greek psychiatry's transition from the hospital to the community

Greek Psychiatry's Transition from the Hospital to the CommunityAuthor(s): Amy V. BlueSource: Medical Anthropology Quarterly, New Series, Vol. 7, No. 3 (Sep., 1993), pp. 301-318Published by: Blackwell Publishing on behalf of the American Anthropological AssociationStable URL: http://www.jstor.org/stable/648932Accessed: 08/05/2010 19:02

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AMY V. BLUE

Department of Behavioral Science University of Kentucky

Greek Psychiatry's Transition from the Hospital to the Community

The psychiatric care system in Greece is currently undergoing a transformation of its service network, propelled to a great extent by recommendations and funding from the European Economic Community (EEC). Formerly, mental-health treatment was provided primarily by large state mental hospitals. The new direction is toward deinstitutionalization and a community-care approach. This article examines the development of the Greek mental health care system through historical and ethnographic data. The history of the system is described briefly; cultural, governmental, and Greek psychiatric contributions to its development are analyzed; and the present reorganization of psychiatric care and the EEC's role is discussed. The case of Greek mental health care illustrates the dynamic nature of a biomedical specialty. [ethnopsychiatry, Greece, European Economic Community, biomedicine]

n 1984, the European Economic Community (EEC) passed Regulation No. 115/84, recommending a reform of the Greek mental health care system. With services concentrated in the large mental hospitals and geographically unevenly

distributed, the Greek system differed substantially from those in other European nations. The EEC's involvement in Greek mental health originates not simply from evaluation of the system's deficiencies, but also from the Community's resolution to socially and economically integrate the physically and mentally disabled into their local communities.

During 1988 and 1989, while I was conducting ethnographic and historical research on Greek psychiatry's social and cultural construction (Blue 1991), Greek psychiatry was transforming its service delivery structure following the EEC recommendations. This reform and reorganization had been formally initiated in 1985 and was projected to continue until 1993. EEC directives and economic assistance from the Community's social fund had been given to the Greek government for the reworking of the nation's mental health care system.

How, with the support and encouragement of an international organization such as the EEC, does a state psychiatric system, implicitly built upon cultural

Medical Anthropology Quarterly 7(3):301-318. Copyright ? 1993, American Anthropological Asso- ciation.

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understandings that mentally ill persons should be institutionalized, shift to community-based care? The Greek case is an illustration that highlights biomedicine's social and dynamic nature. This article examines the Greek psychiatric care system's social construction, including embedded cultural understandings surrounding mental illness and present efforts at reform. The analysis of the system's development draws on historical and ethnographic materials and is presented in three stages. First, I provide a brief historical overview of the system's development in order to characterize it prior to the reform. Second, I present a conceptual framework for understanding the system's construction from cultural, governmental, and Greek psychiatric elements. Third, I describe the current reorganization of Greek psychiatric care, including the EEC's prominent role. The outcome of the reform effort is not yet known, and discussion highlights the remaining problematic aspects of the care system.

The socially and culturally constructed nature of biomedical knowledge and practice has been widely discussed in medical anthropology. Accounts of biomedicine have examined folk beliefs in Anglo-Saxon biomedical practice and models (Gaines 1979, 1982; Helman 1988; Lock 1982), demonstrating that medical knowledge is not wholly distinct from cultural knowledge. More recently, anthro- pologists have explored biomedical practice in diverse cultural contexts (Finkler 1991; Maretzki and Seidler 1985; Ohnuki-Tiemey 1984; Weisberg and Long 1984), indicating that as a scientific enterprise, biomedicine incorporates local knowledge. Political-economic or critical perspectives (e.g., Navarro 1976; Singer, Baer, and Lazarus 1990) have analyzed biomedicine in terms of its relation to the body politic, and McLean (1990) has described the salience of internal political forces in biomedicine's acquisition of knowledge. These works demonstrate that the status accorded to biomedicine as objective and neutral with respect to social differentiation and cultural values is unwarranted (Gaines 1991); social and cultural currents are embedded within and fashion the many biomedicines (Hahn and Gaines 1985).

My research on Greek psychiatry examines a biomedical specialty that is part of a western European psychiatric tradition, yet differs from that tradition in significant ways, differences grounded in a specific cultural and social context. Following a cultural constructivist perspective (Gaines 1991, 1992), I combine historical and ethnographic material to elucidate diachroncially social and cultural contributions to Greek psychiatry. Deconstructing the mental health care system, I show how cultural meanings and macroforces have fashioned the psychiatric ideology underlying the system's structure. The research also documents how an international political and economic force impacts a state biomedical system and leads to its transformation. In transforming the current delivery of Greek psychiatric care, biomedical knowledge is less at work than are global political concerns for the humanitarian treatment of a society's disadvantaged members.

