From mental hygiene to mental health: ideology,discourses and practices in Franco’s Spain (1939–75)

Introduction

Surprisingly, the development of Spanish psychological medicine during the long period of General Franco’s dictatorship (1939–75) has not yet received much historiographical attention (Lázaro and Bujosa, 2000: 165). This fact can probably be explained by two factors: first, the interest aroused by the events of the periods immediately before and after it, the so-called ‘Silver Age’ (Campos, Villasante and Huertas, 2007) and the ‘Democratic Transition’ (García, Espino and Lara, 1998); and second, the early efforts of many of the most qualified observers of Spanish psychological medicine to highlight the strong ideological implications of psychiatry under Franco, and its affinity with the essentially reactionary nature of the regime. Following this interpretive scheme, and despite certain isolated initiatives and the intellectual stature demonstrated by some of its most noteworthy figures, the rigidity of power structures and the intensely conservative character of Francoist social policy (De Riquer, 2010) doomed psychological medicine to a ‘profound demoralization’ (Castilla del Pino, 1977: 102) and an ‘absolute resistance to change’ (González Duro, 1978: 303), which curtailed any possibility for development and innovation.

Although – at least from the point of view of the care institutions (Comelles, 1988: 153–74) – this stagnation is more than obvious, it has been possible over time to take a more objective view of the particular features that confer a certain degree of singularity to Francoist psychiatry. It is worth mentioning the rigorous and highly documented work of Ángel González de Pablo (1987, 1995) and Juan Casco Solís (1995, 1999), who, while maintaining a critical perspective, have laid the foundations for understanding the complex process of theoretical regeneration and institutional restructuring that took place in Spanish psychological medicine in the early years of the Francoist regime. In this process, for example, it is logical to suppose that, despite the undeniable break imposed by the New State with regard to the achievements of the Republican period (1931–6) – and its explicit intention to make a tabula rasa of the immediate past – there were numerous elements of continuity with psychological medicine prior to the Civil War (1936–9); virtually all the psychiatrists aligned with the new regime had trained during that period and shared corporate interests and conceptual references with their colleagues on the Republican side (Campos, 2015).

For this reason, the field of mental hygiene is one of the most fruitful areas in which to observe the historical singularity of Francoist psychiatry and this peculiar combination of breaks and continuities. During the late nineteenth century, there was a shift in focus from nosology to aetiology, from treatment to prevention and from the rehabilitation of individuals to the monitoring of society as a whole, leading to the establishment of mental hygiene as the great ideology of the psychiatric profession (Castel, 1976; Grob, 1987; Toms, 2013). It then played a very important role in the remarkable development of Spanish psychiatry during the 1920s and 1930s. The Spanish mental hygiene movement had an acknowledged influence in the introduction of a new legislative framework (Espino, 1980) and a new model of care that attempted to correct the limitations of traditional mental hospitals through the creation of dispensaries and ‘open services’ (Huertas, 1995). The movement – which started in 1927 with the creation of the Liga Española de Higiene Mental (LEHM) – reinforced the presence of Spanish professionals in international forums (Campos, 1997), promoted the production of various educational publications, and conducted numerous informative campaigns about the nature, treatment and prophylaxis of mental disorders (Valenciano Gayá, 1977: 94–6). Therefore, and thanks to the institutional support provided by the ‘Consejo Superior Psiquiátrico’ (Psychiatric Council) and the Section of Psychiatry and Mental Hygiene of the country’s General Directorate for Health, its activities enabled Spanish psychological medicine to achieve a hitherto unknown level of scientific legitimation, professional maturity, social impact and political recognition (Huertas, 2002: 119–24). ²

Following the Civil War and the exile of some of its most conspicuous figures, the League ceased its activity, and the discourse of the psychiatrists most closely identified with the new regime was initially limited to promoting the ideological affinity among traditional religiosity, conservative nationalism, public order and individual psychological balance (Casco Solís, 1995: 202). However, the creation of dispensaries did not cease, and during the 1950s there were also some isolated attempts to set the old mental hygiene movement in motion again, restoring its international connections and implementing some initiatives intended to reinforce the familiarity of the population with psychopathological discourses and practices (Casco Solís, 1999: 110–12). In this task, for example, the General Directorate for Health devoted a significant number of monographs in its series ‘Al Servicio de España y del Niño Español’ (1938–63) to issues of child psychology, psychiatry and mental hygiene. ³

In any case, and after a few years, the views of Spanish psychiatrists became progressively influenced by the new concepts of mental health, social psychiatry and community care, which were promoted by the World Health Organization (WHO) and other international entities, and dominated psychiatric discourses and practices throughout the second half of the twentieth century (Kringlen, 2003; Novella, 2010a). Thus, the old approach of mental hygiene – essentially focused on the prophylaxis of insanity within the framework of a set of interventionist policies of social defence – was transformed, from the beginning of the 1960s, into a much more ambitious and comprehensive project which sought to promote the psycho-social balance and performance of individuals in the context of increasingly socialized health-related discourses and networks of care (Dowbiggin, 2011: 132–82). In the final years of the dictatorship, these ideas inspired and guided the (timid) initiatives of the Patronato Nacional de Asistencia Psiquiátrica (National Board of Psychiatric Care, PANAP, founded in 1955), which implemented a modest programme for ‘mental health education’ and supported several proposals for modernizing and reforming psychiatric care.

