Introduction

In the early 1960s a social service volunteer visiting a family in the outskirts of Athens noted in her report:

On the arranged date I went to the client’s house. This consisted in one room, if one could consider as a room the hole in which the family—father, mother and three children aged 7–12 years—resided. The sight with which I was confronted is indescribable. Two beds, on which instead of mattress and sheets were piles of rags. On the one bed, the father lay ill. On the other side a table with the few and basic tools with which the father amended toasters, a work which gave him 10 drachmas a day and these not always. The three children were in rags, dirty and undernourished, and terribly pale. Only one went to school. They complained bitterly of their truly dramatic situation. (Proceedings 2/64)

Such living conditions were not exceptional in Greece of the 1950s and 1960s, although this particular family was additionally burdened by illness, which shrank their income.Footnote 1 What was exceptional was the approach undertaken by the service that had sent the volunteer to their house. The Social Aid Stations, founded in the late 1950s in Athens, Piraeus, Thessaloniki and Patrai, linked socio-economic with mental health problems, and attempted to address not only the material but also the emotional and interpersonal difficulties of their clients.

In this paper I explore the aims and work of the Social Aid Stations from their foundation in the late 1950s up to their close at the end of the 1960s. I trace their psychosocial approach in international mental health developments, which were known to the institution that supervised the Stations, the Centre of Mental Health, and in particular mental hygiene and social psychiatry. Both combined social welfare with mental health care and claimed that mental health professionals had a role to play in providing solutions to social problems and in ameliorating social conditions and relationships. Despite these connections, I argue that the psychosocial approach of the Stations was specifically designed to address the socio-economic and cultural conditions and needs of post-war Greek society, as understood by the mental health professionals of the Centre. However, this original psychosocial model did not last long. Its weaknesses, along with the increase of mental health cases, the changes in the character of the Centre for Mental Health and Research and the amelioration of the socio-economic situation of Greece, instigated the re-orientation of the Stations to mental health in the second half of the 1960s. This process was complete in 1968–1969, when two of the Stations were closed down and two were converted to Social Psychiatry Services, thus becoming more aligned to mainstream mental health care practices. In my interpretation of the Station’s story, their successes, shortcomings and transformation provide an insight into the possibilities and problems arising when the social and the psychological meet to comprehend and assist those with both material/practical and mental health problems.

Post-war Greece: socio-economic problems and changes

After World War II, the Axis Occupation and the Greek Civil War (1946–1949), a great section of the rural and urban population of Greece was struggling with serious economic and social problems. The countryside was in ruins and more and more people left their villages to live in Athens and the major cities: the urban population increased from 38% in 1951, reaching 53% in 1971. Infrastructure in cities though was lacking and average housing conditions ranged from basic to bad. Since the state did not undertake an adequate construction programme, illegal dwellings spread and a great number of shacks were to be seen in the outskirts of big cities: in Athens more than six and a half thousand in 1951, and about four thousand in 1957. In 1951 only 27% of houses had electricity, and ten years later the percentage had just reached 53%. At the end of the 1950s the vast majority of houses in Athens (94%) did not have a toilet. Levels of poverty were high. After the Civil War more than one and a half million men, women and children were listed as indigent, while in the 1950s a percentage between 25 and 40% of the population was officially recorded as paupers. In 1960 Greece had the greatest unemployment rate in Europe, and underemployment was a steady feature of economy, especially for farmers. Under these conditions it is not surprising that it was a time of mass migration, mainly to West Germany, the USA and Australia. Even though by the early 1960s the industrial and agricultural production was rising and for many people living conditions were improving, the economic growth was not continuous and, especially after 1963, unemployment and underemployment increased and inflation began to rise, while wages remained stagnant. Therefore great parts of the population continued to be impoverished, and for many living conditions remained hard (Vernardakis and Mavris, 1991, pp 118–132).

At the same time, social and cultural changes were taking place. Urbanisation, along with the spread of women’s work outside the home, the decrease of illiteracy and semi-illiteracy from 42.3% to 32% between 1961 and 1971, and the emergence of more education opportunities were affecting gender and family roles and social perceptions and expectations (Kotzamanis and Androulaki, 2009, pp 87–120; Vernardakis and Mavris, 1991, pp 118–132). Modernisation, understood as the convergence with the industrial and developed countries of the West, was a stated policy aim, and demands for democratisation were rising. After the Civil War and up to 1974 Greece was a ‘sickly’ democracy: the regime was authoritarian, policing every aspect of life and suppressing every element that was thought of as ‘anti-nationalist’ and ‘leftist’ (Nikolakopoulos, 2001). The victory of the government powers in the Civil War had placed the country at the Western, capitalist block, but had not ended the fierce political, ideological and social conflict between the Left and the Right, and the persecution and social exclusion of communists. Things were beginning to change in the 1960s: social movements were emerging and the centre-wing government elected in 1963 attempted a series of social and political reforms. However, this first phase of democratisation in post-war Greece led to strong reactions and to the military dictatorship (1967–1974) (Meynaud, 2002, pp 175–176; Vervenioti, 2000, pp 105–121).

