The Geneva Psychiatry 1980’s Crisis
Psychiatry and Antipsychiatry
Edited by François Ferrero
Part 2: Comments and replies
These comments and replies are presented as received and published on the INHN website. Nevertheless, to prevent repetition those comments relevant to antipsychiatry were placed in part three.
Hector Warnes’ comment on sleep cure with special reference to Alain’s autopsy
Regarding the Ferrero paper, it is not true that Rene Tissot (1917- 2010) followed the Jakob Klaesi (1883-1980) method. Klaesi was very prudent in the use of medication and if you compare the number and the doses of molecules given by him and those given by René Tissot there is a vast difference. I have encountered dysphagia with high doses of neuroleptics and, of course, respiratory depression with high doses of barbiturates. Those mega-doses used by Tissot were never used as far as I know, not even in Russia where sleep treatment was widely practiced because of its Pavlovian basis.
After giving further consideration to the additional information following François Ferrero’s original post, I have been wondering about the dichotomy which ended up becoming a cartesian one: between the biological and the socio-psychological-oriented psychiatrists, between the left and the right wing or even the establishment and the socio-oriented psychiatrists (behind the Geneva inquiry). Indeed, it became a calamity of sorts in the ‘60s but still persists. Even during Freud’s times, his disciples were from both the left and right which led to different interpretations of psychoanalysis. We are therefore plagued by ideological and political bent, not by scientific single-mindedness.
I am well acquainted with Hasan Azima’s sleep therapy because I worked under his guidance. He was trained by Jean Delay and knew intimately the work of Henri Ey on the subject. We had no casualties nor did Ewen Cameron, as far as I know. I was also acquainted with Jakob Klaesi’s original publication. None of these authors ever gave the staggering high doses of psychotropic agents that Dr Tissot did to Alain.
It was not clear whether this additional medication was given independently of the others or in addition to the others. Alain could have had an aspiration pneumonia due to the aspiration of food or vomit. It is the leading cause of death in Parkinson Disease which may cause severe dysphagia. I have seen cases with high doses of incisive neuroleptics who had difficulties in swallowing.
No clinical notes were reported that justifies the very high doses of medication nor the nursing care regarding positioning the patient, close observation and recording of the vital signs of his developing status during the 10 days.
This very unusual overdose of medication was likely to produce adverse effects or put the patient at risk for a complication such a respiratory depression (Tuinal 1800 mg) or severe dystonia or muscle rigidity (trifluoperazine 60). We know that respiratory depression causes a desaturation of the levels of O2 and an increase of carbon dioxide levels in blood.
I would suggest that the patient had nosocomial infection due to the over sedation and immune dysfunction. Since it was not treated in an intensive care unit it probably lacked the strict medical controls inclusive blood tests and chest X rays.
I am afraid that these incidents only serve to detonate the anti-psychiatric movement.
Luc Ciompi’s comments
Toward a new synthesis between social and biological psychiatry
It is highly commendable that François Ferrero reopened the historical crisis of 1980's Geneva psychiatry and recalled it to the younger generations. Back then, this crisis caused a stir far beyond Geneva and beyond the narrow field of psychiatry. The newspapers were full of articles with contradictory reports and personal attacks and counterattacks on all those directly or indirectly involved, political authorities and controlling or supervising institutions included. The emotional waves continued for several months and eventually settled only with considerable delay. For some insiders, they haven’t even completely vanished today. Why all this turmoil?
In my opinion, there were two distinct clusters of factors that combined in this affair with a cumulative effect: the current local and personal circumstances on the one hand; and an increasing, nearly worldwide, long-term antipsychiatry protest and reform movement against traditional psychiatry and its narrowly “medical” or “cerebro-organic” understanding of psychiatric diseases on the other.
The local circumstances and personalities involved have been described extensively by François Ferrero. As for the historical background, some supplements may be useful. The antipsychiatry wave of reforms started in the post-war period and reached a first peak in the late 1960s in certain countries. In the 1970s and 1980s, more or less radical reform efforts of a socio-psychiatric nature started quite simultaneously not only in other places in Switzerland, such as Lausanne, Berne and Zurich, but also in other western countries, especially in England, the USA, Germany and Italy. Reformers mainly questioned the predominantly medical and brain organic models of mental illness, by drawing attention to unfavorable social and institutional circumstances as at least equally important causal factors. In practice, they sought to open and reduce the size of the old prison-like mental psychiatric hospitals by reforming or even replacing them by a whole range of new community-based facilities, such as day and night hospitals, outpatient clinics, rehabilitation centers, sheltered homes, etc. Especially in France and Italy, geographical decentralization and sectorization of the mental health care system was systematically developed. Thus, the Geneva crisis of the 1980s can be seen as a relatively late but virulent manifestation of a wave of criticism which had its origins, in some places, in the 1960s
In an even broader historical context, the Geneva crisis appears as a partial manifestation of a conflict which started, practically, with the beginnings of psychiatry itself as a special branch of medicine in the 19th century: The conflict between those who the Germans used to call Psychiker (“psychists”) and the Somatiker (“somaticists”), e.g., between a more psychodynamic/sociodynamic approach to mental troubles on the one hand, and a biological and psycho-organic approach on the other. The antagonism between these two points of view has been going on for at least 150 years, with an alternating dominance of one or the other during this time. In the middle of the 19th century with its moral treatment, then again in the ‘20s and ‘30s of the 20th century with the mental hygiene movement, and again in the ‘70s and ‘80s with its widespread reforms of the psychiatric care systems, the psychodynamic/socio-psychiatric approach led in many Western countries. Since the decade of the brain (1990-2000), however, up to the present day, it is clearly biological psychiatry, which dominates the scene.
Although discussions on this matter have at least temporarily receded in the public field, the old antagonism between a mainly organic-biological and a psycho-sociodynamic-oriented understanding of mental troubles remains relevant even today. Thus, not only committed professionals, but especially also patients and associations of family members increasingly complain that both in the brain-centered understanding of mental illness as well as in therapy, the currently dominating biological psychiatry severely neglects the patient as a person, his biography and his social and familial context.
A new synthesis between social and biological psychiatry may, however, be emerging from the underground in relation, on the one hand with the mentioned complains, but on the other hand with recent discoveries in the brain sciences concerning neuronal plasticity, the so-called epigenetic effects of the environment on genetic factors, as well as research on the effects of distress and psychic traumata which all show that environmental factors have profound effects on brain functions.
A limitation of Ferrero's account of the "Geneva crisis” to which he is himself pointing is the fact that his presentation is mainly based on media reports and subjective personal experiences only, but less on original documents such as case histories, internal reports or faculty files. It is to be hoped that future psychiatric history research will be able to fill in these gaps, given that the Geneva crisis was certainly paradigmatic for many similar conflicts both in Western Europe and in the US, and that many details of this crisis remain still quite obscure.
François Ferrero’s reply
It is worth remembering
I am grateful to Luc Ciompi for having understood that one of the main purposes of my paper is to remind the younger generation of this drama.
Nonetheless, teaching some dark memories of the history of psychiatry remains difficult and it is usually received with some ambivalence by academics.
The Geneva psychiatric crisis developed relatively late by comparison to many other places. The reason is essentially due to the moral authority and human qualities of the chairman at that time, Julian de Ajuriaguerra.
Ciompi’s comments present a good opportunity to introduce some of his major achievements, for example his well-known research on the long-term course of mental illnesses, especially schizophrenia. Ciompi’s study with Müller (1976) and Ciompi (1980) showed that schizophrenic patients, reexamined more than 36 years after their first admission, had a long-term course more favorable and more variable than believed. At that time, if I am correct, the results of only two or three other longitudinal studies were already published: by Manfred Bleuler (1968, 1978) over a 23-year period and by Huber, Gross and Schüttler (1975) over a 20-year period.
Ciompi (1988) has also proposed a model of the evolution of psychosis, referring to the stress-vulnerability concept by Zubin and Spring (1977) and on the interplay between unfavorable environmental and biological factors. He also underlined the role of pathogenic interactions between emotions and cognitions.
This study was followed by other important contributions to social psychiatry and in particular, the development of alternative treatments. Among them, a small therapeutic community, the Soteria Bern, started 1984 in reference partly to Loren Mosher pilot project in San Francisco (Ciompi, Dauwalder, Maier et al. 1992; Mosher and Menn 1978). It focuses on a non-drug or low-drug treatment for acute schizophrenics in a small, relaxing, and protected environment.
Going back to the Geneva crisis, regardless the choice made to treat Alain with a sleeping cure, it appears that almost all requirements for an appropriate therapeutic setting were missing: isolation instead stimulus-protecting therapeutic environment; absence of close collaboration with the family and with other important persons of reference; lack of information to the patient, family and staff on the treatment and on the existing risks and chances; absence of any elaboration of common realistic goals for the future, etc. This statement has nothing to do with the merits or limitations of one or another psychiatric school - it points to a tragic and incomprehensible example of a very poor psychiatry. Such tragedy could be helpful for the teaching of residents and nurses as an example of inappropriate therapeutic setting with, in that case, its tragic consequences.
Edward Shorter’s comments on Luc Ciompi’s comments
Brain diseases and stress-related illnesses
Dr. Ciompi’s wise juxtaposition of social versus biological psychiatry does account for much recent history, without quite hitting the nail on the head. In fact, there are different kinds of psychiatric disorders with different treatments. The major psychiatric illnesses, such as psychotic depression, melancholia, catatonia, and mania, are brain diseases and they merit biological approaches, just as any biological disorder of the body merits a medical approach. You will not get your melancholic patients well again with psychotherapy or community day clinics.