This paper analyses the discourses, the ideological appropriation and the practical influence of mental hygiene in Spanish psychiatry during the early years of the Francoist regime, and then examines its decline and subsequent replacement by the new paradigm of mental health. By seeking to evaluate the most noteworthy precedents, the distinctive features and the most discernible implications of this conceptual shift, we aim to provide an overview of the history of psychological medicine during the Francoist regime. We will try to identify and highlight not only the breaks and continuities in Spanish psychological medicine during the middle decades of the twentieth century, but also certain significant – and hitherto somewhat overlooked – aspects linking it to the overarching processes that have marked the development of the speciality in recent decades.

Mental hygiene in early Francoism

Without a doubt, one of the most emblematic – and to a large extent foundational – events of Francoist psychiatry was the inaugural address given by Juan José López Ibor as President of the newly founded Sociedad Española de Neurología y Psiquiatría at its first conference, held in Barcelona in January 1942 (Huertas, 2017). In his speech, López Ibor set out the basis of what was meant to be the new ‘national’ psychiatry, harshly attacking the ‘decadent’ actions of his predecessors and praising the Spanish tradition of care for the mentally ill, supposedly founded in the fifteenth century by Father Joan Gilabert Jofré. In his opinion, ‘that beautiful tradition’ had already broken down in the eighteenth century:

The psychiatrists of the nineteenth and early twentieth centuries … were incapable of emulating a simple Mercedarian. Neither the romantic and generous Esquerdo, nor the socialist Jaime Vera, nor the mystic Simarro, nor the worldly Pérez Valdés managed to create the care demanded by the times. The following generations of psychiatrists devoted themselves, almost exclusively, to finding their way around the problems of science, neglecting those of care. Recently, the League for Mental Hygiene tried to put the latter on track again, but it did so with such timidity and praise of foreign contributions that it scarcely managed to turn its desires into realities. (López Ibor, 1942: 17–18)

After criticizing the Republican reforms, particularly the work of the Psychiatric Council and the adoption of Emil Kraepelin’s system for classifying mental illnesses, López Ibor ruled out the possibility that mental hygiene could achieve appreciable goals in the realm of prophylaxis and prevention. He even ridiculed the hard work of the LEHM in the popularization of psychopathological discourses and practices through activities such as the Mental Hygiene Weeks and Missions (1931–5): ‘The Philistine – psychiatrist or not – believes that mental hygiene has no other purpose than eliminating noises, advising the press and similar “missions”’ (p. 23). The underlying argument, to which he referred later, was widely adopted by the psychiatrists of the New State and was very characteristic of the essayistic concerns of the period (Casco Solís, 1999: 100–1); according to this idea, ‘the Spaniard possesses very special biological and psychiatric conditions’ and therefore mental hygiene should ‘be established in Spain on its own basis, suited to our circumstances and to the Spanish personality’ (p. 24).

With such an approach, it is easy to infer that, utterly abandoning the plans developed in previous years, the discourse of mental hygiene was transformed into a rhetorical tool intended to underscore the beneficial effects of the main ideological principles of the new regime, namely, nationalism, anti-Communism, the denial of democratic values, authoritarianism and, of course, traditional (Catholic) religion. A good example of the virulence – and the vacuousness – of the topics dealt with during those years is the lecture entitled ‘New approaches to mental hygiene’, given in February 1942 by Francisco Marco Merenciano at the provincial headquarters of the (sole) political movement of the regime – the so-called ‘Falange’ – in Valencia. For Marco Merenciano, director of the city’s mental asylum, the main aim of mental hygiene was to ‘dilute the magma of resentment, … a disorder of the mind that constitutes a truly social plague’ (Marco Merenciano, 1958: 97) – a resentment that explained Spain’s recent history and the pressing need for dictatorship and repression. In a definition that is more sinister than Nietzschean, Marco Merenciano described resentment as ‘a state of psychological self-poisoning caused by repeated failures, systematically repressing the release of certain emotions and feelings which are normal in themselves (revenge, envy, hate, treachery)’; delaying revenge thus led to ‘thirst for revenge’ and turned individuals into people ‘with poisoned, bitter minds, true enemies of society, because society – they say – is responsible for their failure, and because it is society that sanctions the eternal injustice of their limitation’ (pp. 94–5). For this reason, it was necessary to take action as soon as possible to ‘remove the poison of resentment which weakens hearts and debases souls’, and this in fact required ‘a medical policy with a clear anthropologically defined concept’ (p. 99). Having arrived at this point, Marco Merenciano was now in a position to crudely shift his arguments to the point which actually interested him: the glaring proof that ‘in each resented individual there is always a true Marxist’ which doctors must eliminate:

