Social and Community Psychiatry

Stelios Stylianidis Editor

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

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

ISBN 978-3-319-28614-3 ISBN 978-3-319-28616-7 (eBook) DOI 10.1007/978-3-319-28616-7

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

v vi Foreword models of acute mental health home treatment , a form of community-integrated crisis intervention. From a scientifi c perspective, the minimal number of hospital beds needed remains undetermined as are questions about effectiveness, suitability and possible adverse effects of different community-integrated acute interventions as well as the “dosage”, i.e. the intensity of the required community-integrated services that are capable of preventing hospitalisations. This book describes various specifi c developments for specifi c situation in different parts of Greece, such as day centres, mobile health teams, ACT and home care. Fact is, hospital stays take up only a fraction of time in patients’ lives. Psychiatric treatment occurs essentially in the community. In the community, that is where mental health and social care workers are busy every day to help other people – in times of crisis as well as in situations of long-term needs for different types of assistance for their life in the community in various roles. All these activities and interactions in the community together constitute social psychiatry: prevention, treatment, rehabilitation, the provision of assistance in everyday real-life situations, healing and empowering people and communities towards inclusive community life. However, there is a mismatch between the real- life everyday efforts and the conceptual formulations of this kind of essential work. Consequently, textbooks on social psychiatry are rare. This one is a great step. With its comprehensive range of information, it will reach, educate and motivate different professional groups as well as policymakers, but hopefully also activists and various stakeholders including prominently users of services and their families and friends. It will be welcomed as a state-of-the art textbook as well as an orientation and inspi- ration for further developments. Professor Stelios Stylianidis is held in highest regard in the international research, policy as well as the mental health practice community. His experience covers essential working fi elds from grassroot developments to leadership positions in global organisations, clinical practice in different contexts as well as organisational and policy activities on the local, national and international arena over quite some time – times that have seen and brought on tremendous changes. He and his co-authors address the specifi c situation in Greece on several levels with relevant historical and conceptual assumptions and a variety of practice examples in different locations and situations. They also introduce topical international developments and their implications for Greece, importantly recovery-orientation and the actual patient and human rights situation, especially with regard to persons with psychosocial disabilities. Current government policies of recovery-orientation in traditionally infl uential English-speaking countries follow important changes in mental healthcare over the last decades. Deinstitutionalisation and the community support movement have been accompanied and are intertwined with a strong family movement and a politi- cally infl uential voice of users of services. People with a lived experience of mental health problems and treatments have been an essential force among the pioneers of the recovery movement, who have created the concepts and a language for recovery. As authors of the groundwork for the movement, they have developed and impacted not only alternatives but also Foreword vii international mental health system transformation efforts and specifi c models of recovery-oriented practice. From their work we know that much of recovery is lived outside clinical settings, but also that important challenges concern the roles and responsibilities of mental health professionals in supporting and assisting people with mental health problems in their efforts towards making full use of their health and resilience and achieving their goals in life. Self-determination and individual choice of fl exible support and opportunities, promoting empowerment and hope and assistance in situations of calculated risk are the new indicators of the quality of services. In contrast to a defi - cit model of mental illness, recovery-orientation includes a focus on health promotion, individual strengths and resilience. A shift from demoralising prognostic scepticism towards a rational and optimistic attitude towards recovery and broaden- ing treatment goals beyond symptom reduction and stabilisation require specifi c skills and new forms of cooperation between practitioners and service users, between mental health workers of different backgrounds and between psychiatry and the public. New rules for services, for example, user involvement on all levels and person-centred organisation of care, as well as new tools for clinical collabora- tions, for example, shared decision-making and psychiatric advance directives, are being complemented by new proposals regarding more ethically consistent anti- discrimination and involuntary treatment legislation, as well as participatory approaches to evidence-based medicine and policy. Recovery demands all our best efforts in terms of human rights, patients’ rights, scientifi c and clinical responsibility and service, in the interest of those of us who might become patients and those who have. We learn from those who are using services, those who have used services (ex-users) and those who defi ne themselves through overcoming harmful experiences in the support system (survivors). One prominent example of successful engagement of activists with a lived experience is the explicit inclusion of persons with psychosocial disabilities in the recently widely ratifi ed UN Convention on the Rights of Persons with Disabilities (CRPD). The CRPD puts the force of law behind rights to non-discrimination in key areas, including health, housing, education and employment as well as standards of living and social, political and cultural participation (Bartlett 2012). Community- based services are central to the implementation of the treaty’s provisions. In many ways the fi rst human rights treaty of the twenty-fi rst century epitomises the essentials of recovery. Forged between diplomats and a throng of civil society representatives – many of them persons with disabilities as experts in their own right, including those with psychosocial disabilities (Sabatello and Schulze 2013) – the treaty is the product of a truly participatory process. In a corresponding logic, it makes the consultation of its constituency – persons with disabilities and their rep- resentative organisations, respectively – an obligation. The reality of “nothing about us without us” seems to have arrived and is irre- versibly here to stay: no policy development and no amendment of legislation or elaboration of new regulations shall be undertaken without including experts in their own right – persons with a lived experience of mental health problems and services. The Mental Health Action Plan for Europe, the WHO Global Mental viii Foreword