Then there are a whole variety of stress-related illnesses that have nothing to do with brain disease but are caused by tension, unhappiness, misery, and the host of calamities to which the flesh is heir. Psychological, social and community approaches have a decided role here, medications and “biology” much less so. These patients benefit greatly from psychotherapy and the simple application of human concern and kindness. Nor do they need psychiatrists, when social workers, psychiatric nurse practitioners and psychologists will serve very well.
Unfortunately, in discussions such as this one, brain-disease and stress-related illness are often lumped into one and the “social psychiatrists” and “biological psychiatrists” have a shootout, which is more a dialogue of the deaf than a genuine confrontation.
In Geneva in the 1980s the social psychiatric approach ran amok and patients with brain illnesses were ill served, a violation of medical ethics (we believe that all patients deserve the most appropriate treatment for their condition). But the social zealots in Geneva hid the ECT machine! Unbelievable.
And today, we preach Prozac for all, similarly incredible.
From Geneva to Thomas Insel’s NIMH is a long way. But the trains run on parallel tracks, not on a collision course.
Barry Blackwell on Edward Shorter’s comments
While I agree with Ned Shorter’s characterization assigning specific biological, psychological, or social approaches precedence in the treatment of particular disorders I suggest a more parsimonious approach is to apply a biopsychosocial model to all mental disorders.
For example, while schizophrenia indubitably has an organic etiology, drugs that effectively stifle its positive symptoms often fail to alleviate negative symptoms that impede integration into the community where social and psychological techniques are helpful.
Likewise, melancholia, often considered endogenous, frequently seems to lack obvious psychosocial precipitants that may reveal themselves over time with scrupulous enquiry, hidden behind shame, fear or alexithymia.
Similarly, mania usually yields to carefully titrated lithium, but relapses are common, ushered in by the many causes of poor compliance which respond to a therapeutic alliance that offers comprehensive strategies.
As Ned mentions stress related disorders usually yield to psychological or social interventions directed towards its precipitants but drugs provide equanimity and a respite quelling anxious or somatic symptoms, thus facilitating benefits therapy bestows while stifling triggers for relapse and recurrence.
As noted in a recent posting the contemporary medicalization of psychiatry and severance of therapy from drug treatment, creating the preponderance of med-checks, is contributing to drug dependence, failure to wean; perhaps even to therapeutic despair and suicidal tendencies (Blackwell 2019).
Ambros Uchtenhagen’s comments
The role of political and professional competences
This well-informed and documented paper (including a list of limitations) highlights a period of passage in Swiss psychiatry during which our federal system had different fates in different cantons.
If I allow myself to contribute a comment, it is not based on an adequate knowledge of the Geneva dynamics at that time nor of the main personalities involved.
My visits to Professor Garrone in the early ‘70s were helpful for my task to build up social psychiatry in the Zurich area. Psychiatric reform in democratic western countries coincided with the youth unrest movement of 1968 resulting in an effort to accept new societal values, more liberty of choice for individual lifestyles and more interactive educational concepts replacing the dominant paternalistic model. For psychiatry, it meant moving from mainly custodial hospital regimes to community-based outpatient and intermediate services. Different strategies became implemented to reach that goal: creating new sub-specialties with academic positions, collective leadership, dividing catchment areas into regions or sectors for a better continuity of care, etc.
Extreme positions resulted in the removal of public hospitals (Italy) or even to abandoning all psychiatry’s diagnostic and therapeutic tools (anti-psychiatry) but could not pass the reality test. Others redefined psychiatry as an instrument to reeducate dissident citizens, a blatant abuse of our field.
The fate of these reforms depended not so much on conceptual orientation, but on political and professional competence to avoid the neglect of any of the newly developed treatment approaches – bio-psycho-social – and to care for an adequate division of labor and power among those in charge. It is essential to keep in mind the goals and mandate of psychiatry: to care for the health and wellbeing of patients; to guarantee availability and access for those in need of care; and for the information and safety of the population at large about what is done and how it is done.
Exposing the dynamics in Geneva in that critical period is not only of historical interest. We live today in another period with major changes and challenges: the scarcity of medical students opting for psychiatry; a predominance of neuroscience; a pressure to cut down on tariffs opening controversies; and a distant threat that psychiatrists may be replaced by mental health workers. We are asked to avoid past mistakes, for the sake of our great goals.
François Ferrero’s reply
Ambros Uchtenhagen’s comments sound familiar to me, not only because I’ve known him since I started my psychiatric training. I am aware of his many contributions to psychiatry in Zurich and elsewhere. He is a pioneer in different domains, in family and group psychotherapy, as well as in the organization and planning of psychiatric services. In the 1970s he proposed implementing sectorization in the Canton of Zurich, following the model developed by Christian Müller in the Canton of Vaud. He also promoted Social Psychiatry and was one of the founders of the Swiss Society of Social Psychiatry. Then, when the city of Zurich had to face a massive wave of drug abuses, he developed a very successful system of care, including drop-in centers and emergency units for drug dependents in collaboration with psychiatrists and GPs working in private practice and with many other partners, including medical students. He became an internationally recognized expert in the field.
Uchtenhagen’s comments add valuable testimony on the diversity of Swiss psychiatry.
(See Part 4, “Some characteristics of Switzerland relevant to psychiatry”).
Uchtenhagen also stresses the raison d’être of psychiatry: “To care for the health and wellbeing of patients; to guarantee availability and access for those in need of care; and for the information and safety of the population at large about what is done and how it is done.”
“How it is done?” appears nowadays a prerequisite for psychiatry’s credibility, image and attractivity as it is for medicine at large.
Without giving lessons, Uchtenhagen reminds us of some basic ethical requirements of our engagement.
We have to hear his warning about current difficulties and challenges psychiatry has to face, with the hope it could help to avoid past mistakes.
André Haynal’s* comments: letter to François Ferrero
I hasten to respond quickly to your letter dated July 10,  for which I thank you very much (personal letter, document concerning the history of psychiatry in the 1980s). How much time and energy wasted in the hustle and bustle and intense activity which, as in other cantons and elsewhere, could have been saved. Faithful to the historical peculiarities of Geneva, political overheating and probably the influence of French psychiatry led this Republic on a path which caused a lot of suffering to the careers and the cared for and which, by ideological blindness, did not allow a solution "Politically correct" (therefore: at the time seemed acceptable) to stop this development in time and decently.
A psychiatry unwilling and not daring to be one could not be carried by a majority of serious professionals in a shared project (since there are a lot of contradictory projects).
[Note that it was amazing that in different groups and circles, some creativity continued even during this period.]
De Ajuriaguerra's charismatic impulse, who called himself the boss (le patron) with the face of Janus, did not find an effective and worthy follow-up immediately and gradually deteriorated into a polyphony of contradictions without guidance. Political, managerial problem, without being recognized as such but attributed to the "fault" of the discredited psychiatric conception.
The institution’s management and medical value have taken a long time to find new growth and innovative ideas to establish an adequate governance direction.
Subsequent developments have gradually found their way back to effective care and a collaborative fraternal community interested in shared scientific backgrounds as the basis of activities.
*André Haynal passed away in November 2019.
Jean Garrabé’s comments*
Consequences of May ‘68
Professor François Ferrero’s essay is very interesting for a French psychiatrist of my generation because I knew Julian de Ajuriaguerra at the end of my medical studies in Paris before his departure to Geneva in 1959. I was also in contact with him after 1976 and his return to Paris at the College de France. Like many other French psychiatrists, our contacts occurred mainly at the occasion of de Ajuriaguerra’s participation in the Société de l’Evolution Psychiatrique. This society had suspended its activities during the German occupation in order to protect its Jewish members, for example Eugène Minkowski, from deportation. After the war, its activities resumed.
De Ajuriaguerra has written many articles in the society’s journal, alone or in collaboration. Société de l’Evolution Psychiatrique is one of the French societies that organized the first World Congress of Psychiatry in 1950 in Paris under the leadership of Henry Ey who was my mentor. This congress is the origin of the WPA. The second congress was organized in 1957 in Zurich, under the Presidency of Jean Delay.
I learned psychiatry from the Manuel de Psychiatrie published by Henry Ey, Paul Bernard, and Charles Brisset (1960) and from the Manuel de Psychiatrie de l’Enfant (Handbook of Child Psychiatry and Psychology) by de Ajuriaguerra (1980). I noticed that in both manuals, next to the important parts devoted to the clinic and to psychopathology, important chapters were devoted to juvenile delinquency, including psychiatric procedures of forced hospitalization. In France the 1838 law devoted to these procedures remained in force until 1990. I don’t know if Switzerland or the different Cantons have such a law.
About sectorization in France
In France a simple ministerial circular dated March 1960 introduced the politic of sector, attributing to a medico-social team the responsibility of psychiatric care to a population of about 60,000 inhabitants. Intersectors were also created for child and adolescent psychiatry. Many years later, this circular was followed by a law. The sectorization was implemented progressively in all the French health regions with MDs, nurses, psychologists, social workers, etc.; the sectors teams were attached to psychiatric hospitals, general hospitals, and/or to university hospital centers. It must be noted, from a chronological point of view, that the sectorization coincides more or less with the anti-psychiatric movement.
From my point of view, as chief doctor of a fully sectorized psychiatric hospital service since 1968 in the Yvelines department near Paris, I never had to face such an anti-psychiatric movement.