Historically, is there anything that is a more precise expression of resentment than Marxism? … Marx, like Hegel, like Kant himself, was resentful, … but the fact is that Marxism, more than a product of Marx, is the dregs of society … Marxism is a disease and its treatment is for the most part in our own hands. (pp. 98–9)

However, and beyond the pathologization of the Republican enemy and Marxism (so welcomed by Francoist psychiatrists, whose greatest defender was Antonio Vallejo Nágera, ⁴ former head of the psychiatric services of the rebel army), mental hygiene had to serve the New State, creating Spaniards capable of accepting their fate through ascesis and discipline around a leader (Cayuela Sánchez, 2014). In a talk given at the Consejo de Asesores Provinciales (Council of Provincial Advisors) of Falange in April 1945, Vallejo Nágera himself solemnly declared this by stressing that it was a ‘fundamental duty of all Spanish doctors … to address the mental health of young people, which is today under constant threat, deliberately, by those secret forces challenging the ideological unity of the people’ (Vallejo Nágera, 1945: 34). Of course, this task was all the more urgent given that, as he himself had written some years earlier, ‘supercivilization has … led to the degeneration of the race due to the influence of noxious pathogens harmful to the individual biopsychic constitution’ (Vallejo Nágera, 1941: 19). Among these, he highlighted exploitation of labour, nervous exhaustion and the ‘metropolitan plagues’ (syphilis, tuberculosis, alcoholism), as well as spiritualism, ‘psychic contagion’ and even psychoanalysis. ⁵ In his opinion, sport, military instruction and sexual education – encouraging abstinence prior to marriage – were particularly useful for creating selfless individuals trained to fulfil their historic mission and accept their place in society. But in reality, this goal could only be truly achieved by ‘immunizing’ young people, through education, against the dangers of materialism, liberalism and democratic pluralism.

This was also the view of Eduardo Aunós Pérez, Minister of Justice from 1943 to 1945. In June 1944 he participated in the closing down of a mental hygiene course held in Barcelona, and he took the opportunity to express his conviction that:

the mental health of a people is closely linked to its political system, because wherever anything can be debated in the public forum under the protection of a false concept of freedom, subjecting the most decisive issues to daily reflection under the rule of popular passion, it is natural that a psychological imbalance should occur. (Anon., 1944: 17)

In his opinion, respect for hierarchy, the disappearance of ‘partisan dissension’ and the unity and discipline provided by the new regime had made it possible to re-establish ‘the moral balance of the people’, putting an end to ‘inferiority complexes like envy and class spirit’. Setting itself against the anarchy and base passions triggered by democracy, ‘the collective health’ had been recovered thanks to the ‘sound judgement’ of Franco, the ‘Caudillo’ and ‘leader of the Spanish people’, but above all, thanks to his firm commitment to traditional religiosity, the only safe haven against the evils of modernity:

It is necessary to put several intangible principles beyond the discussion of men, serving as the natural base for social development. These principles must be religious, such as the acknowledgement of Catholic religion as the basis and support for the fraternal co-existence of men, and of moral nature, synthesized in the proper use of Christian thought in daily life. (Anon., 1944: 17)

This was generally the fervent tone of the discourse on mental hygiene in the 1940s, but it must be acknowledged that, from the point of view of the organization of care, the regime’s first initiatives were aimed at continuing with the implementation of dispensaries begun during the years of the Republic. Thus, on 24 May 1943 a decree was passed to create new mental hygiene dispensaries at the provincial institutes of the General Directorate for Health. As explained in the preamble to the decree, dispensaries would make it possible to ‘obtain a high rate of recoveries and remissions’ by treating ‘schizophrenia in the first six months of the disease’, but above all, they would also have ‘positive financial benefits for official bodies, which would see a decline in the number of patients confined to psychiatric facilities’ (BOE, 1943: 5637). ⁶

