The Geneva Psychiatry 1980’s Crisis
Psychiatry and Antipsychiatry
Edited by François Ferrero
Part 3: Psychiatry and Antipsychiatry
François Ferrero: Introduction
It is not easy to find an acceptable definition for “antipsychiatry” despite many options, such as, for example, that of the French dictionary Le Robert: “All theories and therapeutics processes that break with classical psychiatry by denouncing the role of society in the origin and treatment of mental illness” (Robert, Rey-Debove and Rey, 2008).
To broaden this definition, consideration should be given to Edward Shorter’s Historical Dictionary of Psychiatry: “Early in the 1960s, as part of the general intellectual tumult of the time, a protest movement arose against psychiatry. Members of the movement whereby no means all in agreement about doctrine; some argued that there was no such thing as psychiatric illness, others that adverse sociocultural conditions exposed members of marginalized groups to political repression conducted under the guise of medical diagnosis, still others that treating mental patients against their will was unethical, and that electroconvulsive therapy was brain-destroying rather than therapeutic. This grab bag of diverse claims and objectives came together under the banner ‘antipsychiatry’.”
In his 1997 History of Psychiatry, Shorter wrote that the advent of effective new medications for psychosis and neurosis may have induced a certain indifference toward the patient’s need to feel care and that somehow psychiatry’s very real shift to science was associated with an imputed loss of caring. This was a view shared by the antipsychiatrists.
In 1968, the main protest of thousands of young men and woman all around the world was not primarily directed against psychiatry, but against values, morals and ethics inherited from former generations. Another famous slogan, “power to the imagination,” shaped dreams and seemed rich in promises of a better and more fraternal world. Antipsychiatry flourished as a radical questioning of the traditional organization of society, which was nourished by multiple influences, sociological, political, psychological, economical and artistical, i.e., ingredients which would allow a utopia to develop. Antipsychiatry appears also anti-medical, anti-science, anti-methodological and, more generally, anti-intellectual.
Among the enormous amount of literature published on the subject, I suggest a paper by Hagop Akiskal and William McKinney (1973) entitled “Psychiatry and Pseudopsychiatry.” After a presentation of the origins of psychiatry, they discuss the DSM-II (American Psychiatric Association 1968), and its limits, focusing on some selected areas “where the most recent psychiatric manual is totally out of rhyme with recent developments: Schizophrenia, Affective Disorders, Neuroses, Heredity vs Environment, Organic vs Functional Dichotomy.” They try to answer the question: are mental disorders as illnesses? They point also to the increasing number of psychiatrists “who have abandoned the medical model during the past few years.”
The antimedical tenants join the anti-psychiatrists arguing that they are not diseases, but problems of living. They explain the schism in US psychiatry is the result of the opposition between science, humanism and psychiatry. Aware of some degree of exaggeration, they propose to classify US psychiatrists (and clinical psychologists) as more or less “soft headed” or as more or less “tough headed,” pointing some characteristics of each camp viewed by the opposite camp.
The two groups, the traditional psychiatrists and the antimedical tenants, refer to the classification of psychiatrists by August Hollingshead and Frederick Redlich (1958): analytical and psychological (AP) vs directive and organic (DO). The “tough-headed” category appears as a rather homogeneous group corresponding to the DO psychiatrists, who are identified as biologically oriented psychiatrists. The soft-headed category is a heterogeneous group which “in addition to the AP (psychoanalytic) group, includes many new schools that are in open rivalry with it.”
Akiskal and McKinney (1973) proposed to:
· include philosophy of science, epistemology, and linguistics in the residency programs
· increase the number of “true eclectics,” i.e., those capable of real synthesis, and the number of research-minded psychiatrists.
They concluded that “humanism and science cannot be based on rhetoric and wishful thinking. They require hard work and dedication to both scientific methodology and humanistic concern.”
Unfortunately, such a psychiatric residency curriculum remains quite exceptional. As far as Geneva is concerned, a unified, rich and structured curriculum comprising psychiatry and psychotherapy was finally organized only after 1995 by the author and his colleagues, 15 years after the events - maybe a sign that a long crisis was finally over.
Thomas A. Ban: New Ideologies
Several comments in the course of this exchange have implicated that the Geneva 1980’s psychiatry crisis was intimately linked to the antipsychiatry movement that emerged during the 1950s simultaneously with the introduction of the first set of psychotropic drugs with demonstrable therapeutic efficacy.
In my monograph, “Schizophrenia, A Psychopharmacological Approach,” based on a presentation delivered on January 15, 1971, at the Clarke Institute of Psychiatry in Toronto, I addressed concerns about “antipsychiatry” in a section titled “New Ideologies” (Ban 1972). An extract of this section is presented below:
“Schizophrenia is a common disease. Its incidence per year is about 0.15 percent, its prevalence 0.3 percent, and the lifetime probability for any individual to suffer a schizophrenic breakdown about 5. to 2 percent. There are approximately 600,000 schizophrenics in the United States (70,000 in Canada) and more than 200,000 Americans (20,000 Canadians) are presently hospitalized with one or another form of schizophrenia (Lehmann 1970; Mosher 1969). There has been no change in these figures in the psychopharmacological era. There is sufficient evidence that at least certain productive psychopathological symptoms can be controlled by drugs, while first year relapse rates can be cut from 40 to 75 to 5 to 15% with maintenance treatment. Neuroleptics, together with the improvement of milieu in psychiatric hospitals, have considerably transformed the prevailing manifestations of the disease, while the changes in social attitude, together with neuroleptic treatment, have produced an absolute and relative increase in schizophrenic patient population in the community. The reflection of these changes in consciousness led to new ideologies of mental illness in general and schizophrenia in particular. Among the first ideologists was Szasz (1961), a professor of psychiatry, who argued that psychiatry, which deals with "problems in living" is inappropriately subsumed under medicine and that behavior that we call "sick," e.g., schizophrenic behavior, is not physiologically determined.
While Szasz (1961) considered mental illness a myth, Scheff (1970), a professor of sociology, asserts that mental illness is nothing but a label for a wide "residual" category of social offenders. According to him, every society provides its members with a set of explicit norms (understandings governing conduct) and offenses against these norms have conventional names, e.g., theft, perversion. Beyond the explicit norms and their "conventional'' offenses, every society has a countless number of unnamed understandings and offenses against these unnamed residual understandings are usually lumped together in a residual category. He considers mental illness as the residual category in contemporary society and conceives the symptoms of mental illness in general and schizophrenia in particular as offenses (violations) against implicit social understandings. Scheff (1970) interprets the disordered speech and communication of schizophrenics as offenses against culturally prescribed roles of language and expression. Schizophrenic withdrawal, in his interpretation, assumes a "cultural standard, concerning the degree of involvement and the amount of distance between the individual and those around him." Furthermore, Scheff (1970) suggests that the societal reaction against these offenses of implicit social understandings is denial (i.e., ignoring or rationalizing) or labeling. If labeling occurs, the offender is labeled as mentally ill and is launched on a career of chronic punishment.
Similar views were expressed by Laing (1967), a psychoanalyst, who defined schizophrenia as a label which some people pin on other people under certain social circumstances. He believes that schizophrenia is not an illness but "a social fact” and the status quo by "treating as medical patients certain individuals who, assumedly because of the strength of their inner perceptions and experiences, are exceptionally eloquent social critics" (Siegler, Osmond and Mann 1969). Besides accepting schizophrenics as rebels, Laing (1967) also offers them a status above normal people. In his essay, "Politics of Experience," he redefines schizophrenia and suggests that it is a "natural way of healing our own appalling state of alienation called normality." Accordingly, schizophrenia is not an illness, but a "voyage of inner exploration" during which "often through quite ordinary people," now called schizophrenics, "the light begins to break through the cracks in our all-too-closed minds."
The view that schizophrenia is not so much a breakdown as a breakthrough is shared by Dabrowski (1964, 1967), also a psychiatrist. He called it "positive disintegration" and considered it as a natural reaction to stress, which replaces usual problem-solving techniques in severe life crises. Furthermore, Silverman (1970), a psychologist, asserts that neuroleptics, by reducing the clarity of ordinary experience, interfere with schizophrenia's problem-solving process.
A common characteristic of these ideologies is that they adopt a view in opposition to the medical model. Nevertheless, they reflect a period in which the majority of schizophrenic patients can and are living outside of hospitals, a period in which schizophrenia is losing its "physiogenic" character and in which the progress of the schizophrenic process can be prevented, and psychopathological symptoms alleviated. Social-environmental changes were instrumental in this evolution of events, but without neuroleptics, the present state of affairs could not have been reached. Still, the problem is that even with neuroleptics, very little has been achieved. To exaggerate the little, we have achieved and claim that schizophrenia now does not exist is more than ideology, it is a falsehood which is corrected in the context of an alleged "truth" represented by an alleged "objective social interest." Nevertheless, if this falsehood would ever prevail, it would withhold progress towards an understanding of schizophrenia and the schizophrenic patient and could lead to a situation which is contrary to any social interest.”
