changes in 30 mortality-based health indicators during
the financial crisis were investigated in three countries: Finland, Iceland and Greece
(Tapia Granados and Rodriguez 2015). Findings indicate that only five indicators
displayed significant deterioration in Greece: HIV incidence, maternal mortality,
ill-defined conditions, infant mortality and suicide. Consistent with this, it seems
that the impact of the crisis on the health of the Greek population is not across the
board and it has influenced the incidence of particular diseases. Similarly, a recent
24 The Impact of the Economic Crisis in Greece 473

study investigating trends in cardiovascular risk factors during the recession by ana-
lysing three waves of the “Hellas Health” survey in years 2006, 2008 and 2011
revealed that while fruit and vegetable consumption decreased to an alarming degree
during the crisis, trends in smoking prevalence and physical activity were favour-
able (Filippidis et al. 2014). Additionally, socioeconomic disparities in fruit and
vegetable consumption, physical activity and tobacco use were documented, ren-
dering certain people – especially those of lower socioeconomic level – particularly
vulnerable to cardiovascular disease.
In line with the aforementioned, the impact of the recession on health is not uni-
form in Greece, as it has particularly affected the onset of specific diseases and it has
afflicted different population subgroups unevenly.

24.4 Mental Health Consequences: Suicide

The effect of the financial crisis on suicides has engendered a lively debate in Greece
(Economou et al. 2011; Fountoulakis et al. 2012; Kentikelenis et al. 2011; Kontaxakis
et al. 2013; Liaropoulos 2012; Stuckler et al. 2011). Recently, a 30-year interrupted
time series analysis exploring the influence of austerity- and prosperity-related
events on the occurrence of suicide during the time period 1983–2012, based on
data provided by the Hellenic Statistical Authority, corroborated a significant,
abrupt and sustained increase in total suicides (by 35.7 %) after the passage of new
austerity measures in June 2011 (Branas et al. 2015). Similarly, another ecological
study performed a joint point analysis to identify discontinuities in suicide trends
between the time periods 2003–2010 and 2011–2012 as well as it sought to explore
their association with GDP and unemployment throughout the entire period
(Rachiotis et al. 2015). Results from this study confirmed a rise in total suicide rate
by 35 % between 2010 and 2012. Moreover, a significant correlation between sui-
cide mortality and unemployment, especially among working-age men, was also
demonstrated. The strong correlation between suicide mortality and unemployment
has also been supported by another study, which has advanced existing knowledge
about the correlates of suicide mortality in Greece by providing evidence for its
substantial association with public debt, HIV incidence and homicides (Madianos
et al. 2014).
Congruent with these, the recession and the pertinent austerity measures have
gravely impinged on the health of the population by triggering an increase in suicide
mortality. The steep rises in unemployment rates seem to be playing a prominent
role in driving this phenomenon.

24.5 Mental Health Consequences: Common Mental

Disorders

On the grounds of the socioeconomic turmoil in the country and based on interna-
tional evidence suggesting an increase in the prevalence of affective disorders as a
corollary to the global recession (Lee et al. 2010; Wang et al. 2010; WHO 2011), the
474 M. Economou et al.

University Mental Health Research Institute (UMHRI) designed and implemented

a series of repeated nationwide cross-sectional surveys on the prevalence of major
depression and suicidality in years 2008, 2009, 2011 and 2013. All telephone sur-
veys had a similar methodology and drew different samples from the base popula-
tion. The sampling frame was the national phone-number databank, which provides
coverage for the vast majority of households in the country. A random sample of
telephone numbers belonging to individuals were selected from the directory, and
within each household, the person who had their birthday last was selected for the
interview. Response rates were high and all samples were comparable and represen-
tative of the Greek population. For the detection of major depression and suicidality,
the germane modules of the Structured Clinical Interview (SCID-I) were employed
(First et al. 1996). Respondents, who reported experiencing one or both of the two
core symptoms of major depression for at least 2 weeks in the month preceding the
interview, were asked about experiencing seven additional symptoms most of the
time throughout the same time period. Participants recounting at least five symp-
toms overall were further enquired about the extent to which the symptoms inter-
fered with their level of functioning at work and at home and with their interpersonal
relationships. Moreover, they were asked four additional questions in an attempt to
disentangle the presence of major depression from symptoms explained by a gen-
eral medical condition, the direct physiological effect of a substance (medication
and/or street drugs) and bereavement. The diagnosis was found to have good psy-
chometric properties.
For assessing participants’ degree of financial strain, the Index of Personal
Economic Distress, an original, self-constructed scale, was used (Madianos et al.
2011). The particular scale encompasses eight items tapping respondents’ difficulty
in fulfilling daily financial demands of a household during 6 months preceding the
interview. Responses were made on a three-point scale, reflecting a frequency
dimension, (1) never, (2) sometimes and (3) often, while the overall scale score can
range from 8 (no economic hardship) to 24 (serious economic hardship). In the
2013 survey, an item was added in the Index enquiring about participants’ difficulty
in meeting financial obligations related to paying taxes and health/pension contribu-
tions. The persistent nature of the recession in Greece has engendered different
sources of financial strain throughout the years necessitating therefore the revision
of the scale.
All interviews were conducted by well-trained interviewers, graduates of social
sciences.
The findings of all four surveys indicate a gradual but steady increase in 1-month
prevalence of major depression. In particular, in 2008, when the crisis had not begun
in Greece, 1-month prevalence of major depression was 3.3 % (Madianos et al. 2011).
Since then, an upward course has been recorded: 6.8 % in 2009, 8.2 % in 2011 and
12.3 % in 2013 (Madianos et al. 2011; Economou et al. 2013b, 2015). On the con-
trary, 1-month prevalence of suicidality had increased during the time period 2008–
2011; however it declined thereafter. Specifically, pertinent figures for suicidal
ideation were found to be 2.4 % in 2008, 5.2 % in 2009, 6.7 % in 2011 and 2.6 % in
2013, while for suicidal attempt, they were 0.6 % in 2008, 1.1 % in 2009, 1.5 % in
24 The Impact of the Economic Crisis in Greece 475

2011 and 0.9 % in 2013 (Economou et al. 2016). This different pattern of results has
also been observed in South Korea as a result of the Asian economic crisis
(Organization for Economic Cooperation & Development 2007), and it can be
explained in line with evidence suggesting that while depression involves a prolonged
course of symptoms prior to reaching the threshold of a clinical diagnosis, suicidal
acts may constitute an acute response to the onset of a crisis (Hong et al. 2011).
Regarding the risk factors for major depression, throughout the 5-year period of
the recession in Greece, different variables have appeared to be heightening the
odds of suffering from the disorder. The only variable that has consistently consti-
tuted a risk factor for major depression in all four surveys is financial distress. It
merits noting that the strong association between economic hardship and major
depression has been recorded in other studies as well (Ahnquist and Wamala 2011;
Meltzer et al. 2012). Surprisingly, the strong influence of unemployment on major
depression has predominantly emerged in the 2013 survey (Economou et al. 2016),
perhaps due to the steep rises in unemployment rates after 2011 and the growing
realisation of its long duration.
Interestingly, when the impact of unemployment and financial hardship on sui-
cidality is explored, their effects are retained, even after controlling for the presence
of major depression (Economou et al. 2015). In this rationale, during the economic
crisis in Greece, there are suicidality symptoms related to the presence of major
depression as well as symptoms independent of the disorder and pertinent to the
socioeconomic turmoil in the country. This is congruent with the view that apart
from the clinical manifestations of affective disorders in certain individuals in
Greece, there is a widespread “social sorrow” which should not be overlooked or
underestimated (Stylianidis 2011) – for an elaboration on the concept of “social sor-
row”, the reader is encouraged to refer to the germane chapter of the present book.
Moreover, evidence from the UK suggests that in 2010 and 2011 issues pertaining
to financial hardship and employment contributed substantially to 13 % of suicides,
while they were the key contributing factor in 4 % of them (Coope et al. 2015). It is
therefore clear that the occurrence of major depression and suicidality is greatly
influenced by the socioeconomic hallmarks of the recession in Greece: unemploy-
ment and economic hardship.
In sharp contrast to the findings related to major depression, the prevalence of
generalised anxiety disorder (GAD) was found to be impervious to the influence of
the financial crisis. Similarly to major depression, its presence was assessed through
incorporating the corresponding module of the SCID-I in all three surveys (First
et al. 1996). In 2008, 1-year prevalence of GAD was 3.7 %, in 2009 it was 3.8 %,
and in 2011 it was 4 %. In a publication delineating changes in 1-year prevalence of
GAD between 2009 and 2011, it was shown that the most substantial increases were
observed in men, people of working age, married individuals, respondents who had
completed undergraduate studies, employed participants and citizens of Athens
(Economou et al. 2013a). These results are possibly explained by the adverse work-
ing conditions in the country. The fast-paced increases in unemployment as well as
the popularity of part-time employment regimes seem to have created an
476 M. Economou et al.

omnipresent fear of job loss and job insecurity, which in turn has given rise to the
development of GAD.
Interestingly, when a potential protective influence of cognitive social capital on
the presence of major depression and GAD was investigated, the findings were con-
trary to expectations (Economou et al. 2014b). Specifically, interpersonal and insti-
tutional trust, the two indices of cognitive social capital employed, were found to be
inversely related to the presence of major depression but not to GAD. It is highly
likely that trust may alleviate the anxiety triggered by certain environmental stimuli
but cannot cover the full range of events eliciting worry in people who suffer from
the disorder, hence the non-significant impact. Nonetheless, the particular findings
were recorded for people reporting low economic distress. On the other hand, in
people experiencing high financial distress, trust was no longer a protective factor
for neither major depression nor GAD, indicating in this way a moderating influ-
ence of financial strain. The particular finding resembles to some extent research on
high-poverty areas in the USA, where social capital has been linked to elevated rates
of mental distress (Mitchell and LaGory 2002). The authors of the aforementioned
study have argued that community connections in these areas can engender a num-
ber of obligations, leading people to tackle converging difficulties, stemming from
both their personal life and the community. In this reasoning, close interpersonal
relationships, which are founded on trust, can result in additional emotional burden
through social contagion pathways. In line with this, the findings of the epidemio-
logical surveys in Greece echo the conclusions drawn by other researchers that pro-
moting social capital alone, i.e. without addressing socioeconomic indicators, may
be ineffective means for promoting mental health and preventing the onset of men-
tal disorders (Ahnquist et al. 2012; Phongsavan et al. 2006).
Apart from the surveys conducted by the UMHRI, complementary evidence for
the mental health effects of the financial crisis in Greece are yielded from the 2009
to 2010 Psychiatric Morbidity Survey and from data gleaned in the context of the
UMHRI Depression Helpline. The Psychiatric Morbidity Survey was conducted by
the University of Ioannina on a nationally representative sample of the adult popula-
tion in Greece (Skapinakis et al. 2013). It was a household survey and data were
collected between September 2009 and February 2010 (i.e. amid financial crisis).
For assessing participants’ psychiatric morbidity, the Revised Clinical Interview
Schedule (CIS-R) was employed for tapping common mental disorders as well as
the Alcohol Use Disorders Identification Test (AUDIT) for alcohol use. The
response rate of the survey was 54 % and it estimated 1-week prevalence of com-
mon mental disorders. The results of the survey showed that 14 % of the population
suffered from clinical significant psychiatric morbidity. Generalised anxiety disor-
der was the preponderant disorder (prevalence, 4.1 %), followed by depression
(2.9 %), phobias (2.79 %), mixed anxiety-depression (2.67 %), panic disorder
(1.88 %) and obsessive-compulsive disorder (1.69 %). Harmful alcohol use was
recorded for 12.69 % of the population. Regarding the risk factors for mental disor-
ders, female gender, divorced or widowed marital status, low educational attainment
and unemployment were positively associated with clinical significant psychiatric
morbidity. Differences in the prevalence of major depression between the UMHRI
24 The Impact of the Economic Crisis in Greece 477

