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Wednesday, 12.12.2018

FrancoisFerrero: Inquiry of the Geneva 1980s’ Psychiatry Crisis:
Forced Hospitalization,ECT and Sleep Therapy

 

         Events of the 1980s cannot be understood without a look at some of the people and circumstancesof prior years and keeping in mind that the population of the Geneva Canton comprised only 350,000 inhabitants at the time.The University Psychiatric Hospital, Bel-Air, was a monopoly with nootherpublic or private psychiatric hospital in the area. In December 1978 the hospital had 538 patients.

            In the mid-1970sfour professors were in charge of what became the Geneva University Psychiatric Institutions: Julian de Ajuriaguerra, Gaston Garrone, René Tissot and André Haynal.

·         Julian de Ajuriaguerra(1911-1992) was born in Bilbao, in the Basque County ofSpain;studied medicine, neurology and psychiatry in Paris; and was a disciple of André Thomas, Jean Lhermitte, Pierre Janet and Gaëtan de Clérambault. He was also a close friend of some surrealist artists as Paul Eluard, André Breton and Luis Bunuel. During World War 2he lived in Paris; during the Nazi Germany occupationhe was active in the French resistance movement. Later on, he became a member of the “Group Batia,” a group that was instrumental in the “sectorization” of psychiatric services in France. Before he was invited to Geneva University, de Ajuriaguerra was well known for his contributions toneuroanatomy and the re-evaluation of psychomotor pathology,as well as the reeducation of psychomotor and language troubles. He was also a child psychiatrist interested in early development and he founded the journal named La Psychiatriede L’Enfant;his Manuel de Psychiatrie de l’Enfant(1970) remains a classical reference. He also trained as a psychoanalyst under Sacha Nacht. During his 17 years in Geneva, he was able to completely transform the psychiatric organization. His charismatic personality, as well as his teaching methods, attracted a lot of young doctors to Geneva.(Chairman of the University Psychiatric Department, and Director of the Geneva University Psychiatric Institutions, 1959-1976).

·         Gaston Garrone(1924-1991) was born in Cée, Spain;received his medical degree in Turin, Italy; and joined Ferdinand Morel in Geneva, first from 1949-1951, then again in 1952. In 1963, he was appointed Chief of the new Outpatient Clinic named“Centre Psycho-Social.”He was mainly interested in social psychiatry, psychotherapy and psychopharmacology. The book he published with a group ofyoung Colleagues, Crise et Interventions de criseenPsychiatrie (1986), is a good example of his interest in the development of modern approaches in social psychiatry. He was also a very talented organizer.(Chairman, Outpatient Clinic, Geneva University Psychiatric Institutions,1971-1976).

·         René Tissot(1927-2010) was born in Le Locle, Neuchâtel, and received his medical degree in Lausanne. He was trained in neurophysiology, neurology and psychiatry in Paris, Neuchâtel, Basel and Geneva. His main interests were biological psychiatry, neurology and genetic psychology in its application to psychopathology. He was a man of broad culture andclose to Jean Piaget who wrote a preface for one of his books:Introduction à la PsychiatrieBiologique(1979). He was a pioneer in the domain of monoamines and their relationship with psychiatric symptoms, as well as in research and treatment of Parkinson’s disease.(Vice Director, Hospital of the University Psychiatric Institutions, 1971-1976).

·         André Haynal(1930-) was born in Budapest, Hungary, where he first studied psychology and philology before choosing medicine.He received his M.D.from the University of Zurich wherehe trained in neurology andwhere he underwent his first psychoanalysis. He later reoriented his careerinto psychiatry and psychotherapy,first in Lausanne, with Pierre-Bernard Schneider, where he underwenta second psychoanalysis, then in Geneva with Ajuriaguerra and Tissot in the Clinique Bel-Air, andthen with Gaston Garrone at the Outpatient Clinic. After his third psychoanalysis he engaged himself very actively in the Swiss Psychoanalytic Society, becoming President of the Society (1976-1979) and Vice-President of the European Psychoanalytical Federation (1979-1985). His main domains of teaching and research were psychotherapy, psychopathology, psychosomatic illness, medical psychology and behavioral medicine. He is the author of numerous scientific articles and some of his books have beentranslated into different languages, such as “Depression and Creativity”(1985).André Haynal is a man of exceptional broad culture and has a great reputation as an historian of psychoanalysis and publishing;Among his important contributions was his publication of “Controversies in Psychoanalytic Method: From Freud and Ferenczi to Michael Balint” (1990) with J.E. King concerning “the great controversy that began between Freud and Ferenczi and was continued in the work of Balint.”(Vice Chairman, Outpatient Clinics, Geneva University Psychiatric Institutions, 1971-1976).