Since the time of the “psychiatry crisis” in Geneva, well over three decades have passed but in so far as I know François Ferrero’s essay is first to examine it in a historical context. As, in the course of the exchange that followed the presentation of Ferrero’s essay, a possible role of the antipsychiatry movement was implicated in the incident, it would be important to clarify whether this was the case.
Hanfried Helmchen: Some background*
(The personal memories of some events related to psychiatry following the turmoil of 1968 in Germany, particularly in Berlin and Heidelberg. Events are experienced, reported and interpreted. If they apply to the reporter and thereby the interpreter himself, or even aim directly at him, his report and, all the more, his interpretation will not be free from the emotions he experienced at that time and now again.)
Binjamin Wilkomirski became known in the 1990s through his autobiography (Wilkomirski 1995). He described his horrible experiences as a child in a concentration camp in such a lively way that he was invited as an expert for infantile traumatization even to psychotherapeutic specialist conferences. Later it was found that he, a native Swiss, had never been in a concentration camp. Thus, by the “Wilkomirski case” it was proven that the mystification of one’s own ego through identification as a victim was provoked not only by a psychotherapeutic treatment but surely also by great public attention and support” (Stoffels and Ernst 2002).
Considering this I dare – neither as a victim nor as identified with one or another aggressive adversary – describe from my personal viewpoint some disturbing events from that time because they have taught me something about the powerful influence of the contemporary socio-cultural atmosphere on the thinking and behavior of many people and, moreover, about the mutual interactions between this power of the Zeitgeist and the possibilities of independent individual thinking.
A 1985 event shows how much mental suppression may play a role:
During the academic celebration of the 80th birthday for Professor Helmut Coper in 1948, as one of the founding students at the Free University in West Berlin I mentioned that he, as the first chairman of the student executive board, thanked General Clay, the father of the Berlin Airlift on the occasion of his return to the USA, for his support of the founding of the Free University. I quoted the following sentences from Clay’s answer: “Dear Mr. Coper. I do not know of any letter which has given me greater pleasure than yours of 13 May 1949. I assure you of my admiration for the will of the students of the Freie Universität Berlin to maintain academic freedom and of any continued interest in your success.” With the change of the Zeitgeist 20 years later, the rebellion of the academic youth against academic and societal structures considered crusty led to such absurdities as a declaration of loyalty to Erich Honecker, the representative of a totalitarian state structure (the East German DDR), from which, from East to West, the preceding generation of students had escaped. After my speech with this comment on the change in the Zeitgeist, Rolf Kreibich, the first and non-professorial president of the Free University (1969-1973), told me that he had never heard of such an event. I answered that he as the university president at this time must have heard about this event because all the media reported it. Only the former chancellor of the university could remember this event.
The relationship between the individual and the Zeitgeist is not easy to understand. For the Zeitgeist – an undetermined term for the prevailing pattern of thinking and interpreting; the normative framework; the atmosphere and state of mind of an epoch – occasionally changes rapidly, is at the moment never clearly recognizable and, in retrospect, the selection and composition of its manifold manifestations underlie the evaluation of the retrospecting person. Likewise, complex are the conditions of the more or less independent thinking and behavior that rest on any individual’s disposition, actual situation and social function.
In this context I will try to trace how the events – even if today they may appear weird, fancy, unacceptable, partly incredible or trivial – have influenced me and why they were effective: did they confirm my point of view due to the aggressiveness that I experienced as appalling and personally defaming or did they stimulate me to a strengthened confrontation with a rational core that occasionally was recognizable in some deliberate provocations? (Petty 2001). Insofar as my thinking turns out to be a classical product of the Zeitgeist, which is characterized by the “linguistic turn,” i.e., the “aspiration that producing and communicating of historical knowledge, it is mixed inextricably with the epistemological crisis that is linked with the transition from a modern to a ‘postmodern’ condition of culture” (Toews 2001).
1 - Tribunals
The student rebellion of 1968 against the “mustiness of a thousand years underneath the gowns” and, more strongly, against specific conceptions that they personalized in individual professors, sometimes took on a shape – such as the impossibility of continuing a lecture against the clamor of the students – that reminded me of the shouting down of Jewish professors by Nazi students in the early 1930s.
At the end of 1970 assistants (some of whom later became my most loyal coworkers) summoned me to a “tribunal” that became “fashionable” at that time. Such tribunals served to attack (alleged) annoyances by personalization. It could not be avoided that such events fueled the memories of the morally accused persons with what they had experienced or heard about National Socialist and Soviet “show” trials. In the 1950s I had reflected intensively on books of Communist renegades such as Arthur Koestler’s “Darkness at Noon,” but also of intellectuals, such as Czeslav Milosz’ “The Captive Mind,” or Hannah Arendt’s “The Origins of Totalitarianism” and George Orwell’s “Homage to Catalonia.” I by no means compared my situation at that time to the deadly threat of those defendants who were brought up, on demand, to stand before “show” trials. Because they fueled my memories, however, I was concerned with the question how much the effective mechanisms of such tribunals are comparable – seen sociopsychologically. Thus, I ignored the “invitation” to the tribunal – and nothing happened.
A similar situation occurred in 1972 when, as a candidate, I was invited to give a lecture by the appointment commission for the chair of psychiatry at Heidelberg University. I also received an invitation - likewise ignored – by the board representing the medical students for a public hearing that was to take place independently from my presentation in front of the faculty commission. Heidelberg colleagues also gave me student pamphlets (“There were enough Schneiders… beware of Helmchen”) that denied my qualification for the Heidelberg chair with the argument that I, as a biologistic psychiatrist, had a naturalistic, reduced, reactionary understanding of psychiatry.
Similarly, the assistants of the Berlin psychiatric department tried to invite candidates for a position to an independent interview in a tavern near the hospital - before the interview with me. After hearing about this I invited the senior physicians and representatives of the assistants to participate in my interviews. After, in one case, an applicant forced through by this group of coworkers proved a miscast, I had no more difficulties having my decisions accepted as the ultimate ones.
During the overheated discussion following my Heidelberg lecture in the overcrowded lecture hall of the psychiatric hospital, I responded to the inquisitorial question of whether, in psychiatry, I preferred the natural or the social sciences. My comment was that, for me, it is decisive whether the applied method is adequate to the question, as well as the quality of the methodical procedure both in the natural and the social sciences; this answer was not understood because it apparently did not correspond with the above-mentioned prejudice.
After a two-hour-discussion the 36 (!) members of the appointment commission retired with me to the conference room of the department to debrief me. But this was not possible because the students interrupted to “open the meeting to the public.” Therefore, the dean closed the session and I left. Karl-Peter Kisker, also an invited co-applicant and chair of psychiatry at the Hannover Medical School, described this incited, aggressive, and noisy atmosphere later on as “the motion of men through the fiery furnace” (Kisker 1971). It was also the time of the Socialist Patients' Collective (SPK) in Heidelberg, a group of patients from the psychiatric department led, indoctrinated, and radicalized by an assistant of this department (Pross 2016).
The background was the fierce conflict between politicized students and a faculty that was oriented to a traditional claim of quality and achievement. On the one hand, the students attacked the mode of the non-public procedure of professorial appointments as a “reputable fiddle” and urged openness. On the other hand, the students wanted to establish a psychiatry primarily oriented to societal causes and to change fundamentally the social practice of psychiatry instead of a psychiatry denounced as a descriptive-labeling one. Therefore, they demanded that Erich Wulff should be appointed, who alone in this sense would be qualified for the chair. This happened in the larger context that, at the end of the 1960s, broad concepts of psychiatric reforms arose, such as those that led to the influential enquiry of the German Parliament on the situation of German psychiatry (Deutscher Bundestag 1975), mixed with socialistic concepts that aimed at fundamental societal changes. In this retrospective description over so much time, one can scarcely imagine the difficulties of the stakeholders in such an excited and emotionalized atmosphere to recognize the border between an adequate response to a reasonable criticism or a demand for change and an acceptance of misleading ideas, particularly of behavior, that could be perverted into destructive social pathological manifestations such as the instrumentalization of patients in the SPK at the Heidelberg psychiatric hospital or into excesses of the antipsychiatry movement that was again becoming stronger (Kisker 1979).
