Hanfried Helmchen: The role of psychopharmacotherapy in the early development of social psychiatry in Germany

Edward Shorter’s comments

            Hanfried Helmchen is among the most distinguished senior representatives of the psychiatric discipline in Germany. It is a pleasure and an honor to comment upon his paper which presents, for an English-speaking audience for the first time, an overview of the development of social psychiatry in Germany.  But several questions arise from this overview:

1.  What happened to the great German tradition of psychopathology in the exciting moments of this postwar discovery of the social dimension of psychiatry?  It had been Kraepelin, Bumke and Schüle who pioneered the nosological understanding of psychiatric illness that guides us even today in the DSM, which was (unwittingly) very Kraepelinian.  Instead, we find German psychiatry rushing into halfway houses and various social dimensions of what is actually biological brain illness and is not any more socially-caused than measles.  This social psychiatry of the postwar period marked a wonderful turning of the page on the Nazi period.  But was this enthusiasm ideologically inspired rather than clinically?

2.  Professor Helmchen mentions several times the Frankfurt University psychiatric clinic.  Yes, and what happened to this whole Frankfurt tradition of nosology, as exemplified by Karl Kleist and Karl Leonhard?  Kleist was enthusiastic about the Nazi euthanasia themes.  Yet he was also the founder of biological psychiatry in Germany.  What became of all this?  Were these views of psychopathology simply elbowed aside in the rush to establish outpatient centers and halfway houses?  The story that Prof Helmchen tells us, in other words, is a story without a beginning.

3.  Is social psychiatry, however well-meaning, actually therapeutic for seriously ill individuals?  The Germans had an ideologically-driven horror of highly effective treatments such as ECT and preferred “social measures.”  ECT is, to this day, highly restricted in Germany.  Is this feel-good social approach in fact medically ethical if it ignores treatments that will deliver the best possible results for the patient, in favour of treatments that let us turn our back on the Nazis but don’t actually help sick people that much?

            In view of the disaster of pharmacotherapy today, with its witless prescribing of SSRIs for all, not to mention the famous “second-generation antipsychotics,” it would be difficult to argue that what we now have is superior to social psychiatry.  The 15-minute “med check” is clearly not an improvement upon the great amounts of time lovingly invested in the sick individual.  But how do we understand that sick individual:  Is he or she a biological or a social being?

Just asking.

May  23, 2019