Social psychiatry, mental hygiene and the Centre for Mental Health and Research

Mental health professionals were not indifferent to these social changes and challenges. There existed in Greece, as in other countries, proponents of a psychiatry that could and should consider and act upon the social circumstances of the patients in order to successfully prevent and treat mental illness. In Britain and the USA already in the interwar and more so in the first post-war decades, psychiatrists became interested in the social causation of mental illness and attempted to provide services that would address the totality of social and mental health needs of a specific population. They viewed mental illness in the context of social problems and social relationships within various settings, such as the family, school and work (Shepherd, 1980, p 214; Smith, 2016). In interwar and post-war France, mental hygiene dispensaries emphasised the connections between mental and economic problems, tried to change the ways the patients lived, and to facilitate their social adaptation and integration through early treatment and after care (Henckes, 2005, p 57). In Germany, during the 1920s and after the Second World War, psychiatrists, sometimes in cooperation with welfare agencies, tried to alleviate the socio-economic problems of their patients and enable their rehabilitation to society, and established outpatient services (Schmiedebach and Priebe, 2004).

Similar developments were taking place in Greek psychiatry only after the Second World War. Formerly, psychiatry, a joint medical specialty with neurology until 1981, had a restricted institutional and social basis: practitioners and institutions (hospitals, private clinics and doctors’ offices) were few and were usually met with indifference by state authorities and mistrust by the public. A complete training in psychiatry-neurology became possible only in 1905, but in the first half of the twentieth century the majority of psychiatrists-neurologists still studied partially or entirely abroad, mainly in France and Germany (Ploumpidis, 1995). The mental hygiene movement, that gained momentum in Europe and the USA in the interwar period and called for a more socially engaged psychiatry (Thomson, 1995), was practically non-existent in Greece up to the mid-twentieth century (Kritsotaki forthcoming). In addition, psychoanalysis faced great resistance from the psychiatric profession, the Church and society (Atzina, 2004). Yet, since the late 1950s psychiatric hospitals, psychiatrists and training opportunities increased, and a new generation of mental health professionals attempted a renewal of the their field with new institutions and organisations. Many of these professionals shared the vision of a socially active psychiatry and teamed up in 1956 to found a private mental health organisation and service provider, the Centre for Mental Health and Research.

The Centre was in contact with foreign professionals and associations (for example, it was a member of the World Federation of Mental Health) and a great number of its staff had studied abroad: the psychologist and founder of the Centre, Anna Potamianou in France (Paris Sorbonne), the psychiatric social worker Aspasia Tavlaridou in the USA (University of Kentucky and the New York School of Social Work of Columbia University), the psychiatrist Andreas Kaloutsis in France (psychiatric hospitals of Sainte Anne and Hôtel-Dieu in Paris) and the USA (Medical School of the University of Texas), the pedagogue K. Kalantzis in Austria (University of Vienna). Through such channels the Centre was in contact with contemporary developments beyond Greece, such as the British models of social psychiatry, based on which it tried to establish therapeutic communities (Karapanou, 1965, pp 10–12). A stronger influence came from the French mental hygiene dispensaries and the work leading to the ‘Association d’ hygiène mentale et de lutte contre l’ alcoolisme du 13e arrondissement de Paris’ (1958), as Serge Lebovici, a psychoanalyst of the Association, was a stable co-worker of the Centre (Potamianou, 2011). The ‘community work’ of the Association marked the beginnings of the ‘psychiatrie de secteur’: it offered comprehensive mental health services to a geographically specific population, keeping the patients in their living environment and helping them integrate to family and society, based on a solid knowledge of the living conditions of the population (Henckes, 2005, pp 73–75).

The Centre placed its objectives within the ‘mental hygiene movement’, aiming at the protection and promotion of mental health through research and education programmes and community treatment undertaken in outpatient mental health care services (initially a child guidance clinic service and an outpatient service for adults in Athens), but also in the Social Aid Stations, the welfare centres that the Centre supervised. Besides prevention, early intervention and social rehabilitation, mental hygiene had the objective to contribute to the ‘harmonious development’ of the personality and the adjustment of individuals to modern life (Royal National Foundation, 1964, pp 3–4). The Centre’s professionals viewed the 1950s and 1960s as a time of radical change, and saw their mission as to ease the insecurity and psychological tensions arising from the coexistence of modern and traditional beliefs and practices, and thus support the modernisation process. For example, according to the psychiatrist of the outpatient service for adults, ‘the traditional prejudice on women’s work is in conflict with the inevitable necessity and growth of women’s emancipation and thus creates an climate of ambivalence and insecurity’ (Vareltzidis, 1966, p 4). At the same time, mental hygiene aimed at shaping independent and responsible individuals and citizens, who would coexist and cooperate by limiting their liberties on their own. Therefore, mental hygiene would promote the demise of the patriarchal family and the authoritarian political system and would facilitate the democratisation of society (Pipineli-Potamianou, 1965). In what follows, I focus on the Centre’s Social Aid Stations, in order to explore how the Centre conceived and implemented this social vision of mental hygiene.