In 1998 a professor at the Free University of Berlin invited me to a discussion with his students who wanted to prepare a Foucault Tribunal. In the style of the Bertrand Russell Tribunals, which had received considerable public resonance, psychiatry was to be indicted. I invited the professor for a discussion in our clinical conference. He came with his students, some of whom I recognized as members of the “crazy offensive” (“Irren-offensive"). This had been founded in 1980 by Peter Lehmann, a former patient of the department, as a self-help organization which cooperated during the past years with the state association of psychiatry-experienced persons.
They asked me whether I was ready to defend psychiatry at the tribunal. I refused by saying that I was not an actor and therefore was not available for this spectacle in the Volksbühne Theatre theater at Rosa Luxemburg Square. But, above all, I made clear that I saw this as an irresponsible act of nonsense because a position paper was to be presented there in which, among other aspects, the health insurance funds were to be urged to be withdrawn from financing psychiatric treatments because there were no mental illnesses.
About the apparently chaotic course of this four-day tribunal, called “power-delusion- sense,” the leading German newspaper, Frankfurter Allgemeine Zeitung (FAZ) (1998), reported on half a page under the title “Madness giggles at all corners.” The organizers, the above-mentioned antipsychiatry groups, apparently had learned from this article and were able to attain the Russell Tribunal in 2001 for an event called “Freedom of Thought” on the question of human rights in psychiatry. The basis of the accusation, presented by Thomas Szasz, was his thesis that the diagnosis of mental illness produces a state of human submissiveness and thereby constitutes an offense against humanity.
During the fall of 1998 the bronze busts of Karl Bonhoeffer were stolen from the Karl Bonhoeffer Hospital, a large lunatic asylum, and from the Psychiatric Clinic of the Charité where Bonhoeffer had the chair of psychiatry 1912-1938. In 1999 sculptor Igael Tumarkin created an artistically alienated sculpture of the Bonhoeffer busts stolen entitled "Castration thoughts come with angel music" and donated it to the Landesverband Psychiatrie-Erfahrener Berlin-Brandenburg that includes the earlier mentioned Irren-offensive. It was then confiscated in 2001 as stolen goods on the occasion of a vernissage of a circulating exhibition at the above-mentioned theater at the Rosa-Luxemburg-Place, the Volksbühne. Presumably organized by the same group (or its antipsychiatry fellow travelers) via the home page of the Free University, a “chair of madness” appeared. On this web site defamation had been disseminated about the geneticist Peter Propping from Bonn that was extinguished by order of the President of the Free University.
2 - Media
On March 17, 1980, the Spiegel published the cover story called The Gentle Murder (Der sanfte Mord). Over 26 pages the magazine described “delusion dampening neuroleptics … [that] provoke severe, often deadly side effects.” Antipsychiatry utterances such as “ever more schizophrenics are killed gradually or driven into suicide by drug treatment – …a clandestine ‘psychiatric holocaust’.” Members of the German Society for Psychiatry and Neurology (DGPN) urged me, as the society’s president at the time, to take steps against the Spiegel by citing numerous factual errors in this article. Although skeptical about the chances of success of such a step, I accepted the challenge after two patients, referring to this article, told me that they wanted to stop all drugs and end their lives – because now they had it in black- and-white that they could not be helped.
Therefore, I requested a counterstatement from Spiegel to counteract “the discomfiture of the patients and their relatives, which had been apparently provoked by the article in a widespread way” and to protect “those who are active in the care of the mentally ill against unjustified reproaches.” Spiegel rejected the counterstatement by referring to the Hamburg press law because the “sphere of interest of the psychiatrists” was not touched individually by the allegation that they continuously gradually murder, and thus such an allegation would not be grounds for a counterstatement. The German Press Council, then contacted, responded that the “complaint of the DGPN to the Press Council was not the suitable means to lead the discussion in which the Spiegel had intervened with its report.” Albeit the committee of the Press Council “had discussed whether the title ‘The Gentle Murder’ was an exaggerated formulation.”
Then I called on the appropriate department of public prosecution in Hamburg with a lawsuit “against unknown” for defamation and slander. This request was also rejected for the reason that no individual person was defamed. Moreover, the accusation of murder itself did not seem questionable for the prosecutor, because he narrowed it to the notion that its application was related “only to specific drugs.” After this I called on the Federal Minister of Health, reasoning that she as the Minister responsible for medical education should proceed against articles that could discourage the younger generation from an education in the improperly negatively presented psychiatry. I have published the answer without consequences as an example of a ministerial bureaucracy without content.
The speaker of the Federal President, to whom I finally wrote, answered that the President stood above the parties and did not intervene into daily business. But my comment that it is just the task of the President to state his position on a basic question of journalistic ethics apparently influenced his speech at the 275th birthday of the Hildesheim newspaper.
My conclusion from these experiences at that time was: “Everyone talks around this, always using the same formalistic arguments of lack of direct interest. Formerly such an attack on others who have scarcely a chance to defend themselves was called cowardly; today a behavior that only asserts its own opinion and tries to prohibit discussion and other viewpoints is backed legally, however this is not named as what it is, the legitimation of irresponsible spin, but is praised as freedom of press. Cui bono?” (Helmchen and Degkwitz 1980).
Even today, with repeated readings of the Spiegel article, I find its style and particularly some formulations such as the title itself as irresponsible, because it could prevent mentally ill persons from helpful treatment, not the least by stigmatization of the treating institutions, which also abets the stigmatization of the mentally ill. However, I also ask myself today how much some substantial criticism, as was on the agenda of the media, sensitized psychiatrists and their coworkers to shortcomings and particularly to the needs of the patients and thereby contributed to a change of attitude and atmosphere in the treating institutions. Of course, the Zeitgeist articulates itself in the media, which simultaneously manipulate it. In order to achieve this manipulative power, the media overdraw, personalize and emotionalize. It seems not possible to eliminate these social psychological mechanisms; however, it is possible to fight against them, particularly against a demagogic and personal defamatory style if it leads to pressure or even threats for single human beings as well as to counteract derailments of the Zeitgeist. They become dangerous if they rudely simplify and polarize in language and behavior, adopt inhuman features, absolutize the figures of thought behind their actions and thereby can blaze the trail into a totalitarian societal deformation (Welzer and Christ 2005).
In his book “The chemical gag” (Lehmann 1990), Peter Lehmann compared a senior physician of the department to the SS-men in a picture of the selection ramp at Auschwitz. Such defamations did not remain without effect. When I introduced myself during a ward round to a new patient she cried: “Alas, you are this pig.” She came from the “crazy offensive” and had been brought by friends to the department due to severe disorders of behavior as a result of an acute delusional psychosis. After successful treatment she showed her appreciation by bringing flowers every year at Christmas for the nurses of the ward.
However, I also had an opposite experience when a head physician of a psychiatric hospital called me in order to transfer a patient from his hospital for ECT. When I told him that he, as a psychiatrist, had to master this standard treatment himself, he brushed it off by saying that ECT was no longer used in his hospital. In a radio broadcast the same colleague called our department “the shocker clinic.”
In the middle of the 1990s the Social Democratic and Leftist government of Berlin tried to implement a legal prohibition of ECT. I protested against this illegal intrusion into the physicians’ freedom to treat (“Kurierfreiheit”) according to established standards. Nevertheless, in following this ideological intention the physicians’ parliament delegates of the physicians’ board (Delegierten-Versammlung der Ärztekammer) decided that ECT should be performed only after ethical consulting by the physicians’ board. Again, I protested, and after a few weeks the president of the physicians’ board invited the heads of all psychiatric hospitals for consultation on the indication and application of ECT. After the unanimous vote of the leading psychiatrists that ECT was an established and, by narrow indications, a necessary standard therapy, he assured us that he would have the physicians’ parliament vote again in order to revise the former decision. One astonished colleague remarked that the president cannot preempt a vote of the parliament. However, the next session of the parliament reversed its decision.
A patient who had been treated for three months in 1977 wanted, one year later, to consult his case record. His reasoning for this to me was that he needed these documents for his thesis. I refused on the basis of antitherapeutic risks and the threat of the rights of third parties (in this case those of relatives whose statements of the patient’s medical anamnesis had been given only under the premise of confidentiality); furthermore, I argued that the case record served mainly as a memory aid for the physician. Although this reasoning had been used to date, this argument was renounced by the Federal Supreme Court (Bundesgerichtshof - BGH) in 1978 as an expression of an outdated medical approach and the physician was obligated to a documentation as a kind of accountability.
In the following years several courts deduced from this judgement a patient’s right to see “his” own case record. This former patient then also sued the department in front of the regional court. For this lawsuit the patient asked the “assistants of the department of psychiatry” for support, but now by reasoning that he wished “to set a precedent: we as psychiatry patients must have the right to inform ourselves about the diagnosis, therapy, and prognosis. Simultaneously, more than ever, it is in view of known abuses in psychiatric asylums necessary to exercise control” because “the suspicion cannot be excluded that male and female patients are misused as guinea pigs.”