Field research was conducted in 1988 and 1989 for periods of approximately three months each in four psychiatric clinics in the nation: one each in Athens, Ioannina, Thessaloniki, and Chania. Data were gathered through naturalistic obser- vation of clinic activities, including patient consultations and informal and formal interviews with clinic staff. Brief visits were made to other psychiatric services throughout Greece to gather material about the services established since the advent of the reform. Historical information was collected from the few existing works on

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the history of modem Greek psychiatry (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 mental hospitals, which were predominantly asylum-like. The system grew slowly through the 19th century and most of the 20th century by the accretion of asylum units. Today it stands on the threshold of major change.

When Greece became an independent nation in 1832, it had no specialized institutions for the care of the mentally ill; such facilities were located in Ottoman Turkey, and they followed Islamic models of care for the insane. In Greece, traditional responses by families and communities to an acutely disturbed, mentally ill person were informal ecclesiastical interventions and internment in city police station basements (Ploumpidis 1989); specialized medical care was negligible.

The nation's first mental institution was inherited from the British in 1864, when England gave to Greece the Ionian Islands and, with them, a British-founded mental hospital on Corfu. Corfu hospital introduced biomedical psychiatry to Greece. In 1887, the hospital of Dromokaition was established outside Athens, and in the early 20th century, the hospital network expanded with the addition of mental institutions in Soudas (Crete), Thessaloniki, and Athens (the hospital of Daphni). During this period, Greek psychiatry followed European institutional models of treatment for the mentally ill.

Following World War II and the Greek Civil War (1946-49), the five mental hospitals composed the core of the nation's inpatient psychiatric care. In addition, a few local private asylums sheltered the mentally ill. For a variety of reasons, these charitable facilities ceased to function by the late 1950s and never played a significant role in the delivery of public mental health care (Ploumpidis 1989). For those who could afford them, a number of private "neurological-psychiatric" clinics for inpatient treatment existed in Athens, Thessaloniki, and other large provincial towns. In addition, there was Eginition, the university inpatient clinic in Athens. Apart from office-based consultations, mental health care by the early 1950s rested exclusively in inpatient treatment settings, predominantly the public mental hospitals.

The 1950s to the 1970s: Expansion of the Hospital Network

After World War II came a period of overcrowding in mental hospitals, notably at Daphni and Thessaloniki. Daphni, for example, had been intended for 1,500 patients but housed over 2,000, and many patients shared mattresses (Rasidakis 1984). The government's response to institutional overcrowding was 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 Petras Olympou, outside Katerini, and the mental hospital of Tripolis.

Despite this expansion, however, in the mid-1970s the mental health care system in Greece was not significantly different from that of the 1950s; service rested essentially in the public mental institutions. From 1978 national statistics, the ratio of psychiatric beds was 1.5 per 1,000 population, with 56% of the state

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beds used by chronic patients (Stefanis and Madianos 1981). Expansion in service capacity, not service type, characterized the system's development, though Athens and Thessaloniki each had a private, nonprofit mental health center, and the outpatient neurological-psychiatric services of the social insurance fund "IKA" were available. Geographically, services were concentrated in Athens and Thessa- loniki. Of the nation's 13,422 beds (both public and private sectors), 6,847 were located in the Athens metropolitan area and 1,682 in Thessaloniki. Neither psychiatric services nor psychiatrists were available in some regions of the country; 824,742 people in the general population lacked ready access to any mental health care (Stefanis and Madianos 1981).

Contrast with European Neighbors

The Greek mental health care system's concentration on the large mental hospital greatly contrasted with the approach of its European community neighbors by the early 1980s. In Italy, for example, Law 180 of 1978 eradicated the mental hospital as a treatment setting and mandated establishment of community-based services (Scheper-Hughes and Lovell 1987).' In the mid-1970s, the Netherlands initiated a comprehensive reduction in the number of mental hospital beds with a concurrent strengthening of existing semiresidential facilities (Shrameijer 1987). Sectorization of mental health care services, which emphasized treatment outside the mental hospital, was adopted as policy in France in 1960 and substantially implemented as practice after 1972 (Barres 1987). While development of community care has not been uniform across EEC states (Mangen 1987), Greece is one nation in which this development has been comparatively very slow.