Jean Delay, the Société Médico-Psychologique and the origins of WPA
Jean Delay (1907-1987), a student of Pierre Janet, replaced Professor Joseph Levy-Valensi during World War II at the Clinique des Maladies Mentales et de l’Encéphale in Paris. When Levy-Valensi was released from Buchenwald by the Red Army in 1945, we were informed that he passed away immediately after arriving at the camp. Then, Jean Delay was titularized in 1946 and in 1950 he was the President of the first World Congress of Psychiatry which was organized by French societies such as the Evolution Psychiatrique, the Société Médico-Psychologique and the “Paris Psychoanalytical Society.” Delay was elected as the first President of WPA.
During my psychiatric training, I spent one semester in the Centre Psychiatrique d’Orientation et d’Accueil (CPOA), created by Dr Georges Daumézon with the aim to improve the orientation of psychiatric patients admitted to Paris’ Sainte-Anne Hospital from the respective sectors from the Seine Region.
The Société Médico-Psychologique, which was recognized as a public utility under Napoléon III, is one of the founding societies of the WPA. With Jean Delay as President in 1960, then with Henri Baruk in 1968, the Société Médico-Psychologique doesn’t seem to have been disturbed by antipsychiatry. I was the President in 2000 when the WPA jubilee congress was organized in Paris with psychiatrists coming from all over the world; eight came from Switzerland (six from Geneva), including François Ferrero, chairman of the Geneva University and Hospital Department of Psychiatry. The department includes the Bel-Air Hospital, renamed Belle-Idée, where Julian de Ajuriaguerra came in 1959 to reorganize the psychiatric department before returning to Paris in 1976 as chairman of the Neuropsychology Department of the College de France. Retired in the Basque County, he passed away in 1993.
Consequences of May 1968 on French Psychiatry
Regarding some consequences of May 68, the separation of neuropsychiatry into two distinct specialties, including their teaching resulted at the University of Paris, instead of one service, in 10 neurological or psychiatric services with professors of neurology or psychiatry who had to choose between the two specialties. The medical doctors working in psychiatry became hospital practitioners. I don’t know if such reorganization also touched Switzerland.
2016-2018: Sainte-Anne Hospital
An out-of-trade and richly illustrated book was published in 2016 entitled L’hôpital Sainte-Anne, Pionnier de la psychiatrie et des neurosciences au coeur de Paris (The Sainte-Anne Hospital, Pioneer of psychiatry and neurosciences in the heart of Paris). Among the many chapters, I wrote one with a young philosopher entitled Genèse et histoire de la chaire de Clinique des maladies mentales et de l’Encéphale (CMME) et enseignement de la psychiatrie à Sainte-Anne’s (Genesis and History of the Chair of Mental Illness and Brain Disease Clinic [CMME] and Teaching of Psychiatry at Sainte-Anne’s).
It should be noted that the monthly sessions of the Société Médico-Psychologiques in which I try to participate are still organized at the Sainte-Anne Hospital, currently in the Pierre Deniker amphitheater in the new Jean Delay building. His memory is not forgotten. The CMME is also organized in a new building which was named Joseph Levy-Valensi where two portraits of him adorn the entrance hall.
*Jean Garrabé passed away in September 2020.
François Ferrero’s reply
I would like to thank Dr Jean Garrabé who informs us that in 1968 his Service was not confronted with the anti-psychiatry movement. As I did not find any sufficiently documented publication dealing with the scope of the anti-psychiatric demonstrations in France at that time, it is not possible for me to determine whether this situation represents an exception or not.
I answer his question regarding the separation of neuropsychiatry in two different specialties: In Switzerland, psychiatry and neurology were separated since 1931, and psychiatry is a mandatory component to obtain the title of doctor (MD) since 1888, on Auguste Forel proposal.
Eugenio Aguglia’s comments
The opposition between social and biological psychiatry and the Law n.180 in Italy
I found the different comments on the topic to be very interesting and I can say that, regardless of the country in which each one of us studied and worked, we can all draw from a common wealth of experiences and memories about that time of changes, between the end of the ’60s and the beginning of the ’80s, that, starting from politics, has involved every aspect of society.
At the end of the ’60s Italy was also a scene of social turmoil. This turmoil, initiated by left-wing politics, gave life to an antipsychiatry movement.
What was peculiar in Italy was that the attack on the dominant psychiatry was carried out by a psychiatrist himself, Franco Basaglia, a principal exponent of the new currents of “social psychiatry.”
He was born in Venice, and he graduated from medical school in Padua. Always passionate about politics, Basaglia was a militant of the left-wing party Sinistra Indipendente. In 1958 he became professor of psychiatry at the University of Padua where he soon came into conflict with the dominant academic ideology and because of this, in 1961 he decided to leave his teaching position to accept the directorship of the psychiatric hospital in Gorizia.
In Gorizia, Basaglia came into contact with the sad and degrading reality of the asylum and started to put into practice his innovative ideas. He claimed that the relationship between the psychiatrist and the patient had to be “horizontal,” meaning that it should be based on reciprocal collaboration and dialog, rather than on strength and repression. Basaglia also banned ECT at the hospital.
But where did Basaglia’s ideas come from? His approach to mental illness was more phenomenological than biological. Basaglia was very into philosophy and particularly close to the existentialism of Sartre, Binswanger, and Foucault - even to Marxism - and on these ideas he based his psychiatric theories and career.
In 1961, when Basaglia arrived in Gorizia, Foucault’s History of Madness was published. In this literary work the author denies mental illness because, in his opinion, it’s just a social problem and he condemns the structure of the psychiatric hospital because he sees it only as a prison with the only purpose of excluding some people from the rest of society.
On Foucault’s wake, in 1967 Basaglia wrote L’istituzione negata (literally: the institution denied), a manifesto of his antipsychiatry ideas in which he wrote: “to begin with we have to deny everything around us: the disease, our social task, our role.”
To better understand the importance of the Zeitgeist in the Italian psychiatric scenario, we must recall some of the social-political events that involved psychiatry in the late ‘60s and early ‘70s.
In 1968, even in Italy psychology and psychiatry had been the targets of protest by anti-authoritarian and anti-social movements that questioned the role and competency of every field. On the wave of this cultural spirit, Sartre was invited to hold a conference at Bologna University that was under student occupation; in Milan there was thorough opposition to the congress of the Italian Society of Psychiatry.
In 1969 the Italian communist party organized a conference in Rome about psychology, psychiatry, and power relations, entrusting the “basaglians” to give the first speech, following the introduction by Enrico Berlinguer, thus giving political recognition to Franco Basaglia and his group.
In 1973 Basaglia founded a movement called Democratic Psychiatry.
The battles of Basaglia and his movement against the psychiatric system of the time culminated in 1977 with the closure of the psychiatric hospital in Trieste, of which Basaglia himself had meanwhile become director.
Finally, in 1978, with the approval of Law n.180, or the so-called Basaglia law, mental hospitals were definitively closed throughout the national territory. This law was part of the health Law n.833 with which the National Health Service was established. Thanks to this law, the obsolete and aberrant structures that were mental hospitals were replaced with psychiatric wards inside general hospitals, by territorial outpatient facilities and by therapeutic communities in which health workers and patients had equal dignity and rights.
Basaglia, however, was not fully satisfied with this law. In fact, he did not want psychiatric wards in general hospitals; he only hoped for the creation of non-medicalized facilities. The asylums, for Basaglia and his group, did not in fact only represent brutal disciplinary institutions, but they were the expression of the ideological character of psychiatry, seen as the instrument of a bourgeois need for social order and, therefore, ultimately the expression of the class struggle between those who have power and those who suffer for lack of it.
In this idea is evident the passage from phenomenology to Marxism for which, in addition to the closure of the asylums, a more radical political strategy would become necessary to invest the whole structure of the “psychiatric power.”
Law n.180, in addition to the well-recognized merits, also had limits. For example, it left it to the different areas of Italy (Regions) to develop criteria for its implementation and did not address the problem of expenses and funding, thus providing fertile ground for the development of inevitable differences which to this day still exist and led to a serious lack of care that initially had to be sustained by the patients’ families.
Furthermore, when it came to the problem of chronicity, the law espoused the idea that it was only a derivate of institutionalization, while we know well that it is, unfortunately, often the natural consequence of the most serious cases of pathology.
Certainly, Basaglia must be credited with having favored the closure of those violent and brutal places that asylums were, but what beneficial effects can have fully embraced the theses of the so-called “democratic psychiatry” in opposition to those founded on biological principles, including the denial of the existence of mental illness as such? In fact, if it is sacrosanct for patients to have their rights recognized, the first of these is to be treated and not only assisted from a social point of view, precisely because psychiatric patients have the same dignity as any other patient.
For this reason, in my opinion opposition between social and biological psychiatry is counterproductive. In fact, unlike the ‘60s and ‘70s of the last century, if the role of psychosocial factors in the evolution of psychiatric disorders is now recognized, it is also unthinkable nowadays, considering the progress in the field of neuroscience, to deny and ignore the fundamental and primary role of biological factors in the genesis of mental illness.
To strip psychiatry of its medical dignity, in order to carry out philosophical theories that serve to legitimize more political than scientific causes, would end up causing only harm to patients, who would only become a means to serve an ideology, and whose care should instead be the ultimate goal of psychiatry.
Fortunately, nowadays in Italy, thanks to the presence of hospitals, clinics and therapeutic communities on the national territory, there has been in fact an integration of the social and biological models. Starting from the Trieste experience, the model has evolved, guaranteeing an integration between the need to protect the patient and the scientific advances in the field of neuroscience, allowing the integration of rehabilitation and therapeutic pathways.