The publicity of this former patient attracted interest insofar as the German Society of Social Psychiatry (DGSP) placed itself behind him and made the case for donations for him in a letter published in Die Tageszeitung (TAZ) (1980). The regional court of Berlin found in favor of the plaintiff. During the trial of the university’s dissent the hall of the supreme court of Berlin (Kammergericht) was filled with noisy members of the “crazy offensive” (founded by the former patient) who sometimes made it impossible for me, as the expert witness, to answer the questions of the court. Nevertheless, the judges did not call for quiet from the audience.
The Berlin Supreme Court confirmed on June 1, 1981, the judgement of the regional court but allowed for a revision at the BGH. In its judgement on November 23, 1982, the Supreme Court took into consideration the reasons propounded from the psychiatric side (Die Tageszeitung 1982) by which the psychiatrist is not obliged to allow the patient an inspection into his case record; but in each individual case he must weigh how much he will allow inspection, whether the rights of a third party would be an obstacle to such inspection, or whether the patient could be threatened by his inspection.
In the following years additional court decisions broadly removed the still-existing restrictions of the inspection. This probably has contributed to the fact that not only judgmental statements have disappeared from the case reports but also judgments have become much more cautiously formulated. In 2006, after the Federal Constitutional Court (Bundesverfassungsgericht - BverfG) conceded a practically unrestricted right of inspection to a mentally ill patient with a narcissistic personality disorder in forensic commitment, a controversy lasting 30 years that ended in favor of the – however understood – individual right of self-determination.
In retrospect, the controversy around the right of the patient to inspect “his” case record appears as an early beginning of an epoch that since 1990 also legislatively accepted a right of inspection into data collections compiled and administered by public institutions (Schmidt-Assmann 2005). Therefore, it was right legally to clarify the weights and relationships of the touched upon and diverse, but in each case justified, interests, e.g., the right of inspection as opposed to the right of third parties to be protected. The duration of the clarification process over almost three decades may have contributed to an evolutionary change of attitudes and adaptation to the basically new situation of public access to many data collections and to informational self-determination.
I realize that court decisions are not only spoken of as a formula “in the name of the people” but also that judges as individual persons are also exposed as citizens towards the moods and mental states of the population at large (in the media as well as in the court); however, I doubt strongly that the defaming forms of the controversy described above were necessary or even advantageous. After the public hearing in Karlsruhe (the seat of the Federal Court), but before the pronouncement of the court’s decision, I heard by chance from a member of the deciding civil senate that he was glad that there was a large space between himself and the audience because “some wild people had come from Berlin.”
Simultaneously to the processes reported above, the promotion for support of the patients’ demands was intensified into a public campaign, broadened over and above the cause and focused on me. Thus, on July 1, 1982, a whole page article by Götz Aly, a historian, appeared in the newspaper Die Tageszeitung, in which patients were encouraged to grab their case records, along with the following statement: “Among his victims, Mr. Helmchen by now has no reputation to lose; he is feared as an electro-shocker. To his psychiatric pupils he recommends the electro-shock, developed in Italian slaughterhouses for pigs, as a very humane treatment. Up to a short time ago he could perform his drug research and drug trials with his patients without being disturbed. But since some survivors of psychiatric abuse have organized themselves in the Berlin “crazy offensive,” a self-help group, and helped in the makeup of the complaint center for psychiatry the pressure has increased on Mr. Helmchen: the Alternative List (later on integrated into the Green Party) has demanded the closure of the research institution.”
In the beginning of 1982 the Alternative List, represented as a party in the Berlin parliament, wanted to know from the Berlin government: “How many cases of death have occurred in the Psychiatric Clinic of the Free University of Berlin under the responsibility of the psychiatrist Hanfried Helmchen…? How many cases of death have occurred….in so-called clinical trials? In how many cases in which patients died under the responsibility of the psychiatrist Hanfried Helmchen has a prosecutor’s investigation been performed?”
For the very time-consuming reply of these questions some coworkers and I searched through the entire archives of case records for cases of death, which we documented precisely. On the basis of this detailed documentation the responsible Minister for Science and Research answered the inquiry on May 25, 1982, by saying: “The assumption that the activity of the psychiatrist H., a broadly approved and scientifically renowned professor of the Free University, could be the cause of fatalities, is rejected with particular emphasis by the government as unfounded and false. The government explicitly regrets this form of inquiry, which is suitable to damage one’s reputation.”
But this was exactly the aim of the initiators of this campaign since the parliamentary inquiry was brought forward at the spring meeting of the Berlin Society of Psychiatry and Neurology by a masked person who charged the stage at the beginning of the meeting. When I (coming from a distance and thereby delayed) entered the hotel in which the meeting took place, three women with whitewashed boughs “for the deaths of psychiatry” came toward me. When I, surprised, asked one of the women, whom I recognized as a former patient of the department, whether she had ever seen dead persons in the department, she said in tears that someone had told her that. These events were filmed by a camera crew of the second German Television company, Zweites Deutsches Fernsehen. Legal actions were needed to prevent the usage of these illegal shooting of a non-public session.
Many times, coworkers of the department could scarcely recognize their work in media reports and urged me to counteract obviously wrong and defaming publications. Although this sometimes appeared hopeless, it could be seen that, in the long run, factual representations of clinical reality could objectify and differentiate public opinion (as part of the changing Zeitgeist). However, the decisive reason for the change probably was that the great majority of patients appreciated the work of the department, experienced the atmosphere as helpful and could thus contribute to the positive reputation of the department. I also gratefully look back on the helpful and loyal solidarity of my colleagues and coworkers in these bitter altercations.
3 - Public discourse
In 1989, together with the geriatric psychiatrist Siegfried Kanowski and the jurist Hans-Georg Koch, I published a work on “Ethical implications of research with demented ill persons” (Helmchen, Kanowski and Koch 1989). The topic seemed to me just as difficult as it was important, so I established an interdisciplinary working group with psychiatrists, jurists and theologians which published the results of our more than two years of work (1991-1993) in 1995 (Helmchen and Lauter 1995).
Friedrich Leidinger, a psychiatrist in the association of all psychiatric hospitals of the Rheinland (Landschaftsverband Rheinland), argued in a review of the book that “Helmchen and Lauter presumably are the first renowned German psychiatrists since the end of World War II who want to move the borders of the allowed” by discussing untenable allegations “in a suggestive and mystifying language. Nowhere is there evidence of an epidemic of dementia or an increasing risk of becoming demented” (Leidinger 1995). That dementias associated with aging would become one of the large care problems in the near future became commonplace during the past decade but was also seen at that time not only by us but was becoming familiar to many. Without our knowledge, at the same time the Council of Europe prepared a “Convention of Human Rights and Biomedicine” and published their report just before our publication. This caused a passionate public discussion, especially in Germany (de Wachter 1997). Particularly, the conditions named specifically in this convention under which the inclusion into a research project of patients without the capacity to consent could be possible were utterly condemned as an assault against the weakest of the weak. From this side I was defamed as a spokesman of a “total biomedical aspiration to power that is recognizably directed against demented persons.” Letters to me from persons completely unknown to me contended: “by human experiments you risk the consequences of somatic damages with patients entrusted to your care. You can deny it as long and as much as you will – it remains the truth.” Or: “In no case can you exclude the risk of health impairments through your crazy human trials.” Meant were legally required drug trials. With the background of my own experience with demented patients and considering the newest historical knowledge of the National Socialist misuse of psychiatry (Helmchen 2000). I have dealt intensely with the ethical and legal implications of these questions and, in discussions with many experts, have tried to define practically the borders of research actions.
4 - Conclusion
In looking back, I have the impression that I have been urged at least to analyze defined issues (Helmchen and Winau 1986) and, by accepting this, I have perhaps tried to influence the Zeitgeist a little bit, namely in the sense of a more evolutionary-analytic instead of a revolutionary-critical solution of factual problems of psychiatric practice. Whether I would have turned my attention to some of these problems without the provoking, occasionally even inhuman mode of these articulations of problems as intensely as I did, I do not know. I am convinced that my basic attitude toward the patient as a person suffering and seeking help did not change because of this experience. However, the engrossment into the problems (and my increasing experience with many individual fates) made me understand better the individual patient in his illness and made me more sensitive to the expressions of language.
However, this does not change the fact that I have experienced some of these modes of controversy not only as attacks on me personally but also as completely inappropriate in substance, and still see it so today, particularly that the demand of respecting the dignity of the patient was counteracted by distorting and inhuman assaults on psychiatrists and by the instrumentalization of patients as well. Nevertheless, that a dialogue between patient self-help organizations and psychiatrists has begun in the past years in order to counter together disabilities caused by illness is great progress.