By about 1960, there were some 30 dispensaries operating in the country. Their official name was changed to Psychiatry and Mental Hygiene Sections of the Provincial Health Institutes, and in 1954 an expansion of their activities had also been authorized with the creation of ‘Provincial Mental Hygiene Boards’ (BOE, 1954a: 1333). However, the resources allocated to them were generally poor and their functioning was clearly unsatisfactory. In his memoirs, Carlos Castilla del Pino describes with bitter irony the facilities with which he was provided when taking up his position as medical director of the mental hygiene dispensary of Córdoba in 1949: ‘A room on the second floor, with a crack in the ceiling of such enormity that it was possible to see the very sky through it. If it rained, it would have to be vacated immediately. That was the dispensary so rhetorically named’ (Castilla del Pino, 2004: 26). Some years later, the psychiatrist Joaquín Santo-Domingo Carrasco wrote a devastating report for the WHO in which he pointed out their main flaws: insufficient coverage, negligible financial allocation, lack of coordination with other institutions and bodies, strict assignment to provincial capitals and total absence of health education activities. He was also unsparing in his description of the precarious situation in which they carried out their meagre work:

One does not know what might cause more astonishment, surprise and admiration: the financial and operating conditions, generally speaking so adverse that they seem to be intentionally planned to avoid the functioning of the services, or the work carried out by its personnel struggling against wind and tide. (Santo-Domingo Carrasco, 1963: 23)

For its part, the LEHM, virtually absent since the Civil War, was also revitalized by a ministerial order of 10 December 1947, naming Antonio Piga Pascual, Director of the National School of Legal Medicine, as President, and López Ibor, Vallejo Nágera and Eduardo Guija Morales, Director of the mental hospital of Cádiz, as Vice-Presidents (BOE, 1947: 6815). Apparently, this reactivation was motivated solely by the fact that, as there was no record of activity by the League, Spain could not officially be invited to take part in the International Congress on Mental Hygiene held in London in 1948 (Casco Solís, 1999: 112). Whatever the reason, and despite the fact that there was still one final attempt to give it new articles of association (BOE, 1954b: 1393–4) and that it formally continued to exist until the 1970s (Parellada, 1974), the League never resumed any appreciable level of activity, except in some isolated places. And this was especially true following the creation of the PANAP, established by law on 14 April 1955, which took on all competences related to the ‘coordination of preventive services and care facilities’ (BOE, 1955: 2374–7).

Hygiene and mental health

As in other areas of the nation’s life, the arrival of the 1950s tempered the combative rhetoric of the psychiatrists closest to the regime, and the discourse on mental hygiene began to move away from the crude ideological association of Catholic morality, public order and psychological balance to assume a more neutral and technical character, focused especially on the institutional development of the profession and psychiatric care (Casco Solís, 1999: 89; Rojo Sierra, Torres González and Giner Ubago, 1967). In this context, Luis Valenciano Gayá – resuming his earlier role in the popularization campaigns of the 1930s – reflected with more seriousness and rigour on the theoretical and practical aspects of mental hygiene (in the domains of both care and prophylaxis); he was a devout disciple of Gonzalo Rodríguez Lafora and director of the dispensary of Murcia from 1947 to 1967 (Marset Campos, 1985). In a programmatic article published in 1954 in the revived journal Archivos de Neurobiología, Valenciano divided the field of mental hygiene into two large areas: traditional ‘eugenics’, which seeks the ‘improvement of the individual and the group by focusing attention on the germ cells’, and ‘euthenics’, ⁷ which is concerned with bringing about this improvement by acting systematically in the person’s ‘objective and subjective’ environment (concentrically, family, school, work and culture) (Valenciano Gayá, 1954: 372). With this approach, mental hygiene complemented its well-established connections with eugenics, ⁸ but – as Valenciano perceptively pointed out – it also prescribed an unattainable programme according to which ‘man must be accompanied by a psychologist or psychiatrist from cradle to grave’,

in order to decide whether breast-feed or bottle-feed is to be preferred and to teach how to operate the sphincters …, to advise in the most meticulous way at school, to provide guidance on a budding love, to decide on a profession, etc. … Psychiatry is on the verge of being seduced and thinking that it is much powerful than it actually is. (pp. 386–7)

Although other Spanish psychiatrists such as Francisco Alonso Fernández were at that time enthusiastically celebrating this new ‘psychological orientation of mental hygiene’, ⁹ Valenciano, in line with his neuropsychiatric training, expressed his concern that ‘the increasingly greater value given to psychosocial factors’ would lead to losing sight of the ‘somatic components of the disease’:

Systematic, scientific psychiatry, the result of many years of extensive work, cannot be abruptly thrown overboard. . . . Freudian psychiatry with all its contributions and current psycho-sociological trends … must be one of the wings that launch us towards the future; but the other, which we need to balance our flight, is still Kraepelinian psychiatry. (Valenciano Gayá, 1960a: 397–8)

However, on the other hand, he was also very well informed and he valued very positively the growing emphasis of the international mental hygiene movement – restructured in 1948 as the World Federation for Mental Health (WFMH) – on prophylactic and preventive tasks, and he carried out a considerable amount of ‘health promotion’ in his dispensary’s area of influence. This took the form of lectures, courses, work groups, newspaper articles, informative booklets, radio advertisements and careers guidance sessions with students, seminarists, doctors, nurses, educators, teachers and even workers (pp. 393–6).