François Ferrero’s reply
Eugenio Aguglia’s comments have the great merit of helping us to understand what occurred in Italian psychiatry from the 1960s to the 1980s.
Aguglia’s historical and socio-political approach provides us with a fascinating read. He does not forget, however, to remind us of the terrible state of Italian psychiatric hospitals when Franco Basaglia arrived in Gorizia. His comments also allow us to better understand the strengths and alliances which made it possible for Basaglia to have such an influence.
In comparison with Aguglia’s clear text, some publications mention alternative Italian psychiatry; those of which that were published in French have left me feeling somewhat doubtful.
Nonetheless, there is one point of Aguglia’s with which I have had some difficulty agreeing: he appears to liken the ideas of Sartre and Foucault with those of Binswanger, who was, in my opinion, a psychiatrist who did not share their ideas. He managed a clinic (in which Foucault worked during a period of time) with a long and good reputation. In contrast with Freud, he never stopped believing that psychoanalysis was a part of medicine and perhaps we have forgotten that he also received the Golden Kraepelin Medal. I do not think that phenomenology denies the existence of mental illness any more than it does not support the idea of an exclusive social origin of the illness. I will refrain from involving myself in an area which strikes me as particularly difficult, gladly leaving this to others more knowledgeable than me.
As I wrote in my response to Hanfried Helmchen, the protest movements in Geneva were in no way comparable with the violence which hits psychiatry, particularly in Germany and in Italy.
I cannot help but think that the impact of the antipsychiatry movements in these two countries also derives, paradoxically some might say, from the weakness of the influence of psychoanalysis and psychotherapy. In the field of psychiatry, Italy has often followed in the footsteps of France and 1904 Italian law very much resembles 1838 French law.
With regard to psychoanalysis, its first development in Italy was interrupted by World War I. Moreover, the Catholic Church opposed it very early. The role of fascism arrived later on, and fascists did not appear to be worried about the psychoanalytic movement, because of its weakness. However, the introduction of racial laws in 1938 changed completely the situation. “During the entire period of Marxist supremacy in the world of humanities and human sciences (primarily from 1945 until 1960), psychoanalysis was ignored, or deemed a bourgeois science” (David 1982).
From this perspective at least, the situation in France and in Switzerland was very different.
Hector Warnes’ comment on Eugenio Aguglia’s comments
Eugenio Aguglia’s comments on François Ferrero’s paper were excellent! Aguglia described Franco Basaglia's career as a product of the socio-politics of the times. It started off, as he puts it, with politics in the ‘60s; continued by questioning the prevalent idea of mental illness and the call for the abolition of mental asylums and the treatment of those in need in general hospitals; and ended up, at least in Italy, with the integration of social and biological psychiatry and the defeat of Basaglia.
Basaglia, a left-wing psychiatrist, achieved the abolition of ECT and the closure of some mental asylums. The consequences were that the burden of the insane fell on the families and the social order was compromised. In order to carry out his master plan Basaglia was able to get the support of the Judicial Powers. Aguglia outlines very well the sources of his militancy against the medical model of psychiatry (Sartre, Foucault, Laing, and others from the blossoming anti-psychiatric movement, many of whom were psychiatrists themselves). Aguglia wisely and respectfully wrote that Basaglia turned psychiatry into a horizontal (not pyramidal or hierarchical) relationship between patients and psychiatrists where a therapeutic community was built, and diagnoses were ignored in favor of a purely phenomenological approach.
The social upheavals of the decades of the ‘60s, ‘70s and early ‘80s were significant in unleashing many institutional changes and overcoming right-wing authoritarian views. I notice that Aguglia did not make any comments on the protagonists or narrators about whom Ferrero wrote in his paper nor did he offer any details on the denouement of the psychiatric crisis in Italy and the fate of Basaglia.
Tom K.J. Craig’s comments
A quiet revolution
I am most grateful to François Ferrero for letting me see his essay and the associated commentary from psychiatrists in Europe and North America.
I feel very fortunate to have spent most of my professional life surrounded by the relative equanimity of the English character! While a comparable revolution in psychiatric treatment and service delivery took place in the three decades between 1960 and 1990 it was a “quiet revolution” despite a lot of wider social upheaval reflecting the economic crisis and industrial unrest of the 1970s and the riots in opposition to Thatcherism of the 1980s. Despite this unrest (or perhaps because of it), psychiatry faced no mass protests and few occurrences of violence or the destruction of property. The few that I recall concerned attacks on scientists and laboratories by anti-vivisectionists where the focus was not on psychiatry per se. Changes in what was considered good practice in treatment and service delivery certainly occurred, often in response to justifiable criticism, and the more extreme manifestations of physical treatments including insulin coma, psychosurgery and narcotherapy (“sleep cure”) were already largely played out in England by the time I started training in the early 1970s.
William Sargent, probably England’s most influential voice for the more radical physical treatments had already retired in 1973. At the pinnacle of his career, he had been the president of the section of psychiatry at the Royal Society of Medicine and was awarded the Stanley medal and prize by the Royal Society of Health for his work on mental health. Calling himself a “physician in psychological medicine” he had attracted both the admiration of some colleagues and patients and in equal measure the opprobrium of others. He advocated early and intensive treatment including combinations of high dose neuroleptics, barbiturates and antidepressants, electro-convulsive treatment (ECT) and “continuous narcosis” – in which patients were kept asleep or deeply sedated for weeks at a time. This practice had come under censure in Australia where Harry Bailey, another pioneer of deep sleep treatment and in regular correspondence with Sargent, was heavily censured following the death of 26 patients at the Chelmsford Hospital in Sydney. Intensive nursing care of patients undergoing this treatment in London probably saved Sargent from a comparable disaster.
What is surprising perhaps, is how quickly his influence waned here in England. Although his textbook, co-authored with Eliot Slater (Sargant and Slater 1972), was one recommended to new trainees like myself, many of his methods were frowned upon by my supervisors at Mapperley Hospital who had witnessed iatrogenic disasters associated with these interventions and were committed to maintaining the reputation of one of the first hospitals to operate an open-door policy with no locked wards or use of physical restraint. Of Sargent’s physical treatments, only ECT remained as a regularly administered treatment albeit with a wary eye toward mounting criticism and disquiet. In 1976, partly in response to concerns about variation in how ECT was administered and partly in response to pressure from outside the profession, the Royal College of Psychiatrists issued practice guidelines, setting standards for its administration and consent (1977). Unfortunately, the guidelines were ignored by many psychiatrists in England. A survey in 1980 (Pippard and Ellam 1981) revealed huge variations in practice with fewer than half the surveyed centers meeting even minimal standards. Some appallingly poor practice was reported including the use of broken and obsolete machines, and poor practice including using unmodified ECT. This report prompted an editorial in the Lancet that referred to ECT in Britain as being “a shameful state of affairs” (1981).
The writings of Laing (1960), Szasz (1961) and Cooper (1967) had a certain influence, most notably among non-psychiatrist members of the mental health team and the interested public, mainly concerning aspects of psychiatric diagnosis and about psychiatrists as agents of social control. But wider activists, such as the Scientologists, never really got going in England and were at best a minor irritant protesting at psychiatric meetings and conferences. Of far more long-term significance was the activity of groups such as the Mental Patients Union founded in 1972 led by “survivors” of psychiatry who, allied with other progressive patient organizations and champions for human rights had a substantial impact on mental health care, albeit very slowly and often against considerable resistance from the profession. Service user researchers also contributed to the scientific debate about ECT (Rose, Fleichmann, Wykes et al. 2003) and their views were taken into account in subsequent practice guidelines, i.e., National Institute for Health and Care Excellence (NICE) (1963).
By far the greatest and most enduring upheaval in psychiatry in my lifetime was the closure of the hospital asylum and expansion in community care. The major drivers of this policy were moral, therapeutic, and fiscal. From a moral standpoint were observations of the harm caused by prolonged incarceration as shown in the work of Erving Goffman and empirical studies in England led by John Wing (a leading psychiatrist) and George Brown (a sociologist). It was also becoming apparent that the effectiveness of new treatments meant that many of the formerly institutionalized patients could now manage in the community. Enoch Powell, the minister of health in 1960 announced an intention to halve hospital beds by 1975 and shortly thereafter legislation was enacted proposing the complete abolition of the mental asylum system. Deinstitutionalization was also encouraged by the public reaction to scandals involving ill-treatment in asylums. In 1967 a nursing assistant at Ely Hospital in Wales contacted a national newspaper with allegations that many patients were neglected and abused by staff. This triggered a national inquiry that substantiated the allegations and found that the hospital with more than 600 patients with severe learning disability had only 2.5 doctors and a medical director with no formal training in mental health care (Socialist Health Association 1969). This scandal was soon followed by revelations concerning several other asylums and at least 17 inquiries took place in the subsequent decade concerning some of the largest hospital asylums in England. While perhaps the major push for closure was a moral one, there were also strong fiscal incentives with the recognition that the old institutions were no longer financially sustainable. Of interest is the fact that the chairman of the Ely inquiry was Geoffrey Howe, later Chancellor of the Exchequer, and deputy prime minister to Margaret Thatcher. Nevertheless, despite all these pressures, the asylum closure program was quite a drawn-out affair, not finally completed until the mid-1990s.