The Social Aid Stations and psychosocial welfare

The Stations were founded in Athens (in 1954), Thessaloniki (in 1956), Piraeus (in 1957) and Patrai (in 1959) by the Royal National Foundation, an organisation instituted by the King during the Civil War. Initially named ‘First Social Aid Stations’, the Stations were welfare agencies where volunteers gave the ‘first social aid’ to individuals with diverse problems. The ‘clients’, as they were called, were hungry or unemployed; had to get medical care but did not have money or had trouble in getting free hospital treatment; had gone to the city for various reasons but did not have where to stay or how to go back to their villages. Some spent a night or two at the Stations and had dinner there. Others were given food, medicines and clothes; some were helped to get work, find a place to stay, travel or get admitted to hospitals, schools and other institutions. Many were directed to more appropriate welfare services, such as the public Centres of Social Welfare and charitable organisations.

The Stations founder and sponsor, the Royal National Foundation, had the stated aim to raise the moral, educational, social and material standard of the Greek people with welfare, education and community activities. Although these intentions were linked to the fight against communism and the strengthening of nationalism and the loyalty to the King, the Stations’ records do not support the hypothesis that ‘first social aid’ was distributed with political criteria. In addition, the Foundation did not interfere much in the workings of the scientific organisations it funded, such as the National Institute of Research and, up to 1968, the Centre for Mental Health and Research (Potamianou, 2011). Moreover, it seems that the Foundation was open to new ideas and innovations and agreed, already in 1957, a few months after the Centre was founded, to place the Stations under its scientific supervision, thus allowing the shifting of the Stations’ character. Their name was changed to ‘Social Aid Stations’; they became staffed with social workers, and, in Athens and Thessaloniki, with a psychiatrist (in 1961 and 1964, respectively); and their mission moved from social welfare to a combination of social welfare and mental hygiene, which addressed the practical/material and psychological needs of the clients and was meant to serve as an ideal vehicle for applying and disseminating the principles of mental hygiene to a wider part of the Greek population.

This combination was not without precedents. In the post-war period, there were welfare professionals who considered being in ‘caring relationships’ with their clients and thus appropriated psychotherapeutic tools and discourses (Stenner and Taylor, 2008, p 417). In addition, there has been a long history of collaboration between mental health and welfare professionals. In interwar Germany, psychiatrists, social workers and welfare organisations cooperated to meet the social needs of patients, while in French dispensaries medical action was extended through the action of a social service (Dreikurs, 1961; Henckes, 2005, p 52). According to the psychiatrist of the Thessaloniki Station, the combination of welfare and mental health care had already been proposed by Freud and was been applied during the 1960s in the USA in the social psychiatry services for the poor (Liberakis, 1966).Footnote 2 However, the Stations’ initial target population was not the mentally ill, but men, women and children with socio-economic problems, who, it was thought, could benefit from a mental hygiene approach. Although, as we will see, under the Centre’s supervision the Stations expanded their work to people with emotional and social relationships difficulties who did not necessarily have welfare needs, the clientele still required primarily welfare help.

In this sense, when Potamianou stated that the Stations were unique in the world (Potamianou, 1958), she might not have exaggerated. Rather than directly transferring a foreign model, the Centre’s professionals designed the psychosocial welfare of the Stations to match the specific socio-economic and cultural conditions of post-war Greece, as they perceived them. They believed that most Greeks did not have the social, educational or economic background to ask for and accept pure psychiatric support, and that this reluctance could be overcome by the combination of mental hygiene with social assistance (Centre for Mental Health and Research, 1966, p 6 and Centre for Mental Health and Research, 1968a, p 9). This could take place ideally in the Stations, which had many more cases than the Centre’s mental hygiene services. For example, in 1960 the Station of Athens had more than two thousand cases, while the Centre’s child guidance clinic had 199. Additionally, the Stations’ clients were believed to be in greater need of psychiatric help. The psychiatrist of the Thessaloniki Station underlined that they came from ‘the most deprived section of the population of the city (or the country) and the deprivation is not only financial but also educational, social and intellectual’. Many had ‘passive-dependent personalities’ and some were reliant on charity, while most had families with complex social and medical problems. The handling of these cases required a combination of welfare and psychiatric work (Liberakis, 1966). While this view involved an implicit prejudice towards the poor and uneducated urban and rural social strata, it is true that, even if people from these strata were willing to ask for psychiatric help, they had limited access to mental health services. Lacking the means to consult privately a psychiatrist, they could get free mental health care mainly in public psychiatric hospitals, which chiefly provided inpatient treatment to people with severe psychiatric disorders, and, although increasing, were overcrowded and stigmatised. Therefore, psychiatric hospitals were not a viable option for those with mild problems or those who thought they had only socio-economic and not mental health problems.