surveys and the 2009–2010 Psychiatric Morbidity Survey can be accounted for by
the different methodologies adopted: household survey vs. telephone survey (Crete
was excluded from the 2009 to 2010 Psychiatric Morbidity Survey), 1-week preva-
lence vs. 1-month prevalence and CIS-R vs. SCID-I.
With regard to the UMHRI Depression Helpline, a nationwide telephone helpline
providing information on mental health issues and brief counselling services from
2008 to 2014, a steep increase is documented in calls with direct or indirect refer-
ence to the economic decline during the first half of 2010 and onwards (Economou
et al. 2012). The callers who referred to the recession manifested depressive symp-
tomatology of clinical significance to a greater extent than callers who made no
such reference. In addition, a higher frequency of depressive symptoms was dis-
cerned among unemployed individuals, whereas employed people were found to
experience anxiety symptoms to a higher degree. It merits noting that anxiety and
depression symptoms were assessed with the pertinent Goldberg scales (Goldberg
et al. 1988).
Concerning self-reported indicators of mental health, the findings are similar to
the ones derived by the use of clinical instruments, employed in the aforementioned
studies (SCID, CIS-R, Goldberg Depression and Anxiety Scales). Data emanating
from two cross-sectional nationwide surveys in years 2006 and 2011 were com-
pared with regard to depressive symptoms, assessed with the question: “During the
last 4 weeks, how often did you feel sad/depressed and that nothing could improve
your mood?” (Mylona et al. 2014). Findings from this study support that in 2011
there was greater likelihood of respondents reporting feeling sad or depressed as
compared to 2006. Additionally, income, education and unemployment were found
to constitute decisive determinants of depressive symptomatology.
It is therefore conspicuous that the sustained recession in Greece has resulted in
increasing prevalence rates of major depression for the population as a whole. Rises
in unemployment and financial hardship emerge as the most plausible accounts for
this impact.

24.6 Healthcare Consequences

In spite of the growing mental health needs of the population, the ongoing financial
crisis has impinged on the healthcare system as well (Economou et al. 2014a). In the
wake of the economic crisis in Greece, the National Health System (NHS) had
already been in a state of crisis, as demonstrated by substantial problems in effi-
ciency, healthcare provision, organisation, structure and management as well as a
fragmented administrative framework, an extensive private sector, a dearth of pri-
mary healthcare services and insufficient hospitals and workforce (Emmanouilidou
and Burke 2013). Moreover, the absence of a functioning referral system between
primary- and higher-level care in tandem with problematic pricing and provider
reimbursement mechanisms resulted in poor coordination of care, large informal
payments and a sizable black economy, hindering further the system’s ability to
deliver equitable financing and access to services (Liaropoulos et al. 2008).
478 M. Economou et al.

Congruent with these, the recession has brought the country’s healthcare system in
the throes of collapse (McKee et al. 2012). According to a systematic literature review
on the topic, the economic downturn has incurred deleterious consequences on
healthcare, including curbing of public health expenditures, reductions in the number
of health professionals and their salaries, cuts in pensions, decreases in the procure-
ment of medical supplies, rapid reforms in the pharmaceutical and social insurance
sectors as well as inadequate primary healthcare services (Simou and Koutsogeorgou
2014). Furthermore, access to and provision of healthcare services are hampered, out-
of-pocket contributions have persisted and monitoring and efficiency issues have
been discerned. It is noteworthy that while there is a growing unwillingness on the
part of citizens to pay informally for healthcare services, an increasing demand for
these payments, either as a prerequisite for access to services or to redeem services
provided, has been recently demonstrated (Souliotis et al. 2016).
Similar problems have been documented in the mental healthcare system. Mental
health services have downsized their operations and personnel, while public fund-
ing for mental health was reduced by 20 % between 2010 and 2011 and by addi-
tional 55 % between 2011 and 2012 (Anagnostopoulos and Soumaki 2013). The
psychiatric and neurology departments of the Eginition Hospital are on the verge of
collapse, psychiatric inpatient departments of general hospitals have to tackle an
enormous workload as they are operating at 120 % of their capacity and mental
health professionals suffer from burnout and impaired morale (Hyphantis 2013).
Therefore, in spite of the growing mental health needs of the population during
the recession in Greece, the mental healthcare system appears incapable of address-
ing them.

24.7 Alleviating the Mental Health Effects of the Crisis

Various papers have been published in order to provide a comprehensive framework

for mitigating the mental health effects of the economic crisis (Christodoulou and
Christodoulou 2013; Wahlbeck and McDaid 2012; World Health Organization
2011); however, not all of their recommendations fit neatly to the Greek reality.
Restructuring of mental health services should become a top priority, accompanied
by active labour market programmes, debt relief programmes and enhancement of
social capital. In particular, to meet the growing mental health needs of the eco-
nomic crisis, emphasis should be given on buttressing community-based mental
health services, which have been shown to prevent against suicide mortality (Pirkola
et al. 2009; While et al. 2012). An integrated care approach promoting service pro-
vision in primary care will facilitate access to mental healthcare and shift the focus
to prevention and early detection of mental health problems. Concomitantly, the
mental healthcare system must cultivate resilience-strengthening elements in the
community, to create a comprehensive and accessible network while targeting the
stigma attached to mental disorders in order to make services both accessible and
acceptable.
24 The Impact of the Economic Crisis in Greece 479

Active labour market programmes usually endeavour to improve changes of

people finding gainful employment and usually encompass public employment ser-
vices, labour market training, special programmes for young people in transition
from school to work and programmes to provide or promote employment for people
with disabilities. In light of the alarmingly high rates of unemployment in the coun-
try, there is an urgent need for the implementation of this type of interventions.
Regarding debt relief programmes, reforms of bankruptcy laws and establish-
ment of debt management advisors may be helpful in protecting mental health.
Generally, there is a need for national initiatives to encourage cooperation and com-
munication between health services and debt management agencies. Debt manage-
ment advisers should be trained to refer clients to mental healthcare when needed,
and conversely, mental health providers should acknowledge the role of financial
strain and refer people with mental health problems to debt advice bureaus (Fitch
et al. 2009).
For enhancing social capital, participation in community activities should be
encouraged, in line with evidence suggesting that social networks, such as trade
unions, religious congregations and sport clubs, seem to constitute a safety net
against the adverse repercussions of rapid macroeconomic changes (Stuckler
et al. 2009).
To the authors’ knowledge, no policy framework specific to offset the mental
health impact of the recession in Greece has been designed nor implemented.
The only intervention to tackle with the increasing prevalence of major depres-
sion in a cost-effective and empowering manner, while promoting the social capi-
tal of the community amid the recession in Greece, is the joint initiative “Citizens
Against Depression”. In particular, the Regional Development and Mental Health
Association (EPAPSY), the Greek Association for Mood Disorders (MAZI), the
Charity Office of the Archdiocese of Athens and the Association of Families and
Friends of Mental Health of Northern Attica collaborate in order to promote self-
help groups for fighting depression in the community. In March 2014, in the con-
text of “We Are All Citizens” programme funded by EEA Grants for Greece, the
Regional Development and Mental Health Association and the Salten Psychiatric
Centre in Bodo, Norway, developed a bilateral partnership for sharing their
knowledge and experiences of self-help groups. Their programme includes the
following:

(i) Development of a training module

(ii) Development of an e-learning platform, after adjusting training material to an
e-learning format
(iii) Training of professionals who will be involved in ten key areas of Greece
(iv) Group therapy for depression and suicide prevention
(v) Training of users in organising and coordinating self-help groups
(vi) Facilitating self-help groups through establishing local meeting points in four
target areas
(vii) Evaluation
(viii) Dissemination
480 M. Economou et al.

The Maison Blanche Hospital in Paris has joined this effort by designing the
evaluation of the initiative.
The programme is expected to empower individuals suffering from depressive
symptoms, to reduce their perceived isolation and to reinforce their social networks,
therefore fostering resilience. This is a currently ongoing effort and results are
anticipated in the ensuing months.

Conclusion
The persistent recession in Greece has triggered a cascade of dire socioeconomic
consequences, which in turn have impinged on the mental health of the popula-
tion. While mounting evidence corroborates the growing mental health needs of
the population, existing mental health services are incapable of addressing them.
However, there has been no systematic effort on the part of national policy to
design and implement interventions geared towards mitigating the mental health
effects of the crisis. Echoing the conclusions drawn by the ex post evaluation of
the implementation of psychiatric reform in the country (Loukidou et al. 2013),
any plan to counteract the untoward effects of the financial crisis on mental
health in the country relies on local initiatives by particular service providers.
Congruent with this, the contention that the economic downturn may provide a
window of opportunity for restructuring mental healthcare in Greece (Karamanoli
2011; Liaropoulos 2012) seems overoptimistic, if not futile. Concerted efforts –
from policymakers, epidemiologists, health economists, clinicians, patients and
their families – for ameliorating the mental health impact of the recession in
Greece are urgently needed, in order to militate against exacerbation of psychi-
atric morbidity in the foreseeable future and to avoid a potential outbreak of
suicides.

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Afterword: The Economic Crisis
and Mental Health 25
Stelios Stylianidis, Panagiotis Chondros,
and Michael Lavdas

Abstract
In this chapter, we provide a brief description of the European and Greek political
and social context of the economic crisis, in order to gain a better understanding
of the effects of these circumstances on public health and particularly on mental
health. Then, we refer to the impact of the economic crisis on mental and general
public health. Finally, we present certain proposals and innovative initiatives in
the mental health field. Unlike the recurrent distorted ideas and paralysing
inward-looking approach so common in modern Greek psychiatric institutions,
we choοse to present specific examples of interventions which are in keeping
with the spirit of critical rationality and reflection which pervades this book.

25.1 Introduction

The economic crisis produced a number of significant changes on a microeconomic

level, such as loss of jobs and social insecurity about the future, increase in house-
hold debts and rapidly increasing social inequality which threaten social cohesion
and resilience of every person as well as of social links and networks.

S. Stylianidis
Department of Psychology, Panteion University, Athens, Greece
e-mail: [email protected]
P. Chondros • M. Lavdas (*)
Association for Regional Development and Mental Health (EPAPSY), Athens, Greece
e-mail: [email protected]; [email protected]

© Springer International Publishing Switzerland 2016 485

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7_25
486 S. Stylianidis et al.