It would be nice to think that we had learned something about the need for moderation in our treatment and greater caution over potential harms consequent on how we organize and deliver mental health care. But I fear several fundamentals persist. Bubbling along more or less below the surface are continuing concerns about the nature of psychiatric diagnosis, “big pharma,” the psychiatrist as an agent of social control and apparent biases in how treatments are delivered, not least that we in England continue to detain and forcibly treat disproportionately more young black and ethnic minority men. The big institutions may be gone but have been replaced by a plethora of smaller residential “long-stay” settings including forensic units, nursing homes and specialized housing from a wide range of public and private sector providers. The quality of care in this “virtual asylum” is arguably even more difficult to ensure, so it may not be surprising that scandals continue to be uncovered.
A final word on the status of biological approaches is warranted. We are now a quarter-century beyond the launch of the decade of the brain (1990-2000) but little has come from this by way of new treatments of proven efficacy beyond what was available at the start of my training. If anything, efforts to develop new pharmacotherapy is even less than it was in 1990 while it is developments in psychological therapy that have made most progress. Despite this, I imagine there are very few psychiatrists that would deny the benefits of psychotropic medication even if more now share concerns about over-use and the continuing prevalence of high-dose regimens, polypharmacy, and other less well evidenced practice. Outside the profession, opposition to pharmacotherapy persists with fairly regular media reporting of the “explosion” of psychiatric medication in the general population and particular concerns about use in children and the elderly.
I end on a hope that Luc Ciompi is right in his optimism for a new synthesis of biological and social psychiatry.
François Ferrero’s reply
I am grateful to Tom Craig for his personal and very stimulating comment. Tom was fortunate to learn, to practice and to teach Psychiatry surrounded “by the relative equanimity of the English character.”
I wondered what influence British psychiatry had on my early training in the ‘70s and the answer is no influence. The French reference book upon which I relied was that of Henry Ey, Textbook of Psychiatry (Ey, Bernard and Brisset 1974), which proposes an original synthesis of biological, social, and psychological theories called “organodynamics.” In this book, Ey quotes many authors from German, English and American schools. Nevertheless, British influence was practically absent in France and in Geneva, partly because my mentors at that time were mostly oriented toward France and they did not speak English. Moreover, we were not encouraged to complete our training abroad contrary to what was happening in most other departments.
By contrast the influence of English psychoanalysis was much more pronounced and some important authors like Winnicott, Balint, Bowlby and others were quickly translated into French.
There may probably have been other efforts to try to bridge the gap between British and French Psychiatry right after World War II. I would at least like to recall an article by Jacques Lacan which introduced the work of Bion in France. In September 1945, Lacan was in London, and he met Wilfrid Bion and John Rickmann who had jointly published a paper in the Lancet, “Intra-group tensions in therapy. Their study as the task for the group” (1943). Due to their influence, Lacan soon wrote an enthusiastic paper in the journal L’Evolution Psychiatrique, which was directed by his friend Henri Ey, “La psychiatrie anglaise et la guerre” (“English Psychiatry and War”) (1947). He wrote: “We can consider that in these two men the flame of creativity shines.” He considers them “as pioneers of a revolution that transport all our problems to the collective scale” and he underlines the importance and originality of British psychiatry and the influence of psychological sciences, suggesting that in France, “everyone will have to find out.” Is it so surprising? Both Lacan and Bion were interested in the functioning of the human mind and Bion had a good knowledge of French, a language he had learned in France before studying medicine.
(Lacan doesn’t mention Joshua Bierer nor Maxwell Jones, two other pioneers of group psychotherapy [Shorter 1997]).
Unfortunately, Lacan was not followed by many of his French colleagues. I wonder if one could find a possible explanation for this lack of interest in Pierre Pichot’s influential book, A Century of Psychiatry (1983). Indeed, Pichot expressed opinions shared by many French psychiatrists at that time: “During the entire 19th Century, British Psychiatry has occupied an honorable but modest place” and “Sir Aubrey Lewis’ judgment on the weak international influence of British psychiatry undoubtedly corresponds to the facts.”
Later, when I looked for answers to the continued increase in social problems in my service, I began to become aware of certain limits of Sectorization. I discovered the 1976 paper by Christine Vaughn and Julian Leff and I conducted a research project on “Expressed Emotion.” This project led to successful exchanges which helped me broaden my vision of social psychiatry which was essentially based on French authors. It helped me develop a strong collaboration with families and service users.
Tom Craig reminds us that the major drivers of the policy of the closure of hospital asylum and expansion in community care were moral, therapeutic, and fiscal. The same drivers apply also to Geneva psychiatry, with a fourth one being the influence of personal family problems. At the end of the 70s some politicians, including state ministers, were affected in their own families by mental illness and became convinced that time had come to make changes.
Since the first years of public Psychiatry in the 19th century, the relationship between Psychiatry, Society, Finances and Politics was characterized by ambivalence and tensions toward the mission of social control and the ideal of freedom. Even though such a characteristic is not unique to Geneva, we must recognize that conflicts have sometimes contributed to important progress.
In conclusion, I would echo Tom Craig: “I hope that Luc Ciompi is right in his optimism for a future synthesis of biological and social psychiatry.” It will be one of the responsibilities of our successors.
Hanfried Helmchen’s introductory comments
Thank you for asking me to comment on the report by Prof. Ferrero. I think that it is an example of the widespread upheaval in European psychiatry in the 1970s and 1980s as other examples show, such as “the May 1968 events” in Paris (Moussaoui 2002, 2014) or the development and consequences of “law 180” in Italy. This law, initiated by the psychiatrist Franco Basaglia and known as legge Basaglia, was passed by the Italian parliament on May 13, 1978, and started the reform of psychiatry in Italy by closing all lunatic asylums. Initially, it created severe problems for patients and their relatives due to the lack of support for the care of the dismissed mentally ill.
I cannot comment specifically on Professor Ferrero’s report because I have no specific knowledge of the events and their background in Geneva. However, Professor Norman Sartorius will have such an in-depth-knowledge. But I can send you, if interested, a similar report with my own experiences of the corresponding events in Berlin.
There are, of course, more memories of this time, e.g., on ECT, one of the targets of antipsychiatric critics. The director of the large psychiatric hospital “Karl-Bonhoeffer-Klinik” in Berlin once called me in order to transfer one of his long-term patients for ECT (because he and a lot of other psychiatrists had become anxious to perform ECT under the pressure of antipsychiatric groups). I rejected by arguing that he as a psychiatric specialist should perform this standard therapy by himself. A short time later I heard in a radio broadcast the same director denouncing my hospital as the “shocker-clinic.”
In the middle of the 1990s the “red-green” government of Berlin tried to implement a legal prohibition of ECT. I protested against this illegal intrusion into the physician’s freedom to treat (Kurierfreiheit) according to established standards. Nevertheless, following this ideological intention the physician’s parliament of the physician’s board (Delegierten-Versammlungder Ärztekammer) decided that ECT could be performed only after ethical consulting by the physician’s board. Again, I protested, and after a few weeks the president of the physician’s board invited the heads of all psychiatric hospitals for consultation on the indication and application of ECT. After an unequivocal vote of the leading psychiatrists that ECT is an established standard therapy, he assured the conference to vote again in the physician’s parliament in order to reverse 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!
Your invitation to comment on Professor Ferrero’s report stimulated my memories although some of them have lost their precision and some others are presumably forgotten.
François Ferrero’s reply
These comments from Hanfried Helmchen are particularly welcome. They help to broaden the scope of my paper and help to better understand the context, as well as future developments, for example the tentative effort in Germany to implement a legal prohibition of ECT in the mid-1990s.
Of particular interest is Helmchen’s suggestion to return to the 1968 events and I would like to thank him for reminding us of the reference to the excellent biography of Jean Delay by Driss Moussaoui.
My paper does not propose a sufficiently wide perspective of what was going on elsewhere around the world in psychiatry at that time. As with other crises, the Geneva crisis finds his roots in a wider intellectual movement which is well represented by some important books (See Introduction).
Going back to Foucault, even though his theories were then widely criticized, it is of interest to remember that he was trained as a Pathological Psychologist and that he had some clinical experience acquired in Paris’ Sainte-Anne Hospital and in France’s Fresne Prison. He was fluent in German and, at that time, very much interested in phenomenology. He wrote an introduction to a paper by Ludwig Binswanger, “Traum und Existenz” (1930), and published it in French (1954). In 1954, he worked also in the Münsterlingen Hospital, Switzerland, with Roland Kuhn, a representative of the phenomenological movement in psychiatry and well known as the discoverer of Imipramine few years later (Kuhn 1971).
Edward Shorter’s comments
“The Swiss are shooting themselves in the foot”
Written by François Ferrero, a distinguished figure in European psychiatry, this essay is an indictment, not just of Genevan psychiatry in the late 1970s and ‘80s, but of an entire epoch in the history of psychiatry. In those years, psychoanalysis was waning, although by no means vanished, and social-and-community psychiatry was in the ascendancy. Biological psychiatry, as understood in Geneva, seems to have had about the same moral valence as Nazism. If you had a serious psychiatric illness, such as melancholic depression or acute psychosis, you could pretty well forget about receiving effective treatment.
And so, if you did fall grievously ill in Geneva in those years, what was on offer? The clinicians were timidly attempting "sectorization," which is a code word for outpatient treatment in day clinics and halfway houses. Astonishingly, in 1980 they were still offering Jakob Klaesi’s "deep sleep cure," and not just with classical barbiturates but with antipsychotics. And the death of poor Alain seems due not to his "bronchopneumonia," but to acute toxicity from the interaction of a frightening list of medications. So, polypharmacy, for sure, was on offer in Geneva, despite the routine incantations against "biological treatments."