Besides matching the potential and needs of Greeks, the combination of welfare and psychiatric work was proclaimed by the Centre’s professionals as the best solution to the clients’ problems. As Potamianou stressed in a speech to Centre’s social workers and volunteers, material needs—for example for shelter and food—were linked to psychological needs—such as the needs for love and security—and material problems were connected to and often concealed psychological problems (Potamianou, 1962). Thus, the satisfaction of the clients’ social needs was not enough. Social aid was just a source of temporary relief. On the contrary, mental hygiene was viewed as capable to uncover the deeper, psychological causes of material and practical difficulties and have an effect on the clients’ personality and relationships; to mobilise the clients, enabling them to mature socially and psychologically (Potamianou, 1962), become more adjusted, independent and responsible (Pipineli-Potamianou, 1965). In these ways psychosocial welfare would offer more long-lasting results than simple welfare work, making sure that the clients became able to solve their problems on their own, and did not go back to the Stations or turn to other welfare agents for help. In a nutshell, psychosocial welfare was intended to help those in need to cope with the adverse socio-economic conditions of the post-war period, while shaping well-adjusted, independent and responsible individuals. This ambitious tactic corresponded to the objectives of the Centre in regards with the country’s democratisation and modernisation. What remains to assess is how this approach was implemented in practice, and to what extent it was successful.

Implementing psychosocial welfare

The Stations’ psychosocial approach was undertaken by social workers with ‘special psychological and technical knowledge’ under the supervision of a psychologist (mainly Potamianou), a psychiatrist and the psychiatric social worker and scientific vice president of the Centre, Tavlaridou. Volunteers, middle- and upper-class women, who, we may presume, were drawn from the philanthropic pool of the Royal National Foundation, continued to contribute to the Stations’ work, but were subordinate to social workers, as they had no special skills, only ‘love for and interest in’ fellow human beings (Mental Health Section, 1960, p 11). Making social workers the Stations’ main staff, as well as hiring them in the other Centre’s services was a major step towards the professionalisation of social work in Greece. In the 1950s and 1960s social workers, these new, usually young and female, professionals faced many obstacles in carving a professional space for themselves, especially in the psychiatric arena, which was dominated by older men (Tavlaridou-Kaloutsi, 2012). The Centre, which was scientifically managed up to 1969 by a psychologist and a psychiatric social worker, Potamianou and Tavlaridou, young women themselves, organised training sessions for its social workers, and placed them in responsible positions, including them in the psychiatric teams of its mental health services. While the collaboration could be too demanding for social workers (Proceedings 11/64), their relationship with the mental health professionals was easier and less uneven than in the public psychiatric hospitals, to which social workers were slowly making their way during the 1960s. Most importantly, by teaming up with mental health professionals social workers could obtain the necessary basis for handling all, not only mental health cases, while by adopting the psychosocial approach they could assert a unique methodology for their profession. Thus, through work in the mental health field social workers were strengthening their claims for an independent professional status, as had been the case since the early twentieth century in countries such as the USA and Britain (Tice, 1998; Gabriel, 2005 and Long, 2011).

In their daily practice, the Stations’ social workers undertook the ‘social research’, interviewing the clients, and produced the ‘social history’ for each case, even the simplest ones. During the interviews, social workers cooperated with the clients, in order to include them and motivate them in understanding their problems and finding and applying the optimal solution to them. This work was documented in the ‘individual case records’, which were kept anonymously for each client and were usually structured in three parts: history, programme and implemented actions.

Cases were classified in three groups: welfare, adjustment and mixed cases. In an average year like 1960 (Table 1), the majority of cases—59–66% depending of the Station—belonged to the first group, presenting material, economic and practical problems, asking to be admitted to hospitals, schools or institutions, to be given financial or material help (for example food, clothes and medicines), to be helped to find a place to stay or a job. Adjustment cases, a new type of cases after the Stations were placed under the Centre, had emotional problems and problems in their relationships in the family or community. These cases were considerably fewer than the welfare cases, ranging between 3 and 12% depending on the Station. Finally, mixed cases, namely clients with both welfare and adjustment problems were usually in between the two other categories (10–18%).

