Global Side Effects: Counter-Clinics in Mental Health Care

In 2002, when I began field research on community-based psychiatry in northeastern Greece, psychiatric reform had been underway for almost 20 years. The evidence of this national (in fact international) program was everywhere: in the open doors and limited beds at the psychiatry clinic of the district general hospital where I worked; in the small fleet of mobile units that carried treatment teams of clinicians and social workers to visit patients in their homes and primary health care centers in villages up to 100 km from the hospital; in the activities of a nearby mental health association, whose staff provided psychological and psychiatric care free of charge to patients at rural health centers in the region and in a small day hospital at its downtown office, and trained new therapists in the principles of social psychiatry. It was evident in the prescription of “new” psychotropic medications—atypical antipsychotics like Geodon and Seroquel, then being prescribed to patients for not only schizophrenia, but also bipolar disorder and obsessive-compulsive disorder; atypical antidepressants like Wellbutrin and Effexor alongside the SSRIs, which were written just as often for anxiety as depression; the combination for almost all patients of two or more of these medications with anxiolytics. It was evident as well in the recent certification of the psychiatry clinic at the general hospital as a clinical trial site and the conduct of two clinical trials of new medications during my time there. Implemented with the progressive vision of two generations of clinicians, and supported largely by European Union development funds, community-based care in Greece had taken 20 years to take this form: regular therapeutic contacts in outpatient settings, flexible diagnoses, customized cocktails, and off-label uses of new medications—humane care backed up by science. The settings where I conducted my fieldwork composed the very picture of contemporary clinical psychiatry at the dawn of the twenty-first century. During my first week at the general hospital, when I settled into the residents’ office to read through some medical charts, a social worker I had just met asked me: “So is this how it looks in America? ” I had no experience in clinical settings in the United States, so I thought she probably knew as much as I did about how it looked there, and said so. I could tell from her reaction that this was not the right answer; we did not share the premise of cultural relativism, and as an American researcher, I did not have the luxury of choosing not to judge. Her question marked my initiation into the problematic of “global psychiatry” that pervaded my fieldwork in Greece in the early 2000s, in the perpetual comparisons of Greek practices with American standards that hovered in and between so many questions and observations posed to me by clinicians and patients. I eventually became useful to the academic directors of the clinic by lending my English language fluency to their project of translating a diagnostic survey instrument into Greek (Delistamati et al. 2006); they were working with the English edition of the DSM-IV (a Greek translation was published in 2004) and had a series of other translations planned—part of a robust effort to connect the care settings where they worked, and the forms of treatment they offered to their patients, to the larger world of global psychiatry. Deinstitutionalization, a process entrained by political liberalization and patients’ rights movements worldwide since the mid-twentieth century, has successfully shifted clinical care from custodial hospitals to outpatient and community-based settings in many places today, challenging patients to help care for themselves. In many places, psychiatric hospitals have all but disappeared—a double-