Greek Psychiatry's Transition from the Hospital to the Community

Author(s): Amy V. Blue

Source: Medical Anthropology Quarterly, New Series, Vol. 7, No. 3 (Sep., 1993), pp. 301-318
Published by: Blackwell Publishing on behalf of the American Anthropological Association
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AMY V. BLUE
Departmentof BehavioralScience
Universityof Kentucky

Greek Psychiatry's Transition from the

Hospital to the Community

Thepsychiatriccare systemin Greece is currentlyundergoinga transfor-

mation of its service network,propelled to a great extentby recommen-
dations and funding from the European Economic Community(EEC).
Formerly,mental-healthtreatmentwas providedprimarilyby large state
mental hospitals. The new direction is towarddeinstitutionalizationand
a community-careapproach. Thisarticle examinesthedevelopmentof the
Greek mental health care system through historical and ethnographic
data. Thehistoryof the system is describedbriefly;cultural,governmen-
tal, and Greekpsychiatriccontributionsto its developmentare analyzed;
and thepresent reorganizationof psychiatric care and the EEC's role is
discussed. The case of Greekmental health care illustratesthe dynamic
nature of a biomedical specialty. [ethnopsychiatry,Greece, European
Economic Community,biomedicine]

n 1984, the EuropeanEconomic Community (EEC) passed Regulation No.

115/84, recommendinga reformof the Greekmentalhealthcare system. With
servicesconcentratedin the largementalhospitalsandgeographicallyunevenly
distributed,the Greeksystem differed substantiallyfrom those in other European
nations.The EEC'sinvolvementin Greekmentalhealthoriginatesnot simply from
evaluationof the system's deficiencies, but also from the Community'sresolution
to socially and economically integratethe physically and mentally disabled into
theirlocal communities.
During 1988 and 1989, while I was conducting ethnographicand historical
researchon Greekpsychiatry'ssocial andculturalconstruction(Blue 1991), Greek
psychiatry was transformingits service delivery structurefollowing the EEC
recommendations.This reform and reorganizationhad been formally initiated in
1985 and was projected to continue until 1993. EEC directives and economic
assistancefrom the Community'ssocial fund had been given to the Greekgovern-
ment for the reworkingof the nation's mentalhealth care system.
How, with the supportand encouragementof an internationalorganization
such as the EEC, does a state psychiatric system, implicitly built upon cultural

Medical AnthropologyQuarterly7(3):301-318. Copyright? 1993, AmericanAnthropologicalAsso-

ciation.

301
302 MEDICAL ANTHROPOLOGY QUARTERLY

understandingsthatmentallyill persons should be institutionalized,shift to com-

munity-basedcare?The Greekcase is an illustrationthathighlightsbiomedicine's
social and dynamic nature. This article examines the Greek psychiatric care
system's social construction,including embedded cultural understandingssur-
roundingmentalillness andpresentefforts at reform.The analysis of the system's
development draws on historicaland ethnographicmaterialsand is presentedin
threestages.First,I providea briefhistoricaloverview of the system'sdevelopment
in order to characterizeit prior to the reform. Second, I present a conceptual
frameworkfor understandingthe system'sconstructionfrom cultural,governmen-
tal, and Greekpsychiatricelements.Third,I describethe currentreorganizationof
Greek psychiatriccare, includingthe EEC's prominentrole. The outcome of the
reformeffortis not yet known,anddiscussionhighlightsthe remainingproblematic
aspects of the care system.
The socially and culturallyconstructednatureof biomedicalknowledge and
practicehas been widely discussedin medicalanthropology.Accountsof biomedi-
cine have examinedfolk beliefs in Anglo-Saxon biomedical practiceand models
(Gaines 1979, 1982; Helman 1988; Lock 1982), demonstratingthat medical
knowledge is not wholly distinctfrom culturalknowledge. More recently,anthro-
pologists have explored biomedicalpracticein diverse culturalcontexts (Finkler
1991;MaretzkiandSeidler 1985;Ohnuki-Tiemey1984;WeisbergandLong 1984),
indicatingthatas a scientificenterprise,biomedicineincorporateslocal knowledge.
Political-economicor criticalperspectives(e.g., Navarro 1976; Singer, Baer, and
Lazarus1990)have analyzedbiomedicinein termsof its relationto the bodypolitic,
and McLean (1990) has described the salience of internal political forces in
biomedicine's acquisitionof knowledge. These works demonstratethatthe status
accordedto biomedicineas objectiveandneutralwith respectto social differentia-
tion and culturalvalues is unwarranted(Gaines 1991); social and culturalcurrents
areembeddedwithin andfashion the manybiomedicines(HahnandGaines 1985).
My researchon Greekpsychiatryexamines a biomedicalspecialtythatis part
of a western European psychiatric tradition, yet differs from that tradition in
significant ways, differences groundedin a specific culturaland social context.
Following a culturalconstructivistperspective (Gaines 1991, 1992), I combine
historicalandethnographicmaterialto elucidatediachronciallysocial and cultural
contributionsto Greekpsychiatry.Deconstructingthe mentalhealthcare system, I
show how cultural meanings and macroforces have fashioned the psychiatric
ideology underlyingthe system's structure.The researchalso documentshow an
internationalpolitical and economic force impacts a state biomedical system and
leads to its transformation.In transformingthe currentdeliveryof Greekpsychiatric
care, biomedicalknowledge is less at work than are global political concernsfor
the humanitariantreatmentof a society's disadvantagedmembers.
Field researchwas conductedin 1988 and 1989 for periods of approximately
three months each in four psychiatricclinics in the nation: one each in Athens,
Ioannina,Thessaloniki,andChania.Datawere gatheredthroughnaturalisticobser-
vation of clinic activities,includingpatientconsultationsand informaland formal
interviews with clinic staff. Brief visits were made to other psychiatric services
throughoutGreeceto gathermaterialaboutthe servicesestablishedsince the advent
of the reform.Historicalinformationwas collected from the few existing workson
GREEKPSYCHIATRY 303

the history of modem Greekpsychiatry(e.g., Ploumpidis 1983, 1989; Rasidakis

1984).