Cultural, Governmental, and Psychiatric Contributions to the Development of the System

The prominence of the mental hospital in the Greek psychiatric care system has expressed this society's particular management of the mentally ill-institutionalization, often followed by abandonment of the individual in the hospital. This response, and the system upon which it is based, arises from a multiplicity of cultural meanings surrounding mental illness and its locus, the self. These popular meanings and conceptions implicitly underlie government and Greek psychiatric contributions to the system's development.

Cultural Knowledge Surrounding Mental Illness: Definitions, Help-seeking, Stigma, and Conceptions of Self

During the 19th and early 20th centuries in Greece, perceptions of the individual's dangerousness determined whether a mentally ill person was sent to a mental hospital (Ploumpidis 1989). Today, mental illness, "craziness" (trella), in Greece popularly refers to hallucinatory behavior or violent, antisocial behavior defined as "dangerous." Persons brought for psychiatric assistance have uttered "absurd" statements and exhibited "strange" behavior, such as a husband's accusa- tions that others are following him home from work each day, a sister who wipes "dirt" she says appears on the bathroom wall, a son's belief he is a famous Greek basketball star, a daughter's insistence she has seen the Holy Mother.

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A person may also arrive for psychiatric treatment because a compulsory admission has been petitioned with the local public attorney, stating that the individual is dangerous to self or others. This dangerousness may be defined as threatening behavior, such as homicidal attempts or aggressive arguments in the home or disrupting public order, for example, by fights in the male-only coffee shop, the kafenion. As will be seen in the discussion of governmental contributions to the system's development, compulsory treatment is legally based upon perceptions of dangerousness.

Help-seeking for the mentally ill person usually starts with office visits to private practitioners or the outpatient services of university clinics and public hospitals. When hospitalization is recommended, or necessary as in the case of compulsory admissions, it typically occurs first in the private sector. Estimates are that 80 to 85 percent of persons hospitalized in the public mental hospital were originally admitted to a private clinic (Athanasiou 1989). During the course of a person's illness, his or her family increasingly turns to the public mental hospital for hospitalization needs. Economics plays a decisive role in this action because private clinics are expensive and drain the average family of financial resources. After a series of hospitalizations, the help-seeking course often discontinues as the person is left abandoned in the mental hospital, and many families stop any form of contact with their ill member.

In a society in which the family is the primary social unit and kin ties are strong (Campbell 1964; DuBoulay 1974), it may appear paradoxical that a mentally ill person is abandoned by his or her family. Reasons for each family's abandonment of an ill member are complex. Weariness from continued care and perceived threats and fears of violence are often part of a family's decision. Also important is the stigma attached to mental illness in terms of cultural values of honor (Campbell 1964) and the ability of the family to survive as a social unit.

Mental illness in Greece is a highly stigmatizing and shameful condition and, as such, it is similar to other illnesses that affect an individual's strength, physical attractiveness, and social functioning (Blum and Blum 1965). The shame attached to mental illness originates from notions that it is a hereditary condition; mental disorders are conceived as familial and inherited illnesses. In addition, the popular conception that severe mental illness is not curable makes such disorders even 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.

Cultural notions of the self attach this 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 Mediterranean cultural tradition (Gaines 1982), is a self constituted by its relations with other persons, primarily the family, and not inherently independent of them. The individual is not conceived as an autonomous being separate from the group of close associates, and characteristics of one family member reflect upon the entire kin group (Lee 1959; Pollis 1965). For the family, a mentally ill member implies a hereditary, disabling condition in the bloodline and threatens its identity as an honorable unit.

Following the development of mental illness in a member, families become susceptible to social rejection and isolation because of stigma and shame. Social relations with community members are damaged as others avoid association with the family, particularly associations through marriage. Marriages of the patient's

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normal, healthy siblings are difficult to arrange, and the family's ability to continue as an honorable reproductive unit is jeopardized. One psychiatrist in a fieldwork clinic explained to a psychiatric resident that a male patient should leave his natal village, otherwise it would be difficult for his two sisters to marry; "no one would want to marry the one with the crazy." The psychiatrist, well familiar with Greek social responses to mental illness, knew that the stigma associated with mental illness would be problematic for the entire family's maintenance of customary and expected social relations.

Because of stigma and shame and the expectation that 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's condition as "nevra," an inherently nonpsychopathological affective and physiological condition.2 References to a "psychiatric" condition are not made, and the term "nevra" serves to cast ambiguously the exact nature of 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 abandoning him or her in a mental hospital and ceasing any form of contact.