* Translated from the German original into English by Jane Helmchen: Hanfried Helmchen. Chapter 6. Psychiatrists and the “Zeitgeist.” Geschichte der Psychiatrie an der Freien Universität Berlin. Lengerich: Pabst Science Publishers; 2007, pp. 108 -116.
Barry Blackwell’s comments on Hanfried Helmchen
I thank Professor Helmchen for his exemplary, detailed, and insightful analysis of the psychiatry background relevant to the controversial events in Germany during the 1980s raised by François Ferrero.
Helmchen’s frame of reference is the Zeitgeist – a German word for a German epoch defined, according to the Oxford English Dictionary (OED), as: The defining spirit or mood of a particular period in history.
As he notes, “Zeitgeist is an undetermined term for the prevailing pattern of thinking and interpreting.” The term lacks a more precise definition in terms of the degree to which a “particular period” was changed, what factors contributed to bringing the change about and how severe or prolonged the change was.
Helmchen provides telling answers to these issues concerning Germany beginning with a student rebellion in 1968 and an atmosphere persisting for more than 30 years up until the turn of the 21st century. He combines personal experiences throughout, backed up by professional publications, analyses of the lay media and details of the role played in perpetuation by students, patients, quasi-professional organizations, and the press.
Barry Blackwell on antipsychiatry
My comments are directed toward examining and comparing events in Germany to the worldwide anti-psychiatric sentiments present throughout the modern psychotropic drug era in differing forms for variable durations. The countries involved include America, France, Canada, and Germany.
As the first psychotropic drugs began to appear in the mid-20th century, they encountered an existing anti-psychiatric sentiment due to the Catholic church’s concern that psychoanalysis might usurp the spiritual domain. This idea died an early death due to the efforts of two Catholic psychiatrists, Jack Dominian and Frank Ayd.
When I joined the Maudsley Hospital in 1962 Jack Dominian, who went on to a distinguished career as both a psychiatrist and theologian, was among my peers. His ideas, expressed in 32 books, helped resolve the tension and enlighten the doctrinal understanding of intimate relationships.
After completing residency, I migrated to America and met Frank Ayd, a pioneer psychopharmacologist and founding member of the ACNP, who became a friend and colleague. Frank, father of 12 children, was invited by Pope Pius XII to spend a sabbatical in Rome where on Vatican radio he spoke and taught about ethics and psychiatry.
When the first annual meeting of the newly formed CINP met in Rome in September 1958 the Pope gave an opening address. Frank Ayd commented: “Of all the Popes who have reigned in the Catholic Church Pope Pius XII had the greatest interest in medicine. During his papacy he addressed more medical groups and wrote more on medicine, human research and the ethics of medical practice than any of his predecessors” (Ayd 1998).
In 1970 Frank invited his fellow Catholic John Cade to describe his discovery of lithium, the first of the modern psychotropic medicines for manic psychosis, at an international conference in Baltimore (Ayd and Blackwell 1970). The Pope’s representative to the Nixon White House was present during the awards ceremony. This is an example of how skillful advocacy can ameliorate a potentially inclement Zeitgeist.
However, the pioneer psychopharmacologists in America had far more refractory antagonists in the form of their fellow psychiatrists steeped in psychoanalytic ideology. When I joined the Department of Psychiatry at University of Cincinnati in 1970 the chair of almost every academic program in America was an analyst. Ayd describes the atmosphere: “Every pioneer in psychopharmacology can attest that in the early years there was a marked resistance to such therapy by many leaders in psychiatry. In fact, many were ridiculed and denigrated by colleagues faithful to psychodynamic concepts” (Ayd 1998).
While I was welcomed as a faculty member in psychiatry and pharmacology, teaching both medical students and psychiatric residents, the intellectual climate remained mildly hostile. Every other faculty member was an analyst and most of the residents were in analysis with them at a time when the National Board of Examiners waived the need for graduating medical students to do a rotating internship in medicine before entering residency. Anthropologist Margaret Mead, a visiting professor, gave the Department Chair, Maury Levine, a hard time about the residents’ ignorance of medicine. This did not prevent the faculty from warning that if they spent time on the psychosomatic unit under my supervision it “might ruin their career,” a suggestion I challenged and confronted in an open debate with a leading analyst.
Shortly before I left Cincinnati in 1974 Maury Levine developed acute leukemia; on his deathbed he wrote me one if his famous “Memo’s from Maury” promising we would jointly teach a conference integrating dynamic and biological concepts. Sadly, Maury died with the promise unfulfilled, and I left to become Chair of Psychiatry at Wright State University in Dayton, Ohio, where funding was provided by the Federal Government for training humanistic primary care physicians willing to work in underserved areas. This was just before American psychiatry adopted the DSM-III and renounced the psychodynamic diagnostic concepts of its predecessors. So, for almost 20 years the early American Zeitgeist had been largely antagonistic to biological treatments.
Events in France are related in a biography of Jean Delay (Moussaoui 2002) which was reviewed and abstracted on INHN (Blackwell 2014).
Delay, a brilliant polymath, gifted author, and lifetime member of the Académie Française, was the youngest Professor of Medicine in France when, in 1942, he joined the Clinic of Mental Illness and the Brain (CMME) in Paris. He became Chair in1946, at age 39, and turned a virtual asylum into a multi-disciplinary academic institute with laboratories in all the disciplines related to psychiatry. Akin to and contemporary with Aubrey Lewis’s Maudsley Hospital and Institute of Psychiatry in London, CMME was unique and exceptional in France; it was a magnet for the best young doctors from around the world. During his scientific career Delay published more than 40 books and more than 700 scientific papers on a wide variety of topics. He convened the first World Congress of Psychiatry at Paris in1950 and two years later his team published the discovery of chlorpromazine (Delay, Deniker and Harl 1952), the drug that transformed world psychiatry, lead to the closure of asylums and fostered the birth of community care.
In May 1968 dramatic events intruded on this idyllic academic environment: “a sudden thunderstorm in a clouded sky” (Moussaoui 2002). A national Trotskyist revolution erupted, paralyzing France with widespread strikes, blocked public transport and student protests. Ideology was profoundly anti-authoritarian and anti-psychiatric; psychotic and delusional patients were not mentally ill but “victims of the system.” Delay became a scapegoat, an alleged prototype of a “contemptible order of mandarins.” Five hundred students invaded the department, occupied his office and lecture hall, ridiculing his teaching and demanding the separation of psychiatry from medicine. Within two years some of these changes were implemented and Delay, now 70, decided to retire, driven both by ill health and a deep desire to devote himself to literature, his first love.
In his sad concluding remarks, Driss Moussaoui describes the long-term impact of Jean Delay’s fall from grace on French psychiatry: “It is clear that a major page in French psychiatry was turned with Jean Delay’s retirement in1970… and with it the important role that France played internationally… a gradual disinvolvement from the international scene by French psychiatrists occurred” (Moussaoui 2002). Driss identifies contributory factors in this decline including the arrival of DSM-III a decade later and the biological shift in modern psychiatry, as well as the fact that English became the predominant language for international scientific dialogue.
Anti-psychiatric events also intruded on the career of Heinz Lehmann in Canada but with a very different outcome.
Heinz migrated from Germany to Canada in the run up to World War II. At age 26 he had completed his medical education in Germany at Marburg where he studied Ernst Kretschmer, then Vienna to meet Julius Wagner-Jauregg. Familiar with classical psychiatric literature he opted, like Joel Elkes, to shun residency in favor of “on the job” training as a junior psychiatrist at Verdun Hospital in Montreal, an asylum affiliated with the medical school at McGill University (Blackwell 2015).
Here Lehmann was exposed to the full spectrum of psychopathology in mental illness and became a self-taught scientist in early attempts at treatment until he was appointed the Medical Director in 1954 by which time, he was well-versed and a published author in biological research. In that year he learned of the discovery of chlorpromazine in France and conducted his own trial, the first published in English, and for which he received the Lasker Award (Lehmann and Hanrahan 1954). Heinz would later publish the first controlled trial of imipramine in depression (Lehmann, Cahn and Devertuil 1958).
Beginning in 1961 Lehmann began a highly productive epoch of research with Tom Ban in what later became the lead component in the Early Clinical Drug Evaluation Units (ECDEU), funded by the NIMH. Together they studied and published their findings on almost all the new drugs developed during nearly two decades. The decade between 1960 and 1970 saw the “Quiet Revolution” in Quebec during which a Liberal elected government usurped control over health and education from the Catholic Church, establishing Ministries of Health and Education that triggered intense social, political, and cultural change which secularized society and created a welfare state.