In any case, due mainly to the driving force of Ramón Sarró Burbano, Professor of Psychiatry and director of Barcelona’s mental hygiene dispensary (Sánchez Lázaro, 1985), most activities of what the League’s new articles of association continued to call ‘propaganda and popular education’ were carried out mainly in Barcelona in the 1950s. For example, with the support of the authorities and with extensive coverage in the local press, the Catalan capital hosted the 4th Mental Hygiene Week in May 1954. This event included a large number of lectures, colloquia and even cinema sessions showing WFMH films provided by the American Consulate and the British Institute (Campos and Novella, 2017). In addition, the event was used for the official inauguration of various facilities, including the Psychiatric Clinic of the University and a Centre for Children’s Mental Hygiene. It is important to highlight that, both in the opening speech of the Hygiene Week and in various statements to the press, Sarró repeatedly stressed the absolute ideological neutrality of mental hygiene (‘an activity which applies scientific knowledge for the benefit of mental health and with essentially practical aims’); he also pointed out the basic importance of all human sciences (among which, significantly, he defended the contributions of psychoanalysis) to give it a solid foundation. Above all, Sarró described the fundamental shift that was taking place at the international level in terms of the aims and scope of mental hygiene: ‘its primary goal today is to increase mental health, principally among normal people, so that the conception of the purpose of mental hygiene as simply the prevention and care of psychoses is rendered out-of-date’ (quoted in Campos and Novella, 2017: 81).

In the strict sense, these statements by Sarró – who had succeeded in obtaining the admission of Spain to the WFMH in 1951 – must be taken as one of the first testimonies of the arrival in Spain of the new concept of mental health promoted by the WHO, the WFMH and other international bodies. In a much-quoted foreword to the Spanish version of the book by British psychoanalyst James Arthur Hadfield, Psychology and Mental Health (still published in Spain as Psicología e higiene mental), Román Alberca, director of the psychiatric hospital of Murcia and Professor of Psychiatry at the University of Valencia, pointed out in 1952 that psychiatry was undergoing a significant change, as a result of which it no longer aspired to ‘lead man to a precise adaptation to a biological, social and ethical standard’, but to ‘achieve complete harmony between the personality and its goals’ (Alberca, 1952: 15). However, the essay which most systematically presented the general guidelines of the new paradigm appeared in 1957 (Prados Such, 1957) in the journal Revista de Psicología General y Aplicada, a publication founded and edited since 1946 by José Germain, original member of the LEHM, secretary of the Psychiatric Council and medical superintendent of the Psychiatry and Mental Hygiene Section of the General Directorate for Health in the Republican period (Casco Solís, 1999: 91–2). Its author was Miguel Prados Such, a former director of the San José Psychiatric Hospital in Málaga who worked with Lafora at the Cajal Institute; he had been subjected to reprisals at the end of the Civil War and went into exile in Canada, where he became Professor of Psychiatry at McGill University in Montreal, founded and headed the Canadian Psychoanalytic Society and served as a consultant for the WHO on numerous occasions (Linares Maza, 1983).

In a distinctly psychoanalytic explanation and in full agreement with the report issued in 1950 by the Commission of Mental Health Experts of the WHO (Bertolote, 2008), Prados Such defined mental health as the capacity to establish ‘harmonious relationships with others’ and experience ‘a minimal amount of satisfaction which compensates for the sacrifice, however partial, of individual narcissism’ (Prados Such, 1957: 546). The traditional emphasis of mental hygiene had been on the collective dimension (social, genetic and racial) of mental illness and it used specialized hospitals and dispensaries as the emblematic devices of health campaigns in the first half of the twentieth century. In contrast, the new understanding of mental health focused on promoting the ‘emotional and relational equilibrium’ of the individual, underscored the ‘aetiological importance of the social environment’ and proposed the need for a wide care network that should be allowed to intervene ‘in virtually all aspects of human life’ (p. 562). The obvious consequence was that it was very misleading to establish defined boundaries between pathology and normality (‘an ideal that never exists’), and the ‘educational action’ of professionals should in the future focus on:

making the great mass of people acquainted with the new concepts of mental health, fluid rather than static concepts which include the basic idea that all individuals suffer more or less intensely from problems, difficulties and emotional conflicts within ourselves and in relation to the environment, and that, consequently, the important task is not so much to discover the problem as it is to help the person to face their difficulties in the most effective and logical manner. (p. 558)

Two years later, on the occasion of the 12th Annual Meeting of the WFMH in Barcelona, Sarró had the opportunity to repeat, in very similar terms, these (profound) implications of the new culture of mental health; his speech was filmed by the regime’s ‘Noticiario Documental’ (NO-DO).