 

Chronology of some problems: 1973-1980

            The first notable difficulty arose in 1973 when nurses decided to go on strike because of a chronic lack of qualified nurses and bad work conditions, especially in the geriatric and mental development units(Brulhart 2003).It should be noted that a strike is a very rare event in Switzerland, a country where the search for consensus is part of a long cultural tradition. This year was also marked by anunsuccessful, tentative effort to reorganize the adult psychiatric services based on the French system of “sectorization.”

           The following year,1974, during de Ajuriaguerra’s sabbatical leave(Brulhart 2003),an open controversysurrounded the way the research of René Tissot was conducted. This led to the removal of one biologist and of one medical doctor, a decision strongly criticized by a majority of doctors working in the University Psychiatric Hospital, Bel-Air.These events also contribute to the explanation of why, in October 1976, when de Ajuriaguerra retired, the atmosphere in Department of Psychiatry was far from quiet despite the honor of his nomination to Collège de France.

            It has yet to be confirmed that de Ajuriaguerra’ssuccession was unusually organized without national or international competition. Nevertheless, a commission appointed by the medical faculty proposed a new organization based on “sectorization.” The twomost important academic and hospital positions were awardedto Gaston Garrone, who became chairman of the department,and René Tissot, named as Director of the hospital (Bel-Air). With an administrator, these threeformed the Executive Direction.  André Haynal, Director of the outpatient facilities (Centre Psycho-Social) and a delegate of the Chief Medical Doctors, joined the Executive Direction in aso-called Council of Direction.De Ajuriaguerra supportedthis new organization in an August1976 letter sent to all his collaborators:“I am happy to announce that two of my Pupils will succeed me.”

            This strange roleplay could be the result of academic, political and friendly motivations:Gaston Garrone and René Tissot, despite their very different personalities and scientific interests, were also old friends and former close collaborators of Ferdinand Morel, Julian de Ajuriaguerra’spredecessor.Another explanation could be found inRené Tissot’s academic standingat that time:trained first as a neurologist, his main ambition was to become the Chair of Neurology at the Geneva University.However, different explanations, among them political links to the socialist party, or maybe Tissot’svery strong character, prompted the medical faculty to choose another candidate.

            It is not difficult to understand that such areorganization, with a Director for the Psychiatric Hospital and another one for the Outpatient Clinics, was a major obstacle to the sectorization project and that many doctors and nurses were disappointed in the arrangement: how to work together to favor the continuity of care and to implement a variety of therapeutic approachesalsoin the domains of social psychiatry and psychotherapy with two directors, René Tissot and André Haynal, who were unable to collaborate, and a chairman(Garrone) without any authority over his twocolleagues?

            In 1977 the firstappearance of a therapeutic community in one unit of the hospital represented an open expression of the resistance to René Tissot.

            The same year, agroup of young psychiatrists (members of the Association des MédecinsProgressistes),took a position against psychiatric internment (compulsory hospitalization), isolation rooms and electroconvulsive therapy (ECT).

            They also expressed open criticismof some of the research conducted by René Tissot for ethical reasons, such as the absence of the submission of a protocol to the ethical committee, the absence of informed consent or even the lack of competence of some research collaborators.

            And finally, during the same year, the first important public controversy occurred at the occasion of the forced hospitalization of a young woman namedAnna.Showing strange behavior, she was arrested by the police of Canton Solothurn following a demonstration against nuclear power.