Social isolation and rejection from family, frequent consequences of the stigma of mental illness for the ill person, make incorporation into community life challenging and minimal. Such community rejection was illustrated one afternoon while I was traveling with a psychiatric mobile unit in a rural area. The staff wanted to stop and visit a former hospital patient who was living in a nearby village. The man's wife and children resided in the same village, but they refused to live with him. At Easter, he had not been included in any family gathering and had prepared his own traditional holiday lamb for a solitary celebration. The day of our visit, the staff expected to find him in the local kafenion. As we entered the kafenion, the usual clustering of men in groups, playing backgammon or discussing politics, emerged. At a table in the comer sat a lone figure-the former patient. Staff later bemoaned the man's plight and how arduous community life is for the former patient because of the stigma of mental illness and resultant community, and even family, rejection.

Greek popular definitions of mental illness and stigma, intertwined with cultural conceptions of the self, fashion patient abandonment in a culturally meaningful manner in Greek society. The many abandoned patients in Greek mental hospitals expresses a lay view that institutionalization of the "dangerous," socially bothersome, and honor-threatening mentally ill person is the best management. Governmental contributions to the structure of the psychiatric care system and Greek psychiatry's patient care approach have facilitated this abandonment.

The Role of the Government

The Greek government has reinforced the prominence of the large mental hospital in the Greek psychiatric care system through limited financial support for services, the absence of a national mental health policy, and psychiatric legislation.

Financial Support. Historically, the Greek government had provided few funds for mental health care, which limited the creation of new service forms. While statistics on mental health care expenditures are rarely available, one report (Ste- fanis and Madianos 1981) states that in 1978, the cost of each psychiatric bed was

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$2,059 in contrast to $10,252 for general hospital beds. This occurred in spite of the fact that 95 percent of mental hospital beds were occupied in contrast to 73 percent of general hospital beds. Further indicative of the government's minimal mental health care investment is the fact that mental health comprised 9.4 percent of the government's overall health care budget. The newer mental hospitals, such as Leros and Petras Olympou, were preexisting structures (i.e., Italian army barracks and a sanitaria) converted to use as mental hospitals. This conversion was an inexpensive alternative to the establishment of new mental hospitals and precluded extended financing for the establishment of other forms of patient care and living arrangements.

Mental Health Policy. The absence of a national mental health policy or advisory board until the late 1970s also contributed to the persistence of hospital- based treatment for the mentally ill. Government recommendations for additional services followed the pattern of establishing new mental hospitals or adding beds to existing facilities. The state did not attempt to introduce new service forms appearing in other nations, such as day hospitals or community mental health centers. It simply followed an ad hoc approach without innovation and without a coherent vision of national mental health care.

Psychiatric Legislation. Psychiatric legislation has contributed substantially to the perpetuation of the large mental hospital as the primary service in the care system. The nation's first psychiatric legislation 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 mandated financing and supervision through the state. Dictates that adult inpatient care be provided only on a 24-hour basis (Mantonakis 1981) encumbered the creation of new care services and reinforced the hospital's existence.

Legal provisions for patient admission and discharge have facilitated abandonment of mentally ill people, generating hospital overcrowding and the need for additional beds. The original 1862 legislation included no voluntary admission procedures; third-party responsibility was required for the patient's discharge from the hospital. Given the cultural role of kin in Greek society, typically the family of the hospitalized person was held as the party responsible for his or her discharge. If the family refused to sign the patient's discharge (i.e., to accept the individual after his or her "successful" treatment), the patient was unable to leave the institution.

Modifications of the 1862 legislation in 1973 and 1978 established a process for voluntary admission and grounded compulsory admission in the psychiatric determination of the individual's dangerousness to self or others. Fieldwork data indicate that the right to voluntary admission is rarely exercised; the majority of hospital admissions are compulsory. National figures for the percentage of involuntary commitments are unknown. Bairaktaris (1984) cites 1980 to 1981 research stating that of the 62.1 percent of patients for whom the manner of admission to the hospital could be determined, 97.15 percent were compulsory admissions and 2.85 percent were voluntary admissions. This is particularly significant because involuntary commitment is tied to third-party discharge responsibility. Someone, typically a family member, must sign for the person's release.

Greek cultural notions of both mental illness and the self are reflected in the psychiatric legislation. In the original legislation and applications of the present

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standards, the person is not conceived as an autonomous individual with the ability and right to voluntarily commit him/herself. Others, using the notion of "dangerousness," define the need for hospitalization and, subsequently, discharge. In Greek mental health care, the individual's rights are subordinated to those of the family and state through legislation.3 Thus, the nation's psychiatric legislation has contributed to the confinement and abandonment of many persons in the mental hospital with no access, until very recently, to alternative forms of care.