These events had a profound impact on McGill University with faculty unrest and political turmoil. Seeking to prevent the Department of Psychiatry from falling apart the Dean of the School of Medicine persuaded a very reluctant Professor Lehmann to accept the Chair and restore calm, which he accomplished in 1970. This feat coincided with a small Marxist uprising provoked by a visit from French General Charles De Gaulle who urged French-speaking Quebec citizens to push for political sovereignty from Canada. Part of that agenda radicalized youth on the alleged evils of totalitarian government and included a few psychiatric residents who protested the use of psychotropic drugs in psychotic patients as “mind control.” This in turn fed into a broader North American movement among Scientologists and conspiracy theorists led by psychiatrist Peter Breggin, who expressed concern over the Project MKUltra, also called the CIA mind control program, during the Vietnam War. Among the recipients was Ewan Cameron, a predecessor of Lehmann as Chair of Psychiatry at McGill.
In reaction to allegations of psychiatric patient abuse the Canadian government appointed a Citizens Commission of Mental Health that toured 70 major psychiatric facilities throughout Canada, interviewed thousands of patients and catalogued “harmful psychotropic drug effects.” These findings were published in the Scientology magazine, Freedom that included a photograph of Verdun Hospital with a caption, “Some of Lehmann’s experiments were fatal, yet have gone virtually without comment.”
These allegations, which were refuted and discredited, are still posted on Google today. Heinz Lehmann agreed to address these concerns in a public debate with the distinguished philosopher Herbert Marcuse who spoke to the motion, “Psychiatry is an agent of the Establishment.” Heinz spoke against the motion and may have relished the encounter. Marcuse, in his 70s, was a German Jew who, like Lehmann, fled Germany before World War II. Fiercely opposed to totalitarian regimes, his early work combined themes from Marx and Freud. He taught at Harvard and Brandeis where he was known as “The Father of the New Left,” believing that “technology amounted to social control of the individual.” This fit the notion that psychotropic drugs were abusive. Heinz was well equipped to negate this opinion but, while getting the best of the argument, he was attacked by a psychiatric resident armed with a spray can that covered the professor with whipped cream. Without missing a beat Heinz calmly wiped the foam from his face and concluded the debate, widely viewed as the winner.
Politics cooled, Quebec never obtained independence and Heinz emerged with his reputation intact. The Zeitgeist dissipated and Heinz went on to receive numerous awards and accolades. He was President of both the ACNP (1965) and the CINP (1970). In 1970 he became a Fellow of the Royal Society of Canada; in 1976 an Officer of the Order of Canada; and in 1988 he was inducted into the Canadian Medical Hall of Fame, in the distinguished company of William Osler. The citation reads: “He was a humble and affable man who made the world a better place.”
Later in America
Events in America in the early 1970s, also stirred up by the Scientologists lead by psychiatrist Peter Breggin, focused again on the same CIA “mind control” experiments but this time in conjunction with brain stimulation research at Yale University by Spanish psychiatrist Jose Delgado.
Delgado was born in Spain and mentored by Santiago Ramon y Cajal, 1906 Nobel Laureate, often considered “The Father of Neuroscience” (Blackwell 2013). Studying medicine and physiology in Madrid Jose’s education was interrupted when he served on the Republican side in the Spanish Civil War. After the end of the war and a brief time as a prisoner of war he returned to complete doctorates in medicine and physiology, both cum laude. From 1942 till 1950 he conducted research in neurophysiology on selective brain ablation and electrical stimulation in animals, publishing 14 articles and winning several prizes.
In 1950 he won a scholarship to Yale and worked under John Fulton whose pioneer work on prefrontal lobotomy in chimpanzees encouraged Egas Monez to perform the procedure in humans for which Monez received the Nobel Prize in 1949.
Delgado, convinced that brain stimulation was superior to chemotherapy for treating brain disorders, developed a “stimoceiver” for two-way communication with the brain in mobile animals producing changes in affect and behavior. Encouraged by these results and Monez’s treatment of humans, Delgado extended his research to patients with chronic refractory epilepsy and schizophrenia, work published in 1952, the year chlorpromazine was discovered.
In choosing electrical stimulation over chemotherapy (because drugs were metabolized by the liver and blocked by the blood brain barrier), Delgado was eventually proved wrong. The effects of stimulation were often imprecise, poorly replicated and without therapeutic benefit. Nevertheless, his enthusiasm, prolific publications, and dramatic demonstration of stopping a charging bull (which made front page news) led to an invitation to write a book in a series on World Perspectives edited by a well-known philosopher, a series in which several of the world’s leading experts in a spectrum of topics, including three Nobel Laureates, were invited to speculate on the implication of their fields: “to extrapolate an idea in relation to life.”
Delgado chose a provocative title for his volume: Physical Control of the Mind. Towards a Psychocivilized Society (1969). Although his intent was benevolent - “to encourage a future psychocivilized human being, a less cruel, happier and better man” - he extended his philosophical ideas far beyond that which his experimental results justified. In doing so he became the prime scapegoat for the Scientologist cult and their crusade against all things biological, including drugs, ECT and the CIA mind control experiments.
Disastrous for Delgado was the strategy of his detractors to lobby Congress to block all Federal funding for brain stimulation research. In this they succeeded. Unable to fund his research and with his reputation tarnished he accepted the offer of a Chair of Physiological Science at a new medical school in Madrid and left Yale to return to Spain in 1974.
For another quarter century Delgado continued to publish animal research in brain stimulation and books on philosophy in both Spanish and English. His final book, Happiness, achieved 14 editions. After retirement late in life, he and his wife returned to America to live in San Diego where in 2011 he died, unheralded and largely forgotten.
Despite Helmchen’s persistent and cogent opposition, a prevailing anti-psychiatrist agenda - “a state of mind of an epoch” - existed that continued to publicly oppose biological treatments including anti-psychotic medications and ECT supported by public “Tribunals” student protests, hostile media (Spiegel), politicized student bodies and a fellow psychiatrist (Peter Lehman, leader of the “crazy offensive”), all supported by political stratagems and court decisions. Although cautious, Helmchen appears to attribute this to a Zeitgeist derived from “victim identification,” presumably a prevailing public sentiment and sequel to the concentration camps and holocaust atrocities of World War II.
Beginning in the mid-1970s a complex Zeitgeist has evolved in America that is, paradoxically, not anti-psychiatric but a corrupted product of the biological revolution that began in the early 1950s influenced by political, legislative, economic and cultural changes in health care (Blackwell 2017).
By that time each of the novel drugs effective for all the major psychiatric disorders had been discovered. The Federal Government closed the Early Clinical Drug Evaluation Units, the NIMH moved from funding psychopharmacology to genetics and a Republican Congress passed legislation encouraging “information transfer” from academia to industry. Despite collaboration with industry innovative drug development dwindled and Big Pharma switched its resources from creative research to aggressive marketing of “me too” products supported by seductive TV advertising yielding vast profits. Its lobbying force increased to more than 350 and beginning in 1980 Congress passed legislation that mandated the FDA charge higher costs for approving new drugs amounting to 50% of its budget. Meanwhile no changes were made to the outdated statutory requirements for approval since the mid-1960s. Double-blind controlled trials were still against placebos, not cheaper generic drugs, and statistical significance was often achieved before rare but serious side effects became apparent.
In 1980 DSM-III was introduced, a symptom-based program that was easily manipulated by industry and complicit academics - Key Opinion Leaders (KOLs) - to identify novel drug-responsive syndromes. A climate had now developed that allowed the industry to further use its vast profits to infiltrate academia and its professional organizations establishing an economic hegemony over the entire educational and drug testing process (Ban 2006). Conflicts of interest were rampant, glibly admitted but never penalized. Prominent psychiatrists were bribed to “ghost write” research reports and publications, as well as sitting on FDA approval panels, Best Practice Drug and Journal review committees. The ACNP, originally a seed bed for innovative academic psychopharmacology, now had fewer and fewer members involved with less and less dialog between clinical and basic neuroscientists - a founding principle of the organization.
Meanwhile the entire mental health system was moving toward a system of “for profit” health care and medicine as a whole turned from a profession into a business. Large, allegedly “not for profit” health corporations kept an eagle eye on the bottom line and were run by well-paid administrators with large advertising budgets. Increasing numbers of psychiatrists gave up individual practice to become employees subject to “productivity” requirements and without autonomy or political influence.
Stimulated by Professor Helmchen’s concerns about the situation in Germany this essay pursues the topic of the anti-psychiatry influences in depth across four cultures from1952 to the present: America, France, Canada, and Germany.