Greece's Mental Health Care System: A Historical Overview

Historically,Greece's mental health care system consisted of a network of

public mentalhospitals,which were predominantlyasylum-like.The system grew
slowly throughthe 19th centuryand most of the 20th centuryby the accretionof
asylum units. Todayit standson the thresholdof majorchange.
When Greece became an independentnation in 1832, it had no specialized
institutionsfor the care of the mentallyill; such facilities were located in Ottoman
Turkey, and they followed Islamic models of care for the insane. In Greece,
traditionalresponsesby families andcommunitiesto an acutelydisturbed,mentally
ill person were informalecclesiastical interventionsand internmentin city police
stationbasements(Ploumpidis1989); specialized medical care was negligible.
The nation's first mental institutionwas inheritedfrom the British in 1864,
when Englandgave to Greecethe IonianIslandsand,with them, a British-founded
mental hospital on Corfu. Corfu hospital introduced biomedical psychiatry to
Greece.In 1887, the hospitalof Dromokaitionwas establishedoutsideAthens,and
in the early20th century,the hospitalnetworkexpandedwith the additionof mental
institutionsin Soudas (Crete),Thessaloniki,and Athens (the hospital of Daphni).
During this period, Greek psychiatryfollowed Europeaninstitutionalmodels of
treatmentfor the mentallyill.
Following WorldWarII and the Greek Civil War(1946-49), the five mental
hospitals composed the core of the nation'sinpatientpsychiatriccare. In addition,
a few local privateasylumsshelteredthe mentallyill. Fora varietyof reasons,these
charitable facilities ceased to function by the late 1950s and never played a
significantrole in the deliveryof public mentalhealthcare (Ploumpidis1989). For
those who could affordthem,a numberof private"neurological-psychiatric" clinics
for inpatienttreatmentexisted in Athens, Thessaloniki,and other largeprovincial
towns. In addition,there was Eginition, the university inpatientclinic in Athens.
Apartfromoffice-basedconsultations,mentalhealthcare by the early 1950s rested
exclusively in inpatienttreatmentsettings,predominantlythe public mentalhospi-
tals.

The 1950s to the 1970s: Expansionof the Hospital Network

AfterWorldWarII came a periodof overcrowdingin mentalhospitals,notably
at Daphni and Thessaloniki. Daphni, for example, had been intendedfor 1,500
patients but housed over 2,000, and many patients sharedmattresses(Rasidakis
1984). The government'sresponse to institutionalovercrowdingwas to add more
beds to the existing hospitals, but by the mid-1950s this was no longer a viable
solution. Thus, the hospital of Leros was founded in 1958, and later, the mental
hospital of PetrasOlympou,outside Katerini,and the mentalhospital of Tripolis.
Despite this expansion, however, in the mid-1970s the mental health care
system in Greece was not significantlydifferent from that of the 1950s; service
rested essentially in the public mental institutions.From 1978 nationalstatistics,
the ratio of psychiatricbeds was 1.5 per 1,000 population,with 56% of the state
304 MEDICAL
ANTHROPOLOGY
QUARTERLY

beds used by chronicpatients(Stefanisand Madianos 1981). Expansionin service

capacity,not service type, characterizedthe system's development,thoughAthens
and Thessaloniki each had a private, nonprofit mental health center, and the
outpatientneurological-psychiatricservices of the social insurancefund "IKA"
were available.Geographically,services were concentratedin Athensand Thessa-
loniki. Of the nation's 13,422 beds (both public and privatesectors), 6,847 were
located in the Athensmetropolitanareaand 1,682 in Thessaloniki.Neitherpsychi-
atric services nor psychiatristswere available in some regions of the country;
824,742 people in the generalpopulationlacked readyaccess to any mentalhealth
care (Stefanis and Madianos1981).

Contrastwith EuropeanNeighbors
The Greek mental health care system's concentrationon the large mental
hospitalgreatlycontrastedwith the approachof its Europeancommunityneighbors
by the early 1980s. In Italy,for example, Law 180 of 1978 eradicatedthe mental
hospital as a treatmentsetting and mandatedestablishmentof community-based
services (Scheper-Hughesand Lovell 1987).' In the mid-1970s, the Netherlands
initiateda comprehensivereductionin the numberof mentalhospitalbeds with a
concurrentstrengtheningof existing semiresidentialfacilities (Shrameijer1987).
Sectorizationof mentalhealth care services, which emphasizedtreatmentoutside
the mental hospital, was adopted as policy in France in 1960 and substantially
implementedas practiceafter 1972 (Barres1987). While developmentof commu-
nity care has not been uniformacross EEC states (Mangen 1987), Greece is one
nationin which this developmenthas been comparativelyvery slow.

Cultural, Governmental, and Psychiatric Contributions to the Development

of the System
The prominenceof the mentalhospital in the Greekpsychiatriccare system
has expressedthis society'sparticularmanagementof the mentallyill-institution-
alization, often followed by abandonmentof the individual in the hospital. This
response, and the system upon which it is based, arises from a multiplicity of
culturalmeaningssurroundingmentalillness and its locus, the self. These popular
meanings and conceptionsimplicitly underliegovernmentand Greekpsychiatric
contributionsto the system's development.