Greek Psychiatry

Greek psychiatry has also played a critical role in the persistence of the mental hospital. The field was officially "neurology-psychiatry" until 1981, and Greek psychiatrists were trained in a tradition emphasizing organic and institutional treatment of mental illness. Prior to the separation of the specialty into two distinct fields-psychiatry and neurology-residency training consisted of one year of internal medicine, one year of neurology, and one year of psychiatry. Because the only public treatment services available for psychiatric training were inpatient settings, the model of psychiatric treatment imparted to new generations of psychiatrists was institutional.

Based formally upon imported biomedical psychiatric theories (German, French, Anglo-Saxon), Greek psychiatry's patient care approach implicitly adheres to prevailing popular notions of mental illness and treatment and explicitly follows legislative dictates. The specialty's reliance upon the hospital as a primary treatment setting reflects the widespread idea that institutionalization is the proper treatment for the severely disturbing (disturbed) individual. The covert meaning of "dangerousness" is that a mentally ill person is socially dangerous to kin. At the same time, the government has been minimally involved at economic and policy levels in the creation of psychiatric care services other than mental hospitals.

Greek Psychiatry's Definition of Mental Illness. Patients' complaints are placed by Greek psychiatry into two broad categories: "psychosis" and "neurosis." Included in the former are schizophrenia, manic-depression, and severe depression-that is, with psychotic features. The individual's "contact with reality" determines a basic diagnosis; the presence of hallucinations and delusions (being out of contact with reality) distinguishes the "psychotic" from the "neurotic." Psychiatrists rarely refer to the Diagnostic and Statistical Manual-IIIl-Revised or the International Classification of Diseases-9 in the diagnostic procedure, although these classificatory standards are used for research. A formal diagnosis may not be included in a patient's chart, or a catch-all term, "psychotic syndrome," may be used, particularly for prescription and medical certificate purposes.4

Hospitalization in a mental hospital or clinic is typically reserved for persons suffering from psychoses, generally those of an acute nature and following a chronic course. The perceived "dangerousness" of the person to self or others also defines the need for hospitalization, particularly when a formal request for a compulsory examination of the individual has been filed. Regardless of whether the person is actually "dangerous," the individual has hallucinations or delusions to the degree that inpatient care is typically considered the best treatment setting.

Treatment Approach. Greek psychiatry has perpetuated the mental hospital's existence through a narrow treatment approach based primarily upon pharma-

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cological therapies, without psychosocial and vocational therapeutic strategies. Until recently, patients have been hospitalized with minimal therapeutic rehabilitation aimed at allowing them to reenter the community. Fieldwork data from a variety of psychiatric settings, including two months at the mental hospital of Chania, indicate the principal therapy offered to patients is psychoactive medication for the containment of symptoms. Systematic psychotherapy or social and vocational rehabilitation is uncommon, particularly in the mental hospital context. Patient care assumes a custodial and pharmacological approach for the long-term patients; for the newly admitted, medication is used as a suppressant for florid symptoms.

While other professional ethnopsychiatries likewise emphasize biological features of mental illness and rely heavily upon medication, the lack of trained auxiliary personnel-psychiatric nurses, social workers, occupational therapists, and clinical psychologists-in the public sector has reinforced Greek psychiatry's institutional treatment. Table 1 identifies the numbers of such personnel employed in each mental hospital in 1988.

Few nurses in mental hospitals have graduated from nursing degree programs, and until about 1986, there was no program for specialization in psychiatric nursing in Greece. The majority of the nurses, sometimes professionally referred to as "guards," are untrained in the profession and may not have even completed high school. Attempts by staff psychiatrists to organize in-service educational seminars for the nursing staff often fail because the nurses do not wish to use their leisure time for work activities, particularly when there is little likelihood of financial remuneration for such training. Seminars during working hours are difficult to arrange because of patient-care demands.

Social workers, psychologists, and occupational therapists are rare in public services, and none of these fields have professional training programs for work with the chronically mentally ill. Programs for 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 training abroad. These "parapsychiatric personnel" are all unprepared either by special knowledge or by their numerical presence to actively engage patients in a conjunctive psychosocial form of therapy. In the absence of trained parapsychiatric personnel, psychoactive medication has become the only treatment offered.

