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

Hector Warnes' comment on Hanfried Helmchen's reply to Edward Shorter's comment

        I am very impressed by Professor Helmchen’s reply to Professor Shorter who, in my opinion, has gone too far in the "either or" theory of mental illnesses. If we adopt a psycho-social stance it does not mean that we have ruled out a biological basis. In fact, the closing of many inveterate and deteriorated mental asylums was prompted because of the introduction of more effective pharmacological agents. Federal funding was thus invested in community mental health centers in the USA and Canada partly because of institutional abuse scandals in the ‘60s and the widespread development of psychoanalysis and the psychotherapies.

        Further, it was the time that the mentally ill were given more legal rights and the adverse effect of mental asylums were studies particular the overuse of drugs (tardive dyskinesias, robotization and many other adverse effects). The strict authoritarian environment was brilliantly outlined by Erving Goffman's 1961 book Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates. Goffman referred to these places as "Total Institutions" and the process of change as “Deinstitutionalization.”

        Total institutions control almost every aspect of the patient's lives. They live under a regimented life with a system of reward-punishment and are isolated from the society at large. However, there were mental asylums that practiced a humanistic approach where patients, doctors and nurses shared activities and communicated by ergotherapy, art-therapy, group therapies, social outings and so on. It is difficult to know whether this move was successful. Often the sick patient was a burden to the family and ended up being rejected and quite often could not be properly treated in foster homes or community centers.

        Many had to return to psychiatric hospitals which, by then within a different social climate, improved significantly in their ecosystem and milieu (milieu therapy).

        Another significant pioneer in the foundation of therapeutic communities was Maxwell Jones who wrote The therapeutic community: A new treatment method in psychiatry in 1953. There was also impact of philosopher Michel Foucault’s History of Madness, first published in French in 1961 as Folie et Déraison: Histoire de la Folie à l'âge Classique.

        In my opinion the social versus the biological models have not changed substantially the status of our population of chronic patients. There are short comings with either models which need to be addressed. I was taken back when I read a rather pessimistic book, The Anatomy of Evil, written in 2009 by an outstanding forensic psychiatrist Dr. Michael H. Stone.

        We should not forget that pharmacotherapy is complementary to psychotherapy and may induce psychodynamic changes in psychiatric patients as elaborated by Sarwer-Foner GJ (editor) in The Dynamics of Psychiatric Drug Therapy.

        Walter Ritter von Baeyer wrote a seminal article on his “concept of encounter” (Der Begriff der Begegnung in der Psychiatrie) the view on the essential therapeutic factor of bringing about a relationship with the ill individual which was cited by Professor Helmchen. The Heidelberg School of Anthropological Medicine, of which von Baeyer was a co-founder, included great neurologists, psychosomatologists and psychiatrists (to name a few: Viktor von Weizsäcker, Richard Siebeck, Alexander Mitscherlich) and many others influenced by Martin Buber, Karl Barth and Sigmund Freud.

        I wonder why this extraordinary humanization of medicine, including psychiatry, that at time had drifted away from medicine has not been widely accepted in the USA or Canada.

        I thank you very much Professor Helmchen.

References:

Foucault M. History of Madness. Jean Khalfa, editor. Translated by Jonathan Murphy and Jean Khalfa.  Routledge, Taylor and Francis Group, London and New York. 2006.

Goffman E. Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates. Anchor Books. 1961.

Jones M. The therapeutic community: A new treatment method in psychiatry. Basic Books. 1953.

Sarwer-Foner GJ (editor): The Dynamics of Psychiatric Drug Therapy. Springfield, Illinois: Charles C. Thomas; Oxford: Blackwell Scientific Publications Ltd. 1960.

Stone MH. The Anatomy of Evil. Prometheus Books. 2009.

February 27, 2020