CulturalKnowledgeSurroundingMentalIllness: Definitions,Help-seeking,
Stigma,and Conceptionsof Self
During the 19th and early 20th centuries in Greece, perceptions of the
individual'sdangerousnessdeterminedwhethera mentally ill personwas sent to a
mental hospital (Ploumpidis1989). Today,mental illness, "craziness"(trella), in
Greece popularlyrefers to hallucinatorybehavior or violent, antisocial behavior
defined as "dangerous."Persons broughtfor psychiatricassistance have uttered
"absurd"statementsandexhibited"strange"behavior,such as a husband'saccusa-
tions thatothers arefollowing him home from work each day, a sister who wipes
"dirt"she says appearson the bathroomwall, a son's belief he is a famous Greek
basketballstar,a daughter'sinsistence she has seen the Holy Mother.
GREEKPSYCHIATRY 305

A person may also arrive for psychiatric treatmentbecause a compulsory

admission has been petitioned with the local public attorney, stating that the
individualis dangerousto self or others. This dangerousnessmay be defined as
threateningbehavior, such as homicidal attemptsor aggressive argumentsin the
home or disruptingpublic order,for example, by fights in the male-only coffee
shop,the kafenion.As will be seen in the discussionof governmentalcontributions
to the system's development,compulsorytreatmentis legally based upon percep-
tions of dangerousness.
Help-seeking for the mentally ill person usually starts with office visits to
private practitionersor the outpatient services of university clinics and public
hospitals. When hospitalizationis recommended,or necessary as in the case of
compulsoryadmissions,it typicallyoccurs first in the privatesector.Estimatesare
that 80 to 85 percent of persons hospitalized in the public mental hospital were
originally admittedto a private clinic (Athanasiou1989). During the course of a
person's illness, his or her family increasinglyturnsto the public mental hospital
for hospitalizationneeds. Economics plays a decisive role in this action because
privateclinics are expensive and drainthe averagefamily of financial resources.
Aftera series of hospitalizations,the help-seekingcourse often discontinuesas the
person is left abandonedin the mentalhospital,and many families stop any form
of contactwith their ill member.
In a society in which the family is the primarysocial unitandkin ties arestrong
(Campbell 1964; DuBoulay 1974), it may appearparadoxicalthat a mentally ill
personis abandonedby his or her family.Reasonsfor each family's abandonment
of an ill memberarecomplex. Wearinessfromcontinuedcareandperceivedthreats
and fears of violence are often partof a family's decision. Also importantis the
stigma attachedto mental illness in terms of culturalvalues of honor (Campbell
1964) and the ability of the family to survive as a social unit.
Mentalillness in Greeceis a highly stigmatizingand shamefulconditionand,
as such, it is similarto other illnesses thataffect an individual'sstrength,physical
attractiveness,and social functioning(Blum andBlum 1965). The shame attached
to mental illness originatesfrom notions that it is a hereditarycondition; mental
disordersareconceived as familial and inheritedillnesses. In addition,the popular
conceptionthatseverementalillness is not curablemakessuch disorderseven more
shameful.In sum, the person suffering from a mental illness is seen as having a
lifelong disability that"pollutes"(Blum and Blum 1965) the bloodline.
Culturalnotions of the self attachthis shame and stigma not only to the ill
person, but also to the ill person's family. The Greek concept of self, part of the
Mediterraneanculturaltradition(Gaines 1982), is a self constitutedby its relations
with other persons, primarilythe family, and not inherentlyindependentof them.
The individualis not conceived as an autonomousbeing separatefrom the group
of close associates,andcharacteristicsof one familymemberreflectuponthe entire
kin group(Lee 1959; Pollis 1965). For the family,a mentallyill memberimplies a
hereditary,disabling condition in the bloodline and threatensits identity as an
honorableunit.
Following the developmentof mental illness in a member,families become
susceptibleto social rejection and isolation because of stigma and shame. Social
relationswith communitymembersare damagedas others avoid association with
the family, particularlyassociations throughmarriage.Marriagesof the patient's
306 MEDICALANTHROPOLOGY
QUARTERLY

