From Insanity to Mental Health- the novelty of the Hellenic Mental Health Center
Irini Vlahaki
Psychiatrist-Child Psychiatrist
That we turn to the past to outline moments of the course towards psychiatric reformation doesn't spring from the need to praise psychoanalysis. In fact psychoanalysis itself is against any kind of deification. However if this reference is conducted it is to underline the importance of historical investigation; that is to say our starting point and the whole course of where we are today. In this way we can seek our origins and thus position ourselves within the time and string of generations.
The ancient Greeks had deified memory constructing an enormous mythological edifice around remembrance, unlike modern Greeks, who have a disastrous tendency; to ignore the past, erase tradition and break the chain of transition. A real danger is posed when the present ceases to consider the past as a prerequisite. To what experiences should we then have recourse to? This is the reason why our works are more often than not ephemeral, focusing on the individual and ignoring the future.
The Mental Health Center began its operations in the mid fifties as the Mental Health Department of the Royal Foundation of the time and marked its beginning with a multiply symbolic gesture; the foundation of the Child Mental Health Centre in Athens, on 58 Notara street. It was a pioneer for the time. I will now give a brief account.
The Fifties were a turbulent political period. The Civil war was formally over, but division was prevalent. Greece, economically ruined, was trying to lick her wounds by forgetting, since society was unable to take responsibility for its drives, to own up to its mistakes, mourn them and move on. "To know thyself" did not apply. On the contrary, in order to establish social cohesion Greece tightened the cultural norms by promoting the ideologies of nation, religion and family.
The term "Greek- Christian culture" was included in the Constitution of 1952 and formed the basis of the political and social structure of the post-civil war period.
Asylums were mainly the place where Psychiatry was practiced. It was unable to follow the main reformations happening in the West, in the aftermath of World War 2. A collaboration that exceeded individual efforts, capable of creating a scientific dialogue and maintaining a fighting spirit within the psychiatric institutions, were impossible to establish, in order to influence predominant social perceptions about "madness" and fight against fears towards mental illness and the "insane". The term "mental health" was quite unknown to the public, according to G. Lyketsos.
Besides, the anachronistic law of 1862 regarding the insane was still in effect and in 1958 the first colony of the chronic "insane" was established in Leros. By this brief account of the social conditions of the time, I intend to further delineate the difficulty of introducing psychoanalytic thinking in public care settings, rather than ignore the work of individual pioneering psychiatrists, enlightened teachers and cultivated people of that time.
Although the gates of traditionally run services manifested stronger resistance to change, there were some other detours, more open and flexible, such as the "King Paul'" Foundation and its welfare services, named then 1st Social Aid Station.
It was mainly there that human pain and deprivation would turn to, seeking relief. That was the place where mental health professionals were needed to provide containment and understanding and where they could think of ways of appropriate care for their dependents. This thinking already contains the essence of psychodynamic thought, regarding mental health care. In this context, Mrs. A. Potamianou inaugurates her reformatory effort, by adjusting it to the Greek social reality.
A. Potamianou, having studied Psychology in Paris, she experienced the psychiatric reformation movement- inspired by the psychoanalytic thought - that ushered a new manner of clinical thinking. Her work in "L'Hopital des enfants malades", alongside S. Lebovici and R. Diatkine, played a major role later in the training of new members of the Mental Health Center in Athens. Mrs. Potamianou formed psychiatric teams on an equal basis of the members, which was a great innovation for the times and thus she implemented the concept that psychiatric problems need a multi-dimensional understanding and care.
The founding members of the first historical team were, besides Mrs. Potamianou herself, Andreas Kaloutsis, child psychiatrist, Yorgos Filippopoulos, psychiatrist and Anastasia Tavlaridou, social worker. They were all post gradually trained in the western world countries in psychodynamic approach. Later on the team included other important members as well, such as the late Mrs. F. Karapanou, P.Sakellaropoulos, N. Nikolaidis, A. Vareltzidis, Efst. Lymperakis in Salonica and the list of associates kept growing.
What characterised these teams were the team effort and devotion to a common ideal, aiming at:
Breaking isolation and exclusion of the mentally ill
Creating state-of-the-art prevention and treatment services that would set an example and act as a training framework for mental health professionals
Rehabilitating socially and vocationally the mentally ill
Disseminating the principals of mental health, such as preventive action
Developing research initiatives that would delineate mental health problems and needs in Greece, so that appropriate methods and ways of treatment be sought.