Each culture presents a differing picture of the prevailing Zeitgeist, its origins and countering forces displayed in a chronological framework. It begins with America in1952 where Catholic concern over psychiatry competing with religion was quickly disposed of by constructive dialogue between the Papacy and leading psychopharmacologists. A far bigger and longer adverse Zeitgeist was created by psychoanalytic hegemony over biological psychiatry that lasted two decades into the late 1960s and was resolved by the manifest therapeutic superiority of psychopharmacology and an influx of experts from other countries.
Nineteen-sixty-eight was a pivotal year in the evolution of ant-psychiatric movements in all four countries, triggered by Trotskyist, Marxist and Scientology ideologies that viewed psychotic and delusional persons as victims of totalitarian regimes with psychiatry as the agent of suppression through the use of toxic and dangerous biological treatments. Despite their common origin the duration and outcome of each Zeitgeist differed.
France came first when a Trotskyist revolution ousted Jean Delay and the team that discovered chlorpromazine. This provoked an abrupt and complete collapse of the existing French tradition due in part to Delay’s age, ill health, decline in stamina but also an eager exit to pursue his first love in literature and occupy his lifelong seat in the Academie Française. According to his biographer (Moussaoui 2002), the lack of an energetic successor at a time when French Psychiatry was ready to pursue a less biologic direction and the absence of a presence on the international stage contributed to Delay’s departure.
Canada followed almost immediately in 1970 due to a Marxist and Scientology element in the context of Quebec’s Quiet Revolution and attempt to secede from Canada. Much of the anti-psychiatry sentiment was directed at Heinz Lehmann whose robust, energetic resistance and sterling reputation quickly suppressed dissent and sustained a strong and lengthy psychopharmacology tradition in collaboration with Tom Ban and the ECDEU program. (Blackwell 2015).
Immediately following this the Scientologists, under psychiatrist Peter Breggin and opponents of the CIA “mind control” program, attacked Jose Delgado, his brain stimulation research at Yale and his philosophical writings. Their lobbying Congress succeeded; his funding was cut off and he was forced to return to his native Spain in 1974 where he was able to continue his research in animals.
Germany has had an active and by far the most sustained anti-psychiatric movement beginning in 1968, strongly opposed by Professor Helmchen but still influential perhaps due to a sustained Zeitgeist that obtains its energy from deep-seated feelings derived from the evils of the Nazi totalitarian regime during the Second World War, still expressed in contemporary elements of German culture.
Finally, the current sustained Zeitgeist in America is an amalgam of several cultural changes that have evolved over almost four decades beginning in the mid-1970s. While not overtly anti-psychiatric they have profoundly altered the nature of the profession, virtually extinguished the academic discipline of psychopharmacology, and contributed to a sterile epoch in innovative drug development. Paradoxically, due to malign commercial interests, treatment has tilted in a chemophilic direction at the expense of psychosocial interventions (Blackwell 2016) and the profession is mired in an atmosphere of profound pessimism and powerlessness to create change.
Jean-François Dreyfus: My early years in psychiatry 1968-1973
Many distinguished authors insist on the need to separate microhistory, more or less one's own recollections, and macrohistory, more or less the way history is described in textbooks.
Here are some of my recollections of the period starting in 1967 and ending in 1975. It corresponds roughly to the time when I was trained in psychiatry and psychoanalysis.
When I started my medical studies, the curriculum lasted for seven years. Psychiatric specialization required four more years of training for which, courses were also dispensed by the Academic Department of Professor Jean Delay, at Hospital Sainte-Anne, who had achieved world fame by discovering the taming properties of chlorpromazine in mentally ill patients. There was one exception: for historical reasons, neuropsychiatry was also taught in the Neurology Department at La Salpêtrière.
As to practical training, during the first three or four years you were just (unpaid) attendants in hospital departments. There was then a classifying examination and those succeeding became (paid) junior residents for six to eight 6−month terms. Positions were chosen according to seniority then exam rank. As to psychiatrist, once you had completed your junior residency you could take a new classifying examination that promoted you to the (better paid) status of senior resident, which you could enjoy for three to four yearly terms. Again, positions were to be chosen according to seniority and examination ranking. During their last year, senior residents very frequently were recruited as Deputy by Department Chiefs and left to start their career in public asylums.
In France, WW II had a lasting impact on “corrective” institutions. Physicians who belonged to the “Résistance,” mostly progressists, put up a system called “sector” in order to prevent hospitalization. This system was conceived as a preventive net over every territory and took care of patients on a day-to-day basis. This approach had little contact, if any, with Academic departments. The former considered the latter as stuck in byzantine controversies on vocabulary and drug properties and the latter considered the former as utopists.
Now that the stage is set, let me jump to my recollections. My fifth term as a junior resident was due to start in early January 1968. Having tried various fields of somatic medicine, I had elected to go for a term in psychiatry. I was 23 and had no experience in the field. I was supposed to get my MD at the end of the semester, so as to be able to replace colleagues in their practice and earn enough money to get married. However, in the fall of 1967, my future brother-in-law, a graduate of École Polytechnique, a very prestigious institution, told me that computer science was a promising field in medicine. As a notice announced a presentation of this topic to students a few days later, I decided it was worth attending. To cut the story short, it so happened that the Head of the Department where I had been a junior resident for the last semester, coming in late to this meeting, sat next to me by chance. At the end of the session, quite surprised to see me there, he wanted to know if I had an interest in the field and told me that he could obtain, starting after the 1968 summer holidays, a grant for a 1-6-year university training in the domain, which, of course, I accepted; by the end of 1968, I was very busy trying to catch up with maths, logics and programming at the Paris Science Faculty science, which has had a major impact on my professional career.
There were few possibilities to get acquainted with psychiatry. The academic departments, some far away suburban hospitals, were very inconvenient to reach; fortunately, I was able to secure a residency position at the Psychiatry Department of the Paris Hospital of the International University Campus (HICU), a semi−private institution that dealt mainly with foreign students who came to study in Paris.
At HICU, treatment was resolutely psychodynamic. Dr Hubert Flavigny had enlisted two very experienced psychoanalysts as his assistants. The “storm” of May ‘68 disrupted everything, and I have to admit that I was one of the main disruptors. With a low−ranking member of the nursing team, we created, in these small, quiet precincts, a revolutionary committee, which was later converted to a leftist trade−union, still active today. By the end of May, when everything returned to “normal,” I was summoned by Flavigny and asked to leave the department as soon as possible.
I had fallen in love with psychiatry and was senior enough to choose a position in Delay’s department, but when my turn came, there were no longer any available. Finally, I went to hematology and came close to becoming a hematologist.
Holidays, marriage, replacing physicians, Excellence Insititute at the Science Faculty: by September, I had almost forgotten Flavigny and the HICU when I received a mailer inviting me to attend an information meeting to be held by Flavigny at the HICU psychiatry department. There were about 40 former junior residents present and Flavigny explained that he had been appointed professor in one of the new universities that were created as a result of the student riots. If his position was to be maintained, he had to start a training course almost immediately and he wanted to know if any of us was interested. Most of us were, and there was a random draft. Twenty slots were open, and I was the 19th drafted. Thus, I started my psychiatry training.
At the end of this first year of training, there was the competitive examination for a senior residency in psychiatric “sectors.” To my surprise, I came out second and it was difficult not to seize such an opportunity. At that time, I lived outside of Paris, not too far away from one of the “sectorized” hospitals, one that had been built less than 10 years before and that had the reputation of being one of the best examples of “institutional psychiatry.”
As one can understand, I had no real practical experience.
In the fall of 1969, senior residents had been on strike for almost a year, and they boycotted the drafts that occurred every year to renew the hospital psychiatric staffing. This led to an awkward situation as the most experienced senior residents, for instance, those who had been nominated as Department Chiefs in other regionals “asylums,” wanted to leave and take their new positions. A compromise was found: the fourth−year senior residents were to leave and only those positions that had been vacated by their departures would be included in the forthcoming draft. This meant that I was granted a position that usually belonged to the most senior residents while at about the same time I started my own psychoanalysis with a rather prominent Lacanian analyst and was only in the midst of my second year of psychiatry training.
With no experience at all, I found myself in charge of two wards, each with about 25 patients. In addition, the Department Chief had a motto: “I am present through my absence.” At the end of 1970, I had gained some limited experience when the hospital director told me about her grand project: fully converting one of my wards into an institutional therapy unit; she had already selected what she considered to be the best psychiatric nurses to staff this experiment and felt that I would be the right person to carry out this project. Of course, I accepted.
I had no idea what “Institutional Therapy” was. Through reading, I became aware that teams in the UK, Italy and Scandinavia had other approaches to mental health care. I read Laing, Cooper and Basaglia, Gentis, Oury and Tosquelles and armed with my own interpretations of their concepts led our little team on unexpected roads to become, as far as I know, the only functional experiment of antipsychiatry in a public mental hospital in France.