normal,healthysiblings aredifficultto arrange,andthe family's abilityto continue

as an honorablereproductiveunit is jeopardized.One psychiatristin a fieldwork
clinic explained to a psychiatricresidentthata male patientshould leave his natal
village, otherwiseit would be difficultfor his two sisters to marry;"no one would
want to marrythe one with the crazy."The psychiatrist,well familiarwith Greek
social responses to mental illness, knew that the stigma associated with mental
illness would be problematicfor the entirefamily's maintenanceof customaryand
expected social relations.
Because of stigma and shame and the expectationthat fellow villagers will
rejoice in a family's misfortune(Blum and Blum 1965), families wish to conceal
an ill member's condition. During the help-seeking course, families refer to the
member'sconditionas "nevra,"an inherentlynonpsychopathologicalaffectiveand
physiologicalcondition.2Referencesto a "psychiatric"conditionarenot made,and
the term "nevra"serves to cast ambiguouslythe exact natureof the individual's
illness. Hospital stays are explained as visits to out-of-town relatives or business
trips. Finally, a family may conceal the existence of a mentally ill member by
abandoninghim or her in a mentalhospitaland ceasing any form of contact.
Social isolation and rejection from family, frequent consequences of the
stigmaof mentalillness for the ill person,make incorporationinto communitylife
challengingand minimal.Such communityrejectionwas illustratedone afternoon
while I was travelingwith a psychiatricmobile unitin a ruralarea.The staff wanted
to stop and visit a formerhospital patientwho was living in a nearbyvillage. The
man's wife and childrenresided in the same village, but they refused to live with
him. At Easter,he had not been includedin any family gatheringandhad prepared
his own traditionalholiday lamb for a solitarycelebration.The day of our visit, the
staff expected to find him in the local kafenion. As we enteredthe kafenion, the
usual clustering of men in groups, playing backgammonor discussing politics,
emerged.At a table in the comer sat a lone figure-the formerpatient.Staff later
bemoaned the man's plight and how arduouscommunity life is for the former
patientbecause of the stigma of mentalillness and resultantcommunity,and even
family,rejection.
Greek popular definitions of mental illness and stigma, intertwinedwith
cultural conceptions of the self, fashion patient abandonmentin a culturally
meaningfulmannerin Greeksociety.Themanyabandonedpatientsin Greekmental
hospitalsexpresses a lay view thatinstitutionalizationof the "dangerous,"socially
bothersome,and honor-threateningmentally ill person is the best management.
Governmentalcontributionsto the structureof the psychiatric care system and
Greekpsychiatry'spatientcare approachhave facilitatedthis abandonment.

The Role of the Government

The Greek governmenthas reinforcedthe prominenceof the large mental
hospitalin the Greekpsychiatriccare system throughlimited financialsupportfor
services,the absenceof a nationalmentalhealthpolicy, andpsychiatriclegislation.
Financial Support. Historically, the Greek government had provided few
fundsfor mentalhealthcare,whichlimitedthecreationof new serviceforms.While
statisticson mental health care expendituresarerarelyavailable,one report(Ste-
fanis and Madianos 1981) states thatin 1978, the cost of each psychiatricbed was
GREEKPSYCHIATRY 307

$2,059 in contrastto $10,252 for generalhospital beds. This occurredin spite of

the fact that 95 percent of mental hospital beds were occupied in contrastto 73
percentof generalhospital beds. Furtherindicative of the government'sminimal
mentalhealth care investmentis the fact thatmentalhealth comprised9.4 percent
of the government'soverall health care budget.The newer mentalhospitals, such
as Leros and Petras Olympou, were preexisting structures (i.e., Italian army
barracksand a sanitaria)convertedto use as mentalhospitals.This conversionwas
an inexpensive alternative to the establishment of new mental hospitals and
precludedextended financingfor the establishmentof other forms of patientcare
and living arrangements.
Mental Health Policy. The absence of a national mental health policy or
advisory boarduntil the late 1970s also contributedto the persistenceof hospital-
based treatmentfor the mentally ill. Governmentrecommendationsfor additional
services followed the patternof establishingnew mentalhospitals or addingbeds
to existing facilities. The state did not attemptto introducenew service forms
appearingin other nations, such as day hospitals or community mental health
centers. It simply followed an ad hoc approachwithout innovationand without a
coherentvision of nationalmentalhealth care.
Psychiatric Legislation. Psychiatriclegislation has contributedsubstantially
to the perpetuationof the large mentalhospital as the primaryservice in the care
system. The nation's first psychiatriclegislation was passed in 1862 and legally
governed the care of the mentally ill for over 100 years (Ploumpidis 1989). It
established the mental hospital as a public entity and mandatedfinancing and
supervisionthroughthe state.Dictatesthatadultinpatientcarebe providedonly on
a 24-hour basis (Mantonakis1981) encumberedthe creationof new care services
and reinforcedthe hospital'sexistence.
Legal provisions for patient admission and dischargehave facilitatedaban-
donmentof mentallyill people, generatinghospitalovercrowdingand the need for
additionalbeds. The original 1862 legislation included no voluntary admission
procedures;third-partyresponsibilitywas requiredfor the patient'sdischargefrom
the hospital.Given the culturalrole of kin in Greeksociety, typically the family of
the hospitalizedperson was held as the partyresponsiblefor his or her discharge.
If the family refused to sign the patient'sdischarge(i.e., to accept the individual
after his or her "successful" treatment),the patient was unable to leave the
institution.
Modificationsof the 1862 legislationin 1973 and 1978 establisheda process
for voluntaryadmission and groundedcompulsory admission in the psychiatric
determinationof the individual'sdangerousnessto self or others. Fieldworkdata
indicate that the right to voluntaryadmission is rarelyexercised; the majorityof
hospital admissionsare compulsory.Nationalfigures for the percentageof invol-
untarycommitmentsare unknown.Bairaktaris(1984) cites 1980 to 1981 research
stating that of the 62.1 percentof patientsfor whom the mannerof admission to
the hospital could be determined,97.15 percentwere compulsoryadmissions and
2.85 percent were voluntaryadmissions. This is particularlysignificant because
involuntarycommitmentis tied to third-partydischargeresponsibility.Someone,
typically a family member,must sign for the person'srelease.
Greek culturalnotions of both mental illness and the self are reflectedin the
psychiatriclegislation. In the original legislation and applicationsof the present
308 MEDICAL
ANTHROPOLOGY
QUARTERLY

standards,the personis not conceivedas an autonomousindividualwith the ability

and right to voluntarilycommit him/herself.Others,using the notion of "danger-
ousness,"define theneed forhospitalizationand,subsequently,discharge.In Greek
mentalhealth care, the individual'srights are subordinatedto those of the family
andstatethroughlegislation.3Thus,the nation'spsychiatriclegislationhas contrib-
uted to the confinementand abandonmentof many persons in the mentalhospital
with no access, until very recently,to alternativeforms of care.