Table 1 Cases of the Social Aid Stations, 1960
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Mixed cases were ideal for the implementation of psychosocial welfare. For instance, Mr P., 38 years old, once discharged from the sanatorium where he had been living for 6 years, was referred to one of the Stations, in order to be helped to find a job, but also a place to stay, as his wife did not want him back. The social worker implemented a two-level approach: on the one hand, she assisted him in finding a job; on the other hand she tried to resolve the couple’s problems. When the wife declined to go to the Station and insisted in getting a divorce, the social worker redirected her efforts to helping the client find a home, as well as overcome his sadness and bitterness and accept the divorce. After several months of frequent interviews with the social worker, the client

seemed more self-assured. He was happy with his work and gave the impression of someone who was determined and ready to deal with the difficulties of life with more confidence (Centre for Mental Health and Research, 1965, pp 21–22).

The case was reported in a Centre’s publication on the Stations, dating from 1965, and was meant to underscore the possibilities and successes of psychosocial welfare. Instead of just providing Mr P. with shelter and work, it enabled him to adjust to his new life and strengthened his independence and self-esteem. If all cases were as successful, the Stations’ supervisors could claim that their work with individuals could have contributed to the improvement and progress of society.

Yet, Mr P. was in many ways an ideal client: from the start he had asked for both practical and emotional support, and he was willing to cooperate with the social worker in both levels. More challenging were clients who presented only welfare demands, to whom the social workers were still expected to apply the psychosocial approach. For example, Mrs L., who lived with her family in the appalling conditions we saw at the introduction, went to the Athens Station in the early 1960s to request food for her children. The social worker noted that she was having ‘difficulties in the organisation of her family life. There is no order at home; money is not managed in a rational fashion; the children are unkempt etc.’. However, Mrs L. did not want to discuss and get other help with these issues, and left the Station after receiving food.

The social worker had a second chance to work with Mrs L. a few months later, when she returned to the Station, asking again for material help, as her husband was ill. This time she talked about her personal life: she related she had headaches and dizziness, her nerves ‘hurt’, she was often angry at her children and had rows with her husband, who hit her when drunk. The social worker noted that Mrs L. had neurotic symptoms, that her relationships with her husband were not harmonious and that things at home were not pleasant. Given the complexity of the problems, the social worker proposed a more stable cooperation, and this time the client accepted. She was referred to the hospital to have physical examinations, and was examined by the psychiatrist of the Centre. It was concluded that her symptoms were psychological and she was diagnosed with ‘conversion hysteria’, namely the state in which emotional stresses were turned to physical symptoms, such as dizziness and headaches.

In terms of treatment, Mrs L. was given medicines—the record does not give more information on the kind of medicines—and psychological support. In addition, a volunteer visited the family four times, bringing food and clothes, but also observing and attempting to change the personality of the husband and wife and the organisation of the family life. Noting that the wife was very nervous, she suggested to her that she stopped nagging, kept her house clean and took care of the children. She went with her to the school and talked to the principle, in order to make sure that all three children would regularly go to school, and made arrangements for the children to receive proper food and rest, as they were pale and weak. For the husband the volunteer stated that it was not physical illness that stopped him for working, but lack of motivation and confidence; his personality was ‘asleep’. She tried to motivate him by stressing to him that his children needed better care. Although he seemed keen to work, when she found him a job, she saw that he ‘was struggling with himself. His ego wanted, but he lacked the confidence, the sick side of his character created resistance and fear in him’. Subsequently the volunteer became sterner and told him that if he did not take that job ‘neither the Station nor I will be interested any more in him, as both he and his wife are young people and have to become useful to society and not count on others for everything’. After that, Mr L. got the job and the financial situation of the family improved. They moved into a better house, where Mrs L. was assisted by the volunteer to organise the family life. Mrs L. headaches and dizziness had disappeared thanks to the medicines and the psychological support by the social worker. Husband and wife expressed their gratitude for the calm and ‘mental peace’ of their family life (Proceedings 2/64).

As illustrated by the case of Mrs L., the psychosocial approach combined a modern methodology based on psychiatry, psychology and social work, with more traditional, philanthropic practices. It was not devoid of moral connotations, but presupposed the notions of ‘good’ husband and wife, mother and father, and citizen, and linked independence, responsibility and adjustment with productivity and usefulness to society. Moreover, even though the Stations’ middle-class staff and volunteers were supposed to refrain from moral judgement, this was not always the case. Especially volunteers, but social workers too, found it hard to understand and accept the lifestyle and decisions of their most disadvantaged clients. In these cases, instead of working with them, in order to make them psychologically aware, they gave them direct instructions, without much psychological consideration and insight. Nevertheless, Mrs L. case was considered by the Station’s administration highly successful, in regards with the way in which mental hygiene and social welfare were effectively combined, leading to a strong impact to the clients’ life.