Greek psychiatric patients accept and expect medication as the primary treatment for their condition, which is spoken of by them and their families as "nevra" and not as a psychological problem (Blue 1991). Medication places their illness in the category of physical illnesses, which are also treated by "farmaka" or medications. For patients and their family members, medication frames the condition as a treatable physiological disorder, not a stigmatizing, incurable "mental" affliction. Other forms of therapy, such as psychotherapy and social and vocational therapies for the mentally ill, have not become public convention. The image of the severely mentally ill person as one who requires institutionalization to safeguard society and (implicitly) protect a family's honor has precluded the lay appeal of therapies intended to reintegrate the mentally ill person into local society.

Greek psychiatry's traditional therapeutic approach to hospitalized patients has supported the mental hospital's existence; in turn, institutionalization of patients has maintained the hospital as a preeminent treatment setting. Greek psychia-

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TABLE 1 Personnel in Public Mental Hospitals in Greece, by Size and Professional Resources.

Occupational Hospital Beds Nurses Social Workers Psychologists Therapists

16 degreed Chania 355 118 practicals 9 4 5

5 degreed I degreed Leros 1,600 385 practicals 5 nondegreed 0 2

2 degreed Corfu 410 100 practicals 0 0 2

64 degreed Daphni 2,300 437 practicals 8 5 17 Dromokaition 880 200a 5 19 9 Petras Olympou 450 85a 1 0 0 Thessaloniki 950 156a 10 7 2

aInformation does not distinguish those nurses who have degrees. Source: From the Directory of Psychiatric Services Centers of Mental Hygiene and Rehabilitation in Greece, March-April 1988.

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GREEK PSYCHIATRY

try, embedded with Greek cultural understandings surrounding mental illness and working within the confines of governmental dictates, expresses the enmeshment of cultural attitudes and macro forces in its institutionalization of patients.

Reorganization of the Greek Mental Health Care System

By the early 1980s, a hint of change began to appear in the traditional mental health service delivery structure and associated psychiatric treatment ideology. Ambitious academicians who had been exposed to different psychiatric models abroad began to establish a few innovative and alternative services. A day hospital was instituted at Eginition (Mantonakis 1981); two community mental-health centers with defined catchment areas were established, one in Athens (Madianos 1983) and the other in Thessaloniki (Manos and Logothetis 1983); a 24-hour emergency system was operating for Athens (Stefanis and Madianos 1981); and a department of psychiatry in a general hospital was created in Alexandropoulis and another planned in Ioannina.

These treatment setting innovations provided present and future practitioners with a new model of psychiatric reality. The primacy of the mental hospital was being supplanted by a variety of new patient care forms directed at short-term hospitalization and community-based treatment. At the same time, psychiatry was separated from neurology, resulting in changes in specialty qualifications; psychiatric residency now consists of three years of psychiatric training, which is to occur in a variety of clinical settings.

While these new university-based services were the seeds for an expansion of the nation's basic mental health care delivery system, the National Health System, established by the socialist government (1981-89), served to point service provi- sion in a new direction. Under article 21 of the 1983 National Health System law, mental health services were to be decentralized through the creation of additional mental health centers and psychiatric departments in general hospitals. This was a significant step in the redirection of psychiatric care in the nation, for it mandated the establishment of a broader service network and stepped away from the sole reliance upon the mental hospital. This was also one of the rare instances in which a Greek government actively involved itself in the design of mental health care delivery.

Entrance of the European Economic Community

A stronger impetus for substantial change in the configuration of the mental health system appeared from the EEC.5 In 1983, the EEC responded to 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 reform the medical, social, and vocational rehabilitation of persons in Greek psychiatric institutions. Fifty-five percent of public expenditures would be covered by EEC aid through the administration of grants. An investigative team was appointed to examine the nation's psychiatric care and to provide the Commis- sion with proposals for care improvements. In March of 1984, Regulation No. 115/84 was adopted, containing specific recommendations for a reworking of the overall mental health care system. This regulation adheres to the EEC's policy of

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reintegrating the physically and mentally disabled into the social and work life of member nations.

The basic thrust of the EEC's recommendations has been the continuation of Greek efforts to decentralize psychiatric services and to adopt a community-care approach. This is to be accomplished through community psychiatric care sectors throughout the country, each housing a network of services, composed of (1) a community mental health center and day-care facilities; (2) a psychiatric department in a general hospital; (3) short- and long-stay residencies; (4) vocational training programs; and (5) in predominantly rural areas, mobile units.