GreekPsychiatry
Greekpsychiatryhas also playeda criticalrole in the persistenceof the mental
hospital. The field was officially "neurology-psychiatry"until 1981, and Greek
psychiatrists were trained in a traditionemphasizing organic and institutional
treatmentof mentalillness. Priorto the separationof the specialtyinto two distinct
fields-psychiatry and neurology-residency training consisted of one year of
internalmedicine, one year of neurology,and one year of psychiatry.Because the
only public treatmentservices available for psychiatric training were inpatient
settings, the model of psychiatrictreatmentimpartedto new generationsof psy-
chiatristswas institutional.
Based formally upon imported biomedical psychiatric theories (German,
French,Anglo-Saxon),Greekpsychiatry'spatientcareapproachimplicitlyadheres
to prevailingpopularnotionsof mentalillness andtreatmentandexplicitly follows
legislativedictates.The specialty'srelianceuponthehospitalas a primarytreatment
settingreflects the widespreadidea thatinstitutionalizationis the propertreatment
for the severely disturbing(disturbed)individual.The covert meaningof "danger-
ousness"is thata mentallyill personis socially dangerousto kin. At the same time,
the governmenthas been minimallyinvolved at economic andpolicy levels in the
creationof psychiatriccare services otherthanmentalhospitals.
Greek Psychiatry's Definition of Mental Illness. Patients' complaints are
placedby Greekpsychiatryinto two broadcategories:"psychosis"and"neurosis."
Included in the former are schizophrenia,manic-depression,and severe depres-
sion-that is, with psychotic features. The individual's "contact with reality"
determinesa basic diagnosis;the presence of hallucinationsand delusions (being
out of contact with reality) distinguishes the "psychotic"from the "neurotic."
Psychiatristsrarelyrefer to the Diagnostic and StatisticalManual-IIIl-Revised or
theInternationalClassificationof Diseases-9 in thediagnosticprocedure,although
these classificatorystandardsareused for research.A formaldiagnosismay not be
included in a patient'schart,or a catch-all term, "psychotic syndrome,"may be
used, particularlyfor prescriptionand medical certificatepurposes.4
Hospitalizationin a mentalhospitalor clinic is typicallyreservedfor persons
suffering from psychoses, generally those of an acute nature and following a
chroniccourse. The perceived"dangerousness"of the personto self or othersalso
defines the need for hospitalization,particularlywhen a formal request for a
compulsoryexaminationof the individualhas been filed. Regardlessof whether
the person is actually "dangerous,"the individualhas hallucinationsor delusions
to the degree thatinpatientcare is typically consideredthe best treatmentsetting.
TreatmentApproach.Greekpsychiatryhas perpetuatedthe mentalhospital's
existence through a narrow treatmentapproachbased primarilyupon pharma-
GREEKPSYCHIATRY 309

cological therapies, without psychosocial and vocational therapeuticstrategies.

Until recently,patientshave been hospitalizedwith minimal therapeuticrehabili-
tation aimed at allowing them to reenterthe community.Fieldwork data from a
variety of psychiatric settings, including two months at the mental hospital of
Chania,indicatetheprincipaltherapyofferedto patientsis psychoactivemedication
for the containmentof symptoms.Systematic psychotherapyor social and voca-
tional rehabilitationis uncommon, particularlyin the mental hospital context.
Patientcare assumes a custodialand pharmacologicalapproachfor the long-term
patients; for the newly admitted,medication is used as a suppressantfor florid
symptoms.
While other professional ethnopsychiatrieslikewise emphasize biological
features of mental illness and rely heavily upon medication, the lack of trained
auxiliary personnel-psychiatric nurses, social workers, occupationaltherapists,
and clinical psychologists-in the public sector has reinforcedGreekpsychiatry's
institutionaltreatment.Table 1 identifiesthe numbersof such personnelemployed
in each mentalhospital in 1988.
Few nursesin mentalhospitalshave graduatedfrom nursingdegreeprograms,
anduntilabout 1986, therewas no programfor specializationin psychiatricnursing
in Greece. The majorityof the nurses, sometimes professionally referredto as
"guards,"are untrainedin the profession and may not have even completedhigh
school. Attemptsby staff psychiatriststo organizein-service educationalseminars
for the nursing staff often fail because the nurses do not wish to use their leisure
time for work activities, particularlywhen there is little likelihood of financial
remunerationfor such training.Seminars during working hours are difficult to
arrangebecause of patient-caredemands.
Social workers,psychologists, and occupationaltherapistsare rarein public
services, andnone of thesefields haveprofessionaltrainingprogramsfor workwith
the chronically mentally ill. Programsfor a master's degree in social work are
unavailable in Greece, and psychologists who wish to be educated beyond the
bachelor's level must receive trainingabroad.These "parapsychiatricpersonnel"
are all unpreparedeither by special knowledge or by their numericalpresenceto
actively engage patients in a conjunctive psychosocial form of therapy.In the
absenceof trainedparapsychiatric personnel,psychoactivemedicationhas become
the only treatmentoffered.
Greek psychiatric patients accept and expect medication as the primary
treatmentfor their condition, which is spoken of by them and their families as
"nevra"and not as a psychologicalproblem(Blue 1991). Medicationplaces their
illness in the categoryof physicalillnesses, which are also treatedby "farmaka"or
medications.For patientsandtheirfamily members,medicationframesthe condi-
tion as a treatablephysiological disorder,not a stigmatizing,incurable"mental"
affliction.Otherforms of therapy,such as psychotherapyand social andvocational
therapiesfor the mentallyill, have not become public convention.The imageof the
severely mentally ill person as one who requiresinstitutionalizationto safeguard
society and (implicitly) protecta family's honor has precludedthe lay appeal of
therapiesintendedto reintegratethe mentally ill person into local society.
Greek psychiatry'straditionaltherapeuticapproachto hospitalizedpatients
has supportedthe mental hospital's existence; in turn, institutionalizationof pa-
tientshas maintainedthe hospitalas a preeminenttreatmentsetting.Greekpsychia-
 TABLE 1
Personnel in Public Mental Hospitals in Greece, by Size and Professional R