The concept of psychiatry has changed, and it is no longer a medical speciality restricted to severe forms of maladjustment to the environment. Such disorders are only a chapter of the new psychiatry, which following the work of Freud is inspired by the concept of mental health given by the WHO, i.e. a state of perfect physical, psychological and social wellbeing. Whenever an individual is below this state … he falls under the jurisdiction of modern psychiatry. (Sarró, 1960: 3)

In his opinion, this approach was perfectly applicable to the new social and cultural reality of the Spanish population, whose great transformation from a predominantly agrarian society into an industrial one was already very clear, and thus inferred the existence of a significant body of neurotic disorders and emotional imbalances, ¹⁰ although some of his colleagues did not agree. Compared with the post-war utopia of a country finally freed from illness by means of the crudest and most emphatic ideological reaffirmation, the final years of the 1950s revealed once again the alarming presence of the mental suffering characteristic of the contemporary world. For Sarró, these ‘difficulties in the emotional adaptation of the Spaniard to our age’ could be explained by the survival of traditional values and attitudes and, more specifically, of the ‘mentality and spirit of the gentleman’ who ‘feels obliged to be tough and interprets neurosis as a weakness’ (p. 11). For his part, López Ibor, always skilful and refined in handling his arguments, was by this time already wondering whether Spanish society as a whole was – like the rest of the Western world – ‘becoming itself neurotic’, and more particularly the victim of an excessive ‘shift towards intimacy’, nihilism and mass culture (López Ibor, 1964: 17–18).

Promoting mental health

‘The psychologization of Spanish doctors is imperative and urgent. A basic knowledge of psychodiagnostics and psychotherapy is now as indispensable for the practice of medicine as the art of prescribing antibiotics’ (Facultad de Medicina de Barcelona, 1960: 3). This statement was used by the Department of Psychiatry at the University of Barcelona to promote a course on ‘Psychotherapeutic training for the general practitioner’ which, among many other activities (lectures, colloquia, seminars, film sessions, etc.), was programmed in 1960 on the occasion of the World Mental Health Year promoted by the WFMH and made official by the Spanish Government at the request of the PANAP (Anon., 1960). ¹¹ As part of these activities, and coinciding with the 6th National Congress of Neuropsychiatry being held at the same time in the city (Solé Sagarra, 1960: 306), the LEHM – whose presidency was then to be assumed by Sarró – organized a ‘Meeting of Mental Health Experts’ in the Catalan capital. This meeting was chaired by José Fernández Turégano, first secretary-general of the PANAP, who announced the preparation of a ‘National Plan for Mental Health’ based on the regional plan developed by Sarró (Casco Solís, 1999: 94).

Valenciano Gayá, who was very active and interested in these issues, immediately published a ‘Contribution to the National Plan for Mental Health’; he was convinced of the perfect ideological neutrality of his proposals and suggested the preparation and discussion of ‘a minimal set of concepts related to mental hygiene whose validity is unanimously accepted’ in order to conduct a ‘national campaign’ (Valenciano Gayá, 1960b: 149). This campaign would have to be implemented through ‘direct action with the public’ and ‘skilful and sustained effort’ in multiple spheres (education, labour, medicine, law, religion, etc.), disseminating on a mass scale a number of proposals promoting the emotional and relational balance of the individual:

Not over-developing sentimental relationships in any sphere …; promoting an honest knowledge of oneself from childhood; not emphasizing feelings of guilt; not excessively imposing … external patterns of behaviour; explaining the stages or phases of personality development …; showing values without coercion, allowing sufficient room for choice; not promoting … aggressive feelings, but rather those of solidarity …; avoiding … the choice and idealization of false egos …; always encouraging the deployment of authenticity; … performing a good choice and selection of subjects; demonstrating the … importance of the environment and human relationships; in group relations, along with the necessary hierarchization, allowing sufficient room for the spontaneity, sincerity and initiative of the individual. (pp. 149–50) ¹²