Antipsychiatry has many flavors. What were ours?
1) Build some consensus on the approach to be used. We were given a full week of non−stop discussions to come to a common way of thinking about “madness” and how it was not to be dealt with. In particular, offensive public comments on patients’ behaviors were to be banned.
2) Only admit to the ward patients who were voted in by nursing staff and resident patients. Newcomers were to agree to a less paternalistic approach of their difficulties.
3) Promote our own approach to the patients even if it broke the rules of the hospital. We even considered demolishing the hospital fence to have our own access to the outside world.
4) Resort to our own resources even in case of emergencies and leave out as much as possible the administrative procedures and resources of the “asylum” so as to make both patients and team more self−reliant.
5) Provide continuous theoretical training on mental disorders to patients and staff. Self−development was also recommended, and associations, students and universities were approached to provide it at affordable costs.
6) Hierarchy based on a supposedly better theoretical appraisal was abolished. Any team member could spend therapeutic time with a patient; even other patients in the ward were called in a therapist role if it was felt they had a better relationship to some patients.
7) Compulsory antipsychotic treatment was discontinued, but patients were strongly encouraged to take it on a voluntary basis. Pros and cons of these treatments were a regular topic for the weekly ward assembly. However, the Hospital Director was informed when we had doubts about a patient’s evolution and when she came for rounds − which became less and less frequent with time. However, we made it clear that her only possible decision if she disagreed with the way we were dealing with a patient was to decide to reinstate a patient to a “normal ward,” which she never did.
8) No alcohol would be allowed on the ward, even for festive events, and this rule was only broken once, after being specifically discussed by the general assembly, on New Year’s Eve. Of course, no addictive drug was allowed in the ward although Mandrax® was still easily available.
9) Conversely to what took place in other wards, the doors of our building were always open and no curfew nor any permissions to wander in the huge hospital park were required.
10) Patients were invited to participate in activities such as therapeutic groups, ergotherapy, cultural visits and sports. A social worker came every two weeks to help patient’s reintegration. However, no specific deadline was set for their return to the outside world.
11) Every institutional decision was made in general assembly meetings that took place at least once a week but in some periods were conducted on a daily basis. Most decisions led to a vote in which patients' votes were put on the same par as staff's ones.
12) Most therapeutic sessions were video recorded (I happened to have one of the first camcorders available to amateurs worldwide) and could be replayed, to improve our practices in specific training sessions.
13) Admission of new patients to the ward, as proposed by other wards, was subject to a vote after the newcomer had spent several hours in the ward to discuss the move with other patients and staff.
14) Sex (the ward was mixed) was authorized with four caveats: it was to be freely consensual; it was not to hamper other patient’s lives; sex between members of the nursing team was not allowed in the ward; and sex between resident patients and staff was prohibited in the hospital compound.
Most certainly there were certainly other rules and procedures but 50 years later, with no written documents available, I may have missed some other important ones.
No patient was admitted directly to the ward. They were each referred by one of the six “normal” hospital wards. Initial recruitment was slow but progressively increased and we reached our full capacity of 25 patients after about six months of operation. However, we had reasons to suspect that wards proposed some of their most difficult patients just to get rid of them.
Most of these referrals were psychotic patients. Some of them with florid delusional states, some of them with residual schizophrenia. All of them were anticipated to remain inpatients for several years. In a few cases, symptoms were aggravated by severe alcohol addiction. None of them, however, was considered dangerous and none was hospitalized on authority’s orders. A few cases of paranoid delusions and chronic (hypo)manic states completed the sample.
Over the 16 months of the ward’s existence only two patients left hospital, an outcome that matched the general hospital record for such patients. Two more patients found a regular working position (with a salary) inside the hospital. No patient deteriorated to the point of being sent back to a closed ward. Treatments levels were drastically decreased. One patient committed suicide after being denied access to his children by his former spouse.
Administrative difficulties started right after the ward was opened and a long−waged guerilla war started with administration and other wards.
Patients were found wandering at night in the hospital and other teams felt it dangerous. Patients were found having sex outside the ward and this was considered shocking. In both cases we refused to take any offensive action.
The gatekeepers refused to let patients out without a “leave” formulary. To prevent patients from jumping over the hospital walls, we responded by preparing blank pre-signed formularies that anyone could access on demand. Normally, meals were brought from the central kitchen at prespecified times and trolleys were collected one hour later. Since we were unable to have this routine changed, we requested to receive our share of food unprepared and uncooked. From that time on, the ward’s kitchen became an active place. Everyone was to perform some domestic tasks and I remember the disapproving glance of the Director when he found me with a broom dusting a patient's room.
Every patient got at least half a day of personalized therapeutic interaction per week, three or four times more than in a “regular ward.” All in all, we demonstrated that even such patients could be dealt with as human beings without repressive containment. One sure sign that this “worked” was that one after another, parents started to come and visit and even children came to see and play with their hospitalized mothers or fathers.
All this came to an abrupt end.
A young woman, about 25, severely delusional and clearly ambivalent was admitted to the ward. She was quite attractive and attracted most of the males. One evening, after she had refused the advances of two patients, both went out to the local pub and came back quite drunk and sexually excited. They wanted to enter the room of their prey. Two nurses, a man, and a woman, denied them access to her room and ultimately barricaded themselves with her in her room. The two drunkards announced that they would smash everything in the pavilion if they were not let in. None of the patients felt strong enough to confront them; the two nurses did not give in. The other pavilions while on alert did not call the emergency intervention team.
The next morning, when called by the incoming nursing team, I arrived to find not a single windowpane left intact, the TV smashed, and all wooden furniture reduced to fragments. In the hospital, the scandal was enormous and teams from other wards gathered in front of the devastated building while some patients had already started cleaning the floor.
The Hospital Director, without making any investigation, called a meeting and announced that she had decided to terminate the experiment and close the pavilion. All nursing staff and patients were to go back to their former positions. I was asked to take a leave immediately and was told that she would not accept me as a resident if I dared to come back on the next draft. Patients were anxiously waiting for us to come back from the meeting.
We then had our last general assembly and, when confronted by the Director’s decision, the patients unanimously decided that they would lock themselves with us in the pavilion and go on a hunger strike. We refused. We argued that, after all, we were a nursing staff and that they were patients. We could not let them endanger themselves through a hunger strike. After all, we were not those irresponsible persons the Director had depicted, and we would vouch for those who were far less rational than us. Although a few voted to stay and despite the unanimous vote of the patients, we reluctantly left.
I ended up with a very poor reputation and since I had one or two additional residency terms to complete, I picked a new position in the psychiatric unit in a general hospital. On my very first day, the Head Physician, who was never present, came to me and took me for an interview in his office; he clearly notified me that if I dared disrupt the successful routine he had initiated, he would just fire me.
One may think that this ends the story but as we love saying: “Impossible n’est pas Français!” Three years earlier: before the Senior Resident Examination, to validate my last term as a junior resident I had managed to do this term in Pierre Pichot’s department. His department was created on the ashes of the former Delay’s department: one department was for Pichot (retaining the former official denomination: Clinique des maladies mentales et de l’Encéphale) and one for Deniker.
Pichot did not think I was a good psychiatrist, although subsequently he became more friendly, but he loved my statistical and computer abilities. While being considered by many as a dangerous rebel, I stayed in his department for more than 12 years as a dilettante part−timer, under various titles being more or less responsible for methodology, statistics and computing. And he liked me.
In 1973, we received a grant from the army for a pilot study on the feasibility of using computers to automate questionnaires on the personality of officers−to−be. Interviews with psychiatrists were compared to results of computerized questionnaires completed by the same individuals. The study was considered so advanced that even the national TV came to make a film of us. As I needed to produce a graduation paper for psychiatric specialization, Pichot suggested that I could report these preliminary results, which I did.
However, there was still strong antagonism between various groups in psychiatry, in particular between psychotherapy−oriented groups, such as those of Flavigny’s heirs, and those evolving towards a more hard−science oriented approach, with Pichot among them. When I presented my work to the jury of psychodynamically oriented psychiatrists (at that time they still considered me as “The Antipsychiatrist”). They all believed that I had changed sides and was now a tenant of the opposing school. Fortunately, Pichot, at that time, was at the acme of his influence. Before flunking me, the President of the Jury phoned him. I do not know exactly what was said but I was later told that Pichot requested that they let me pass. All the other candidates were awarded a pass mark one level higher than mine, just to make clear how my judges disagreed with the approach there reported.
“But Dreyfus, why on earth did you participate in the antipsychiatry project and then in a depersonalizing approach with computers?” Answered Dreyfus, somewhat too ironically: “Because I found them amusing!”
March 24, 2022