And what was not on offer? The clinicians (and probably the nursing staff) seem to have been hysterically opposed to convulsive therapy. The two ECT devices were "stolen" in 1980 and deposited symbolically in some public place. The message, "See what awful things they're doing at Bel-Air!" The ECT devices were never replaced and when, years later, Ferrero made inquiries about the status of ECT in the university psychiatric hospital, he was told that the prohibition of ECT in Geneva "is similar to a custom which somehow has the force of law." In other words, community opinion is so strongly opposed to ECT that we needn't bother formally outlawing it. It is unclear how these clinicians might have treated patients with melancholia, psychotic depression, delirious mania, and lethal catatonia -- evidently with the resources of social-and-community psychiatry. In retrospect, this constitutes a flagrant violation of the moral obligation to provide effective treatment.
Ferrero is very interested in local political issues, such as who is in charge of what service. And to the people of the time, this doubtless appeared to be of vast importance. Yet with the perspective of 40 years, these matters are trivial. The main point is that the social fashions of the 1970s and ‘80s -- rather than medical science -- guided the therapeutic choices of these Genevan clinicians. And the social fashions were profoundly anti-therapeutic.
Today, Swiss psychiatry is embroiled in another of these convulsions, this time inveighing against the drug trials of the 1950s and ‘60s as somehow ethically deficient. No signed consent forms! No videotaping of patient agreement to take part in psychopharmacological investigations! The horror! Even today, the Swiss succeed in shooting themselves in the foot.
François Ferrero’s reply
It is not an easy task to answer to Ned Shorter’s passionate and critical statement because he uses generalizations such as “The Swiss,” or phrases such as: “Biological psychiatry, as understood in Geneva, seems to have had about the same moral valence as Nazism.”
Despite my admiration for his wonderful publications and brilliant career, I cannot follow all his comments. In Geneva in the ‘80s, the comparison to Nazism could have been shared by a maximum of two or three dozen very active people linked to the Extreme Left. Nonetheless, even in those troubled years, most of the public, including the patients, their families and the medical community was expecting a more integrative Psychiatry in Bel-Air, more space for other approaches in the treatments as well in the teaching of other than biological psychiatry. The conclusions of the Investigative Committee expressed the same wish.
This request for an integrative Psychiatry was not original and was in line with George Engel’s famous 1977 paper on the bio-psycho-social model (Engel 1977).
Electroconvulsive therapy was not, by far, representative of the entire domain of biological psychiatry and moreover only two Psychiatrists openly refused it despite the strong opposition in the community opinion.
After the 1982 psychiatric reorganization and despite difficulties, the Geneva University Psychiatric Institutions were able to deliver efficient treatments to all kind of patients and to stay creative.
In my paper I tried to put the 1980 Geneva drama in its historical context and to provide understanding, not only the drama itself, an individual tragedy, but also how a group of well-known and talented professionals was able to ignore the danger of the situation. I also wonder how the entire “System,” including psychiatry, medical faculty, university, media, and the public reacted to it.
In my answer to Barry Blackwell’s comment, I underlined the role of politicians. No doubt that a very small number of “Activists” were successful in “tetanizing” many politicians on such matters as electroconvulsive therapy. I cannot respond to Shorter without considering the wonderful additional information provided by Hanfried Helmchen (2018). It would be very interesting to know more about what was going on in other countries.
Going back to Geneva, I must acknowledge that one unfavorable characteristic of the psychiatric organization was the monopolistic situation of Bel-Air which probably represented a specific risk. At the time, it was the only Psychiatric Hospital and no private psychiatric beds existed. The situation was completely different for ambulatory treatment with a great number of psychiatrists and psychologists working in private practice.
Despite that, in some cases, thanks to the health insurance system, it was possible to hospitalize a patient in another Canton, mainly Vaud or Valais. The closest alternatives were the Rives de Prangins Hospital and the private clinic, La Métairie, in Nyon, located 30 kilometers from Geneva. We used this clinic in particular when a colleague or someone working in Bel-Air had to be hospitalized.
Barry Blackwell’s comments
Confusing Zeitgeist or wider implications for psychiatry?
Ferrero’s essay is interesting and thought provoking although clearly ongoing. Realistically, however, it is also an incomplete and unresolved glimpse into the micro-climate of the capital of a Swiss Canton at the time of worldwide turmoil, as psychiatry struggled to define its relationship to its biological, psychological, and social building blocks.
Obviously, the final analysis will be related to the personas of the principal actors in the drama and the local social, political, and scientific climate. Some of these are described in detail but are not yet clearly linked to the distress and dilemmas they created.
In a nutshell, this scenario is similar to the Osheroff case in America which erupted in the mid-1980s over the psychiatric patient’s right to effective treatment – psychodynamic psychotherapy or medication for depression.
History suggests 1980 also marked a worldwide watershed between psychoanalytic, biological, and biopsychosocial paradigms. In America it was the year DSM-III delivered a multi-axial diagnostic system based on consensus definitions that neglected classical etiologic and descriptive syndromes. Biological enthusiasts considered it a definitive triumph for an ego-inflating integration of psychiatry into the mainstream of medicine although doubts about its validity are prevalent and persist (Wakefield 2016).
Well before 1980 there were disturbing controversies about the role of specific psychiatric treatments, including insulin coma therapy, and the need for informed consent (Sharma 2015). In France Jean Delay’s impeccable career and world-famous Institute were disrupted by student riots fed by Communist innuendo that it was abusive and inappropriate to treat schizophrenia with medication (Blackwell 2014). The telltale fate of Delgado’s advocacy for electrical brain stimulation ruined his career in America (Blackwell 2013). Finally, worldwide ECT has endured scrutiny and denigration that Kellner (2011) compares to abortion. His references from 1982 on support the contention that, “Almost all the controversy about ECT is anecdotal, unsupported by evidence.”
Perhaps the real purpose and questions posed by Ferrero’s Geneva crisis are to what extent is this just another interesting example of the influence of an evolving and confusing Zeitgeist or does it have unique and wider implications for psychiatry worldwide?
François Ferrero’s reply
I am grateful to Barry Blackwell for his appreciation of my essay and to acknowledge that it is “incomplete.” I am fully aware of that. I tried to base my paper on solid sources avoiding, up to now, expressing my personal opinions. Nonetheless, such stimulating comments encourage me to go further.
I would like to add one dimension to his remark that the “final analysis will be related to the personas of the principal actors in the drama and the local, social and scientific climate.”
It concerns the political dimension.
It is obvious that the general climate in Geneva at that time was influenced by personas. However, this statement has to be put in relation with a long conflicting history between the Political world and Psychiatry, represented by some Directors of Psychiatry. This conflictual relationship goes back to the creation of the first psychiatric asylum in Geneva in 1832, a topic developed in part 4. That is to say, the 1980 drama and its consequences must be contextualized and replaced in a long history.
I have to admit that at the time, at the end of ‘70s, I was less aware of the political dimension of these conflicts.
Since then, I have understood that this drama offered a unique opportunity for the Right to take over the Geneva Ministry of Health after about 20 years of Socialist power. Since the ‘80s the Right has never abandoned it.
Of course, these events have created great distress and dilemmas and I have probably not sufficiently developed this aspect.
Yet, I did point out: “these 12 months were difficult for the psychiatric teams and probably for many patients… The collaboration between Colleagues working in the psychiatric Hospital or in the Outpatient Clinics was extremely limited.”
There was a lot of suffering during these years, and we lost a lot of energy. Despite that, some talented people were able to succeed, to stay creative and to develop valuable research projects.
Barry Blackwell’s response to François Ferrero
François Ferrero’s reply concerning the Geneva Crisis gets to the root of the problem with a switch in 1980 from socialist to Right wing political power – presumably Republican or capitalist. This coincides precisely with an eight-year period of Republican political dominance under President Ronald Reagan in America. The legislation passed by Congress during that time, combined with other societal changes, created a zeitgeist leading to the corruption of the psychopharmaceutical industry that was also enabled by members of a complicit psychiatric profession with unchecked “conflicts of interest” (Blackwell 2016).
This has resulted in the demise of ethical neuropsychopharmacology to the point where the American College of Neuropsychopharmacology (ACNP), founded in 1961, is considering changing its by-laws and name to replace “Neuropsychopharmacology” with “Neuroscience.”
It will be interesting to hear if events in Geneva mirror those in America.
François Ferrero’s reply
Regarding the differences between the USA and the Geneva’s situation, the main one is that Geneva and, more generally Switzerland, have never faced such a deinstitutionalization movement. If the number of psychiatric beds has decreased gradually, the budget allocated to psychiatry was also increased regularly at least until the last important reform in 2000. It was then possible to support the development of outpatient clinics and of many alternatives. This continuous development was made possible thanks to an important financial support by the government which includes the support of numerous therapeutic innovations as well as patient associations.
David S. Janowsky’s comments
How to be a Centrist?
I found the article to be most interesting, especially from my point of view as a psychiatrist trained in the USA in the mid-1960s. I have known nothing of the events that occurred in Geneva in the 1970s and 1980s, but these events have a remarkably familiar ring to them. This is in part because I believe that at that time I stood soundly in the middle of the themes and conflicts of the times and was a centrist in my point of view. In my time as a young psychiatrist, I ran two “therapeutic communities,” attended on a conventional ward and served as director of a crisis emergency service in a public hospital. I practiced as a psychotherapist and as a biologic and pharmacologic practitioner and researcher. Here are some of my impressions:
The 1970s were a very interesting time. Psychiatrists located in the community had traditionally practiced psychotherapy and/or psychoanalysis, giving psychiatric drugs as needed with some trepidation. Others practiced as inpatient doctors in public and private facilities, for the most part being biologically oriented, usually having large caseloads consisting of patients who for the most part remained chronically ill and who experienced long hospital stays.