Hospital Beds Nurses Social Workers P

16 degreed
Chania 355 118 practicals 9
5 degreed I degreed
Leros 1,600 385 practicals 5 nondegreed
2 degreed
Corfu 410 100 practicals 0
64 degreed
Daphni 2,300 437 practicals 8
Dromokaition 880 200a 5
PetrasOlympou 450 85a 1
Thessaloniki 950 156a 10
does not distinguishthose nurseswho have degrees.
aInformation
Source:Fromthe Directoryof PsychiatricServices Centersof MentalHygiene andRehabilitationin G
GREEK PSYCHIATRY 311

try,embeddedwith Greek culturalunderstandingssurroundingmental illness and

working within the confines of governmentaldictates,expresses the enmeshment
of culturalattitudesand macroforces in its institutionalizationof patients.

Reorganization of the Greek Mental Health Care System

By the early 1980s, a hint of changebegan to appearin the traditionalmental
health service delivery structureand associated psychiatric treatmentideology.
Ambitious academicianswho had been exposed to differentpsychiatricmodels
abroadbegan to establisha few innovativeand alternativeservices. A day hospital
was instituted at Eginition (Mantonakis 1981); two community mental-health
centers with defined catchmentareaswere established,one in Athens (Madianos
1983) and the other in Thessaloniki (Manos and Logothetis 1983); a 24-hour
emergencysystem was operatingfor Athens (Stefanis and Madianos 1981); and a
departmentof psychiatryin a generalhospitalwas createdin Alexandropoulisand
anotherplannedin Ioannina.
These treatmentsetting innovationsprovidedpresentand futurepractitioners
with a new model of psychiatricreality.The primacyof the mental hospital was
being supplantedby a variety of new patient care forms directed at short-term
hospitalizationand community-basedtreatment.At the same time, psychiatrywas
separatedfrom neurology,resultingin changes in specialty qualifications;psychi-
atricresidencynow consists of threeyearsof psychiatrictraining,which is to occur
in a varietyof clinical settings.
While these new university-basedservices were the seeds for an expansionof
the nation'sbasic mentalhealthcaredeliverysystem, the NationalHealthSystem,
establishedby the socialist government(1981-89), served to point service provi-
sion in a new direction.Under article21 of the 1983 NationalHealth System law,
mental health services were to be decentralizedthroughthe creationof additional
mentalhealth centersand psychiatricdepartmentsin generalhospitals.This was a
significantstep in the redirectionof psychiatriccare in the nation,for it mandated
the establishmentof a broaderservice network and stepped away from the sole
relianceupon the mentalhospital.This was also one of the rareinstancesin which
a Greek governmentactively involved itself in the design of mental health care
delivery.

Entranceof the EuropeanEconomic Community

A strongerimpetusfor substantialchange in the configurationof the mental
health system appearedfrom the EEC.5In 1983, the EEC respondedto a Greek
government request for additional financial assistance in social programs by
proposing financial support of up to 60 million ECU over a five-year period
(1984-89) to reformthe medical, social, and vocationalrehabilitationof persons
in Greek psychiatricinstitutions.Fifty-five percentof public expenditureswould
be coveredby EEC aid throughthe administrationof grants.An investigativeteam
was appointedto examine the nation'spsychiatriccare andto providethe Commis-
sion with proposals for care improvements.In March of 1984, Regulation No.
115/84 was adopted,containingspecific recommendationsfor a reworkingof the
overall mental health care system. This regulationadheresto the EEC's policy of
312 MEDICAL
ANTHROPOLOGY
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reintegratingthe physically and mentallydisabled into the social and work life of
membernations.
The basic thrustof the EEC's recommendationshas been the continuationof
Greek efforts to decentralizepsychiatricservices and to adopt a community-care
approach.This is to be accomplishedthroughcommunitypsychiatriccare sectors
throughoutthe country,each housing a network of services, composed of (1) a
communitymental health center and day-carefacilities; (2) a psychiatricdepart-
ment in a general hospital; (3) short- and long-stay residencies; (4) vocational
trainingprograms;and (5) in predominantlyruralareas,mobile units.
The EEChasemphasizedeffortsto graduallydeinstitutionalizethe chronically
mentally ill and integratethem into communitylife. All hospital patientswere to
be classified by age andorigin and theirmental and physical conditionevaluated.
Following this, patients were to be divided into diagnostic categories and the
mentallyill separatedfrom the mentallyhandicappedand otherpatients.(Reflect-
ing the older specialty neurology-psychiatry,epileptics, and persons with organic
brain syndromeshave also been placed in these institutions.)While some of the
deinstitutionalizationprogramswill be briefly describedbelow, here I emphasize
thatthe deinstitutionalization is to be progressiveandto occurwithintheboundaries
of shelteredresidenciesand continuedpsychiatriccare.6
Fellowshipsfor the trainingof Greekmentalhealthpersonnelin EECmember
nationshave also beenincludedin theprogramof financialsupport,as well as funds
for the constructionor refurbishingof existing hospitals. An era of "psychiatric
reform" has commenced in the nation, with the EEC providing a number of
incentives.
During fieldworkin 1988 to 1989, I found that the reform'sgeneralphiloso-
phy, as expressedby psychiatristsandothermentalhealthcareprofessionals,is the
nonhospitalizationof the mentally ill person whenever possible and short-term
hospitalizationwhen necessary.People are to be treatedin theirfamily, work, and
communityenvironments,not sent away to a mentalhospitalfor care.If inpatient
treatmentis necessary,to stabilizeor monitormore closely a person'smedication,
it is to occur in the contextof a psychiatricdepartmentin a generalhospitalandfor
a brief periodof time. Only personswho are considered"dangerousto themselves
or others around"are thought to require "closed" (mental hospital or private
inpatientclinic) treatment.
Following the EEC proposalsand reflecting this new philosophyof commu-
nitycare,new publicpsychiatricserviceshave sproutedup aroundthenation.These
services are not only expandingthe treatmentsettings availablefor patients,they
are simultaneouslyprovidingGreekpsychiatrywith new therapeuticalternatives.
Correspondingly,the traditionalapproachto institutionaland custodial care is
shifting to rehabilitativeand "communitycare"(Mavreas 1987) strategies;a new
psychiatricideology is emergent.