The EEC has emphasized efforts to gradually deinstitutionalize the chronically mentally ill and integrate them into community life. All hospital patients were to be classified by age and origin and their mental and physical condition evaluated. Following this, patients were to be divided into diagnostic categories and the mentally ill separated from the mentally handicapped and other patients. (Reflect- ing the older specialty neurology-psychiatry, epileptics, and persons with organic brain syndromes have also been placed in these institutions.) While some of the deinstitutionalization programs will be briefly described below, here I emphasize that the deinstitutionalization is to be progressive and to occur within the boundaries of sheltered residencies and continued psychiatric care.6

Fellowships for the training of Greek mental health personnel in EEC member nations have also been included in the program of financial support, as well as funds for the construction or refurbishing of existing hospitals. An era of "psychiatric reform" has commenced in the nation, with the EEC providing a number of incentives.

During fieldwork in 1988 to 1989, I found that the reform's general philosophy, as expressed by psychiatrists and other mental health care professionals, is the nonhospitalization of the mentally ill person whenever possible and short-term hospitalization when necessary. People are to be treated in their family, work, and community environments, not sent away to a mental hospital for care. If inpatient treatment is necessary, to stabilize or monitor more closely a person's medication, it is to occur in the context of a psychiatric department in a general hospital and for a brief period of time. Only persons who are considered "dangerous to themselves or others around" are thought to require "closed" (mental hospital or private inpatient clinic) treatment.

Following the EEC proposals and reflecting this new philosophy of community care, new public psychiatric services have sprouted up around the nation. These services are not only expanding the treatment settings available for patients, they are simultaneously providing Greek psychiatry with new therapeutic alternatives. Correspondingly, the traditional approach to institutional and custodial care is shifting to rehabilitative and "community care" (Mavreas 1987) strategies; a new psychiatric ideology is emergent.

New Psychiatric Services in the Nation

Following the EEC mandates, the establishment of departments of psychiatry in general hospitals has been occurring throughout the nation, both in Athens and Thessaloniki, as well as smaller provincial towns. These departments house about 20 beds and serve patients in an acute condition for a brief period of time. The large

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mental hospitals are restructuring their physical organization to accommodate the differentiation between acute, recent admissions and chronic, long-term patients. For example, the hospital of Thessaloniki constructed new "acute" units on its grounds to separate new admissions from the chronic patients. At the hospital of Petras Olympou, one ward was redecorated to create a less "institutional" atmos- phere and serve new admissions only. Mobile units, such as in Evrou and Fokida, visit patients either at local health centers or in their homes so that they do not have to travel inconvenient distances to receive outpatient care and follow-up.

Long- and short-stay residences have been created to help in deinstitutionalization. These residences offer the former residents of Daphni, Thessaloniki, or one of the other mental hospitals, the opportunity for sheltered living in the community. The residences typically house 10 to 15 people and provide a social and vocational rehabilitation program. For example, those living in Eginition's long-term resi- dence, located in downtown Athens, participate in an associated vocational program and may learn woodworking, leatherworking, sewing, and other vocational activities. In Amfissa, in the province of Fokida, some residents in the home program tend olive trees and engage in other agricultural tasks, a few work in an automotive shop, and others sell beverages and ice cream in a playground across the street from the house.

According to the psychiatric reform philosophy, these deinstitutionalization programs all have similar goals of providing formerly hospitalized patients with the skills necessary for community living. Mental health professionals recognize that the majority of patients will always require supervised living, though they hope that some may eventually live on their own, return to their families, or reside with a roommate. The emphasis on vocational training is to provide the person with activity and the skills to generate income for the purchase of personal items. Psychiatrists generally serve in a supervisory capacity in the programs, monitoring patients' medications and symptoms and attending to the direction and administration of the programs. Day-to-day contact and work with patients is performed by 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 problematic and all-too-common legacy of the mental hospital-the former patients' inability to engage in simple tasks of daily living, such as eating with utensils and maintaining personal hygiene. This inability often stems from a lack of motivation to assume self-care responsibilities. Years of institutional life in which all personal needs are met by hospital staff creates an attitude and habit of passivity and inactivity that is difficult to break. In fact, some programs experienced difficulty recruiting hospital patients to join them because of patient apprehension and apathy. One program staff member recalled a male patient from Daphni who was interested in living at the Eginition home but was so anxious about learning how to take the bus that he finally refused to enter the program.

Discussion

The current Greek psychiatric reform in the European context exemplifies how the social policy of a larger body politic is prescribing the refashioning of a state biomedical psychiatry's treatment approach. Through Regulation No. 115/84,

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Greek psychiatry's traditional custodial management of the mentally ill in large mental hospitals is being supplanted by a community-based involvement with the individual.