Such changes – dramatic both in terms of intensity and quality – are decisive for
the life and survival of citizens, as well as the ability to invest in a better future,
insofar as this ability is closely linked to the economic, mental and family resources
of rapidly growing and expanding excluded social groups.
It is generally acknowledged, based on research data from the public health and
public mental health field, that unemployment, poverty, homelessness, breakdown of
family and social bonds and the difficulty and/or lack of access to health services have
a negative impact on the mental health indicators of the general population (Saraceno
et al. 2007; Saraceno and Barbui 1997; Mezzich and Saraceno 2007; Drew et al.
2005). All available literature demonstrates that social inequalities have the most
negative impact on the outcome of the mental health of individuals, along with unem-
ployment, part-time employment, job insecurity, low educational and social level
(Marmot 2005, 2013; Patel et al. 2010; Bambra 2010). A degraded urban environment
and low quality of life lead to an increase in the prevalence of mental disorders.
The impact of the economic crisis on southern European countries has led, inter
alia, to budget cuts for health, mental health, social services and programmes, as
well as to significant cuts in the social benefits and disability pensions.
In Greece, the multilevel crisis and protracted recession have had a decisive
effect on the rise in prevalence of mental disorders in the general population and, in
particular, the increase in cases of depression and attempted suicide, as well the
increase in applications for psychiatric and psychological help and treatment, while
at the same time, the dismantlement of public mental health service system, due to
underfunding, is under way (Stylianidis 2012).
Consequently, the major challenges faced by the partners in the field mental
health and the suspended psychiatric reforms should be “preventive” in nature and
are as follows:

To prevent the exclusion or degradation of mental health due to social policy priori-
ties and health policies in general
To prevent the further fragmentation and weakening of the network of mental health
structures and to reduce staff burnout
To stimulate the resourcefulness of therapeutic teams and public health policymak-
ers and to provide innovative responses to a range of new social suffering, social
exclusion and psychopathology issues
To develop new innovative actions and cooperations and to substantiate their effec-
tiveness under the current conditions and opportunities arising from the pro-
tracted crisis

It goes without saying that the management of and response to these challenges
exceed the limits of the psychiatric community and the wider field of mental health
in general. For this reason, we are setting out below a broad introduction to the
sociological framework of the crisis at European level. In an overall systemic crisis,
such as the current crisis, there is an urgent need for the active participation of pro-
fessionals, the movements of families and users of mental health services in the
development of political interventions and proposals which operate effectively on
the local level and to plan interventions on the national and European level.
25 Afterword: The Economic Crisis and Mental Health 487

25.2 The Deficit of Democracy in Europe, Social Insecurity

and Vulnerable Social Ties

The European project was initially based by its fathers on a political and cultural
vision and the desire to unify the old continent after two destructive wars, which
had begun in Europe. The original core Member States of the former EEC had a
sound basis of common financial interests as well as the political will to develop
a rule of law and a strong social protection net for its most vulnerable social
groups. Free access of European citizens to quality health, social welfare and
education services, as well as the declared aim of reducing social inequalities and
social exclusion formed part of the European identity, a non-negotiable axiologi-
cal system.
According to Castel (2003), there are two main types of protection:

(a) Constitutional protection, which guarantees the basic freedoms and safety of
goods and persons in a framework based on the rule of law
(b) Social protection, which covers the basic risks that could lead a person to a
deterioration of his/her situation, such as illness, accidents, old age, social
exclusion situations and “transience” of existence

These two keystones are the basis of the European project under the shared
vision for a post-war Europe. These principles of protection came close to such
an axiological, ethical, legal and institutional level that Western Europe was
characterised a “secure” society, in the sense that it was capable of providing
security and protection to its members. The position we advocate here is that the
manner in which democracy operates in the European region in these times of
systemic crisis has a dark side to it, an increasing deficit which creates insecu-
rity, instability and threat against citizens, people previously protected by the
rule of law.
In a very sketchy way, we can describe three main deficits of democracy:

(a) A policy deficit in relation to the dominant narrative of market overinvestment

without regulatory measures consistent with a globalised economy, the protec-
tion of banks and stock exchanges – a deficit which, inter alia, results in the
marginalisation of the traditional policy role. Today, policy, and, moreover, the
composition of governments, is imposed by the markets and not by the political
institutions.
For instance, the increasing accumulation of capital is not invested in the
establishment of new innovative enterprises and the creation of new jobs and,
consequently, to curb the phenomenon of unemployment and its numerous
implications. This stagnation reproduces the vicious cycle of increasing social
inequalities and social exclusion, the vulnerability of new social groups and
also wars or threats of war.
(b) A deficit of democracy in the functioning of European institutions and, notably,
the European Commission. If we consider the matter from a purely formal per-
spective, there is no deficit in the EU, insofar as its leaders are elected by the
488 S. Stylianidis et al.

national and European elective bodies. However, the decision-making process

and crisis management of both economic and international conflicts, lack of
procedural transparency and lobbying in various areas (foreign policy, financ-
ing, targeted controls, criteria governing the selection of programmes, etc.)
indicate this is a “nondemocratic” democracy. Prime ministers are elected by
the citizens of the Member States. However, they are just pawns in a geopoliti-
cal chess game determined by the International Monetary Fund (IMF), the
European Central Bank (ECT) and European Commission bureaucrats. The real
influence of the European Parliament is in fact insignificant in this complicated
jigsaw puzzle of interests, just as marginal as the influence of civic society and
the Council of Europe.

Daily, we are seeing a crisis of confidence which defines the relationship between
the EU and its citizens. The citizens’ lukewarm participation in European elections
confirms this claim. In fact, European institutions cannot claim any real legitimacy
without a minimum level of economic, social and cultural cohesion. By way of
illustration, we refer to a recent article by Jäcklein (2014), “10 threats to Europeans”,
published in the respected Monde Diplomatique where the above information can
be found in one place:

Disregard of basic worker’s rights

Reduction of workers’ rights to collective representation
Relaxation of technical norms and standards
Restrictions on the free movement of people
Absence of sanctions against abuse
The progressive disappearance of public services
Increased unemployment
Loss of confidentiality of personal data
Subordination of people to intellectual property rights
Subordination of states to laws tailor made for multinationals

Unable to react in the face of these “threats”, national governments – as also

witnessed in Greece – are experiencing a dramatic weakening of their role. There
are two basic reasons for this: First, because every decision taken by a Member
State government comes up against a faceless bureaucratic mechanism of the
European Commission which requires compliance with the rules and previous
agreements, aimed at the so-called European harmonisation of the partners. Second,
because traditional political parties can no longer perform the role of representing
their social base, insofar as they are confronted with insurmountable difficulties in
effectively fulfilling the citizens’ agenda in the face of the above-mentioned “grey
area” of how European institutions operate.
We find ourselves between an illusion and a tragedy: this Europe does not inter-
est its citizens-electors enough to mobilise them in order to radically change this
hopeless situation. Conversely, the rise of Eurosceptics, populists and extreme
right-wing parties with their divisive rhetoric in the last elections makes this change
a far more complex and difficult task.
25 Afterword: The Economic Crisis and Mental Health 489

A fundamental antithesis which allows us to gain a better understanding of the

current crisis is that a process of alliance aimed at creating a common currency was
brought forward. However, this “Euro agreement” was not supported by a relevant
process to ensure the political union of the Member States. As a direct result, “eco-
nomic stabilisation” rather than the political management of the crisis was imposed,
under German leadership, through the imposition of extreme austerity measures.
Unemployment was the key weapon in reducing the southern European country
competitiveness deficit, resulting, inter alia, in a lack of growth, drop in family
income, worsening of budgetary deficits, a huge social cost and a dramatic increase
in social inequalities (Lapavitsas 2014). In short, neoliberal policy imposed stabili-
sation through the destruction on the European South.

25.3 Social Insecurity and Uncertainty About the Future

These dramatic changes, both political and economic, have many implications on
the cohesion of every social structure. The last decade for most European countries
was marked by a rather latent and less clear move towards individualism, growing
insecurity and weakening of collectivism. Everyone is fighting for themselves, their
individual survival or the strengthening of their own group’s narrow special inter-
ests. Systemic media present such profound transformations of society, financial
disaster and breakdown of interpersonal and social relations as a “matter of course”
and as a current requirement for mobility, adaptation, temporary redundancy of
workers and “flexicurity”, as the institutionalization of job insecurity has been
shamelessly defined in EU “jargon”. Everything is fluid and mobile; without fixed
points of reference, everything is ephemeral, both labour relations and emotional
relationships and human relationships (Bauman 2013a, b).
When the implementation of the rules of “deregulation” of labour relations meets
with serious resistance, when the model of “precarious growth” is not established
(Beck 1992), then a tough austerity policy is imposed to remove the obstacles aris-
ing from budgetary deficits. Austerity policies which are promoted with dogmatic
fanaticism in Europe by the mechanisms of German hegemony – with a protestant
flavour to them – should be imposed exclusively since “There Is No Alternative”
(TINA).
Within the framework of such dominance of the neoliberal model of economic
and social governance, every social solidarity concept and tradition is degraded
and discredited as resistance to market liberalisation, competitiveness and self-
regulation of free trade. Every coherent social protection programme which, of
course, differs from the various humanitarian actions promoted by the Media is
considered a relic of the past, part of a costly and ineffective welfare state, which
stands in the way of “unlocking” creativity and autonomy in the area of “entrepre-
neurship” of every free individual. Hereat, we note a full distortion of reality by
the mandarins of the markets, which is based on certain actual problems and fail-
ures of the welfare state, in Greece and in Europe: instead of improving and evalu-
ating the services and benefits, we close down services and cancel social protection
(Sakellis 2012).
490 S. Stylianidis et al.

However, new vulnerable social groups are emerging as a result of the crisis:
the poor, the disabled, the homeless and the elderly, children without protection,
unprotected mothers, single-parent families, migrating populations due to wars
and disasters, economic migrants and political refugees and the long-term unem-
ployed. All these people are living in a vicious cycle of poverty, social exclusion
and physical and mental vulnerability, which in turn leads to their greater margin-
alization (see also conclusions in the Chap. 4). It is self-evident that the way to
deal with and care for all these “outcasts” of a system which produces increasing
inequalities cannot be to classify them into diagnostic categories and create – in a
setting of shortage of resources – specialised services for each separate category.
As aptly put by Castel (2000, 2013), addressing the complex needs of such popu-
lations is not just about securing material resources, but primarily about redesign-
ing a social policy which takes seriously into account the growing process of
social disaffiliation.
The conclusions of the researchers participating in the study of the social phe-
nomena of globalisation and the systemic features of the economic crisis are largely
in agreement (Giddens 2004; Beck 1992, 2006).

25.4 Greece’s Special Situation

There is an immense volume of literature about the special features of the Greek
crisis in the wider European context, too much in fact to be presented in the context
of this chapter. Unavoidably, we shall limit ourselves to making our observations on
certain aspects of the crisis which are directly or indirectly related to the failure of
the reforms in our country and, consequently, the suspended step of Greek psychi-
atric reform and the enormous challenges facing the fragmented system of mental
health services in our country under extreme crisis conditions.
The need for bold reforms in Greece was already clear since the birth of the
Greek state in the face of the “ineffective, irrational and/or morally unacceptable
mode of operation of its institutions” (Veremis et al. 2011).
For several years, various clandestine processes have been underway which have
brought the country to the brink of the abyss, namely, the autistic political system,
the gradual weakening and unbridled partisanship of institutions, widespread cor-
ruption, lawlessness and impunity, distorting of incentives and national introversion
(Veremis, Tsoukas op. cit.: 12).
As Pantazopoulos (2013) characteristically points out regarding the common
logic after the transition from dictatorship to democracy: “The people’s proactive
creativity was blocked, social responsibility was undermined and political elitists
were ‘coerced’ in becoming a component of society because of the way in which the
social bond was symbolically represented within a self-victimising but, at the same
time, resistant society. The problem, therefore, is political and cultural. Political in
that the political order is not independent of social interests, therefore, the first is
high-jacked by the latter. Cultural in that meaning-generating structures remained
intact (political nationalist-populism)”.
25 Afterword: The Economic Crisis and Mental Health 491

Greece became, once again, Europe’s utopia, but which Europe and what kind of
utopia? Tsoukalas (2012) wrote that the European Union is not characterised by a
deficit of democracy as claimed so far. It has developed into a mechanism detached
from European societies, which operates as the battering ram of the general interests
of the financial system. It is forcibly trying to make European societies adapt to a
new bare market capitalism model, devoid of any pre-capitalism remnants and also
devoid of social compensation mechanisms which date from the historical compro-
mises dictated, inter alia, by post-war social-democratic politics. It is the triumph of
market ethics and principles, which is expressed via a punitive speech code and a
possessive morality. Greece represents the utopia of implementing such a policy.
That is why everyone is aware that the challenge is not to write off the debt but to
change the country based on the European new neoliberal model.