As biologic psychiatry and psychopharmacology evolved over the 1960s and 1970s, a schism evolved and grew, with ardent supporters of what each group believed consisting of acceptable treatment and point of view. I believe there was, overall, mutual tension between those who believed in the biologic psychiatry revolution (clinicians and researchers in and out of academia) wherein discovery of the right molecule and/or the right drug would be a cure-all for mental illness. These biological practitioners and researchers considered themselves to be purveyors of the truth and looked with some disdain, maybe even contempt, on their psycho-dynamically/psychoanalytically oriented peers. Similarly, at the other extreme, those who believed in the power of psychotherapy and psychoanalysis (those who initially were the predominant group) considered their biologically oriented brothers and sisters to be shallow, rigid, the antithesis of the humanism that psychiatry was supposed to represent.
To add to the mix, psychiatry, at least in my eyes, was considered somewhat of a joke of a medical specialty, thought of by fellow non-psychiatric physicians to consist of pseudo physicians who were fuzzy headed and impressionistic, practicing more of a religion or a cult than a scientifically based endeavor and looking to cure their own problems. I personally was subjected to such pressure from peers and family as a medical student, as well as to the irony of being told I was too sane to be a psychiatrist. Developing a medical model based on neuroscience and psychopharmacology offered the hope of legitimacy and peer respect; it gave structure to what seemed more mystical than objective. Finally, psychiatry was to be a science.
Furthermore, the growing influence of clinical psychologists and clinical social worker psychotherapists presented a growing threat to the psychotherapy-practicing psychiatrists, edging psychiatrists toward a niche as drug dispensers at the extreme.
All of this was also reflected in the “revolution” of the times: the schism between the “hippy generation” and those of a more conventional bent. The cultural revolution of the 1960s and 1970s reflected a contempt for the “establishment” — freedom, a focus on the experiential which often included experiencing the hallucinatory effects of drugs, the brotherhood of mankind and a revulsion to the Vietnam war. It would be natural that those who identified with such concepts would on average be attracted to more humanistic and socially oriented treatments, those focused on self-actualization, whereas the more cognitively oriented might be more interested in the miracle of psychotropic drugs, biological remedies and the treatment of named and identifiable diseases, rather than in states of mind. The therapeutic community, with its blurring of roles, its delegating of influence and decision-making to patients and decision-making by consensus, reflected an extension of the humanistic point of view. This contrasted with the pyramidal structure of the usual psychiatric inpatient units which predominated and predominate to this day.
Adding to the mix was an anti-psychiatric bias by a sector of the pubic and some patients and their families, as well as organizations such as NAPA (Network Against Psychiatric Assault) and scientology, which were strongly against such treatments as ECT, antipsychotic medications, forced hospitalization and involuntary drugging. These groups and individuals were able to exert strong political pressure and to accomplish regulatory legislation to control the purported “abuses.”
My hypothesis is that the above influences and the differing personalities which tended to align with each side of the divide, led to the difficulties Dr Ferrero describes. Here, and I will speculate — I am relatively sure that Dr Tissot was a hard-core biologist, actually a would-be neurologist who had a more authoritarian, analytic and judging personality. I would guess that Drs Garrone and Haynal were relatively more inclined toward having more flexible, feeling, open-to-change, nonjudgmental personalities, and perspectives. Having to work together within the format of a sectorization organization based on a continuum of care probably proved very difficult. This was especially true in the case of the Geneva crisis, since there was no obvious strong leader to integrate the opposing perspectives, or mandate that one or the other go along with the leader’s philosophy or go elsewhere.
François Ferrero’s Reply
David Janowsky’s exceptional experience sounds very familiar to me, and I confirm that it was not an easy task during the ‘70s and ‘80s to defend such a position as a “Centrist.”
His remark about psychiatrists who practice psychotherapy, or even psychoanalysis, and give psychiatric drugs with some “trepidation,” evokes a lot of memories. During my post graduate training in Geneva and Paris I received much better training in psychotherapy, with a lot of individual and group supervision, than I did in psychopharmacology which was, including in Bel-Air Hospital in Geneva, definitely poor. At that time, there was no drug monitoring, and our knowledge of adverse events and drug interactions was also extremely limited.
For most of my colleagues in training, it was a true problem to combine psychiatric and a psychotherapeutic treatment. This question was discussed openly with Daniel Widlöcher during my postgraduate training in Paris. Daniel Widlöcher was a famous, very respected, and open-minded French psychoanalyst, child psychiatrist and professor at La Salpêtrière in Paris.
He proposed working jointly with a colleague and sharing the responsibility of treatment, assuming alternatively for one Patient the role of the Psychotherapist and for another Patient the role of the Psychiatrist.
It was a pretty complex organization which required very good collaboration and strong confidence between the two colleagues.
Back to Geneva: I decided not to follow Widlöcher’s suggestion and began to combine both responsibilities.
I was convinced that Switzerland had some good assets for organizing combined treatments, thanks to a double title of MD, specializing in psychiatry and psychotherapy.
This interesting page of the history of Swiss psychiatry goes back to 1931, with the adoption of the first regulation of the medical specialties by the Federation of the Swiss Medical Doctors (FMH) which introduced a separation between psychiatry and neurology.
(I will not discuss here the implications and consequences of such a decision which was also made in France in 1969 under the pressure of the “Young Psychiatrists.”)
In 1935 a meeting of Swiss psychotherapists was held in Zurich with 33 participants. This meeting introduced the first split in the community of psychotherapists with the creation of two societies: the Swiss Society of Medical Psychotherapy, headed by Walter Morgenthaler and supported by the majority of MDs; and the Swiss Society of Practical Psychology, led by Carl Gustav Jung. Jung was of the opinion that the interests of psychotherapists and psychiatrists were too different (divergent) for developing a fruitful collaboration. His Society attracted mainly non-MDs.
Going back to Janowsky’s comment: I fully agree with his description of the cultural revolution.
As mentioned in my answer to Barry Blackwell, the main question at that time, at least from my point of view, was that of the relationship to authority in every domain of society.
Janowsky’s last paragraph is fascinating to me: How is it possible to have such a clear understanding of what was going on in the small city of Geneva?
David Janowsky’s response to François Ferrero
I very much enjoyed all the comments and dialogue concerning Ferrero’s essay and his reply to my comment. I will limit my comments concerning Ferrero’s reply to one issue. Dr. Ferrero’s last sentence reads: “Janowsky’s last paragraph is fascinating to me: How was it possible to have such a clear understanding what was going on in the small city of Geneva?” My answer is that I applied the components of the Myers Briggs Type Indicator (MBTI) (Myers and McCaulley 1998), a somewhat controversial temperament measuring device used widely in management and industry, that I have used previously to profile depressed and suicidal patients (Janowsky, Hong, Morter and Howe 2002; Janowsky, Morter, Hong and Howe 1999).
The MBTI divides temperament/personality into four dichotomies: extroversion/introversion, sensing/intuitive, thinking/feeling and judging/perceiving. It is similar in many ways to the more popular 5-factor NEO Personality Inventory scale (MacDonald, Anderson, Tsagarakis and Holland 1994). The MBTI components are as follows:
· Extraverts (E) - sociability, interaction, external, breadth, extensive, gregarious, speak than think, multiple relationships, energy expenditure
· Introverts (I) - territoriality, concentration, depth, intensive, energy conservation, reflective, limited relationships, internal reactions, reflective, think than speak
· Sensors (S) - direct, present, realistic, actual, down to earth, fact oriented, practical, specific
· Intuitives (N) - random, future oriented, conceptual, inspiration, theoretical, head in clouds, fantasy, ingenuity, energy conservation
· Thinkers (T) - objective, firm minded, law oriented, just, clarity, analytical, policy, detached, firmness
· Feelers (F) - subjective, tenderhearted, focused on circumstances, uses persuasion, humane, harmony, appreciative, social values, involved
· Judgers (J) - resolved, decided, fixed, control oriented, closure, planned, structure, definite, scheduled
· Perceivers (P) - pending, wait and see, flexible, adaptable, open ended, openness, flow, tentative, spontaneous, what deadline
Given the possible combinations, there are thus 16 types (INFP, ENFP, ISTP, ISTJ, etc.) which represent different styles of interacting and perceiving as well as styles of management and job preferences. For example, of 61 chemistry scientists surveyed, 0% had an ENFP profile whereas, in contrast, 16.39% had an ISTJ profile. Of 177 rehabilitation counselors, 20.34% were ENFP types and 5.08 % were ISTJ types. Of the chemistry scientists, 72.13% were thinkers and 27.87% were feelers. In contrast, of 177 rehabilitation counselors, only 33.33% were thinking types and 66.67% were feeling types (Myers and McCaulley 1998).
An abbreviated vignette describing the ISTJ MBTI type was written as follows: Serious, quiet, earns success by concentration and thoroughness. Practical, orderly, matter of fact, logical, realistic, and dependable. See to it that everything is well organized. Take responsibility. Make up their own minds as to what should be accomplished and work toward it steadily, regardless of protest and distractions (Kroeger and Thuesen 1992).
A vignette for the ENFP type is as follows: “Warmly enthusiastic, high spirited, ingenious, imaginative. Able to do almost anything that interests them. Quick with a solution for any difficulty and ready to help anyone with a problem. Often relies on their ability to improvise instead of preparing in advance. Can usually find compelling reasons for whatever they want” (Kroeger and Thuesen 1992).