Despite the fact that the National Plan never materialized, this type of programmatic work devoted to the concept and the ‘promotion of mental health’ would occupy a very important place in the publications of Spanish psychiatrists in the following years. Assuming the psychosocial orientation which dominated the specialized literature of the time, and freely combining elements from the old tradition of mental hygiene with the new guidelines supplied by international entities, a good number of authors – such as psychiatrist Enrique Grañén Raso from Barcelona – tried to contribute to ‘a more vigorous development in practical applications and on a mass scale of the precepts of modern mental health’ (Grañén Raso, 1969: 9). According to him, this should take ‘the goal of human wellbeing in all its aspects’ as a point of reference (p. 19). More prudently, some psychiatrists tried to establish more practical criteria. So, for instance, Antonio Linares Maza, a former disciple of Prados Such in Málaga, associated mental health with six fundamental factors: the absence of objective or subjectively demonstrable mental disorders; adequate adaptation to the physical, socio-cultural and professional environment; acceptance of one’s own sexuality and that of others; optimum and balanced development of the possibilities of the personality; an aptitude for joy and happiness; and the ‘dynamic balance of the personality, … a sort of homeostasis ranging from cellular biochemistry to socio-cultural and moral values’ ¹³ (Linares Maza, 1972: 116–17). ¹⁴ However, broadly speaking, it was clear that achieving such a loosely defined psychological state of health was an enormous undertaking that had to be developed in virtually every sphere of life (relationships, sexuality, work, education, upbringing, etc.) in order to reinforce the ‘relative mental health of the vast majority of us’ (López Sánchez, 1972: 11).

Embedded in the technocratic fervour of the age (González Duro, 1978: 291–8), the new conceptual framework encouraged and inspired various reform proposals to update the country’s outdated, unsuitable and insufficient infrastructure for psychiatric care, and to reorient it according to the new aims and scope of the specialty. These proposals did not yet aim to change the traditional centrality and pre-eminence of the psychiatric hospital or to fully integrate mental health care into the framework of general health care (PANAP, 1967). But, following the general WHO guidelines, they already anticipated and included some elements that would become established in the following decades, such as the reorganization of outpatient care with a sector-based model of services and multi-disciplinary teams; the creation of psychiatric units at general hospitals; emphasis on rehabilitation, psychoeducation and socio-therapeutic techniques; the need to involve general practitioners in mental health care; and the project of creating a parallel care network in order to handle the specific problems of alcoholism and drug addiction (Kringlen, 2003; Novella, 2010a).

There was only limited progress in mental health care, as the proposed changes clearly exceeded the framework of the health care administration and social policy under Franco (Marset Campos, Sáez Gómez and Martínez Navarro, 1995). However, the new paradigm did inspire new discourses and practices in a field to which most adherents of the new ideology of mental health attributed great significance. Thus, driven and guided by its new secretary-general, Adolfo Serigó Segarra, in the late 1960s PANAP created a Mental Health Education Unit at the Gran Hospital del Estado in Madrid (now the Hospital de la Princesa) and implemented several educational publishing projects, including the journal Salud Mental and the series of papers Cuadernos para la Educación en Salud Mental. The journal began on a very limited scale in September 1968, and it was not until 1974 that it was edited more carefully and also started to be widely distributed across the country, although sporadically. In its first issue, the editorial – undoubtedly written by Serigó Segarra – warned of the great difficulty of providing a positive definition of mental health at the individual and social levels, due to the ‘intense subjectivism of such a shifting and slippery terrain’, while it declared his determination to ‘avoid all unnecessary and ultimately harmful dogmatism’ to approach ‘the prevention of mental illnesses’ from an ‘entirely modern’ perspective ([Serigó Segarra], 1974). The first issue included a bitter reflection by the journal’s deputy editor, José Soria, on the growing mental health problems faced by Western societies due to the ‘uncomfortable cultural climate for man’ produced by the ‘cult of success, personal triumph, rabid competitiveness’ and the resulting ‘dissatisfaction, emptiness and loss of individuality’ (Soria, 1974a: 10–11). There was also a brief report on the new Pilot Mental Health Centre opened by the PANAP in February 1972 in one of Madrid’s central neighbourhoods (Sola, 1974), as well as the announcement of a curious ‘check-up for the man on the street’ which the journal hoped to undertake with the goal of ‘gathering the opinion of anyone, without any other qualification than that of citizenship, who can provide clear and precise ideas about their problems, frustrations and hopes’ (Anon., 1974).