25.5 Economic Crisis and Mental Health

From 2009 and onwards, a number of articles were published, at both European and
national level, in scientific and other publications about the effects of the economic
crisis on health (Karanikolos et al. 2013; Marmot and Bell 2009). The World Health
Organisation already since 2001 makes it perfectly clear that the correlation between
socioeconomic factors, such as unemployment, the uncertain work environment, the
move down the social ladder, housing and other specific health indicators, is undis-
putable and substantiated by solid research facts (WHO 2003, 2009). The depletion
and lack of resources, at the personal and state level, appear to be affecting the qual-
ity of life, access to adequate and appropriate care and the population’s level of
health (Tsiantou and Kyriopoulos 2010).
As far as Greece is concerned, there is a division of opinion as to whether spe-
cific indicators, such as, for instance, suicides, have worsened and whether this is a
result of the crisis (Kentikelenis et al. 2011, 2012, 2014; Madianos et al. 2011;
Fountoulakis and Theodorakis 2014; Fountoulakis et al. 2012). In the 1990s, while
researching the role of various factors which could help us interpret this data, such
as dietary habits or informal care networks, we frequently encountered the term
“paradox of health” (Philalithis 2001) which described the fact that health indica-
tors, e.g. life expectancy, cardiovascular diseases, etc., in Greece – despite its fewer
health resources – were better. According to the OECD’s data (2014a), the paradox,
on a first reading of “hard” indicators, seems to have persisted. Health expenditure
as a percentage of GDP increased from 8 % in 2000 to 9.3 % in 2012 and was even
up to 10 % in 2010. However, per capita spending on health fell from 3,000 USD to
2,100 USD compared to an average of 3,100 and 3,200, respectively (OECD 2014b).
The number of available doctors increased from 4.3 per 1,000 persons to 6.2 in 2011
(highest rate in OECD countries) and the number of nurses from 2.7 per 1,000 per-
sons to 3.3 in 2009 (one of the lowest rankings, 32nd out of 34 countries). Life
expectancy at birth increased from 78.2 years in 2000 to 80.7 in 2012 and mortality
due to cancer and cardiovascular disease fell at a rate matching the average of
OECD countries.
492 S. Stylianidis et al.

On the other hand, however, there is a long list of data showing the existence of
considerable problems, a wide disparity in access to adequate care and low levels of
meeting needs. When the patients’ personal opinion is required and the evaluation
is based on self-reference (which, methodologically, is particularly important in the
field of social psychiatry), the findings are highly unfavourable.
In relation to the use of health service, studies show that (Kyriopoulos 2014;
National School of Public Health 2013):

• One out of three Greeks is forced to modify his/her therapy, by reducing their
medication dosage because of financial difficulties.
• Sixty percent of chronically ill patients have no access to health services or are
on a long waiting list.
• Chronically ill patients have reduced by 30 % their visits to primary health ser-
vices in the period 2011–2013.
• Chronically ill patients have reduced by 50 % their primary healthcare spending
in the period 2011–2013.
• Hospitalisations for major depression owing to the economic crisis have increased
by 50 %.
• Life expectancy is expected to decrease by 3 years as a result of the deterioration
in the quality of life.
• Since 2008, infant mortality has increased from 3.31 to 4.28 in 2009, 4.36 in
2010 and 4.01 in 2011.
• The annual public per capita pharmaceutical expenditure will amount approxi-
mately to €170, which is the lowest figure in OECD countries.
• Eight out of ten Greeks are forced to reduce spending for daily necessities in
order to afford their medication.
• Four out of ten Greeks have reduced spending for food to save money for their
medication.

According to a survey conducted on behalf of the Athens Medical Association

(2014) on doctors-members of the AMA (ISA), insured persons of the EOPYY
(National Organisation for Healthcare Services Provision) and patient associations,
the data on patient access to health were unfavourable (sample: 200 AMA members,
800 persons >29 years old and 10 patient associations). Patients quit their treatment
because they cannot afford their contribution towards the cost of it. One out of three
patients reported that they were unable to find an associated doctor. Sixty-six per-
cent of doctors believe that health services have deteriorated. The most important
problem put forward by patients is that they did not find an EOPYY associated doc-
tor, while a considerable percentage stated that they were forced to discontinue their
treatment or omit a dose because they could not afford to pay their contribution.
Specifically, 18 % of respondents stated that they could not afford to pay for their
medication, whereas 11 % were unable to find their medication easily.
And although the specific data were obtained from a sample pertaining to Athens,
a study by the Hellenic Open University and the Centre for Health Studies of the
University of Athens Faculty of Medicine, conducted on a representative sample of
25 Afterword: The Economic Crisis and Mental Health 493

1,000 people in October 2010 (Pappa et al. 2013), showed that 99 people, 10 % of
the total sample, reported that their healthcare needs were not being met and that the
two basic reasons for this were cost and lack of time.
More specific data show that the possibility of not receiving essential health ser-
vices is increased where children are concerned, in the case of women and in the
case of individuals with mental disorders or individuals with secondary education
only. Therefore, the findings suggest that the socio-demographic characteristics and
level of health are important factors which explain why healthcare needs are not
being met. Researchers report that such needs will continue to grow, a fact which
will exacerbate inequalities in health and access to healthcare services. Another
study has shown a significant 15 % increase in the level of non-satisfaction of health
needs in a period of 2 years (Kentikelenis et al. 2011).
The data correlated from two studies conducted nationwide by the Department
of Health Economics of the National School of Public Health in 2006 and 2011
provide information on 10,572 individuals (Zavras et al. 2013). The results showed
that poor health levels by self-reference are more often found in the elderly, the
unemployed, pensioners, housewives and individuals suffering from chronic dis-
eases. By contrast, men, individuals with a higher educational level and those with
higher benefits, are more likely to report a better level of health for themselves.
Also, the likelihood of poor health level reports increases during an economic
crisis.
The Hellenic National Committee for UNICEF, in its annual Report “The
Situation of Children in Greece 2014 – The Effects of the Economic Crisis on
Children”, which was prepared in cooperation with the University of Athens and
outlines the situation of children in our country, states that the number of children
exposed to the risk of poverty in Greece in 2012 was over half a million and actually
stood at 521,000, a number which corresponds to 26.9 % of all children, compared
to 23.7 % in 2011. The number children exposed to the risk to poverty or social
exclusion amount to 686,000 in 2012, compared to 30.5 % in 2011. 52 % of poor
households with children in 2012, compared to 44.3 % in 2011, reported being
unable to afford a diet which includes the consumption of chicken, meat, fish or
vegetables of equal nutritional value every second day.
Social protection benefits for 2011 amounted to 28.0 % of GDP or €60.1 billion
and decreased by 4.9 % compared to 2009, a year where they amounted to €63.2
billion. Specifically, family-children social protection benefits to meet family-
children-related needs remain unchanged compared to the GDP rate, standing at
1.8 % for 2011, below the EU average (2.2 %), and amount to €3.7 billion, down by
513 million or 12.1 % from 2009 (€4.2 billion). It is estimated that a considerable
number of children in Greece have no medical and hospital care as a result of their
parents losing social security rights, while other alternative forms of delivery of
medical and hospital care do not cover the entire population.
Generally, children’s living conditions have deteriorated, as 74.1 % of poor
households with children and 29.5 % of nonpoor households reported being unable
to meet their extraordinary but also daily living costs. The inability to meet such
needs, particularly where children are concerned, lowers their living standards, can
494 S. Stylianidis et al.

expose them to serious health risks, limit their growth potential and push them to the
fringes of society (UNICEF 2014, page 35).
Finally, the economic crisis has affected health and healthcare in Greece. It is
obvious that apart from the question of how such data should be methodologi-
cally defined and measured, there is also the question of how such data should be
interpreted in political terms and used and, subsequently, to respond to the crisis.
It should be noted that when Sir Douglas Black produced the first reports on
inequalities in health based on socioeconomic criteria in the late 1970s (Black
Report 1982), the conservative government in the UK prevented their publica-
tion. Nevertheless, they prompted large the scale studies later conducted by the
WHO and other international organisations. Furthermore, in 2010, Sir
M. Marmot, former president of the International Institute for Society and Health
and Chairman of the WHO Commission on Social Determinants in Health,
expressed his concern at the way in which reports on inequalities in health and
cuts in resources are being accepted. Finally, in 2012, in a system such as the
British system, where control and monitoring, fulfilment of indicators and crite-
ria and systematic reporting prevails, the disclosure that 43 persons in hospital
wards died of reasons which was unrelated to their pathology caused quite an
uproar. This disclosure caused Prime Minister Cameron to intervene, and it was
considered a national disgrace by the British people. The report on the Mid
Staffordshire NHS Foundation Trust Public Inquiry by Sir R. Francis, which fol-
lowed after the scandal, is a landmark in the history of the difficulties arising in
any thorough assessment and surveillance of a health system, calling attention to
the need to take in account not just numeric indicators but also the opinions of
patients and employees.
It is still too early to provide a clear answer as to the precise extent and manner
in which the economic crisis will impair the health of the citizens and healthcare.
Although various structures and actions seem to be absorbing a large part of this
social and economic strain, all actions to address inequalities, the protection of vul-
nerable groups and the restructuring of health resources must be immediate.