New PsychiatricServicesin the Nation

Following the EEC mandates,the establishmentof departmentsof psychiatry
in generalhospitals has been occurringthroughoutthe nation,both in Athens and
Thessaloniki,as well as smallerprovincialtowns. These departmentshouse about
20 beds andserve patientsin an acuteconditionfor a briefperiodof time.The large
GREEKPSYCHIATRY 313

mentalhospitals arerestructuringtheirphysical organizationto accommodatethe

differentiationbetween acute, recent admissions and chronic,long-termpatients.
For example, the hospital of Thessaloniki constructednew "acute"units on its
groundsto separatenew admissions from the chronic patients.At the hospital of
PetrasOlympou,one wardwas redecoratedto create a less "institutional"atmos-
phere and serve new admissionsonly. Mobile units, such as in Evrou and Fokida,
visit patientseitherat local healthcentersor in theirhomes so thatthey do not have
to travelinconvenientdistancesto receive outpatientcare andfollow-up.
Long- and short-stayresidenceshave been createdto help in deinstitutionali-
zation.These residencesoffer the formerresidentsof Daphni,Thessaloniki,or one
of the othermentalhospitals,the opportunityfor shelteredliving in the community.
The residencestypicallyhouse 10 to 15 people andprovidea social and vocational
rehabilitationprogram.For example, those living in Eginition's long-term resi-
dence,locatedin downtownAthens,participatein anassociatedvocationalprogram
and may learnwoodworking,leatherworking,sewing, and othervocationalactivi-
ties. In Amfissa, in the province of Fokida, some residentsin the home program
tend olive trees andengage in otheragriculturaltasks, a few workin an automotive
shop, andotherssell beveragesandice creamin a playgroundacrossthe streetfrom
the house.
According to the psychiatricreform philosophy,these deinstitutionalization
programsall have similar goals of providingformerlyhospitalizedpatients with
the skills necessaryfor communityliving. Mental healthprofessionalsrecognize
thatthe majorityof patientswill alwaysrequiresupervisedliving, thoughthey hope
that some may eventuallylive on theirown, returnto theirfamilies, or reside with
a roommate.The emphasis on vocational trainingis to provide the person with
activity and the skills to generate income for the purchase of personal items.
Psychiatristsgenerallyserve in a supervisorycapacityin the programs,monitoring
patients'medicationsand symptomsand attendingto the directionand administra-
tion of the programs.Day-to-day contact and work with patientsis performedby
social workers,nurses,and occasionally a psychologist.
Professionals explained to me that the primary and initial aim of these
residences is to allow patients to acquire basic social skills. This points to a
problematicand all-too-common legacy of the mental hospital-the former pa-
tients'inabilityto engage in simple tasksof daily living, suchas eatingwith utensils
and maintaining personal hygiene. This inability often stems from a lack of
motivationto assume self-careresponsibilities.Yearsof institutionallife in which
all personalneeds aremet by hospitalstaff createsan attitudeandhabitof passivity
and inactivity that is difficult to break. In fact, some programs experienced
difficulty recruitinghospitalpatientsto join them because of patientapprehension
and apathy.One programstaff memberrecalled a male patientfrom Daphni who
was interestedin living at the Eginition home but was so anxious about learning
how to take the bus thathe finally refused to enter the program.

