François Ferrero: Inquiry of the Geneva 1980s’ Psychiatry Crisis
François Ferrero’s reply to Edward Shorter’s comment

           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 impressive 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, the majority 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.

           The request for a more integrative Psychiatry was not original and was in line with George Engel’s famous 1977 paper on the bio-psycho-social model (Engel 1977).

           Moreover, electroconvulsive therapy was not, by far, representative of the entire domain of biological psychiatry: as has been now corrected in my paper, only two Psychiatrists openly refused it.

           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 (Ferrero 2019b). 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 (Ferrero 2019a), 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 taking into account 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 have to 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 praxis.

           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.

           At this point in our exchanges, I guess it could be useful to briefly describe some of the originalities of the Swiss political organization and its influence on psychiatry. I hope it will contribute to a better understanding of my answers to Shorter.

Some characteristics of Switzerland

·         Switzerland was never a centralized State, but a Confederation of Cantons, which was progressively built between 1291 and 1815, piece by piece, that is to say, Canton by Canton. Every Canton has his own Government including a ministry of health, teaching, security or economy etc. The advantages are numerous for the health care system, too: the Canton is not only responsible for guaranteeing access to care for its population, it is also responsible for its organization. Thanks to this system, politicians remain in close contact with the population. The question of whether to increase the power of the Federal Government is a matter of continuous discussion, not only through numerous votes following an initiative or a referendum. The main point is to reach a broad consensus.

·         In line with this organization, every Canton has its own General Hospital and, with very few exceptions, its own Psychiatric Hospital. The majority of these were created between 1835 and 1900. This explains why Switzerland had never huge Psychiatric Hospitals.

·         Since the second half of the 19^th century, five Cantons have a Medical Faculty: Geneva, Lausanne, Bern, Basel and Zurich; the five Medical Directors of these faculties were also appointed Chair of Psychiatry at their respective University.

·         As early as 1888, psychiatry was included as a mandatory domain for the federal final exams and for receiving the title of MD.

·         Nearly all psychiatric hospitals are recognized as centers for postgraduate training. This responsibility was never delegated exclusively to the University Hospitals.

·         All psychiatrists are members of the Society of Psychiatry -- now the Swiss Society of Psychiatry and Psychotherapy. The advantage is to promote close contacts between psychiatrists working in different settings, such as  public services, universities, private practice or in private psychiatric clinics.

·         A long tradition of continuity exists between the hospitals and the outpatient clinics, as well as between university departments and Cantonal or private hospitals.

·         Some of these hospitals had an international reputation: Kreuzlingen with Ludwig Binswanger, Münsingen with Max Müller, Münsterlingen with Roland Kuhn, etc.

·         Medical Directors usually received their training in foreign countries, e.g.,

           Eugen Bleuler (1857-1933), was not only trained in Zürich with August Forel, but also in Paris with Charcot, and in London and Munich with von Gudden. His first position as Medical Director was at the Zürich Psychiatric Cantonal Hospital Rheinau, and not at the University Hospital. Bleuler was the first Medical Director at the famous Burghölzli who was able to speak Swiss German with his patients. The majority of the previous Medical Directors, who came often from Germany, were speaking only Hochdeutsch (high German taught in schools).

           Carl Gustav Jung (1875-1961) trained in Zürich with Eugen Bleuler, in Paris with Pierre Janet and Alfred Binet and in London before coming back to Zürich and receiving his title as adjunct Professor at the University in 1904.

           Ludwig Binswanger (1881-1966) trained at Burghölzli with Bleuler and Jung, and also in Lausanne and Heidelberg before taking the responsibility of the Bellevue Clinic in Kreuzlingen, (Thurgau), a clinic owned by his family.

           Hermann Rorschach (1884-1922) trained in Neuchâtel, Zürich, Bern and Berlin. His first important position was at the Münsterlingen Klinik (Thurgau). He then moved to the University Hospital Waldau in Bern and became finally Adjunct Medical Director at the Cantonal Psychiatric Hospital in Herisau (Appenzell).

This list could be much longer.

           The goal here is to provide an understanding of at least three characteristics of Swiss Psychiatry: first, the absence of a unique School of reference; secondly, its great diversity, enriched by many different influences and traditions; and thirdly, its continuous exchange between Cantonal and University Hospitals.

           The Swiss organization allows me to explain why Shorter’s comment, “Even today, the Swiss succeed in shooting themselves in the foot,” is inappropriate. The ongoing investigation of potential ethical problems in drug trials by Roland Kuhn has nothing to do with a Swiss centralized political decision. It is exclusively the responsibility of the Thurgau Canton where the Münsterlingen Psychiatric Hospital is located and where Roland Kuhn was the Medical Director.

           With Pierre Baumann, we have already presented on the INHN website some “Preliminary notes on the official inquiry of the clinical research activities of Roland Kuhn” (Baumann and Ferrero 2017). An additional version will follow the publication of the official report.

           While I could also devote a paragraph to Sectorization, which has not much in common, at least in Geneva or elsewhere in Switzerland, with Shorter’s caricatural presentation, it will be part of one of further commentaries.

References:

Baumann P, Ferrero F. An official inquiry of the clinical research activities (1946-1972) of Roland Kuhn (1912-2005) - Preliminary notes. INHN June 1, 2017.

Engel G. The need for a new medical mode: a challenge for biomedicine. Science. 1977; 196: 129-136.

Ferrero F. François Ferrero’s reply to Barry Blackwell’s comment. Inquiry of the Geneva 1980s’ Psychiatry Crisis. INHN Feb. 7, 2019a.

Ferrero F. Summary of Alain’s Autopsy. François Ferrero: Inquiry of the Geneva 1980s’ Psychiatry Crisis. INHN Feb. 14, 2019b.

Helmchen H. Comment. Francois Ferrero: Inquiry of the Geneva 1980s’ Psychiatry Crisis. INHN July 26, 2018.

February 28, 2019