25.6 Economic Crisis, Social Protection System and Mental

Health

It has been established (WHO 2003) that individuals who are at the lower end of the
social ladder are two times more likely to suffer from a mental disorder. The effects
of the economic crisis on the mental health of adults are particularly evident in the
higher rates of mental disorders and, specifically, depression running at 8.2 % in
2011 as opposed to 3.3 % in 2008 (Economou et al. 2013). Furthermore, suicidal
ideation among individuals who already receive medication has increased to 22.7 %
(2011) compared to 4.5 % in 2009 (Economou et al. 2013), while the use of antide-
pressants has increased by 34.8 % (2006–2011) (Kyriopoulos 2014). Mental
25 Afterword: The Economic Crisis and Mental Health 495

disorder rates have increased considerably; however, only one out of four patients
suffering from a mental disorder is receiving treatment.
In children and adolescents, the cases of psychosocial problems have increased
by 40 %. Specifically, behavioural disorders rose by 28 %, suicide attempts by 20 %
and school dropout by 25 %. Cases of domestic tension have increased by 51 % (due
to a parent’s unemployment, serious financial problems and debts) (Anagnostopoulos
and Soumaki 2013). A study by Stylianidis et al. (2014) is currently underway and
already demonstrates high involuntary hospitalisation rates (60 % in the “Dafni”
Psychiatric Hospital and 50 % in the Sismanogleio General Hospital), while one of
its most important findings includes the fragmentation of mental healthcare where
the rates of the “revolving door” phenomena are high.
The fragmentation characterising the provision of mental health services, as
demonstrated by the “ex-post evaluation” (MHSS 2010, 2012), is a structural weak-
ness of the public system which has a direct impact on the particularly high thera-
peutic gap in Greece, standing at 75 % (Skapinakis et al. 2013).
The current socioeconomic conditions and their effect on mental health can be
interpreted using the “social determinants” model, as more and more studies sub-
stantiate the development of mental disorders caused by the coexistence of one or
more aggravating factors. For example, the development of depression has been
associated with people of low social and economic status, people whose social posi-
tion has been undermined or who have experienced violence and the stigma which
is becoming a characteristic of persons who are in such a position. Panoussis (2012)
classifies the homeless, the working poor, the unemployed and the temporarily
employed as an “other people” category and not just poorer and continues saying
that “Income poverty and the lack of resources lead to human poverty which is
understood to mean the denial of common values. […] A poor person feels entitled
and automatically justified in his/her final rejection of the constant ultimate value of
life and the values of the society in which he/she lives. On the other hand, poverty
is often defined as weakness, poor people are blamed for their failure, solidarity and
compassion are continuously disparaged, the enrichment of one person is dramatic
for another person and, ultimately, excluded persons are doomed to share between
them only the public ills”. This gives us an idea of the connection with depression
as we are not referring to a loss and a consequent bereavement but a process which
includes blame and shame, factors which significantly add to the likelihood of asso-
ciating the loss with the development of a depressive symptomatology (Kendler
et al. 2008). On the basis of the social determinants already mentioned, it is apparent
that social and economic inequality has a significant impact on mental health, per-
haps greater than poverty in the strict sense of the limited financial resources. In the
current crisis, people in vulnerable groups are faced with the “freedom of no choice”
(Panoussis 2012), and therefore, they not only have to face their limited financial
resources but also uncertainty, limited access to health and mental health services, a
low sense of self-esteem, shame and guilt which create a “poverty culture”. The
current phenomena of psychiatric symptomatology constitute, according to
496 S. Stylianidis et al.

Stylianidis (2011), “the transient clinic”. In his own words: “The clinical signs of
the psychotic function which could easily create confusion with a mass of people
who live (survive better) in a state of extreme social exclusion and lack of symbolic,
imagined and actual inclusion in and integration into a social group” and goes on to
define the “transient clinic” as the psychopathology of the “street”, through which
emerges the same symptomatology found in a prepsychotic or antecedent schizo-
phrenic syndrome. This symptomatology is found “in many social groups, such as
the ‘healthy’ poor and destitute, the homeless, drug addicts without shelter, alcohol-
ics, immigrants looking for work, the long-term unemployed, political refugees
seeking asylum, mental patients wondering about expressing – often in a loud man-
ner – their delirious activities” (Stylianidis 2011).
The “Gini” index, where values from 0 (absolute equality) to 1 (absolute inequal-
ity) are assigned, is used in an attempt to “measure” economic inequality. In Greece,
the specific index (0.3448 in 2009 to 0.3678 in 2012) has increased significantly
from 2009 to 2012 (0.3448 in 2009 to 0.3678 in 2012). Thus, as noted by Matsaganis
and Leventi (2013), although the austerity measures theoretically targeted the rich,
in practice they led to a dramatic loss of income for population groups at the bottom
of the income ladder, adversely affecting their already difficult financial situation.
They specifically note that persons at the bottom of the income ladder lost 24.2 %
of their precrisis income between 2009 and 2012. And if we adjust this percentage
on the basis of income distribution in 2012, then the poorer 10 % of the population
has lost 56.5 % of its income, and these percentages are clearly lower as we climb
up the income ladder.
We realise even more that the conditions of the socioeconomic crisis call for the
development of good practices to achieve the best possible result with few resources
(cost effective) to support and protect vulnerable social groups.

25.7 Actions to Counter and Overcome the Crisis

In light of the considerations set out in the introduction from a sociological perspec-
tive, it is clear that such actions must be specifically designed to address the com-
plex needs arising and must also be innovative. For this reason, we should first
examine the macro-level importance of innovative actions in the formulation of
mental health policies. Unavoidably, the question of whether individual experiences
of innovative actions can provide answers to the questions of a mental health system
is raised. According to Bachrach (1980), the differences between a mental health
system and a “model programme” are significant and substantial leading to the fail-
ure of the latter to provide comprehensive answers to the general problems facing a
mental health system. The differences lie in the objectives set, the groups targeted,
the techniques used to identify “cases”, the allocation of resources and funds and
the evaluation procedures applied. In conclusion, it could be argued that innovative
actions contribute little to the problems of a mental health system. However, the
importance of innovative actions lies in their experimental and pioneering orienta-
tion and the principles they are attempting to apply. What are the characteristics of
an innovative action?
25 Afterword: The Economic Crisis and Mental Health 497

Innovative Actions
Implement new and original ideas to a limited extent, i.e. an idea or a series of ideas
is put into practice for the first time on a small scale. Such new actions challenge
established practices and all that they signify (attitudes, perceptions and mentali-
ties) or modify them creatively by setting, for the most part, improvement as
their main objective (in both cases).
They are experimental oriented: a change is introduced which also includes an
assumption about their outcome.
They try new approaches and practices in order to test their effectiveness. Actually,
they are an assumption which is under examination aiming to improve under-
standing of the phenomena currently being studied or to provide better answers
to the hoped-for result of such actions.
They are subject to internal and/or external evaluation. The evaluation of innova-
tive actions is deemed necessary in order to validate or otherwise the effective-
ness of the new actions being tested. Usually, such evaluations concern
comparative procedures, i.e. the products of such innovative actions by com-
paring them to the respective products resulting from existing, established
practices.
They comprise a cluster of numerous and specific attributes – e.g. combined use of
dissimilar resources, specialised or highly trained staff and more favourable
funding, which renders them unique events frozen in the specific time period in
which they are taking place.
Despite the unique character of innovative actions, they aspire to be dissemi-
nated, reproduced and generalized on a greater scale. This, however, depends
on a number of factor which usually include the characteristics of the frame-
work in which such innovative action takes place, the degree and extent of its
specific characteristics and the contents of the evaluation in relation to the
effects triggered by its implementation (as also described above, an innova-
tive action is more of an assumption than a definitive answer to a hoped-for
result).
The admissibility of an innovative action by those to which it is addressed or
involves is differentiated depending on the time it takes place. Its experimental
and/or sometimes radical orientation might cause some form of resistance which
subsequently subsides.
The substantiation of an innovative action as such needs to be validated principally
by those who are affected by such planned changes or expected effects.
The innovation may involve a new idea, approach and/or mode of implementation.

25.8 Innovative Actions: Implementation Examples

Mobile Mental Health Units

The organisation of mobile units (for a detailed description, see relevant Chapter)
involves some elements of innovation and is a community type of care which pro-
vides answers to the needs of the community.
498 S. Stylianidis et al.

Self-Help, Networking and Therapeutic Support in Treating

Depression

To counter the effects of the economic crisis, actions are needed to enhance social
sustainability. The objective of the WHO-EC Partnership Project on User
Empowerment in Mental Health (2008–2011) was to support Member States
improve user and carer empowerment strategies and actions. The basic qualities of
empowerment according to the WHO and the EU are:

Self-reliance
Dignity and respect
Power – ability to decide
Access to information and resources
Sense of belonging and contributing to a wider community

At the community level, the above is achieved according to the experts and the
good practice examples reported by:

State funding for the establishment and operation of local user and carer
associations
Self-help groups and other user and carer community networks
Training provided to social partners, such as employers, police officers and the
Media, on combating stigma (WHO, Regional Office for Europe 2011)

Therefore, according to these principles, any action promoting the concept and
practices of self-help promotes social sustainability. Depression and suicidal ten-
dency are directly linked to social exclusion and the wider social conditions and, as
a result, also include population groups mentioned in the above matters of horizon-
tal interest. The action is based on the concept of empowerment of mental health
service users and persons with a psychiatric disability. Empowerment aims to
change the degree of choices, influence and control of a person in his/her life. The
key to empowerment is the removal of barriers preventing access to training, care
and representation actions and the transformation of power relationships, such as
the patient-specialist relationship (WHO 2011).
The action aims to create a support model for depression which can be dissemi-
nated at no great cost. The main purpose is to train mental health service users,
people with depressive symptomatology in organising self-help groups for depres-
sion. An intervention will be implemented in stages as follows: (a) design of the
intervention (training material for the therapeutic intervention and training in self-
help), (b) development of an online platform and systemisation of training material
in electronic format for e-learning, (c) training of trainers to intervene in ten action
areas, (d) therapeutic groups for depression and suicidal tendency, (e) user training
on the organisation of self-help groups, (f) development and support of self-help
groups, (g) evaluation and (h) dissemination of results.
25 Afterword: The Economic Crisis and Mental Health 499

This action could increase the provision of social welfare services to vulnerable
social groups. Depression often leads people to isolation and has a significant
impact on their quality of life. It also leads to the disruption of social ties. It affects
groups of people living both in urban as well as in remote areas. This action aims to
create a support model which can be disseminated at no great cost, even in areas
where mental health services are not available or limited. It combines therapeutic
treatment, the training of people suffering from depression to cope with the disease
and the organisation of self-help groups using the self-organisation methodology.
The WHO and EU guidelines stress the importance of user empowerment actions
and self-help actions. Therefore, the purpose of this project is to provide social wel-
fare services to people suffering from depression and to train user groups to set up
self-help groups. The distance learning method through the online platform will
enable users throughout Greece to receive training on the methodology of
self-help.

Implementation of the WHO mhGAP Package to Train Non-

specialists in Identifying and Dealing with Mental Health
Problems

Mental health services cover only a small fraction of the general population’s psy-
chiatric morbidity. In countries with a developed primary healthcare (PHC) system,
most mental disorders, primarily those known as “common mental disorders”, such
as anxiety disorders, depression, etc., are covered by the PHC services, which are
key contributors to the follow-up of serious mental disorders, always in cooperation
with the mental health services in each area (Üstün and Sartorius 1995). The causes
vary, from the stigmatisation of the mental disorder and the subsequent unwilling-
ness of patients to receive treatment, the difficulty in accessing mental health ser-
vices, the absence of education of PHC personnel to the identification and
management of mental disorders, etc. This action includes educational interven-
tions as well as the monitoring and evaluation of the function of PHC services and
mental health services in mental health regions where it is implemented.
Therefore, as already mentioned in detail above, the implementation of such
action is appropriate for the Greek health system which is facing tremendous chal-
lenges in the provision of care services and the protection of human rights of people
with mental, neurological and substance use disorders. At the same time, mental,
neurological and substance use disorders interfere, in substantial ways, with the
ability of children to learn and the ability of adults to function in families, at work,
and in society at large. Also, there is a widely shared but mistaken idea that improve-
ments in mental health require sophisticated and expensive technologies and highly
specialised staff. However, what is required is increasing the capacity of the primary
healthcare system for delivery of an integrated package of care by training, support
and supervision. That is why, in October 2010, the WHO launched the Mental
Health Gap Action Programme (mhGAP), to address the lack of care, especially in
500 S. Stylianidis et al.

low- and middle-income countries, for people suffering from mental, neurological
and substance use disorders. Against this background, the WHO designed the
“mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders
in Non-Specialized Health Settings”, a technical tool for implementation of the
mhGAP Programme. It provides the full range of recommendations to facilitate
high-quality care services provided at first and second level facilities by non-
specialist healthcare providers in resource-poor settings.