Given the contrasting job interests and probable work styles of Dr Tissot versus those of Drs Garrone and Haynal, and some of the behaviors mentioned by Dr Ferrero in describing these individuals, I was able to speculate as to their opposing personality and philosophical biases and how these could have caused clashes.
Carlos Morra’s comments: The re-emergence of anti-psychiatry in Latin America
I noted that in the exchange that followed the presentation of François Ferrero’s essay the possibility that events taking place in Geneva well over 30 years ago, anti-psychiatry might have played a role.
I thought it might be relevant to bring to attention the fact that the anti-psychiatry movement has remained alive; in the last few years Argentina experienced the reappearance of it.
In the disguise of defending patient’s rights, the government proposed eliminating psychiatric clinics and hospitals. The role of the psychiatrist as coordinator of the mental health team was questioned and the psychiatrist was equated with all the other members of the team in decision making regarding patient´s treatments and hospitalizations. The training of a psychiatrist was considered to be equivalent to that of a general practitioner and a psychologist together and if an institution has both, a psychologist and a general practitioner, it was legislated that there was no need to for a psychiatrist to treat patients with mental disorders.
The denial of mental illness and its replacement with a new concept labeled subjective mental suffering led treatment, especially for chronic mental patients, outside of psychiatric practice - they should never be hospitalized in a psychiatric clinic. In case of acute episodes, patients should be treated in a general hospital. Otherwise, they should be left on their own without any consideration that most of these patients become homeless and many may be prosecuted and jailed.
This thinking is being legislated currently in Argentina supported by the Pan-American Health Organization (PAHO), founded in 1902.
Barry Blackwell’s comments on Carlos Morra’s comments
Carlos Morra expresses concerns about the anti-psychiatry sentiment contained in the pending National Law of Mental Health (No.26, 657) which the Argentine government intends to implement country-wide and impose on the Morra Foundation and its hospitals on January 1, 2020 (Morra 2019).
One can understand why, at first glance, this can be construed as anti-psychiatric. It proposes replacing mental illness with a concept labelled subjective mental suffering, treatment for which should be carried on “outside the hospitalization setting and within the principles of primary health care or in general hospitals in the public network.”
Treatment teams must be interdisciplinary, “made up of professionals, technicians, and other trained workers with due accreditation of the competent authority. This includes the areas of psychology, psychiatry, social work, nursing, occupational therapy and other disciplines or relevant fields.”
Certain aspects of treatment including involuntary hospitalization and imminent risk must be attested to by two professionals from different disciplines, one of whom must be a psychologist or a psychiatrist.
Every hospitalization and each institution must be approved of and monitored by a Review Board and a judge “to protect the human rights of users of mental health services… The Board shall consist of representatives of the Ministry of Health, the National Human Rights Secretariat, the Ministry of Defense, user and family associations, professionals and other health workers and non-governmental organizations committed to the defense of human rights.”
This legislation is derived from principles identified by a variety of national and international bodies including the United Nations, the Pan-American Health Organization, and the World Health Organization.
It would be intrepid and foolhardy for a psychiatrist from a different nation and culture to pick apart the details of this legislation and its imminent implementation. It is highly idealistic, even praiseworthy in its intent to stifle stigma and unify behavioral health with primary care. It is also complex, bureaucratic, unwieldy, and almost certainly costly to the public purse and will confront the same obstacles and pitfalls that have bedeviled other nations’ attempts to provide humane, effective, and decent treatment for people who suffer from “severe and persistent mental illness,” different from “subjective mental suffering,” a somewhat diminutive and trivializing term.
A synopsis of my own experience: trained in Britain at the Institute of Psychiatry and Maudsley Hospital, followed by a life-time career in America may offer a worthwhile perspective. Complex biopsychosocial predicaments, public stigma, imperfect treatments, unpredictable costs and large profit margins stifled and corrupted the best of intentions (Blackwell 2011).
During the 19th century in America Dorothea Dix struggled mightily to persuade the Federal Government to assume the cost of treating severe mental illnesses but when Congress declined, care devolved onto state and county asylums. Located at a safe distance and out of sight from urban communities they were partially funded from farms run by inmates which social activists parsed as slavery. Religious principals followed and when they too failed to cope with the size of the population extreme physical methods intruded: ECT, lobotomy, insulin coma, cold showers, and potent sedatives.
In mid-20th century chlorpromazine arrived, followed rapidly by other “ant-psychotic medications.” These anti-psychotic medications stifled hallucinations and delusions, restored some insight but failed to restore the necessary cognitive and social skills needed to survive in the community. And, in the early 1950s and 1960s “deinstitutionalization,” also known as the “revolving door,” shuttled patients back and forth between asylums and local communities.
In 1963 a well-meaning President Kennedy persuaded congress to pass the Community Mental Health Act. Over 17 years it funded 789 Community Mental Health Centers (CMHC’s) at a cost in today’s dollars of $20.3 billion. The intention was that “the cold mercy of custodial institutions would be supplanted by the open warmth of community concern and capability.” As psychiatrist Fuller Torrey and the Treatment Advocacy Center would document, this failed (Torrey 2013). The CMHC’s treated only between 3-7% of patients released from asylums, preferring instead to treat the “worried well.” While half those with severe and persistent mental illness who had intact families did well, the remainder failed. Meanwhile 75% of the asylum beds were now gone; many sufferings severe mental illness had no medical insurance, and some became homeless.
In 1981 President Reagan was elected; he “trimmed the Welfare Rolls” making matters worse and moved the Federal money for mental health from community care and into “block grants” for states to allocate at their discretion, some of which trickled down to city homelessness programs.
In 1996 Congress passed the Mental Health Parity Act which, for the first time, provided mental health insurance coverage and mandated “parity” with medical and surgical coverage. Congress failed to specify guidelines and for several years insurance companies developed their own restrictive guidelines that undercut the legislative intent. Caps were imposed on hospital days and outpatient visits as well as annual and lifetime limits. In 2008 Congress passed the “Mental Health Parity and Addiction Equity Act” limiting these practices but failed to include a mechanism to monitor compliance or evaluate the implementation of statutory requirements.
From 1980 until my retirement in 1994 I was founding chair of an academic psychiatry program located at an urban inner-city hospital in mid-West America. This was a time of increasing income disparity and corporate greed. Medicine became a business rather than a profession. We set up a residency training program but many of our inner-city patients still had no mental health insurance. The Federal Government passed legislation stipulating lengths of stay for inpatients, reducing hospital revenue. In two decades, seven inner city hospitals went bankrupt and those surviving were taken over by large health care corporations, allegedly “not-for-profit.” With an eagle eye on the bottom line, they were unwilling to accept the low payments associated with mental health insurance for the indigent. My inner-city hospital was forced to close the psychiatric inpatient unit and terminate our training program.
Our local university hospital had never had an inpatient psychiatry unit and together all the not-for-profit health care corporations declined to accept psychiatric patients in their emergency rooms, relying on the county public hospital beds to accommodate them. While their main motivation may be economic, they also seek to avoid psychotic patients who might disturb their pristine milieu. Mental health services in our city are now severely depleted. It often takes weeks, sometimes months to obtain an outpatient appointment.
As a founding member and contributor to the International Neuropsychopharmacology History Network (INHN) I am delighted that it has found a new home with the Morra Foundation and wish it well as it adapts to these new legislative mandates. As a pragmatist and amateur historian, I feel obliged to share an old metaphor that reminds us “The road to hell is paved with good intentions.” I hope they really are “good” and that the “road” is consequently smooth. Google ascribes this wisdom to either “a murky English origin” or to “Saint Bernard of Clairvaux,” who first penned it in the French language during 1732.
Hector Warnes’ comments on Carlos Morra’s comments
I just read Carlos Morra’s comment on François Ferrero’s essay as related to the anti-psychiatry movement and would like to comment that I lived through the anti-psychiatry movement.
I never met Thomas Szasz, one of the leaders of the movement, but in my opinion, he was one of the most brilliant psychiatrists I ever heard or read. He raised important questions regarding the validity of many psychiatric diagnoses, and we are still doing the same. The real anti-psychiatry leaders were mostly radical left psychiatrists like David Cooper and the Sartre admirer, Ronald Laing and even the more militant Franco Basaglia from Italy. Some of the issues raised by David Healey were also raised by Szasz. Anti-psychiatry has many connotations: moral, ethical, human rights, political, cultural, and social.
In Argentina the movement is related to power conflicts between psychologists and psychiatrists. The former has acquired a great deal of power and believe they are entitled to take over medical territories, as well as to be the spokespersons for the countless forms of psychotherapy; they even applied for brief training in psychopharmacology to deal with acute cases. Many forensic psychologists are called to court regarding their evaluation of psychiatric patients as they seek to take over the field previously handled by psychiatrists. On the other hand, neurologists have taken over the field of degenerative brain disorders, epilepsy, attention deficit disorders and autism. The latter is also handled by psychologists and child psychiatrists. Autism is really a spectrum disorder with countless possible etiological factors. Most psychiatrists have followed the "American way" and have no training in psychoanalysis, practicing instead what is called biological psychiatry.
Regarding the new Mental Health Act: in my opinion has more to do with human rights but I agree with Carlos regarding the trend to enact laws affecting psychiatric patients by a team integrated with social workers, psychologists, lawyers, sociologists and maybe one psychiatrist chosen by a psychologist.
March 17, 2022