Undeniably, the case appeared to have turned out positively at least in comparison with the majority of welfare cases, in which work was limited to the material and practical problems and needs of the clients. An example was a ‘poorly dressed’ 16 years old, who was brought to the Thessaloniki Station by a police officer in an August night of 1961. He had come to the city to find employment, but had not managed to get a job and was planning to depart for his village the next morning. Possibly under the officer’s pressure, he requested to spend the night at the Station, so that he would not be on the street. Indeed, he stayed at the Station, but left the next morning without seeing the social worker, as was expected for all cases, and it is not known whether he went back to his village or stayed in the city (Case record 14290). Even in welfare cases in which the clients did meet the social worker, often ‘simple social work’ was applied. This focused on socio-economic problems and did not involve mental hygiene and the effort to know and shape the clients’ personality and relationships and reveal and treat their mental health problems.

Restriction to simple social work was due to two reasons. Firstly, many clients objected to the mental hygiene approach and refused to talk about personal issues. They just wanted to have their material and practical problems resolved. The predominance of welfare and mixed cases indicates that most clients turned to the Stations because they were in dire socio-economic conditions. Although an array of social services were provided by the state, the Church and private organisations, the welfare system was neither well developed or organised, and clients had to move between different providers and benefactors. Within this context—and taking into consideration the lack of familiarisation with and acceptance of mental health professionals in 1950s Greece—the main motive for turning to the Stations was their connection to the powerful Royal National Foundation, not the ‘psy’ element that distinguished them from other welfare services. The second reason why simple social work dominated the Stations’ practice was that the Stations were insufficient funded. This meant that the social workers were few, while the clients were many. For example, in Athens three social workers handled more than two thousand cases a year. Even with the help of the more numerous volunteers, it was impossible for them to investigate and handle all the cases in all their social and psychological aspects, as the Centre expected them to do. Under these circumstances, already in the mid 1960s it became obvious that the Stations could not apply the psychosocial approach to the great number of welfare cases, and thus could not disperse mental hygiene and achieve its ambitious aims as effectively as the Centre initially anticipated.

From ‘social aid’ to ‘social psychiatry’

While the implementation of the psychosocial approach in the bulk of welfare cases was proving problematic, a new trend was becoming manifest in the early 1960s: ‘adjustment’ cases, namely cases with emotional or interpersonal problems, were increasing (Tavlaridou, 1961, p 71). These clients received psychological support and counselling by the social workers, or, when things were more complex, were referred to the psychiatrists and psychologists of the Centre. For instance, Mr T., 26 years old, went to the Athens Station in 1960 asking for help in his marriage. His wife wanted a divorce, because she spent much time at home alone and felt neglected. Mr T. was working long hours, in the morning as a labourer and in the afternoon as a lower clerk. His employer suggested that the Social Aid Station could help. The social research showed that the wife had been suffering deprivation since her early childhood: she had been poor and had to work since she was 13 years old. In addition, recently she had had a baby and was under much pressure. The husband, on the other hand, did not show her love and affection. He focused on meeting her material needs—this was why he was working so hard—but he neglected her emotional and psychological needs. The social worker suggested that husband and wife had separate counselling sessions with different social workers (Proceedings 30/60). The course of the case was not recorded; yet its analysis highlights that the social worker was meant to alert the client on the importance of his wife’s emotional needs and on the ways he could answer them.

Such cases demonstrate that under the Centre’s supervision the Stations still served the less privileged social strata, but had expanded their scope from dealing with material and practical demands. Although adjustment cases remained a minority in the Stations in the first half of the 1960s, they indicate that even those who had a hard time making ends meet were becoming more aware of the possibility and worth of getting professional help for interpersonal problems. Along with the shortcomings of the psychosocial approach, the increase of adjustment cases—interpreted as a rising social demand for psychological intervention—was a factor that prompted the Centre to strengthen the Stations’ mental health aspect.

Already in 1965 it was possible for Potamianou to propose the decrease of welfare cases, arguing that their predominance did not match the aims of the Centre (Proceedings 10/65). Some members of the Stations’ staff were sceptical towards this change, claiming that social problems often caused or exacerbated mental illness, and that it was not always easy to distinguish between welfare and adjustment cases before the assessment process was complete (Meeting 14–15/6/66). Despite such objections, the character of the Stations changed considerably in the next years. On the one hand, the total number of cases decreased, the decrease being most remarkable in the greatest Stations, in Athens and Thessaloniki, where in contrast to more than fifteen thousand cases in the five years between 1957 and 1961, less than two and three thousand respectively were handled in the five years between 1964 and 1968 (Table 2).