Direct and Indirect Beneficiaries

Patients in the field and their families
PHC services
Mental health services

Expected Results
Increase in treated psychiatric morbidity in the field and consequent reduction of
“covert” psychiatric morbidity
Improvement of the skills of PHC professionals in identifying and managing mental
disorders
Improvement of cooperation between mental health services and PHC
Improvement of follow-up of patients with serious mental disorders and reduction
of losses in follow-up

Potential Obstacles to Implementation

Indifference of local mental health entities or PHC.
Doctors’ lack of time.
General practitioners believe they are already trained.
Reactions of local stakeholders.

Employment Support to Persons with a Mental Disorder:

The Example of Social Cooperatives

It would be ironic, in a period of high long-term unemployment rates – youth unem-

ployment and social exclusion – to set the objective of occupational integration and
rehabilitation of persons with a mental disorder. However, good practices in the
field of social economy in Greece and abroad show that it is possible to identify
innovative actions and synergies with other alternative social economy fields which
can widen the possibilities for the users’ social reintegration by creating new jobs.
Gainful employment is a crucial issue for the mental health of every person.
Unemployment rates for persons with mental disorders are higher compared to
those with any other disability. The current socioeconomic conditions also make the
employment of persons with mental disorders more difficult. Social cooperatives
(Koi.SPE) are an innovative legal form of social enterprise in the European area
introduced in 1999 by Article 12 of Law 2716/1999 “Development and modernisa-
tion of mental health services and other provisions”. It is designed for “the
25 Afterword: The Economic Crisis and Mental Health 501

socio-economic and occupational integration of persons with serious psychosocial

problems and contributes to their treatment and greatest possible financial indepen-
dence”. As mentioned by Mitrouli and as provided by the instruments of incorpora-
tion of the social cooperative, “A Social Cooperative is both a therapeutic unit and
a cooperative social enterprise. It is a commercial law legal entity whose members
have limited liability. It may engage in any economic activity and may, at the same
time, produce, supply, consume and, generally, provide services and goods. It is
established in a Municipality and the idea is that one Social Cooperative should be
set up in each Mental Health Region”. So far, 23 social cooperatives have been cre-
ated and operate throughout Greece, while, at the same time, a second level
Panhellenic body was set up in 2011 to represent social cooperatives, the Panhellenic
Social Cooperative Association to enhance their representation and interconnection
with public and international organisations [Additional information is available on
the POKOISPE website].

Development of a Consultation Stations Network to Promote

Dementia Prevention and Intervention Actions in Urban Areas
and Remote Islands

Services and structures for dementia in Greek are mainly initiatives by non-profit
organisations, Alzheimer Societies, and are found principally in the two larger
urban centres, Athens and Thessaloniki. There are at present 23 memory clinics, 16
day centres for dementia patients and 3 care at home programmes for dementia
patients in Greece, while the recorded number of families with persons suffering
from dementia amounts to 200,000. The needs are ever increasing, and the supply
of services is limited and often irregular due to underfunding problems (Efthymiou
et al. 2012).
The aim of the Athens Association for Alzheimer’s Disease and Related
Disorders initiative in cooperation with the Regional Development and Mental
Health Association (EPAPSY) and CMT Prooptiki is the development of dementia
services, to be provided in spaces and structures that the target population are able
to visit on a daily basis. In addition, the development of an online distance learning
platform will support the training of health professionals within the areas where
consultation stations operate as well as every interested health professional in gen-
eral, by providing access to educational material on dementia and other interactive
services as well.
This action covers the operation of 17 consultation stations for dementia preven-
tion and intervention for the general population in Athens and the Cyclades. The
project will be implemented in stages as follows: (a) development of standards and
scientific planning by a group of experts, (b) set-up and training of an implementa-
tion team consisting of 11 health professionals, (c) operation of dementia consulta-
tion stations which will provide the population dementia prevention programmes
(assessment of mental functions/screening, mental empowerment groups for healthy
elderly people, informational speeches in the community) and dementia
502 S. Stylianidis et al.

intervention programmes (operation of memory clinics, non-pharmaceutical

interventions for dementia patients and their carers), (d) distance learning for health
and care professionals from all over Greece to enable the widest possible implemen-
tation of the programme to as many areas as possible, (e) publicity measures and
measures for dissemination of results and (f) assessment of the programme.

Host Families: Case Example of Implementation by the Patras

SOPSY (Association of Families for Mental Health)

Tomaras et al. (2005) report that, at the national level, Law 2716/1999 on the
“Development and modernisation of mental health services and other provisions”
(Government Gazette 96/A/17.5.1999) counts “host families” among psychosocial
units or programmes. Ministerial Decisions No. 19353 (Government Gazette
1433/B/22.10.2001) and 35724 (Government Gazette 485/B/19.4.2002) work out
the details of the provisions of the law. Finally, Ministerial Decision No. 39321
(Government Gazette 453/B/16.4.2010) allows the development of “organised fos-
ter and host families” (among several other “complementary actions”) by mental
health units which, according to Law 2716/1999, belong to non-profit private law
entities.
The Patras SOPSY foster family programme, in cooperation with the General
Hospital of Arta Psychiatry Department, fulfils all the conditions to become an
example of good practice because of the substantial involvement of families, users
and citizens and an innovative programme linked to the entire range of sectorised
mental health and social welfare services with specific actions at local and national
level.
Indications regarding the use of foster families as a psychosocial rehabilitation
tool are more focused on the patient’s personal history and a competently prepared
individual care plan than on diagnostic criteria. The persons put forward for place-
ment in foster families have a disadvantage (temporary or lasting) in managing their
daily lives which is associated with their mental disorder. Therefore, the framework
of foster families is situated midway between a care and psychosocial rehabilitation
space and a life place.
The interdisciplinary team responsible for the final selection of such patients
needs to take seriously into account the foster family’s resilience, ability and poten-
tial psychopathology (Stylianidis et al. 2013). As Stylianidis et al. (2013) go on to
say, based on a review of literature and good practices, although no strong empirical
basis exists to support their validity and effectiveness, two conclusions can be drawn:

The main objective set for the first therapeutic foster family type model is the con-
tinuity of psychosocial rehabilitation, housing and social integration in the shift
from the hospital to independent living in the community.
The second type focuses on the main objective of stabilising the course of the seri-
ous mental disorder and reduces relapses and readmissions with the least possi-
ble economic cost.
25 Afterword: The Economic Crisis and Mental Health 503

It is self-evident that the first type, that of the continuous dynamic rehabilitation-
recovery-cure and independent living process, has to be the strategic choice of this
programme, with the following specific objectives:

Improvement of initial symptomatology of patients

Prevention of relapses
Prevention of readmissions
Social inclusion and independent living
Improvement of quality of life of patients
Increase of patient satisfaction compared to traditional psychosocial rehabilitation
housing structures
Savings
Improved networking and synergies between foster families and various services
within the framework of sectorisation
Promotion of patient empowerment and participation throughout the social inclu-
sion process

Assertive Community Treatment (ACT) and Community Care

Home intervention – (Assertive Community Treatment) – is an intensive interven-

tion programme in the community for people with serious mental conditions (usu-
ally schizophrenia or psychotic disorders). The programme may prove to be
particularly effective in preventing repeated hospitalisations, by reducing not only
costs but also the mental and emotional effect of hospitalisations, particularly after
a court order for involuntary psychiatric assessment. The ACT model is already
implemented at the EPAPSY Day Centre, Fifth Psychiatric Region (for more infor-
mation, please see the Chap. 13).

Telepsychiatry

The use of technologies to provide remote mental health services in areas with
limited access to health services for geographic or socioeconomic reasons is
particularly important. Online consultation and teleconferencing in a telepsychiatry
setting may prove particularly useful practices in crisis intervention (e.g. in super-
vising professionals), the consultation, prevention and rehabilitation of a person (for
more information, please see the Chap. 16).

25.9 Conclusions: Comments

As mental health professionals, it is important to overcome our paralysing introver-

sion, the result of numerous frustrations and accumulated disappointment on the
suspended step of so-called reform. In addition, we must look at European reality
504 S. Stylianidis et al.

and its institutions not just as a source of financing and a substitute for the crum-
bling Greek state but also as an area of challenges, exchanges and know-how.
We must create a shared vision of change in a European social solidarity and
cohesion setting. It is also important not to consider the problem of public mental
health from one dimension only, demanding things from an untrustworthy state but
also blaming it, but also to promote new types of synergies, innovations and net-
working with stakeholders and persons who do not belong to the narrow field of
mental health.
Such types of synergies which provide a stable framework for advanced psychi-
atric reform practices are (a) the empowerment and involvement of the families,
friends and users of mental health services at all mental health service levels, assess-
ment and participation in the decision-making process to enable the operation of the
system and (b) the systematic synergy and integration of mental health actions (psy-
chiatric care, prevention, etc.), particularly under crisis and dramatic lack of
resources conditions, to more comprehensive social and healthcare structures so as
to fully meet the people’s basic needs.
We must develop what we refer to as the routine of clinical practice, repetition
and burnout of staff in mental health units and, by utilising new ideas and knowl-
edge, transform it to what the great art critic, Arthur Danto, defined as “transfigura-
tion of the commonplace”. We can move towards collective demands together with
other social and political forces, to achieve a new social state which creates a frame-
work for the development of equal possibilities and opportunities for all citizens;
towards the rationalisation, reorganisation and qualitative improvement of existing
services; and towards the development of a new structure for the social state through
education, assessment, targeted operation, economic growth, as well as the neces-
sary changes in policy and institutional processes (Stylianidis 2014).

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Index

A Asylums. See also Madness;

Abstraction, 29 Mental health
Abuse, child, 345 in eighteenth century, 6
Alcohol Use Disorders Identification Test first, in Valencia, 5
(AUDIT), 464 Hôpital Général, 5
American Nervousness (Beard), 7 locking, 5, 7
Anglo-Saxon movement, 22 in mid-seventeenth century, 5
Animal magnetism, 7
Antipsychiatry, 12–13, 22, 23, 26, 32, 33, 98
Assertive community treatment (ACT), 491 B
abnormality, 250 Being and Time (Heidegger), 31
accommodation facilities, 269 The Birth of the Clinic (Foucault), 22
and AOT teams, UK Brief psychotherapy
daycare structures, 255 cognitive-behavioural treatment, 291
housing structures, 256 conventional evaluation methods, 292
inpatient services, 255 EPAPSY Day Centre, 296–298
Association for Regional Development, Gestalt experiential techniques, 292
263–264 historical overview
characteristics, 252 “cathartic” method, 278
clinical orientation, 251, 270–271 clinical approaches, 280
by CMHT, UK (see Community Mental “corrective emotional experience”,
Health Teams (CMHT)) concept of, 281
“coercion”, concept of, 250 early psychoanalytical attitude, 279
commitment, 269, 272 early therapeutic approaches and
daily life skills activities, 268, 271 techniques, 278
Franco Basaglia Daycare Centre, 238 Freud’s theory, 279
frequency of visits, 268, 271 patient’s regression, 279
Global Assessment of Functioning, 265 Rank’s theory, 280
in Greece, 262–263 therapeutic interventions, 280
interventions, 271 initial assessment, 282–284
medication regimen, 268, 271 and interpersonal psychotherapy
methodological tools, 265 (IPT), 291
patient self-empowerment system, 250 longer-term benefits, 290
psychopathological illnesses, 251 methodological limitations, 292
psychosocial history, 266–267, 270 “open” psychotherapy treatments, 278
quality of life, 251 patient’s transference, 287
rehabilitation and accommodation, 272 psychodynamic approach
social welfare benefits and financial aid, 272 interpersonal existence and
team intervention, 267–268 interpretation, 287
in USA, 252–253 Malan’s technique, 289

