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Friday, 24.11.2017

Hanfried Helmchen: Das Janusgesicht der Psychiatrie. Nutzen und Risiken psychiatrischen Handelns
The Janus Face of Psychiatry. Benefits and Risks of Psychiatric Action
Stuttgart: Kohlhammer; 2017, p. 236

Reviewed by Hanfried Helmchen


Contents: The book reflects the benefit-risk-relationship of psychiatric action in three parts.

            The first part describes the development of psychiatric action in the 19th century: psychiatric action in madhouses and lunatic asylums had formed psychiatry as an institution since the beginning of the century; the majority of mentally ill persons, particularly those with chronic conditions, were held in safe custody in often overcrowded and understaffed asylums, which sometimes also abolished the benefits of protection, care and support. In the second half of the 19th century, psychiatric action developed additionally as academic teaching and research in universities, e.g., in Berlin (since 1865 with Wilhelm Griesinger) and Heidelberg (since 1878, and 1891-1903 with Emil Kraepelin).  However, the benefits of introducing scientific methods into psychiatry, such as finding an evidence base for diagnosis and treatment, as well as the reputation of science-based medicine, were overshadowed by the risk of narrowing the clinical approach and by focusing on the disease behind which the individuality of the patient could disappear. Specific examples of benefit intended by the psychiatrist and harm experienced by the patient are:

1) psychiatric action in asylums to which the majority of patients had been referred by compulsory admission made the psychiatrist a double agent for the individual mentally ill person, but also more or less for society, i.e. combining psychiatric action for the benefit of the individual patient with the benefit for his social environment, and thereby with the risk of neglecting the patient’s personal needs and interests;

2) the benefit of work in asylums, particularly as a systematic stepwise enterprise according to the actual capacity of the patient, such as introduced by Hermann Simon (1929), implied the risk of exploitation;

3) the benefit of treating the disease (“Krankheit”) could be impaired by the risk of missing the patient’s illness (“Kranksein”). 

            The second part of the book deals with differentiation of psychiatric action in the 20th century structured by the three dimensions of the bio-psycho-social model:

1) Biological thinking in psychiatry developed in the context of the overwhelming success of scientific methods, e.g. in microbiology (the inventor and industrialist Werner von Siemens declared “the century of natural science” in 1886). Its benefits for evidence based on findings with relevance for psychiatry are shown in a line of landmark events beginning with the case of Phineas Gage (1848) and that of Paul Broca (1861) and continuing up to the modern broad spectrum of neuroscientific methods, e.g. neuroimaging or molecular genetics; risks appear in relating such biological findings to psychopathology, e.g., by misleading statements of some neuroscientists denying the free will with its consequences for forensic psychiatry. Possible benefits, e.g., gain of epidemiological knowledge by screening studies, may be discredited by the risks of misinterpretation, or by informing the proband on accidental findings with questionable pathological value, or by overestimating the clinical value of biomarkers. Psychiatric action in treating mentally ill patients by so-called biological interventions were stimulated by empirical findings such as the successful treatment of patients with progressive paresis of the insane by an artificial transient malaria infection (Julius Wagner v. Jauregg 1917), or of patients with psychotic conditions by inducing epileptic fits (“shock-treatments”) with central stimulants by Ladislaus v. Meduna 1935, with insulin by Manfred Sakel 1933, or with electricity by Cerletty and Bini 1938, and since 1952, the initially overwhelming success with almost all psychiatric conditions by more or less specifically acting psychotropic drugs (Laborit 1952; Jean Delay, Pierre Deniker, Jean-Marie Harl 1952; John Cade 1949). Their benefits for patients not only terminated, reduced, or shortened the suffering of mentally ill persons, changing the view from hospitalization to rehabilitation and outpatient (extramural) treatment and lowering the threshold of voluntary admission, but also stimulated a spirit of optimism and the development of neuropsychopharmacology.  However, now after six decades of clinical experience with psychotropic drug treatment its risks and disadvantages have become clear, i.e., the relationship of benefits to risks has changed to the disadvantages, particularly in the view of critical patients who call themselves “psychiatry-experienced persons” (“Psychiatrie-Erfahrene”); psychiatrists, too, are disappointed about the conceptual gridlock, the non-use of alternatives in elucidation of the mechanisms of effectiveness, and the lack of new drugs with more specificity, effectivity and efficiency. Ethical risks of psychiatric action with psychotropic drugs are discussed, e.g., informing the patient about the risk of tardive hyperkinesis, or methods of dealing with patients rejecting strongly indicated depot neuroleptics (e.g., in-home treatment); the benefit of well-being as a main goal in substitution treatment of heroin addicts as opposed to the risk of continuing the addiction; potential benefits and risks of drug-induced enhancement that underline the question of the concept of man.