            Anna opposed the police and the day after her arrest a psychiatrist decided to send her to Bel-Air Hospital. (Althoughher medical chartwas not consulted, she probably suffered an acute psychotic episode, called boufféedélirantein French psychiatry). She tried to refuse her compulsory hospitalization, protested with a hunger-strike and received ECT. This hospitalization was the beginning of a violentstruggle in Geneva and far away, with demonstrations andnumerous newspaperarticles.

            Tissot’sresponseto this situation was particularly rigid and almost unbelievable at the time of de Ajuriaguerra. According to a 1977 letter to the Tribune de Genève sent by two doctors, he convened all doctors working in the Psychiatric Hospital for few minutes in his office and asked them: “Are you of the opinion that electroconvulsive therapy is questionable as a treatment?Please, answer by yes or no.”One senior resident answered “no” and one resident refused to answer; both were removed from the Hospital. This decision was followed by a long judicial battle.Nevertheless, the government supported the decision of the Director. A letter of protest was also sent to Tissot by a group of colleagues. So, a few months after de Ajuriaguerra’s retirement, the atmospheresurrounding Geneva psychiatry was extremely difficult. More letters related to psychiatry and to patients’ rights were also published in 1977.

            The year 1979 saw thecreation of an “Association Defending the Rights of Psychiatric Users.”As time passed, severalarticles were published in the Journal de Genèvenewspaper.In 1980 Norman Sartorius and Solange de Marignac et al.published La santé mentale à Genève (Mental Health in Geneva) in a “Quarterly Review Dossiers Publics” in which they noted: “The number of Psychiatrists per thousand inhabitants (in Geneva) is one of the highest in the World…and the situation is as favorable for the rest of the infrastructure…Despite that, a dissatisfaction exists… Too many drugs are prescribed, not enough efforts are made for informing the public and to eliminate the stigma…” The ADUPSY, also in 1980, published a weekly journal Tout Va Bien Hebdocriticizing the psychiatric hospitalanditsDirector, as well as his research.

            In January 1980,two ECT devices were stolen and left atthe front door of the President of the Psychiatric Supervisory Council(Conseil de Surveillance Psychiatrique).The devices were in the admission units, most probably in the nurse’s office. It seems difficult to steal them without some kind of inside collaboration.

The Conseil de Surveillance Psychiatrique was created around 1936 and was extremely powerful. Itreceived complaints from citizens regarding possible troubled individuals, was allowed to make an evaluation and made the decisions on forced hospitalization.The “Conseil” was also responsible for the “surveillance” of the University Psychiatric Hospital, Bel-Airand was informed of every hospitalization. Its’ members were primarilypsychiatrists, including its president, and also include some lawyers or judges;the Attorney General was also present in all sessions.One of the main decisions after 1980 was a profound modification of the role of the “Conseil,” giving it much less power, for example, endingitsright to hospitalize people.

June 1980:Alain’s sleep cure

            Alain’s hospitalization,seclusion room and treatment were approved by the Psychiatric Supervisory Council (as reported in a 1982 Tout Va Bien Hebdo article). Hissleep cure was conducted and supervised by René Tissot. Alain,who suffered from a recognized, investigated but underestimated, bronchopneumonia,as confirmed later by autopsy,received daily during 10 days oftreatment(The autopsy’s report and the patient’s chart were not consulted by the author):

Trifluoperazine 60 mg

Levomepromazine 600mg

Promethazine 300 mg

Tuinal (Barbiturate) 1800 mg

Flunitrazepam 12 ml

Trihexyphenidyl (Dosage not found)

            On June 29th, Alain passed away.Because he was also an active member of the ADUPSY, his death was followed by a political storm and by demonstrations against the so-called abuses in psychiatry. Following his death,in addition to a first autopsy made in Geneva (strongly criticized because it was made by a member of the Investigations Committee. See below), anotherautopsywas conducted by two colleagues from the Universities of Bern and Zurich. A criminal complaint was also opened. Yet, the justice system worked very slowly and concluded,nine years later in 1989, that there was“no ground of prosecution”-- Non-lieu, the case was dismissed.