© Springer International Publishing Switzerland 2016 509

S. Stylianidis (ed.), Social and Community Psychiatry: Towards a Critical,
Patient-Oriented Approach, DOI 10.1007/978-3-319-28616-7
510 Index

Brief psychotherapy (cont.) primary healthcare doctors, 199

personality and mental health psychological and social functionality,
development, 288 193
psychic representations, 288 resources and consistency, lack of, 209
randomised control trials (RCTs), 289 rights of children, 194
self, concept of, 287 schools and teachers, 199
triangle of conflict, 288 social integration and participation, 195
socioeconomic crisis conditions, 278 socioeconomic and cultural crisis, 197,
socioeconomic framework, 281–282 200, 204
supplementary sessions, 286 sources of referrals, 203–204
theoretical approaches and technical supervision, role of, 206
intervention, 290 Chiswick Women’s Aid, 346
therapeutic alliance, 284–285, 292–293 Citizens and Madness (Dorner), 12
therapist’s attitude, 285–286, 293–295 Clinical governance (CG), 410
training and supervision, 295–296 Clinical psychology, 10
Community care, 491
Community Mental Health Teams (CMHT)
C assessment and brief treatment/referral
Causality relations teams, 260
confidence interval, 43 care co-ordinator/case manager, 258
confounding, 46–47 characteristics, 256–257
direction of causality, 47 crisis resolution and home treatment teams,
information bias, 44 261
investigator bias, 45 early intervention psychosis teams, 261
misclassification error, 44 emergency duty teams/out of hours teams,
non-participation, 46 261
randomised controlled test, 43 fixated threat assessment teams, 261
recall bias, 44 forensic mental health teams, 261–262
selection bias, 44, 45 homeless outreach teams, 262
significance testing, 43 recovery and rehabilitation teams, 260–261
testing methods, 44 staff, 259
types, 44 Community psychiatry
Child psychiatry Daycare Centres for Autistic Children,
definition, 195–196 99–100
mobile mental health units, NE and effects on mental health, 128
Western Cyclades ethnopsychiatric approach, 107–108
ACT, 198 Halfway Houses, 100–104
assessment and recording, 206–208 institutional framework, 376
child abuse, 209 Kulturarbeit, 105, 106
Children’s Health Fund, 198 mental pathologies, 107
demographic variables, 201 neurotic inhibitions and symptoms, 105
diagnosis, 201, 202 postmodernism, 106, 107
economic crisis, 210 psychiatric reform, 98–99
emotional disorders and behavioural psychoanalytical institutes, 97–98
problems, 205 psychosocial rehabilitation and recovery,
historical background, 196–197 382
international conventions and TT dynamics, 377
declarations, 194 The Construction of the Psychoanalytical
mental disorders prevalence, 194 Space, 372
mental health prevention and promotion Continuing day treatment (CDT) programmes,
actions, 208–209 216
parental involvement, 199 Continuous quality improvement (CQI)
parental stress, 205 framework, 410
physical and psychological effects, 195 Critical psychiatry, 12, 18–21, 146, 317
Index 511

D social integration and recovery, 217

Daseinsanalyse. See Psychiatric staff, 224
phenomenology theoretical model
Daycare units/hospitals Bion’s containment and concepts, 221
admission, 217 cognitive-behavioural therapy (CBT),
for Alzheimer’s disease, 218 223
for autism spectrum disorders, 218 cognitive model, 223
case management milieu therapy, 220
care system, 229 negative beliefs, 223
community ties, 230 preconscious, 222
day-to-day skills, 230 psychoanalytical theoretical approach,
medication, 229 221, 222
patient’s environment, 229 psychocognition, 222
professional integration, 230 quality of life, 223
replases, prevention of, 230 schizophrenia, 223
support and supervision, 230 social skills models, 224
theoretical model and principles, therapeutic community, 220, 221
227–229 transitional day hospitals, 217
CDT programs, 216 WARP Declaration, 216
complementary service, 217 Deficit of democracy and European Union
costs and care, 242–243 constitutional protection, 475
definition, 217 “Euro agreement”, 477
factors and parameters, 243 European harmonisation, 476
Franco Basaglia Daycare Centre policy deficit, 475
ACT, 238 social protection, 475
diagnoses of attendees, 232 Deinstitutionalisation movement, 12–13
money management, 236 Disability-adjusted life years (DALY), 63
psychiatric diagnosis and follow-up, Doctor–patient relationship
236 biological determinism, 432
psychosocial rehabilitation unit, collective democracy of health, 434
233–236 daily institutional/clinical experience, 432
psychotherapy service, 237 psychiatric culture, 434
self-care and health promotion groups, self-determination, 435
236 training programmes, 435
social club, 237 user involvement, 433
social skills training, 236 Dolhuysjes, 5
historical development, 218–219 Domestic violence
infrastructure, 224 anger and stress management skills, 356–357
mental health services, 217 child abuse, 345
multidisciplinary team, 224–226 communication development, 356–357
neo-institutionalism and asylum’s counselling women, 353–355
functions, 242 criminal mediation, 346
networking cultural admixtures and migration, 344
and mental health promotion, 238–239 definitions, 344–345
PSCYHARGOS III Programme, 240 family idealisation, 343–344, 348
social cohesion, 239 feminist theory, 346
social cooperatives, 239 financial resources, 344
psychosocial rehabilitation, 216, 218 fluid circumstances, 344
recovery model, 216 Greek financial crisis, 347
research, evaluation and documentation, group therapy, 356
240–241 health sciences, 344
services, 226–227 identification and assessment (see Risk
social clubs, 218 assessment)
512 Index

Domestic violence (cont.) Electroconvulsive therapy (ECT), 11

male victims, 349 E-mental health
management counselling, 333
with adult victims, 351–353 “difficult” calls, 335
with minor victims, 357–358 information, 333
mental health community service, child online psychological support
abuse, 358–360 benefits, 338
Panhellenic study, 347 counselling via live chat, 337
primary victims, 347 determination, 337
self-determination and human dignity, 346 e-mails, 337
social exclusion and mental disorders, 344 ethical considerations, 338–340
Double alienation, 22 online self-help/support groups, 338
Dysfunction of the mental health system, 37, video conferencing, 337–338
180, 223, 235 psychological support helpline, 332–333
support, 333
telepsychiatry
E clarification, issues, 334
Economic and social crisis closure, 334
British system, 482 content exploration, 334
children’s living conditions, 481 defintion, 336
deficit of democracy in Europe, 475–477 relationship establishment, 334
Greece service, 336–337
GDP, 458 EPAPSY-Association for Regional
healthcare consequences, 460–461, Development and Mental Health
465–466 chi-square statistical verification, 412–413
health-related consequences, 458, management, 410–411
466–468 mental health promotion, 409
mental disorders, 461–465 PROJECT method, 410
socioeconomic consequences, 459–460 PSYCHARGOS, 409
suicide, 461 psychosocial rehabilitation, 409
Troika, 458 sample rated performance, 414
innovative actions sound impact indicators, 410
ACT, 491 Epidemiology
consultation stations network, 489–490 Europe, 449–450
dementia prevention and intervention Greece, 450–451
actions, 489–490 investigative design (see Investigative design)
employment support, 488–489 Ethical and moral issues, 159
mobile units, 485 Ethnopsychiatry, 107–108, 315–317
networking and therapeutic support, Europe
486–487 compulsory admission criteria, 442
patient-specialist relationship, 486 ECHR, 441
Patras SOPSY, 490–491 epidemiology, 449–450
self-help, 486 legal support provision, 443
state funding, 486 mental illness, 442
telepsychiatry, 491 national laws and policies, 441
WHO mhGAP package, 487–488 user involvement, 429–430
insecurity and ties, 477–478 European Court of Human Rights
multilevel crisis, 474 (ECHR), 441
protracted recession, 474 European Federation of Families of People
psychiatric and psychological help and with Mental Illness (EUFAMI), 429
treatment, 474 Evaluation, social psychiatry services
reflection, 462 administrative procedures and
social inequality, 473 outcomes, 390
and social protection system, 482–484 assessment indices, 393
socio-demographic characteristics, 481 clinical-therapeutic programmes, 390
sociological perspective, 484 cost/effectiveness analysis, 395
Index 513

decision-making process, 390 and online databases and platforms, 66–67

efficacy and effectiveness, 392 parental behaviour, 65
extended health system, 390 personal and social level, 61
financial quality, 392 psychotropic drugs, 62
high-quality services, 391 resource availability
and human rights, 401, 402 DALYs, 67–68
interpersonal component, 391 high conditions, 69–70
matrix model, 393 low conditions, 67, 69
medical quality, 392 middle conditions, 69
mental health services, 393–395 rights to mental health, 59
pubic health system, 399–401 self-directed psychological treatment
service quality, 391 exercises., 62
social quality, 392 social determinants, 64, 67, 72, 73
structure-process-outcome, 391 social support, 65
treatment protocols, 393 treatment gap, 60–63
Evidence-based medicine, 53–54 trust and security, 65
Existentialism World Health Report, 2008, 64
Anglo-Saxon movement, 22 Governing the Soul (Rose), 33
and asylums, 21–23 Great confinement, 5, 17, 23, 25
biomedical model, 24 Greece
Burton’s and Basaglia’s notion, 22 epidemiology, 450–451
critical psychiatry, 19–20 EUNOMIA, 448
double alienation, 22 financial crisis, 347
existence, 19 involuntary hospitalisation, 444, 446
and Foucault, 21–26 National Emergency Centre (EKAV), 448
institutional neurosis, 22 patient’s assessment, 444
moral treatment, 21 psychiatric epidemiology, 54–55, 57
pathology of madness, 23 therapy, 443
Pinel, 21–24, 26 user involvement, 430–432
Renaissance, 25 Greece’s special situation, 478–479
Greek mental health system, 78, 399
Group therapy, 12
F
Feminist theory, 346
Freudian theory, 10 H
Halfway Houses
deinstitutionalisation, 102
G in institutions, 101
Generalised anxiety disorder (GAD), 463 mental health institution, 102–104
Global Burden of Disease (GBD), 63 residential units and sheltered
Global mental health accommodation, 100–101
accessibility, 60, 61, 65, 66, 71 Hard biomedical model, 18, 19
DALY, 63 Health. See also Mental health
definition, 59 aspects of, 119
depression and suicidality, 73 functional definition, 118
economic burden of mental disorders, 64 historic definition of, 118
estimate cost types, 64 illness prevention, 121
GBD, 63 interdependence, mental and physical, 118
human rights, 61 promotion, 120–121
life expectancy, 65 WHO definition, 118
local services, 65 Health promotion, 120–121
in low-, middle-and high-income settings, The History of Madness (Foucault), 12, 21, 23
60, 61 Hôpital Général, 5
material conditions, 65 Human superorganism, 128
MGMH, 61–62 Husserlian phenomenology, 29–32
national level, 65 Hypnotism, 8
514 Index