2) The psychic dimension summarizes the benefits and risks of the former unspecific methods of psychiatric action (isolation, separation of curable from incurable patients, shock treatment, “moral management,” “no restraint,” occupational therapy) and deals with the currently used psychotherapeutic methods, especially the up to now underdeveloped knowledge of their risks: the mode of informed consent is insufficient, as well as the definition of unwanted effects (e.g., a contradictory interpretation of a separation or of a depression as a benefit (perhaps by the psychiatrist) or as a realized risk (by the patient), and the (at least by the patient) rather unknown risks of unwanted effects of psychotherapy, such as its failure; deterioration or relapse; side-effects; and dropout or technical mistakes of performance, such as a wrong indication or irregular performance, that are not explicitly enough differentiated.  The risks of unethical misconduct, such as a breach of confidentiality or a violation of integrity borders, are sparsely reflected in the training and supervision of psychotherapists.

3) The social dimension of psychiatry developed in the context of social sciences, social medicine and social hygiene by which society reacted to the pauperism and the “social question” during the last third of the 19th century; the term “social psychiatry” appeared first in 1904. The concern of social psychiatry was chronically mentally ill patients; the improvement of their care and rehabilitation by extramural activities were its objective. However, the benefits of social psychiatric reforms tended to degenerate by the absolute direction of reform ideas for the collective group of the mentally ill at the expense of individual patients, e.g., a) the development of extramural services (“Außendienst”) by mental hospitals as open care (“offene Fürsorge”) in the 1920s (Gustav Kolb 1919) was misused; b) the recruiting for sterilization by the National Socialists in the 1930s of the well-documented patients; the worldwide fundamental conviction of preventive eugenics as the only measure to reduce the burdens of society by the increasing number of mentally ill human beings reached the mind even of humane psychiatrists receptive to the eugenic movement, especially in times of economic need; the very rigorous implementation by National Socialists,  also by coercion, of a sterilization law in order, they maintained, to “protect” the healthy population (“Volkskörper”) against genetic diseases; c) the much deadlier, for the mentally ill, radical and inhuman execution of the National Socialistic psychiatric policy to heal the curable and annihilation of the incurable (the concept of “Heilen und Vernichten”) by so-called euthanasia (In this context, a doubling of the self [Robert Lifton 1986] or the formation of a second consciousness in killing psychiatrists under the influence of a complete other normative codex [Wolfgang Bialas 1914] is discussed); d) the innovative organization of a network by Scotch-American psychiatrist Ewing Cameron of 10 mental hospitals in Manitoba as community mental health (CMH) centers and the foundation of the first psychiatric day hospital in the world, while these social psychiatric benefits were overshadowed by megalomaniac ideas of social engineering, e.g., to prevent all mentally ill people from becoming parents (1946); e) the desolate conditions of living in the large mental hospitals of Görtz and Trieste encouraged Italian psychiatrists (Franco Basaglia 1971) to fight to close these hospitals and to push through a radical law to substitute the closed hospitals by CMH centers; however, the technical flaws of this law led to an excessive demand on the unprepared relatives of the discharged patients and to dangerous risks for them; the hasty and radical performance of a basic beneficial idea was forced through at the expense of individual patients; and f) at the same time the German parliament (1975) initiated a profound reform of the psychiatric care system according to modern concepts of social psychiatry, but  its claim of shared decision making was not fulfilled with regard to de-hospitalization, and the current process of patient-oriented individualizing care and treatment is characterized by a search for an optimal balance between respecting the will of the self-determined mentally ill individual and the psychiatrist’s obligation for caring for the patient. 