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

Wien, Austria Michaela Amering

Bibliography

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

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

Dr. Marianne Farkas Center for Psychiatric Rehabilitation Boston University, USA

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

Prof. Benedetto Saraceno, School of Medical Sciences, Nova University of Lisbon, Portugal

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

Dr. Shekhar Saxena Department of Mental Health and Substance Abuse World Health Organization, Geneva, Switzerland

ix x About the Book

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

Dr. José Miguel Caldas de Almeida Department of Mental Health NOVA University of Lisbon, Portugal Introd uction

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

xi xii Introduction

(such as biological treatments to ease symptoms, or psychotherapy or psychosocial interventions). In conclusion, social psychiatry deals with the impact of the social environment on an individual’s mental health and with how individuals facing mental problems interact with their social environment.

Social Psychiatry and the Situation in European Countries

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

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

Psychiatric and Mental Health: Conceptual Clarifications

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

Let’s take a more systematic look at the reasons for this confusion, by going on a brief historical journey. Over the last 30 years at European and global level, an extension and impressive transformation in the role of the initial mission and objectives of public psychiatry (namely, prognosis, treatment and rehabilitation of mental illnesses) have been observed. This expansion has benefi ted general mental health policy aimed at preventing and treating all forms of psychological pain, including non-pathological forms, while it has also attempted to modify social representations of the general public using mental health promotion and education methods. Thanks to that development, the initially “closed” discourse of clinical psychiatry began to spread to all levels of social organisation (social work, education, the workplace, trade union, associations, civic organisations, even lifestyle magazines), but there had not been any real debate about what the boundaries, objectives and nature of its clinical and therapeutic work were. One visible consequence of this dissemination of “psy” discourse through all levels and networks of day-to-day life (Stylianidis 2008), among others, was an immense mushrooming in the “psy” mar- ket through the unthinking, unsubstantiated multiplication of hundreds of psycho- therapeutic schools that sought to “treat the normal” and “develop everyone’s personal skills and potential”. In the 1880s American psychiatrists were already using the expression “mental health” in reference to preventative actions in the urban environment, to avoid behavioural disorders emerging in children (Ehrenberg and Lovell 2001). Thirty years later the psychiatrist Adolf Meyer founded the American “mental health” movement, whose key aim was to prevent psychiatric illnesses through research and psychiatric care for mental disorders in the community. In 1922 the French psychiatrist Edouard Toulouse (1865–1947) took the initia- tive to set up a “mental disease prevention” clinic in Paris which combined open structures and social services, making it the forerunner of the French psychiatric sector, which only crystallised in the form we know it today in 1960 (Lovell, op. cit.). Toulouse believed then that synergies between the American and French mental health movement could trigger a radical transformation of traditional psychiatry on a global scale (Ahrenfeld 1958). One can clearly understand that that so-ambitious forecast came to naught. There are various defi nitions of mental health, none of which is really satisfactory. The most comprehensive defi nition is given by the WHO, which defi nes mental health as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruit- fully, and is able to make a contribution to her or