Table 2 Number of cases in the Social Aid Stations, 1957–1968
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On the other hand, the number of ‘mental health cases’, as the adjustment cases came to be called, gradually increased. In 1968, although the Stations still had welfare cases (which in the Athens and Patrai Station remained the majority), mental health cases reached a percentage between 23 and 58%, depending on the Station (Table 3). The orientation to mental health was also evidenced by the gradual establishment of psychiatric departments within the Stations in the 1960s. Having a resident psychiatrist meant more active psychiatric involvement in more cases. The psychiatrist could now examine and treat more clients and have a more pronounced role in supervising and training the staff, both social workers and volunteers, to ensure the proper psychological handling of the cases (Royal National Foundation, 1964, pp 9–10).

Table 3 Type of cases in the Social Aid Stations 1968
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The process of orientating the Stations from welfare to mental health eventually culminated in a major change: in 1968 two of the Stations, in Patrai and Athens, were closed down, and in 1969 the other two, in Piraeus and Thessaloniki, were turned into Social Psychiatry Services of the Centre of Mental Health and Research. Their name reveals the influence of social psychiatry on the Centre’s discourse and practice in the 1960s and beyond (in the 1970s and 1980s). According to the Centre’s first psychiatrist, A. Kaloutsis, social psychiatry aimed at ‘integrating the psychiatric-psychopathological event within the course of the social existence of the individual and the group’. Among other issues, social psychiatry was particularly interested in population studies and the effects of biological factors (such as age and gender) and culture (including ethnicity, social class, urban, industrial or rural environment etc.) on mental health. In sum, social psychiatry was ‘interested in studying the social dialogue of the individual’ and proposed a new way of understanding mental illness in relation to the patients’ socio-economic background and social relationships. Moreover, it included new initiatives for the prevention, treatment and, more crucially, after-care within the community through various programmes and extra-mural facilities such as day hospitals, night hospitals and patients’ clubs (Kaloutsis, n. d., p 1).

Grounded on these notions of social psychiatry, the Services emphasised how social conditions shaped the behaviour, relationships and mental health of the individual (Proceedings 9/69 and Proceedings 1/65). In Thessaloniki, a commonly used diagnosis in the following years was ‘reactive disorders’, given to 20% of the patients in 1978, to denote the impact of events and conditions of life, such as family, health and financial problems. What is more, the Services addressed not only the mental health but also the socio-economic problems of the patients: social workers, still the most numerous members of staff, and volunteers, still active in the Services, looked for the necessary resources to cover the patients’ needs in medicines, food, clothes and housing. Moreover, patients were given small remunerations for participating in occupational therapy and working in the Services’ workshops, while emphasis was placed on finding them work. Professional rehabilitation was seen as key to social rehabilitation, not only because work itself was thought of as therapeutic, but also because it paved the way to a more independent life.

Therefore, as in the Social Aid Stations, in Social Psychiatry Services mental health care and social help were combined. Yet, the balance between welfare and mental health had shifted towards the second. The new Services were not welfare centres, but psychiatric outpatient services. They gradually stopped serving welfare cases, employed more mental health professionals (psychiatrists and psychologists), and made more extensive use of psychiatric tools and methods: patients were diagnosed according to the International Classification of Diseases of the World Health Organisation and treated with psychopharmacology (mostly antipsychotics, sedatives and antidepressants), psychotherapy (mainly counselling, but also deeper forms of psychotherapy, such as psychoanalytic psychotherapy) and social therapy (most notably in protected workshops and day care units).

The move away from welfare was reflected in the social profile of the patients. As we have seen, the clients of the Social Aid Stations belonged to the unprivileged socio-economic strata and, when given psychological and psychiatric treatment, this was free. In the 1970s the Social Psychiatry Services still had patients who lived in dire economic conditions and were treated for free, as long as they were registered as paupers. However, many had their fees covered by social security funds or had the economic means to pay for themselves. In other words, the Social Psychiatry Services had a more socially diverse clientele than the Stations, including patients from the middle classes.Footnote 3

The shutting down of two of the Stations and the turning of the other two into psychiatric services was initially instigated, as we have seen, not only by the unsuccessful implementation of psychosocial welfare but also by the increase of adjustment cases in the early 1960s. The extent and rapidity of the increase of mental health cases between 1960 and 1968 (Tables 1 and 3) indicates that it was brought about by a policy change reflecting the decision of the Centre’s leadership to orientate the Stations to mental health. However, the increase was also connected with cultural changes of the late 1960s and 1970s, when the urban population of Greece and especially the new middle-class clients of the Social Psychiatry Services and the other services of the Centre were becoming more open to psychiatric and psychological interpretations and methods, making stronger demands for new mental health services (Kritsotaki, 2016b). Less easy is to assess the role of social workers, the frontline professionals of Stations, to the establishment of the Social Psychiatry Services, as their opinions were not documented. In any case, they were positively affected by the change: they remained the main staff in the new Services and their professional status and working conditions improved, since they became members of the psychiatric team and their cases were reduced in number. The volunteers also saw a change in their status: they obtained a more formal role, as they founded official organisations in Athens and Thessaloniki, in order to promote the work of the Services through fundraising and social activities, such as outings and parties, for the patients (Kritsotaki, 2016b, p 213).