Discussion
The currentGreekpsychiatricreformin theEuropeancontextexemplifies how
the social policy of a largerbody politic is prescribingthe refashioningof a state
biomedical psychiatry's treatment approach. Through Regulation No. 115/84,
314 MEDICALANTHROPOLOGY
QUARTERLY

Greek psychiatry'straditionalcustodial managementof the mentally ill in large

mentalhospitals is being supplantedby a community-basedinvolvementwith the
individual.
The outcome of the reform movement remains to be seen. Field research
indicatedthat certainproblematicthemes reminiscentof the previouscare system
are apparent.One concernsa perceived lack of personnel.Programdirectorsand
staff members told me that their programs would function more smoothly if
additionalpersonnelwere available. Sometimes this problemwas createdby the
government'srefusalto appointmore staff and, therefore,need to pay additional
salaries.Anotherthemeconcernsthe lack of specializedknowledgeandtrainingof
existing personnel.To compensatefor this, programstrain staff themselves and
include regulareducationalseminarsas partof their internalservices. While the
EEC has providedopportunitiesfor specialized trainingof mentalhealth profes-
sionals, few had taken advantageof these opportunitieswhile I was doing field-
work.
State bureaucracyis also a problemin the implementationof these programs,
according to staff (see also Herzfeld 1991). Staff members and directorscom-
plained universallyaboutthe bureaucracyinvolved in institutingand maintaining
the various services. Rules andregulationsregardingconstructionand equipment
costs, paperworkdemands,the acquisitionof official signatures,and a perception
of a bureaucraticmachinerythatis indifferentto the establishmentand success of
the programsall add to the general frustrationof people workingto develop the
services.
A final, pervasivedifficulty has been families' acceptanceof theirformerly
hospitalizedmentallyill memberand the traditionalsocial and familialostracism
of these persons. To decrease the social ignoranceand stigma surroundingthese
disorders,public educationaboutmentalillness has comprisedone componentof
many of the new services.Deinstitutionalizationprogramshave includedworking
with a patient's family to develop their acceptance of the patient in the local
community,if not in the home. This, accordingto staff, has been very difficult to
accomplish.At times, as in the case of the previously describedformerpatientin
the village kafenion,communityandfamily rejectionpersists.The abilityof reform
effortsto influenceentrenchedculturalattitudessurroundingmentalillness will be
vital for the reform'sultimatesuccess.
In this article,the culturalmeanings and macroforcesthat have historically
perpetuatedthe institutionalnatureof the Greekpsychiatriccaresystemhave been
deconstructed.Througha knowledge of the system's developmentand its contrib-
uting sources, the socially constructednatureof a biomedical specialty is eluci-
dated.At present,the EECmandatesarealteringthe influenceof governmentaland
Greek psychiatric contributionsto the system, demonstratingnot only how a
political entityreconstructsa biomedicalpsychiatry'streatmentapproach,butalso
how, simultaneously,the forces that have partiallyconstructedthat approachare
affected.
More is at stakein the developmentof the mentalhealthcare system thanthe
type andnumberof servicesimplemented.Culturalknowledgeandsocial responses
are implicitly presentin the foundationon which the service system is built. The
EEC's proposalsto reconfigureGreek psychiatricservices and deinstitutionalize
patients are set against culturally grounded social responses to the mentally ill
GREEKPSYCHIATRY 315

individual. To what extent the psychiatric reform will be successful in light of these
responses remains a critical and neglected question. Mental health policymakers,
both foreign and domestic, can clamor and advocate repairing a system's apparent
structural defects; institutions can be condemned and patients transferred to new
living quarters. However, without a "cultural critique" (Gaines 1991; Marcus and
Fischer 1986) and an understanding of the salient cultural meanings constructing
the system, reform mandates may be socially naive and become disappointingly
inept. Reforms intended to improve patients' quality of life by a literal change of
structure greatly ignore the social consequences that also affect quality of life.

NOTES

Acknowledgments.An earlierversionof this articlewas presentedat the Modem Greek

Studies Association Conference, Gainesville, Florida, in November 1991. Research was
supportedby a Fulbright-HaysDoctoral DissertationResearchAbroadFellowship. Prepa-
rationof the manuscripthas been supportedby grantnumberMH15730 from the National
Institute of Mental Health. I thank Gene Gallagher and four anonymous reviewers for
valuablesuggestionson the preparationof this manuscript.
Correspondencemay be addressed to the author at the Departmentof Behavioral
Science, Universityof Kentucky,Lexington,KY 40536-0086.
1. In Italy,leftists andthe CommunistPartywere instrumentalin the reorganizationof
mental health care and the passage of Law 180 (Scheper-Hughesand Lovell 1987). In
Greece, the Greek CommunistParty(KKE) has been silent on the issue of mental health
care. This silence originates, I suggest, from the Party's strict adherence to the Soviet
ideological line (Kapetanyannis1987); psychiatriccare in the former Soviet Union was
institutional.Of my informants,those most critical of the traditionalGreek psychiatric
system followed leftist political leanings.
2. Nevra has been studiedboth within Greekvillage settings (Clark 1989; LoMonaco
1991) and among immigrantsin Canada(Dunk 1989; Lock 1990, 1991). All authorshave
situatednevrawithin the anthropologyof nerves (Davis and Guamaccia 1989). In addition
to being a somatizedexperience,nevrais an affective conditionof"irritability,"and, within
the psychiatriccontext, can harbormeaningsof psychopathology(Blue 1991).
3. Greece's overarchinglegislative foundationresonates with traditionalGreek cul-
turalconceptionsof the self. Germanlegal positivism,not Anglo-Saxonliberalism,provides
the frameworkfor state-individualrelationsin Greece, and the state's rights and not those
of the individualare emphasized(Pollis 1987).
4. The term "psychotic syndrome"often is used intentionally by psychiatristson
writtendocumentsto help destigmatizethe patient'scondition,accordingto informants.The
phrasedoes not harborthe popularlyknown and fearedmeaningsof the word "schizophre-
nia" and ambiguouslydescribesthe patient'scondition.
5. Greecebecame an official memberof the EuropeanEconomic Communityin 1980.
6. The process of deinstitutionalizationin Greece appearsnot to mimic the United
States' grandclosure of hospitals and subsequentcommunityabandonmentof mentally ill
personson the streets.

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