About sleep cures

            To my knowledge, sleep cures were the exception at that time in the University Psychiatric Hospital, Bel-Air. Very rarelyhave Ipersonally conducted such cures, which were still considered useful, but were also a very demanding integrative treatment. The work of Paul-Claude Racamier (1924-1996), a psychoanalyst who was also a very close collaborator of Charles Durand in the Psychiatric Hospital Rives de Prangins, had also a strong influence.

In addition to other components, the pharmacological aspect during a 24-hour period was comprised of:

Flunitrazepam 4mg

Levomepromazine 200 mg

Promethazine 100 mg, and only if necessary

Promazine up to 100 mg

 some Chloralhydrate

            At that time, themain reference book was HenriEy’s1974 Manuel de psychiatrie (Manual of Psychiatry), which included one short chapter devoted to sleep cures. 

            After reviewingvarious articles in the French literature aboutthe different types of sleep cures, thatwhich was normally used in France was called “intermediate”and fell between the classical Jakob Klaesi’s(1883-1980) narcotherapy and the light sleep cures. The articles discuss some indications and conclude that the sleep cure is a psychosomatic treatment and that it is difficult to dissociate the psychotherapeutic and physiotherapeutic factors. Proposed pharmacological treatmentsare:light barbiturates, like Amobarbital, 0.60-0.80 g per 24 hours;or long barbiturates like Gardenal, 0.50-1 g per 24 hours;and neuroleptics, like chlorpromazine, 100-150 mg per 24 hours. They also suggest thatsome opiates or hypnotics could be added if necessary.

            Some prerequisites for treatment are also clearly stated:a quiet place;a trained team of nurses; systematic and somatic investigations, including the cardiovascular, respiratory and hepatorenal systems. The authors add also two crucial requirements:a psychological preparation and the acceptance by the patient after having received all necessary information.

In September1980: The government appoints anInvestigative Committee

            Under strong social and political pressure, and after weeks of hesitation, the government finally made the decision on September 16th to appoint an Investigative Committee.

Members of the committee were: President, Daniel Sorg, MD, general practitioner, Vice-President of the Psychiatric Administrative Council;Charles Durand, MD, Em Professor, Geneva University, former Director of thePsychiatric Hospital Rives de Prangins; Ralph Straub, MD, Professor of Pharmacology, Geneva University; Jacques Bernheim, MD, Professor of Forensic Medicine, Geneva University; and M Jacques Tagini, former General Secretary of the Geneva Health Department.

            Without delay, the Psychiatric Administrative Council decided to remove the collegial Council of Direction and to appoint the Administrative Director as General Director.During that interim organization, Gaston Garrone became Medical Director(1980-1982). It was the end of more than a century of a psychiatric hospital direction under the responsibility of a MD.

Before 1980, The General Director, called the “Director” of the University Psychiatric Institutions, was a psychiatrist and not an administrator - de Ajuriaguerra, then Garrone. The Administrative Director was placed under the Director. In 1980, an Administrator was appointed as General Director and Garrone became “only” Medical Director. This represents a very important modification, including for the budget, the responsibilities of nurses and other collaborators, etc. It was the end of what was called “The medical power.”

The years 1980-1981

            These 12 months were difficultfor the psychiatric teams and probably for many patients at the University Psychiatric Hospital, Bel-Air. The collaboration between colleagues working in the Psychiatric Hospital or in the Outpatient Clinics was extremely limited. Many articles were published in the newspapers, including some of them which allowed René Tissot and André Haynalto freely express and explain their position and ideas. Tissot received also some kind of support from other directors of psychiatric Clinics in the French speaking Cantons of Switzerland(Suisse-romande) who published a letter in the Journal de Genève. Another letter was also published in the famous newspaper “Le Monde” by colleagues working in different countries.

Everyone was waiting for the conclusion of the Investigation Committee.

            In September 1981, after having received the investigation report, the Ministry of Health and the government decided to publish it in the newspapers. The Journal de Genève published an article on September 11thentitled: Versune revolution de la psychiatriegenevoise(Towards a revolution of the Geneva psychiatry), signed by SB.

Summary of the Investigation Report

            Many problems listed in the report resulted in the University Psychiatric Hospital, Bel-Air, specifically,andthe Psychiatric Department in general,being judged dysfunctional.