The aim was not to provide services to the great numbers of cases, although in the welfare services, the number of patients was huge. The goal was to insure quality of care and to demonstrate the kind of care that could be provided outside the psychiatric ward, in order to avoid psychiatric induction, as much as possible. In the case of people presenting adjustment problems, the aim was to impede bad prognosis or to facilitate creative utilisation of each person’s potential.
From the old files that extant today we can see that those psychiatric teams had greatly invested in their clients and the pioneering way of attending the patient; that is the continuity of care and the development of a therapeutic relation. The patients' files are examples of clinical semantics, whereby both the effort to understand the symptom (the patient's psychic work) and the surrounding context are depicted.
The discovery of the symptom’s meaning created a clear distinction between the psychoanalytic and the medically-oriented psychiatric practice, on an international level. In other words, a new therapeutic stance is introduced, based on the understanding of what happened to the patient and to his immediate context in the past and at present. This would form the basis of knowledge to be used as a starting point of the therapeutic approach.
This denoted a remarkable change of perceiving the patient, psychic pain and mental illness, since it differentiated therapy from the usual medical model (the patient considered as the result of accumulated symptoms), by introducing the concept of care. In order to provide care, co-operation between the team members was a prerequisite.
Samples of the weekly team meetings’ minutes concerning the cases still remain. There are registered not only the decisions taken concerning support and treatment of the cases, but also the justification for these actions. Their actions are given meaning and this forms the core of psychodynamic approach in care.
The psychiatric team is additionally supported by case supervision. In supervision records we identify the attempt to understand consciously the emotional reactions evoked in the therapist, either due to the patient’s pathology or the counter-transferential reactions of the therapist towards the patient. These terms were not recorded at the time, being perhaps quite abstruse to people lacking the necessary training on the one hand, and because the aim was not to memorize terms, but to experience and bring into consciousness parts of the therapist’s self. A relevant article by Mrs. Potamianou, presented on the 1st European Child Psychiatry Conference in Paris, in 1960, titled: "The maturity of the social worker as a maturating factor of family stances", referring to a supervised case, is worth mentioning.
Another training technique used to understand mental health professionals’ and educators’ personal behavior was role playing. And all that was happening in the sixties!
An additionally important dimension of the versatile treatment of patients with mental illness was the effort to develop awareness of mental health, to motivate, sensitize and convince other services in the community to participate. An example of that was the pioneering work done in schools, parents’ groups, volunteers’ groups, the police, private clinics, judiciary services, patients’ work-places etc.
Today it is widely known that the basic principals of psychiatric reformation consider openness, exchange of ideas and co operations imperative, although in Greece it is sometimes difficult to implement them. (ourselves)Us, primarily, need to demonstrate maturity that the mentally ill lack, in order to help them develop. As one can see from the archives, the quantity and quality of collaborations between the Centre’s staff and with external organizations is impressive.
These versatile and long-term collaborations created a common therapeutic idea that underwent constant elaboration, thought and producing new decisions. Let’s consider the difference between the new concept of functioning of mental health services’ and the old-fashioned, rigid spirit prevailing in the psychiatric units of the time of standard orientation; that is to say a brief clinical interview and medications prescription, not allowing the patient to talk about himself and benefit from psychological support, or even more so from psychoanalytic psychotherapy, which was rather unknown at the time.
The decisions regarded the planning of new services, by assessing referrals towards the Centre’s services, but also the needs for mental health care that emerged from the community. In 1962, a service offering special education was created for mentally retarded children and adolescents, named "Stoupatheio". It was associated with the Parents of the Maladjusted Children Union and it was run by the illuminated pedagogue K. Kalantzis, along with the important teaching couple, Mr. and Mrs. Drosou.
In 1961 the Consulting Department for Adults began operating within the context of the Social Aid Station of Athens, as an independent department, with P Sakellaropoulos- psychiatrist and child psychiatrist- as the Head of the department, since 1962, and F Karapanou, psychologist. Meanwhile, in 1964 the Social Aid Stations of Piraeus and Salonica began to evolve into Social Psychiatry Services.
The Therapeutic Club began operating in Salonica in 1965 that later became a Day Care Service for patients with serious mental illness. Later on the Protective Workshop was established. The Day Care Unit in Salonica was the first such unit to be created in Greece.
In 1958 the Center for Vocational Guidance started functioning. Since 1965 a specialized unit of Psychoanalytic Psychotherapy is established in Athens, including supervision and theoretical modules, under Mrs. F Karapanou.