In total, nine issues of Salud Mental were published up to 1978. Each was devoted to a single subject: ‘modern’ psychiatric care, aggression and violence, adolescence and social change, behavioural disorders in children, the elderly and society, the family, alcoholism, life in big cities and sexuality. The journal was complemented by the series Cuadernos para la Educación en Salud Mental, a collection of 51 booklets which were published up to 1979 with the support first of the General Directorate for Health and later of the Ministry of Health and Social Security. Largely written by Serigó Segarra with the goal of ‘providing information about the necessary aspects for human, physical, psychological and social balance’, the Cuadernos gathered a wide range of content from diverse disciplines (medicine, psychology, pedagogy, sociology and even literature) and tackled numerous topics related to heredity, school environment, the family, psychological development, sexuality, drugs and employment. ¹⁵ Despite what this variety of subjects might suggest, its psychosocial focus was so obvious that even the booklets devoted to more biological matters stressed the predominant role of social, educational or simply environmental factors in the majority of the spheres and phenomena of life. ¹⁶

These years also saw other similar initiatives from scientific societies, health care institutions and commercial publishers interested in a seemingly expanding market. Noteworthy among these projects are the Cuadernos Genus de Sexología, Genética y Psicología, a series of booklets published between 1968 and 1972 by Editorial Nova Terra in Barcelona; the 14 issues included monographs devoted to the ‘forgotten mental health’ (Anon., 1968), neurosis and family crisis. The Rapports de Psicología y Psiquiatría Pediátricas (Paediatric Psychology and Psychiatry Reports) (1968–76) had a more professional profile. Their editor was Catalan psychiatrist, Diego Parellada – Sarró’s successor as the President of the LEHM – and they were published in Barcelona with the clear support of the pharmaceutical industry (Doménech i Llaberia, 2008). Although the publications focused on the psychopathological problems of childhood, the Rapports in general and Parellada in particular published many articles on ‘psychiatric prevention’, the ‘concept of mental health’ and the ‘preservation of mental health’. The publications can therefore also be taken as clear proof of the decisive shift, in the preceding years, in the professional ideology and rhetoric of psychiatrists. In one of his papers, Parellada concluded:

Mental hygiene is becoming increasingly important, not only in the prevention of psychiatric diseases, but also in the promotion of good personal psychological development, which is linked to both the creation of personal wellbeing and a better social environment and brings many benefits for each and every member of the community. (Parellada, 1975: 26)

Concluding remarks

On the occasion of the 4th World Congress of Psychiatry held in Madrid in September 1966, the Propaganda and Mental Hygiene Section of the PANAP asked two disciples of López Ibor, Luis Aliño Testor and Fernando Claramunt López, to prepare a booklet to be distributed free to all attendees. It described the distinguished tradition of Spanish psychiatry – highlighting the cultivation of a idiosyncratic psychotherapy whose anthropological and existential foundations emanated directly from ‘the depths of the Spanish way of being’ – and the significant effort recently made by the authorities of the regime to modernize psychiatric care (Aliño Testor and Claramunt López, 1966). Significantly, just a few years later this reactionary and self-congratulatory discourse vanished as a result of the new social, cultural and political climate of late Francoism (Tusell, 2007), the innovative attitude of a new generation of professionals (González de Chávez, 2003) and shocking reports on the deplorable conditions at public mental hospitals such as those prepared by Guillermo Díaz-Plaja for Triunfo (Díaz-Plaja, 1971) and Ángel María de Lera for Tribuna Médica (De Lera, 1972). These developments led not only to a radical questioning of the theoretical and practical assumptions of the specialty, but also to a widespread acquaintance with the climate of misery and abandonment in which the care given to mental patients took place in the country. From then onwards, Spanish psychiatry was increasingly influenced by the pressure of public awareness of the dreadful state of its institutions, but – as we have seen – it was also affected by the unstoppable spread of the dynamic and expansive discourse on mental health, fuelling a ‘structural’ paradox which would strongly influence its development in the following decades (Comelles, 1988: 175–214).

In general terms, then, it can be said that the end of the Francoist regime and the consolidation of parliamentary democracy represented an undeniable break in the implementation of an effective renovation of psychiatric care (García, 1995; García et al., 1998). But the implications of the new concept of mental health had already been present in Spain since at least the 1960s and had inspired some health education programmes and various proposals for reforming care. This did not translate into substantial action, but we should not overlook the growing influence in the country of a new ideology that would ultimately shift the focus of psychiatric discourses and practices from the collective and national interest to individual wellbeing, from the biological to the psychosocial (or from genetics to the environment), from psychosis to neurosis, from obligations to rights, and, above all, from a very restrictive to a much broader definition with regard to its problems and attributions.

In short, the Francoist regime appears to be a period with particular characteristics in the sphere of psychiatric discourses and practices. However, it was also the era which, at a deeper level, brought about the decisive transition between the approaches characteristic of a corporate and tutelary mentality and therefore of so-called ‘interventionist biopolitics’ (Vázquez García, 2009) centred around the expert management of the social risks of mental illness. It also introduced a new understanding of psychiatric and psychotherapeutic action closer to the assumptions of what has come to be defined as ‘liberal governmentality’ (Rose, 1999), that is, more willing to accept and recognize the autonomy and the active role of individuals who cultivate the imperative of responsibility and embark on a search for self-realization and inner growth.