            As shown in the documents, the critics pointed to the medical direction, the unsatisfactory postgraduate training, the excessive importance given to biological treatments, the too frequent sleep cures, all“without clear guidelines… the isolation rooms similar to prison cells, without call bells nor guidelines for their use.” The law of silence in the hospital was also criticized, as well as the lack of transparency of the medical direction and the “rigid and inadequate attitude” of the Director. Some parts of the report also give an overview ofRené Tissot’sresearch, underliningsome ethical problems.

            The critics also touched on the responsibility of Gaston Garrone and the psychiatric organization as a whole, for example the poor sectorization based only on catchment areas and on geographical criteria, without any regard norpromotion of continuity of care,etc.

            According to the Investigative Committee, the main error was not the capability of René Tissot, but the creation, in 1976, of the position of Medical Director of the University Psychiatric Hospital, Bel-Air:

“Giving to Professor Tissot this responsibility which offered him naturally to take some distance with the outpatient care, one permitted to his natural inclination toward biological psychiatry to develop at the expense of other aspects of psychiatry…He demonstrated that he was not accepting a global conception of psychiatry and that his orientation into biological psychiatry prevented him from taking into account the psychosocial and psychotherapic aspects in the therapeutic interventions.”

            Immediately after the publication of the investigation report, many articles were published in the newspapers and in the 1981 Journal Tout Va Bien Hebdo.

After 1981

            During the following year, 1982, the government presented a report on the reorganization of the University Psychiatric Institutionsand another one to answer to a petition brought by ADUPSY.

In October 1982, a new organization was set up in order to promote a more active sectorization and diversity of treatments. The adult psychiatry was divided into two services, comprising some hospital units and outpatient clinics: the first service, with two sectors, was placed under the responsibility of Gaston Garrone, with two chief psychiatrists; the other service, with one sector, fell under the responsibility of André Haynal with one chief psychiatrist (the author).

Consequently,as a result ofthis new organization, a group of senior doctors, some of them very competent, weremore or less forced to resign anddecided to go into private practice. It includes senior doctors working in the University Psychiatric Hospital, Bel-Airor in the Outpatient Clinics.

             Garrone saved his position as chief of the Psychiatric Department, but he lost a lot of his power in this crisis; the same can be said of René Tissot who ended up with a small inpatient unit in the hospital. After losing his appeal against the reorganization in front of the highest Federal Court, Tissot decided to reduce his work load to 50% and to develop his research activities at the University Aix-Marseille where, in 1986, he was appointed to the FrenchNational Center for Scientific Research (CNRS).

Comments

The main limitation of this paper is my lack of competence or expertise in the domain of the history of psychiatry and, up to now, the absence of consultation of some documents: medical charts, report of autopsy etc. We are waiting for authorization and we hope to have access to these documents in a near future.

            This overview is based on open access sources. Nevertheless, confronted to so many documents, articles and even books published on the subject, and in order make a fair presentation, supporting documents were selected from not only official publications of the government, but also newspaper articles and papers published by Members of the Association for the Defense of the Psychiatry Users (ADUPSY).

            Another limitation is that all references are in French.

            Almost 40 years later, it is not easy to construct a clear picture of these troubled years. From my point of view, a good part of the difficulty is due to some political decisions made at the time: first of all, the government put very strict limits on the work of the Investigative Committee, including the prohibition by the General Attorney, a strong supporter of René Tissot, to provide access to medical charts. Other limitations touched on the inquiry into research activities, as well as on accusations of violence in the psychiatric hospital.

            Secondly, some decisions by the Medical Faculty appear questionable, if confirmed, such as the absence of international competition for de Ajuriaguerra’s successor.

            Thirdly, the composition of the five-member Investigative Committeeappears skewed by the choice made by the Ministry of Health:it includedthreecolleagues of René Tissot andall five came from Geneva.

            Psychiatry has faced difficult times throughout its history and has had a conflictual or ambivalent relationship with Justice, Politics, Media and Society. It is partly due to the fact that the role and boundaries of Psychiatry practitioners were never easy to clarify: What about their possible and very variable role for public security or social stability? The context in Geneva during these years was also complicated by political elections. As a result, between 1980-1982, Geneva had three different ministries of Health, each coming from a different political party.