            The third part of the book deals with benefits and risks of common interventions in the context of psychiatric action, such as informing a patient in order to receive his/her consent, or acting between the obligation of confidentiality and the obligation of disclosure (“Tarasoff” 1974), or considering the benefits of documentation for research or for a quick and comprehensive overview of the individual patient’s data for his treatment in relation to the risks with regard to data protection against third parties, particularly institutional ones such as insurance companies or employers. Clinical research trials imply a paradigm of benefit-risk-evaluation, i.e., the benefit of scientific knowledge as opposed to the potential realization of risks for the wellbeing of the patient, as well as the necessary cooperation with the pharmaceutical industry that contains the risk of biasing the psychiatrist’s judgement by economic influences; specific concern about how not to withhold the benefit of a new and putatively more effective intervention from patients who are unable to consent validly and are thereby excluded by most regulations from participating in research. A longer subchapter describes the certainty and meaning of psychiatric diagnoses, their instrumental character against their risks of reification, their benefits for a reliable communication, and the limits of the concept of psychiatric disease as defined not only by psychopathological symptoms, but also by subjective suffering and impairment of social participation. A short chapter reviews the advantage of the medical model that includes the mentally ill into the social benefits of the legal insurance system (at least in Germany), but is tainted by the risk of missing the psychic and/or the social dimension. A further chapter reviews the change of interpretations of psychiatric history by historians over the course of time, and their dependency on the change of the socio-cultural context. A final remark on the future of psychiatry emphasizes not only knowledge and skills, but also a clear mindset and firm attitude as necessary capacities of the psychiatrist and names as his unique features knowledge and competence in dealing with subjectivity, an interdisciplinary view of the brain as an “organ of relations,” and a concept of openness toward the mentally ill, i.e., to take him seriously and to find common features in controversial positions, e.g., an – for both the patient and the psychiatrist – acceptable balance between the patient’s right of self-determination and the psychiatrist’s obligation to care.

AUTHOR’S STATEMENT: This book reflects the changes in psychiatry in my clinical experience over more than half a century. Thus, in the 1950s the patient had to accept side effects of an intervention, however, nowadays the patient will be encouraged to speak about unwanted effects in order to minimize them for his well-being and better adherence; or the relationship of benefits to risks of psychopharmacotherapy has changed from an overwhelming impression of benefits to increased reflection of risks (or even rejection by “psychiatry-experienced” persons); or only currently the limited knowledge of patients about the risks of psychotherapy became a focus of its systematic investigation; or the benefits of social psychiatric reforms degenerated repeatedly due to the absolute direction of reform ideas toward the collective group of the mentally ill at the expense of individual patients.

            My main conclusion is that psychiatric action aims for the well-being of the mentally ill, but it also holds the risk of unwanted effects and must respect this. This “Janus Face of Psychiatry” comes across if benefits and risks of psychiatric action are judged differently, or even in a completely varying way, by the patient and the psychiatrist, or if the relationship of benefits to risks shifts. The book aims at finding complementary solutions for this occasionally “antagonistic” described tension; its objective is to sensitize psychiatrists for the primacy of the well-being of the individual patient, which limits all indications of psychiatric action for both the collective group of mentally ill persons and for diagnostic and therapeutic measures for the individual patient.


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October 19, 2017