Moreover, the demise of the Stations was connected with other trends inside and outside of the Centre for Mental Health and Research. On the one hand, at the end of the 1960s the Centre’s psychiatric character became more pronounced and the mental hygiene discourse lost its prominence. Although the Centre still aimed at facilitating the individual’s ability to cope with the challenges of modern life, this effort was more clearly demarcated: it did not include the whole of society, and its modernisation and democratisation, but was restricted to patients and families who consulted the Centre’s mental health services (Kritsotaki, 2014). On the other hand, the urgent post-war social circumstances that dictated the mixture of mental hygiene with social welfare had, to some extent at least, faded. Between 1950 and 1973 the net capital income tripled, and a large part of the population saw their living standard rising. Housing conditions improved, nutrition became richer and consumer goods, like the car, radio and telephone, became more accessible (Close, 2002, pp 76–78). Within this context, by the late 1960s the Stations were not seen either as fitting the agenda of the Centre or as necessary for Greek society as they had in the late 1950s.

Conclusion

The Social Aid Stations were welfare services that in the harsh conditions of the 1950s adopted a mental health approach, in order to provide more long-lasting and comprehensive solutions to socio-economic problems, uncover and treat mental health problems, shape independent and well-adjusted individuals and promote the modernisation and democratisation of society. The Centre for Mental Health and Research, the organisation that turned the Stations into centres of psychosocial welfare, was aware of how social psychiatry and mental hygiene in other countries emphasised the socio-economic causes and consequences of mental illness, and created programmes and extra-mural services to address both the social and mental health needs of their catchment area. At the same time the Stations were distinct, in that they did not limit their scope to the mentally ill, but through the combination of mental hygiene and social welfare tried to apply and disseminate the methods and principles of mental hygiene to a wider population, who did not have or did not know they had mental health problems, originating mainly from the unprivileged urban and rural social strata. The psychosocial approach was meant to match the economic, social and cultural conditions of post-war Greece and provide the best (more permanent and inclusive) solutions to its problems.

While the Centre stressed and took pride in the uniqueness of the Stations, within a decade they had ceased to exist. This was due to the specific terms and the shortcomings of their operation, the limitation of the Centre’s mental hygiene discourse, and the socio-economic and cultural changes of the 1960s. Already in the middle of the decade it had become obvious that social welfare outweighed mental hygiene and absorbed most of the time and effort of the social workers. The implementation of psychosocial welfare was unattainable for a great number of cases, and the Stations were not efficient in carrying out the mental hygiene work they were supposed to. At the same time, the Centre’s scientific administration was increasingly questioning the welfare character of the Stations, pointing out its inconsistency with the aims of the Centre. This became more pronounced in the next years, when the Centre’s psychiatric profile was strengthened and its discourse became less concerned with the whole of society and more orientated to the micro-level of the individuals and families treated. Finally, in the course of the 1960s the socio-economic situation of many Greeks was improving, while the number of people asking for help for emotional and interpersonal problems was increasing. Thus, the psychosocial approach came to be seen as irrelevant not only to the Centre’s work but also to society’s needs and expectations.

The history of the Social Aid Stations is important in that it highlights the uneasy relationship between the social and the psychological. Different trends in mental health and social policy have given different answers as to where the one ends and the other begins, in which ways and to which degrees they intertwine, and which should absorb more resources. Several efforts to combine them have taken place: the psychological has long played a part in social welfare, and the social aspects of mental health have been studied. Especially in later years, since the 1980s, and increasingly in the 2000s, academics, practitioners and organisations have evoked the concept of ‘psychosocial welfare’ in order to treat inseparably the individual/psychological and social level, and address ‘the subjective and emotional experiences of welfare users and providers alongside issues of redistribution and social justice’. Nevertheless, it has been hard to find a balance between the focus on the social, public aspects of life and the feelings, experiences and private relationships of the individual (Stenner and Taylor, 2008 quote, p 416). As the history of the Social Aid Stations demonstrates, even agents determined to equally address the social and the psychological, and to extend the social influence of mental health sciences, faced many challenges—economic, social and cultural—and often opted—or were forced—to focus on the psychological. Amidst the current Greek and European economic crisis, with its severe social and mental health consequences, such historical examples can serve as a point of reference for rethinking the place of the social in mental health care and the place of the psychological in social welfare.

Data availability

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.