The newspapers considered what was presented as a profound reform of Geneva Psychiatry, as seen in Serge Bimpage’s 1982Ce qui se fait pour réformer la psychiatriegenevoise (What is done to reform the Geneva Psychiatry).

A note about the legend of the ECT ban in Geneva:

            Afterthe two ECT devices were stolen in the year 1980, these devices were not replaced by theDirection. In the year 1999, I received a quite ambiguous answer from the General Secretariat of the Geneva University Hospitals:

“…To our knowledge, it doesn’t exist a specific legal provision preventing electroconvulsive treatments.

“Only psychosurgery and isolation rooms are clearly treated in the Law K 1 25.

“On the other hand, it appears that a long use is proscribing this treatment in Geneva. This situation is similar to a custom which has somehow the force of law.”

Julian de Ajuriaguerra said that “psychiatry has always to do with freedom”-- still a very sensitive remark.He also said that if it is difficult to give a simple definition of freedom, everyone understands what the absence of freedom means.

 

References:

Arsever S.Qui peutêtreinterné et pour quels motifs? Journal de Genève, Sept. 4, 1979.

 

Arsever S.Quelrecourscontre un internementabusif? Journal de Genève, Sept. 5-6, 1979.

 

ArseverS. Une nouvelle loi se prépare sur les soinspsychiatriques. Journal de Genève, Sept. 7, 1979.

Bimpage S. Ce qui se fait pour réformer la psychiatriegenevoise, Journal de Genève, Oct. 26, 1982.

Brulhart A. Ed. De Bel-Air à Belle-Idée, 2 siècles de psychiatrie à Genève. Genève: Georg Médecine et Hygiène; 1900 – 2000, 2003.

de Ajuriaguerra J.Manuel de psychiatrie de l'enfant. Paris: Masson et Cie, 1970.

de Ajuriaguerra J.  Letter tocollaborators.August 1976.

Enckell M, Bierens de HahnB. Letter to the Tribune de Genève, September 14, 1977.

 

Ey H, Bernard P, BrissetC,Ed.Manuel de psychiatrie. 4th edition. Paris: Masson; 1974.

Haynal A. Depression and Creativity. New York: International University Press; 1985.

Haynal A, King JE. Controversies in Psychoanalytic Method: From Freud and Ferenczi to Michael Balint. New York: NYU Press;1990.

Klaesi J. Uber die therapeutischeAnwendung der “Dauernnarkose” mittelsSomnifensbeiSchizophrenen. Zeitschriftfür die gesammte Neurologie und Psychiatrie 1922 ; 74:557-92.

Rapport du Conseil d’Etat au Grand Conseil sur la réorganisation des institutions universitaires de psychiatrie. Secrétariat du Grand Conseil, April 28, 1982.

Rapport du Conseil d’Etat au Grand Conseil sur la pétition de l’ADUPSY, Secrétariat du Grand Conseil, April 28, 1982.

Racamier P.C., avec la collaboration de L.Carretier, La cure de sommeildans la perspective psychothérapique. In Lambert P.A. (Ed). Actualités de thérapeutiquepsychiatrique: 2è série. Masson (Ed), Paris, 1967. pp. 225-264.

Sartorius N, de MarignacS, et al. La santé mentale à Genève. Dossiers Publics, Genève, No 21, February 1980.

Steinauer J.Les cobayes du Professeur. Tout Va Bien Hebdo, October 17, 1980.

Steinauer J.Anatomied’unecliniquepsychiatrique. Tout Va Bien Hebdo, Sept. 18, 1981.

Steinauer J.La Psychiatrie a mal aux Têtes. Tout Va Bien Hebdo, Sept. 18, 1981.

Steinauer J.Des rondsdansl’eau. Tout Va Bien Hebdo, Sept. 25, 1981.

Steinauer J.Le Fou du Rhône, Documents sur la crisepsychiatriquegenevoise. Tout Va Bien Hebdo and ADUPSY, Geneva, 1982.

 

 

 

Acknowledgments

My warm thanks to Tom Ban who encouraged me to go back to these years and to write this paper.

May 31, 2018