his community”. The positive dimension of mental health is stressed in WHO’s defi nition of health which states that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infi rmity”. The inadequacy of the defi nition derives from the fact that the concept of mental health necessarily requires a value judgement: mental health means nothing except in the context of a socio-cultural system which dominates in a given historical period. This relativisation makes it diffi cult to recognise objective elements in the defi nition which are universally acceptable. A brief analysis of some of the Introduction xv prevailing defi nitions shows that the same criteria systematically crop up again and again: there are defi nitions based on the absence of mental illness, on identifying mental health with normalcy, or even vague states of “well-being” deriving from a balanced personality or from problem-free adjustment and integration to the social world. Psychiatry is a scientifi c discipline dealing with the treatment of mental disorders, but mental health is a discipline relating to the psychosocial well-being of individuals and communities. Consequently, the twin ideas of illness/treatment are not suffi cient for or capable of incorporating the aspect of social pain, exclusion and vulnerability which are characteristic of millions of individuals on the planet, irre- spective of the presence or absence of specifi c mental disorders. Consequently, such a reading raises major epistemological diffi culties. The fi rst diffi culty is associated with the nature of psychopathology, since the term “disease” on its own is a source of confusion about the special nature of psychiatry to the extent that it applies too across the rest of medicine. The second diffi culty is that the fi eld of psychopathology, and the wider fi eld of mental disorders, has become exceptionally complicated, as evidenced by the successive, constantly expanding classifi cation systems that encompass the ever-increasing number of new pathologies, which are published by the WHO (ICD) and IPA (DSM). The third diffi culty derives from the diversity and relativity of mental illnesses, which are widely known thanks to the contribution of phenomenology, psychoanalysis and ethnopsychiatry. Thus, defi ning mental health by reference to normalcy and problem-free adjustment criteria remains exceptionally fl uid and fragile. Besides, the well-documented concerns expressed by Georges Canguilhem (Le normal et le pathologique 1972) and a series of other philosophers have made it legitimate for us to ask the question “what is normal?” To render the defi nition clear, do we need to adapt ourselves to a statisti- cal model or a simplifying model? Both one and the other confl ict with ordinary observation and the logic of a “neutral” evaluator. In contrast to these approaches, references to purely subjective criteria, i.e. the subjective condition and experience of “well-being”, the way in which we perceive our self image personal balance and happiness, quite self-evidently are not fi rm scientifi c criteria, especially if one espouses Popperian logic. In the context of this book, it is necessary to examine this paradoxical condition about the fl uidity of defi nitions of mental health from three viewpoints. Firstly, as a fi eld of special activities for promoting mental health and educating others about it, which is something constantly evolving and developing. Secondly, as a body of new knowledge, especially in relation to new forms of social pain and new social pathologies (new forms of depression, new forms of addiction, new forms of grief, new forms of “antisocial” behaviour) (Ehrenberg 2008, 2010). Thirdly, mental health can be understood as a set of historically defi ned ways in which psychological pain can be expressed. By examining these three viewpoints together, we can better formulate a defi nition for mental health, both from the results of new practices (deinstitutionalisation and care in the community, the recovery movement, the movement of users of mental health services and their families, new forms of empowerment and advocacy) and from a fresh reading of its dynamic representations. xvi Introduction