The outcome of the reform movement remains to be seen. Field research indicated that certain problematic themes reminiscent of the previous care system are apparent. One concerns a perceived lack of personnel. Program directors and staff members told me that their programs would function more smoothly if additional personnel were available. Sometimes this problem was created by the government's refusal to appoint more staff and, therefore, need to pay additional salaries. Another theme concerns the lack of specialized knowledge and training of existing personnel. To compensate for this, programs train staff themselves and include regular educational seminars as part of their internal services. While the EEC has provided opportunities for specialized training of mental health professionals, few had taken advantage of these opportunities while I was doing fieldwork.

State bureaucracy is also a problem in the implementation of these programs, according to staff (see also Herzfeld 1991). Staff members and directors com- plained universally about the bureaucracy involved in instituting and maintaining the various services. Rules and regulations regarding construction and equipment costs, paperwork demands, the acquisition of official signatures, and a perception of a bureaucratic machinery that is indifferent to the establishment and success of the programs all add to the general frustration of people working to develop the services.

A final, pervasive difficulty has been families' acceptance of their formerly hospitalized mentally ill member and the traditional social and familial ostracism of these persons. To decrease the social ignorance and stigma surrounding these disorders, public education about mental illness has comprised one component of many of the new services. Deinstitutionalization programs have included working with a patient's family to develop their acceptance of the patient in the local community, if not in the home. This, according to staff, has been very difficult to accomplish. At times, as in the case of the previously described former patient in the village kafenion, community and family rejection persists. The ability of reform efforts to influence entrenched cultural attitudes surrounding mental illness will be vital for the reform's ultimate success.

In this article, the cultural meanings and macroforces that have historically perpetuated the institutional nature of the Greek psychiatric care system have been deconstructed. Through a knowledge of the system's development and its contrib- uting sources, the socially constructed nature of a biomedical specialty is eluci- dated. At present, the EEC mandates are altering the influence of governmental and Greek psychiatric contributions to the system, demonstrating not only how a political entity reconstructs a biomedical psychiatry's treatment approach, but also how, simultaneously, the forces that have partially constructed that approach are affected.

More is at stake in the development of the mental health care system than the type and number of services implemented. Cultural knowledge and social responses are implicitly present in the foundation on which the service system is built. The EEC's proposals to reconfigure Greek psychiatric services and deinstitutionalize patients are set against culturally grounded social responses to the mentally ill

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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 earlier version of this article was presented at the Modem Greek Studies Association Conference, Gainesville, Florida, in November 1991. Research was supported by a Fulbright-Hays Doctoral Dissertation Research Abroad Fellowship. Prepa- ration of the manuscript has been supported by grant number MH15730 from the National Institute of Mental Health. I thank Gene Gallagher and four anonymous reviewers for valuable suggestions on the preparation of this manuscript.

Correspondence may be addressed to the author at the Department of Behavioral Science, University of Kentucky, Lexington, KY 40536-0086.

1. In Italy, leftists and the Communist Party were instrumental in the reorganization of mental health care and the passage of Law 180 (Scheper-Hughes and Lovell 1987). In Greece, the Greek Communist Party (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 (Kapetanyannis 1987); psychiatric care in the former Soviet Union was institutional. Of my informants, those most critical of the traditional Greek psychiatric system followed leftist political leanings.

2. Nevra has been studied both within Greek village settings (Clark 1989; LoMonaco 1991) and among immigrants in Canada (Dunk 1989; Lock 1990, 1991). All authors have situated nevra within the anthropology of nerves (Davis and Guamaccia 1989). In addition to being a somatized experience, nevra is an affective condition of"irritability," and, within the psychiatric context, can harbor meanings of psychopathology (Blue 1991).

3. Greece's overarching legislative foundation resonates with traditional Greek cultural conceptions of the self. German legal positivism, not Anglo-Saxon liberalism, provides the framework for state-individual relations in Greece, and the state's rights and not those of the individual are emphasized (Pollis 1987).

4. The term "psychotic syndrome" often is used intentionally by psychiatrists on written documents to help destigmatize the patient's condition, according to informants. The phrase does not harbor the popularly known and feared meanings of the word "schizophrenia" and ambiguously describes the patient's condition.

5. Greece became an official member of the European Economic Community in 1980. 6. The process of deinstitutionalization in Greece appears not to mimic the United

States' grand closure of hospitals and subsequent community abandonment of mentally ill persons on the streets.

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