A Training Service is organized offering programs of intense and high quality activity. I will just mention here a characteristic example. In 1968, the Mental Health Center in collaboration with the Greek Pediatrics Association and the Institute for Child Health organizes a 3-day seminar titled: "Mental Health problems in infants and toddlers". Responsible for the seminar were two French child psychiatrists and psychoanalysts: R. Diatkine and M. Soulé.
The training aimed at producing well-grounded mental health professionals, as well as to disseminate mental health principles to allied professionals, social services and the general public. Moreover, the Research and Publishing Service was organized, demonstrating remarkable results. The first Autistic Children Unit in Greece was established in 1973. The activities that took place within the first 20 years of the Center’s function could not be mentioned in this brief account. To conclude though, the Mental Health and Research Center (as named at the Act of Establishment in 1964, when it turned independent from the Royal Foundation and became a Private Legal Entity) is the first official effort to implement psychiatric reformation in Greece and to introduce psychoanalytic thinking and the principles of Social Psychiatry in Public Care. It has and still constitutes the largest out-patient mental health services provider in Greece with branches in all the main Greek cities, apart from Athens, Piraeus, Salonica, Patras, Herakleion of Crete, Volos and Zante. From its beginning till present the prevailing concept of the Center is to develop Services forming a collaborating network that create a therapeutic context in which mentally ill patients and their families can have their needs addressed. The vast experience of the Mental Health Center was not effectively utilized by the State, but nevertheless it was acknowledged by collaborating foreign organizations.
It did not seem however to affect, at least directly, the traditionally run services. E. Lymperakis established in Salonica, collaboration with both professor of Psychiatry Manos, in order to provide training in Psychoanalytic Psychotherapy to Psychiatry residents, and the Psychology Department of the Philosophy School.
Characteristic of the negative stance of part of the Psychiatric society towards reformations in the psychiatric institutions is an incident mentioned by Mrs. Potamianou. In 1959 the Center organized the first seminar for psychiatrists working in psychiatric hospitals in Athens. The reference addressing the need of establishing psychiatric teams, whose members share an egalitarian basis, evoked negative remarks. However, we believe that there was an ascending influence. The Mental Health Center has always been and still remains active in the dissemination of certain ideas that are nowadays considered common ground in Greece.
In the 60s additional reformatory efforts begun to take place; in the Child Psychiatric Hospital "Daou Pentelis" the child psychiatric team of the time – P.Sakellaropoulos, L. Leousi, Th. Zolota – attempted to organize the hospital in a non-institutionalised basis. However, the undisguised government interventionism, the difficulty to train administrative and more importantly nursing staff lead this effort to failure.
In "Theotokos" a Boarding Unit was established, but the main care was provided on an outpatient basis. The head of the department was P. Sakellaropoulos.
During 1963-1967 a reformatory effort began at the University Clinic of "Aeginiteio" Hospital, with Professor of Psychiatry and Psychoanalyst D. Kouretas and Assistant Professors P. Sakellaropoulos, G. Babatzanis, N. Nikolaidis and E. Papathomopoulos.
The big secret behind the Mental Health Center’s creativity and pioneer work has been the elicitation of a collaborating spirit that carried a vision; they worked methodically and wholeheartedly, despite the adverse circumstances and they did not spare hard work and time.
This collaborative spirit, achieved with much effort, was not repeated once the pioneers withdrew, although there have been to date creative moments and mental health professionals, with high quality training, who delivered important work.
An additional important factor is that the Center’s staff did not work in the Public Sector; they did not seek vocational stability as much, maybe because the satisfaction drawn from both work and training were considered more significant. The Mental Health Center throughout its turbulent and sometimes difficult course tried to maintain its basic principles.
Its main orientation towards psychotherapeutic approach of the patient, its interest and thoughtfulness around mental health and the function of services, its insistence in constant training, make it a suitable workplace for mental health scientists, psycho dynamically trained, or for psychoanalysts that are interested in the development of Public psychiatric care. Many of the participants of this symposium have worked, are currently working, or have some kind of collaboration with the Mental Health Center.
To conclude, the Mental Health Center is not simply a legacy from the past, but an ongoing bet, whose outcome is being determined on a day to day basis, through constant effort, both in their work in the community and on their personal development.
In every time and age there are those persistent that identify themselves with the attempt to fulfill their beliefs, while lacking guarantees.
Irini Vlahaki
Psychiatrist, Child Psychiatrist,
Psychoanalyst, Psychotherapist,
Vice- Scientific Director of the Hellenic Center for Mental Health Research, Member of the Hellenic Society of Psychoanalytic Psychotherapy