WHAT IS REALLY HAPPENING IN GREECE WITH THE "COMPLETION OF PSYCHIATRIC REFORM"?

Interview with Giouzepas Stylianos, a clinical psychologist and scientific director of the ARGO program

by Mariami Gatenashvili

In the summer of 2024, mental health centres faced a bill that resulted in radical changes to their operation. The bill, titled “Completion of Psychiatric Reform,” received much criticism as it promotes the privatisation of mental health services.

To better understand the situation in Greece, we interviewed Giouzepas Stylianos, a clinical psychologist and scientific director of the ARGO program, to explain the situation.

What is the difference in how things operated before and after the bill was passed?

Before the bill was passed, there were 36 sectors across Greece concerning mental health, and within these sectors, mental health services were required to be organised, including primary, secondary, and tertiary services, such as prevention centres, community mental health centres, and hospitals.

The entire psychiatric reform in Greece began from the negative image of the hospitals in Leros, Petra Olympou, and Tripoli in the 1980s. This led to a series of obligations towards the European Union, with funding for the creation of community mental health services. Unfortunately, the financial crises from 2010 onwards meant that many of these services were never completed.

Regarding addiction treatment over the last 40 years, various initiatives have established a wide range of addiction treatment services in Greece, covering all approaches from strictly structured hierarchical communities and therapeutic communities to substitution programs. These operated mainly in urban centres, and 75 prevention centres were established across Greece.

The bill passed on Tuesday, July 30, changes the entire field of mental health. Instead of 36 sectors, there are now 9 health regions, expanding the area of responsibility and essentially abolishing the 2 main central psychiatric hospitals in Thessaloniki and Attica without detailing what new community mental health services will be created in local communities. This leaves the situation incomplete and problematic, enlarging the area of responsibility and increasing the problems and difficulties for people with mental health issues to access the national health system.

In mental health, we see a shrinking of the public sector, which is left understaffed since there have been no hires since 2010, with poor facilities collapsing and all funding diverted to the private sector. Services that people received for free and with quality will, in the coming years, be paid for by insurance and out-of-pocket.

Who will fund addiction services with these changes?

Initially, users will receive funding from the state. This funding will be minimal for shortterm interventions, but for long-term interventions, which mental health and addiction treatment require, they will have to pay themselves.

In addiction treatment, it gets worse; all existing organisations, such as the Center for the Treatment of Dependent Individuals, the Organization Against Drugs, and the ARGO program, are abolished and merged under a new organisation that only discusses its administration and not what will happen going forward.

What negative impacts do you see in the mental health and addiction sectors?

In mental health, there will be a shift to the private sector and its growth, while in addiction treatment, we have no clear picture of which existing services will continue after the bill’s implementation, both theoretically and practically. All addiction services are abolished from the date of the bill’s application, and a scientific and administrative council appointed by the minister will evaluate and decide what will exist in the field.

This is problematic because there are various addiction treatment approaches in Greece, and users could choose which suited them. This reform attempts to erase this diversity, leaving only dry treatment and a substitution unit, homogenising all dry therapeutic programs.

How will this change affect individuals with dependencies?

There is already insecurity among people currently in services about what will happen, especially for those starting their recovery. There’s uncertainty about which services will remain. This causes significant distress among those who have taken their first steps towards recovery, and we cannot answer what will happen in the future.

Gradually, with the bill’s implementation, there will be short-term addiction initiatives, as seen in Germany. They will be funded by insurance, mainly private, and if one does not succeed in 3-6 months, state funding will end, and the user will have to pay out of pocket.

Such practices seen abroad contradict scientific beliefs that longer and more prolonged involvement in addiction services leads to more successful and lasting recovery.

Looking at a five or ten-year horizon, I fear the number of addicted individuals unable to access addiction services will increase, and new substances and addictive behaviours will worsen the situation.

Does this model seem to work in Germany?

We collaborate with programs in Germany and communicate with them. People working there describe how difficult this system makes it for an addicted person because, in 3 or 6 months, they would have to stop treatment if they couldn’t pay the insurance or out of pocket. Unfortunately, this logic is coming here, and I fear the system will worsen because the number of addicted individuals will increase along with the substances.

What reactions have there been in the scientific community regarding this reform?

The bill, passed in July, has been known since early November 2023. We requested discussions with the relevant deputy minister many times; some meetings occurred, but there was no substantial dialogue. The bill remained 95% the same, except for prevention, which, due to its relation with the Ministry of Interior, was entirely removed from the bill. So, in essence, no dialogue occurred with field workers, employees, and scientific bodies.

Reactions are multi-level. The bill abolishes a 40-year network that worked and was built from the work of field people and public funds, providing detoxified users and meeting local community needs.

The bill’s logic is the opposite. The Ministry decides what will happen in each area, contrary to scientific community logic.

All modern health organisations talk about the participation of health service recipients, their families, and the local community in decision-making. Here, we have a bill with the exact opposite logic, with the minister appointing the 9-member administrative council overseeing all addiction services in Greece.

How does this practically affect ARGO’s work?

“ All addiction services are abolished from the date of the bill’s application, and a scientific and administrative council appointed by the minister will evaluate and decide what will exist in the field. ”

Everyone at ARGO, from colleagues, and members to parents, doesn’t know where we will end up, what ARGO’s future is, and if it will even exist. The implementation date of the bill moved from September 1, 2024, to January 1, 2025. By January 1, 2025, ARGO might not exist, replaced by something different. This means that ARGO’s philosophy, methodology, and organisational structure, the relationships it built with the local community, and its profile, which attracted dependent individuals seeking recovery, may disappear.

Regarding employees, we face another issue. We, the employees of ARGO and similar addiction programs in Greece’s psychiatric hospitals, will have to choose within a month of the bill’s implementation whether to move to mental health, staying in the public sector, or to the National Organization for the Prevention and Treatment of Addictions, which is private.

Many colleagues trained, experienced, and passionate about addiction will abandon it due to this difficult change, remaining in mental health. This leads to significant understaffing of existing mental health and addiction services and a wave of resignations in other organisations.

What do you think would be the ideal reform to help mental health and addiction centres?

Changes in the field are necessary as mental health and addiction are evolving phenomena. Addiction today differs from the 80s and 90s. The profile of users has changed, with new psychoactive substances emerging, and heroin is no longer dominant. Younger people are more dependent on cannabis and screens.

The ideal reform should strengthen existing community interventions and services, allowing them the freedom to develop local interventions to meet their needs through systematic dialogue with other agencies. Wherever this model was applied, it was highly successful. Conversely, central decision-making and ideas were unsuccessful.

Therefore, meaningful dialogue, strengthening local community initiatives and existing services, and cooperation among existing services are crucial.

In 2019 and 2022, those working in addiction presented a national action plan to the Prime Minister with agreements for all services and steps needed. This plan outlines what should be done, but the government has a different idea, which I fear serves private interests and opens the field of addiction to private initiatives.