I M
Illness prevention, 121 Madness. See also Asylums; Mental health
Individual and social pain as alienation, 22–25
ethnopsychiatric approach, 107–108 cause of, 6
Kulturarbeit, 105, 106 ethics and hermeneutics of, 18
mental pathologies, 107 Foucault’s theory on, 25–26
neurotic inhibitions and symptoms, 105 partial/occasional, 21
postmodernism, 106, 107 pathology of, 23
Individualised socialisation, 35 traitement moral, 4–7
In-patient services and out-patient–social Manu militari, 14
mental health centres, 99 Matrix model, 240, 392–393
Institutional neurosis, 22 Mental disorders
Insulin comas, 11 AUDIT, 464
International Association for Child and GAD, 463, 464
Adolescent Psychiatry, 123 Index of Personal Economic Distress, 462
International Convention on the Rights of psychometric properties., 462
Persons with Disabilities (CRPD), SCID-I, 462
61 UMHRI, 461–462, 464
Interpersonal cognitive problem-solving unemployment and financial hardship, 463
programme (ICPS), 122 Mental health. See also Asylums; Health;
Interpersonal psychotherapy (IPT), 291 Madness; Promotion, mental health
Investigative design antiquity, 4
advantages and disadvantages, 48, 49 biomedical model, 13
case-control studies, 51 Byzantine Empire, 4–5
classic cohort studies, 51–52 development of, 4
ecological studies, 48, 50 DSM-III, 13
and evidence-based medicine, 53–54 hypnotism, 8
experimental studies, 48 Italian deinstitutionalisation movement, 12
involuntary hospitalisation, 47–48 managed care, 13
observational studies, 48 Mental Health Declaration for Europe, 118
randomised controlled tests, 52–53 nervous disorders, 7
synchronic/cross-sectional studies, 50–51 neurasthenias, 7–8
systematic review of abstracts, 48 neuroses, 8
Involuntary hospitalisation nineteenth century, end of, 7
in Athens, 452–453 Ottoman Empire, 5
clinical indicators, 451 prevalence, mental disorder, 119–120
compulsory admission/involuntary prevention, 8–9
treatment, 440 promotion (see Promotion, mental health)
epidemiology (see Epidemiology) psychiatric revolution, 14
human rights (patients’ movement), psychotherapists, in USA, 4
440–441 Victorian era illnesses, 7–8
psychiatric care, 440 WHO definition, 119
public safety, 440 Mental health community service, child abuse,
study of outcomes, 451–452 358–360
treatment, 452 Mental health movement
Italian deinstitutionalisation movement, 12 clinical psychology, 10
Freudian theory, 10
military activities, 9–10
L prefrontal lobotomies, 11
Legislative framework shell shock, 10
Europe (see Europe) shock treatments, 11
Greece (see Greece) WWI, 9–10
Lived experiences, 26–32 WWII, 10
Index 515

Mental health structures identity, 323

classification system, 396 inadequacy of resources, 324
clinical information, 397–398 personal characteristics, 311
epidemiological research, 396 political and socioeconomic framework, 311
ethical and deontological basis, 86 post-migration stress and weight, 312
political support, 85 prevalence, 311
psychiatric reform, 393–395 PTSD, 311
psychiatric treatments, 87 risk of victimisation, 325
quality assurance, 393 social interaction characteristics, 311
Mental institution, 370, 375, 377, 419 therapeutic alliance, 323–324
Mental states, 28 Military neuroses, 10
Mesmerism, 7 Modern psychiatry, transformation
Metropolitan Athens “agentic” subjectivities, 34
classes and ethnic minorities, 135 contemporary approaches, 33–35
data analysis, 137 globalised capitalism, 34
discrimination and sense of insecurity, 142 Miller’s approach, 33
feasibility sampling, 136 narratives, 34
interview tool, 137 new therapeutic techniques, 34
mental illnesses, 140 psychotherapeutic drugs, 34
migrants and homeless population, 135 subjective-existential experience, 33
physical illnesses, 139 Moral treatment, 21
poverty, 136 The Myth of Mental Illness (Szasz), 12
self-image, 138
socio-demographic profile, 137–138
stress and depression, 136 N
substance dependence, 140–141 Neoliberalism
Micro-social crises, 22 exile of the paternal figure, 35
Migrants’ mental healthcare “hedonist” ideal, 35
access to rights, 324 internal exile, 35
Babel Day Centre, in Athens mass media and advertising, 35–36
client-centred network, 319 passive attitude, 35
communication, 320 professional life, 36
community links, 322 social bond, 36, 37
daily routine, 322 social disaffiliation, 37
education, 325–326 social insecurity, 36
external circumstances, 321 Neo-liberal model, 36, 477, 479
family constellation, 321 Nervous system diseases, 7–9
legal position, 322 Neurasthenias, 7–8
media campaign, 318 Neuroleptics, 11
mental resilience, 319 Neutral introspection, 27
networking, 325 The New Psychology and Its Relation to Life
nostalgic disorientation, 320 (Tansley), 10
Papadopoulos’ theoretical approach, The Normal and the Pathological
320, 321 (Canguilhem), 24
physical health, 321 Not Made of Wood (Foudraine), 12
psychological/psychiatric state, 322
reception process, 322
volunteering, 326 O
chronic pain, 311 Observational neutrality, 28
cultural competence, 313–314 Online counselling
cultural mediation, 315 counselling via live chat, 337
definition, 310 exchange of e-mails, 337
ethnopsychiatry, 315–317 video conferencing, 337–338
516 Index

Online psychotherapy programme evaluation, 126–127

benefits, 338 web of life, 128
counselling via live chat, 337 ICPS, 122
determination, 337 importance of, 121–122
e-mails, 337 International Association for Child and
ethical considerations, 338–340 Adolescent Psychiatry, 123
online self-help/support groups, 338 intervention programme, for adolescents,
video conferencing, 337–338 122, 123
Operation procedures, mental health system, parents and teachers, primary school, 123
390, 393–395 PATHS programme, 122
Organisational culture RIPP programme, 122
assessment scale, 406 school environment, 122, 123
behavioural norms, 407 Psychiatric epidemiology
EPAPSY (see EPAPSY-Association for causality relations
Regional Development and Mental bias, 44–46
Health) confounding, 46–47
factorial analysis, 414 direction of causality, 47
graphic rating scale, 406 definition, 42
health sector, quality and performance, 409 documentation, 42, 50, 53
intervention limitations, 418 and evidence-based medicine, 53–54
macro-culture theory, 407 in Greece, 54–55
microculture theory, 407 homogenisation, 57
qualitative analysis, 416–417 methodology, 42, 52
rating of structures, 415 prevalence of disorders, 42, 43
Psychiatric institutions, 376, 380, 381, 383
Psychiatric phenomenology, 29–32. See also
P Subject and phenomenology
Patras SOPSY (Association of Families for Psychiatric reform
Mental Health), 490–491 in Greece
Phenomenology. See Subject and cost-benefit, 87
phenomenology education system, 77
Philosophical foundations. See Subject and epidemiological data, 83, 88
phenomenology ethical and deontological basis, 86
Positive and Negative Syndrome Scale evidence-based best practices, 89
(PANSS), 265 health system, 79
Postmodern individualism, 33 mental disorder, 83
Post-traumatic stress disorder (PTSD), 311 mental health and care services, legal
The Power of Psychiatry framework, 80
(Miller and Rose), 33 objections, 87–88
Prefrontal lobotomies, 11 political support, 85
Promoting Alternative Thinking Strategies primary healthcare, 77
(PATHS) programme, 122 PSYCHARGOS programme, 81
Promotion, mental health psychiatric treatments, 87
in Cyclades, 2, 12 public health perspective, 88
in Greece resource availability, 79, 87
assertive learning, 124–125 social principles, 78
awareness-raising groups, 125 welfare network, 85
disadvantage, 128 of mental health system, 393–395
experiential learning, 125 quality assurance, 393
intellectual and emotional processes, Psychiatrists
125 madness and neurasthenia, 8
planning interventions, 124–125 military, 9–10
primary protection, children and schizophrenia, 11
adolescents, 123–124 social work, 8
Index 517

Psychiatry and Anti-psychiatry (Cooper), 12 patient’s sexual impulses, 366

Psychiatry and psychocognition, 222, 242 psychoanalytical development, 366
Psychoanalytical structures in the community psychosocial rehabilitation and
in hospital services and in community, recovery, 382
97–104 and psychotic disorders (see Psychoses)
individual and community pain, 104–108 psychotic pathology, 366
mental health structures, 108 recovery process, 382
processuality, 109 supervision process, 383
subjectivity and mental pain (see Subject TT (see Therapeutic team (TT)
of mental pain) Shell shock, 10
Psychoses Social disaffiliation, 37
adolescence, 369 Socio-economic inequality, 194–195, 483
chronic psychotic pathology, 369 Sociological foundations
healthcare institutions, 369 community psychiatry, 18
mental life, 368 critical psychiatry, 18
schizophrenia, 368 great confinement, 17
sexuality, 367 hard biomedical model, 18, 19
subjectification process, 370 reductionism, 17, 18
Psychotherapists, 4, 8, 11 social psychiatry, 18
Pubic mental health system evaluation, soft biomedical model, 18, 19
399–401 traditional psychiatry, 18
Soft biomedical model, 18, 19
Staff assessment, mental health see
Q Organisational culture
Quality assurance, 392, 393, 395 Stavros Niarchos Foundation, 123–124
Structured Clinical Interview (SCID-I), 462
Subject and phenomenology
R abstraction, 29
Radicalism, 11–13 analogic and symbolic components, 31
Rationalism, 13–14 analysis of existence, 31
Reactivity, 374 Cartesian approach, 28–29
Reductionism, 11, 17, 18, 21, 434 conscious experience, 27
Reflexive knowledge, 27 epokhe, Husserl, 29, 30, 32
Renaissance, 22, 25, 26 Heidegger phenomenology, 31–32
Responding in Peaceful and Positive Ways Husserlian phenomenology, 29–32
(RIPP) programme, 122 introspective approach, 28
Revised Clinical Interview Schedule (CIS-R), Jackson’s thesis, 28
464 jealousy, 28
Risk assessment mental states, defined, 28
medical care, 351 nonrepresentation, 30–31
physical injuries, 350 observational neutrality, 28
psychological symptoms, 350 pain and anger, 27
psychosomatic symptoms, 350 phenomenology, defined, 26–27, 29
preconceptions, 29
reflexive knowledge, 27
S Subject of mental pain
Safety plan, 351–353 atheoretical classification system, 96
Sexuality of patients clinical approach, 96
acute psychotic episode, 380–381 diagnostic and therapeutic value, 95
countertransference particularities, subject-based psychiatry, 97
372–375 traitement moral, 95
deinstitutionalisation, 366 Systemic family psychotherapy, 12
institutional psychotherapy, 366 System structural elements, 269
518 Index

T U
Telepsychiatry, 491 University Mental Health Research Institute
clarification, issues, 334 (UMHRI), 461–462
closure, 334 User and family participation
content exploration, 334 advocacy, 426–427
defintion, 336 asylum-based, closed care, 427
relationship establishment, 334 EMILIA project, 428
service, 336–337 empowerment process, 425–426
Therapeutic team (TT) at European Level, 429–430
collective illusion, 370 functionality, 428–429
connection and transformation processes, in Greece, 430–432
370 mental health professional relationship,
“counterfeit”, 371 432–435
group matrix, 370 quality of life, 428–429
group mental instrument, 370 social role and position, 426
human communication, 371 symptomatology, 428–429
mental institution, 370
psychoanalysis, 371
psychotic psychopathology, 370 V
recovery-healing, mental disease, 371 Victorian era illnesses, 7–8
“relational grid”, 372
Transference-counter-transference (CT)
autoerotic/aloerotic function of release, 374 W
collateral CT, 374, 375 Web of life, 128
Freudian concept, 373
personal analysis, 372
projective identification, 374 Y
psychoanalytical theory, 375 Years lived with disability (YLD), 62
psychotic patient’s disease, 376
saviour syndrome, 373
transmutation, 374
Treaties of Madness (1758), 6