The detailed essays in this special issue of Medical History provide an opportunity for reflection on common themes as well as on differing medical and historical contexts, specifically examining the organization and practice of European social psychiatry, its various definitions, as well as the history of psychotherapy, in twentieth-century Germany, Holland and Great Britain. The chance has also arisen for one of the two guest editors to comment briefly on various other points that seem pertinent, by way of brief introduction. His fellow guest editor, Harry Oosterhuis, is the author of one essay and co-author of another.

The term “social psychiatry” became current in the Netherlands from the late 1920s. Its meaning was imprecise. In a general way, the term referred to psychiatric approaches of mental illness that focused on its social origins and backgrounds. In this broad interpretation social psychiatry was connected to the psycho-hygienic goal of preventing mental disorders, but also to epidemiological research on the distribution of mental illness among the population at large. The treatment called “active therapy”, introduced in Dutch mental asylums in the 1920s and geared towards the social rehabilitation of the mentally ill (especially through work), was also linked with social psychiatry. In a more narrow sense social psychiatry indicated what before the 1960s was usually called “after-care” and “pre-care”: forms of medical and social assistance for patients who had been discharged from the mental asylum or who had not yet been institutionalized. This article focuses on the twentieth-century development of Dutch social psychiatry in this more narrow sense, without, however, losing sight of its wider context: on the one hand institutional psychiatry for the insane and on the other the mental hygiene movement and several outpatient mental health facilities, which targeted a variety of groups with psychosocial and behavioural problems. In fact, the vacillating position of pre- and after-care services was again and again determined by developments in these adjacent psychiatric and mental health care domains. This overview is chronologically divided into three periods: the period between and during the two world wars, when psychiatric pre- and aftercare came into being; the post-Second World War era until 1982, when the Social-Psychiatric Services expanded and professionalized; and the 1980s and 1990s, when they became integrated in community mental health centres.

The early history of psychotherapy in the Netherlands hardly differs from that of the surrounding countries. Somewhat later than in France and Germany, psychotherapy appeared during the last decades of the nineteenth century, with general practitioners who started to treat their patients (mainly for all kinds of somatic complaints) by psychological means. In the early decades of the twentieth century, psychotherapy was narrowed down to mainly psychoanalytic treatment. The patient population consisted of a small élite group of people who belonged to the upper social classes. The practice of psychotherapy was restricted to some “enlightened” psychoanalysts.

In the first decades of the twentieth century, German-language papers were published which included the term “soziale Psychiatrie” in their titles. At the same time modern concepts of extramural psychiatric care were being developed. Yet, the meaning of “sozial” (“social” in English) varied widely. This was partly due to its ambiguity. “Social” can be used in the sense of small communities or the wider public; it refers to interpersonal relationships, or to relationships between individuals and social groups or other communities. According to this latter meaning, “social” can emphasize the interests of social groups rather than those of the individual. This is how the term was used at the end of the 1920s and during the National Socialist era. On the other hand, “social” may indicate a friendly and humane intention, a philanthropic approach. It was in this sense that the term was widely used in the 1970s when philanthropic psychiatrists and others called for psychiatric reform and the closure or downsizing of asylums for the mentally ill. Moreover, in association with psychiatry, it can mean both the social dimension of mental illness (including the aetiology) that is assumed to lie in human relationships and in social circumstances, and the social and economic effects of mental illness. In parallel with these shifting meanings of the term “social”, the established models of twentieth-century ambulant psychiatric care also showed a variety of structural characteristics.

Looking back at almost fifty years of psychotherapy in post-war Germany, Annemarie Dührssen (1916–98), one of the grand old ladies of the discipline, proudly presented a story of success in 1994. In the immediate post-war years, between 1946 and 1950, there were already a considerable number of individuals and groups all over the country active in establishing hospitals or outpatient clinics exclusively devoted to psychosomatic medicine and psychotherapy; in 1950, the first university programme in the subject was set up in Heidelberg; in 1967, psychoanalytically oriented psychotherapy was included in the catalogue of services offered by the statutory health insurance system; and in 1970, psychosomatic medicine and psychotherapy had become obligatory subjects in the curriculum of medical students, resulting in the establishment of chairs in these areas at almost every medical faculty in West Germany.

During the Second World War, it is argued, “the neuroses of battle” not only deepened an understanding of “psychopathological mechanisms”, but also created opportunities for the practice of psychotherapy, while its perceived efficacy led to a broader acceptance within medicine and society once peace had returned. This recognition is contrasted with the aftermath of the First World War when a network of outpatient clinics, set up by the Ministry of Pensions to treat veterans with shell shock, were closed within a few years in response to financial pressures and doubts about their therapeutic value. In the private sector, psychoanalysis under the leadership of Ernest Jones remained an idiosyncratic activity confined largely to the affluent middle classes of London. According to Gregorio Kohon, “it was strongly opposed by the general public, the Church, the medical and psychiatric establishment, and the press”. The Medico-Psychological Clinic of London, originally set up in 1913, offered psychotherapy on three afternoons a week in premises at 30 Brunswick Square under the direction of Dr James Glover. However, it closed in 1923 after Glover and his brother Edward had both become psychoanalysts. As the First World War drew to a close, Maurice Craig helped to persuade Sir Ernest Cassel to fund a hospital for ‘Functional and Nervous Disorders’ at Penshurst, Kent, to treat neuroses in the civilian population. Although moved to permanent premises near Richmond, it remained small-scale and at the time no attempt was made to establish a network of similar institutions throughout the UK. The Tavistock Clinic, opened in Bloomsbury in 1920, struggled to secure funding throughout the interwar period and its efforts to win official recognition from the University of London were consistently rebutted. Thus, despite the epidemic of shell shock and other so-called war neuroses, psychotherapy remained a marginal activity during the 1920s and 1930s.