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

Maroussi , Greece Stelios Stylianidis

Bibliography

Ahrenfeld RH (1958) Psychiatry in the British Army in the second world war. Routledge & K. Paul. Becker T, Knapp M, Knudsen HC, Schene A, Tansella M, Thornicroft G (1999) The EPSILON study of schizophrenia in ﬁ ve European countries. Design and methodology for standardising outcome measures and comparing patterns of care and service costs. Br J Psychiatry 175(6):514–521 Canguilhem G (1972) Le normal et le pathologique . Presses Universitaires de France Ehrenberg A (2008) La fatigue d ’être soi : dépression et société . Odile Jacob, Paris Ehrenberg A (2010) La Société du malaise . Odile Jacob, Paris Ehrenberg A, Lovell A (2001) Maladie mentale en mutation (La ): Psychiatrie et société . Odile Jacob, Paris Fryers T, Melzer D, Jenkins R (2003) Social inequalities and the common mental disorders. Soc Psychiatry Psychiatr Epidemiol 38(5):229–237 Herrman H, Saxena S, Moodie R (2005) Promoting mental health: concepts, emerging evidence, practice: a report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne. World Health Organization. Kleinman A (2012) Culture, bereavement and psychiatry. Lancet 379:608–609 Morgan C, Bhugra D (2010) Principles of social psychiatry. Wiley-Blackwell Parker G (2014) The DSM-5 classiﬁ cations of mood disorders: same fallacies and fault lines. Acta Psychiatr Scand 24 Feb. [early view] doi: 10.1111/acps.12253 Patel V, Saraceno B, Kleinman A (2006) Beyond evidence: the moral case for international mental health. Am J Psychiatry 163(8):1312–1315 Ruggeri M, Elena Bertani M (2010) Mental Health in Europe: learning from differences. In: Principles of social psychiatry, 2nd edn., pp 499–516 Saraceno B (2014) Discorso globale, sofferenze locali. Analisi critica del Movimento di salute mental globale. Il Saggiatore, Milano Tansella M, Thornicroft G (2001) The principles underlying community care. In: Textbook of community psychiatry. Oxford University Press, Oxford, pp 155–165 Introduction xvii

Thornicroft G, Tansella M (2009) Better mental health care. Cambridge University Press, Cambridge, pp 1–184 Thornicroft G, Tansella M (2013) The balanced care model for global mental health. Psychol Med 43(04):849–863 World Health Organization (WHO) (2005) Mental health atlas: 2005. http://www.who.int/men- tal_health/evidence/atlas/global_results.pdf . Accessed on 7 Jul 2014 World Health Organization (WHO) (2008) The global burden of disease 2004 update. http://www. who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf . Accessed 7 Jul 2014 World Health Organization (WHO) (2010) mhGAP intervention guide for mental, neurological and substance use disorders in non-specialised health settings: mental health Gap Action Programme (mhGAP) World Health Organization (WHO) (2013) Mental health action plan 2013–2020. http://apps.who. int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf Accessed 7 Jul 2014 Karavatos T (2014) Acceptance of DSM-5: “The problem with DSM-5 isn’t in the 5 but in the DSM”. (in Greek) Synapsis J 32(10):4–8 World Health Organization (2001) The World Health report 2001: mental health: new understanding, new hope. World Health Organization Stylianidis S (2008) Transformations in psychiatry: in search of new examples for a new mental health policy (in Greek). In: Stylianidis S, Stylianoudi MGL (ed.). Community and psychiatric reform: The experience of Evia, 1988–2008. Topos Press, Athens, pp 443–477

C o n t e n t s

Part I Social Psychiatry

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

Part II Applications of Social Psychiatry

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

xix xx Contents

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

Part III Evaluation

19 Evaluation of Social Psychiatry Services ...... 389 Stelios Stylianidis , Petros Skapinakis , Venetsanos Mavreas , and Michael Lavdas Contents xxi

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

Part IV Empowering and Rights in Mental Health

22 User and Family Participation in Mental Health Services ...... 437 Panagiotis Chondros , Stelios Stylianidis , and Michael Lavdas 23 Involuntary Hospitalisation: Legislative Framework, Epidemiology and Outcome ...... 451 Stelios Stylianidis , Lily Evangelia Peppou , Nektarios Drakonakis , and Emilia Panagou 24 The Impact of the Economic Crisis in Greece: Epidemiological Perspective and Community Implications ...... 469 Marina Economou , Lily Evangelia Peppou , Kyriakos Souliotis , and Stelios Stylianidis 25 Afterword: The Economic Crisis and Mental Health ...... 485 Stelios Stylianidis , Panagiotis Chondros , and Michael Lavdas Index ...... 509