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From the catastrophe to a humane mental‐health care and successful research in G erman psychiatry (1951–2012) – as I remember it

2013; Wiley; Volume: 127; Issue: 6 Linguagem: Inglês

10.1111/acps.12061

1600-0447

Heinz Häfner,

Psychosomatic Disorders and Their Treatments

Since I took up my first job as a resident at the Psychiatric Hospital of the University of Tübingen on 1 June, 1951, psychiatry, in Germany in particular, has undergone a barely imaginable change. A professional life of more than 60 years spent under such conditions is not easy to condense. In addition, my duties outgrew those of a mere physician, researcher and an academic teacher at various points of my professional career. For this reason, I can offer only fragments from my past. I grew up in a family of entrepreneurs in Munich, Germany. They were as down-to-earth as they were cosmopolitan. Since 1540, my ancestors had run a farm with an attached brewery and later a hotel in the small Franconian spa town Streitberg. The family had never before produced medical doctors. My initial plan was to study chemistry, hoping to be able to one day engage myself in productive research in this rationally structured discipline. But the world did not remain what it was back then. I spent my youth in the National Socialist era and during the Second World War. My parents were staunch opponents of the Nazi regime. After Hitler's rise to power in 1933, my best friend's father, the editor of the Münchner Neueste Nachrichten, Erwein von Aretin, was brutally beaten up by members of the National Socialist Sturmabteilung (SA). The execution of a few hundred men without a court trial in the so-called Röhm Affair in 1934 was another event that truly upset my parents. In 1936, our milkman returned from the concentration camp of Dachau in a battered state. In the following years, I experienced many a farewell of my parents’ Jewish friends who were forced to emigrate. Early experiences like these are impossible to forget. At the age of 10 in 1936, I was forced to join the Hitlerjugend (HJ, Hitler Youth). As a teenager, I ignored my parent's warnings, sometimes defiantly voicing my political convictions. A senior HJ leader filed a report about me. As a 14-year-old, I was not yet criminally responsible, so I was brought before a regional HJ court. The sentence was one of degradation – I had been a kind of lower officer – and a ‘dishonourable discharge’ from the HJ on the grounds of subversive statements. This event alarmed me and my parents a great deal. Excluded from the HJ, I no longer had to attend roll-calls, military training and political indoctrination courses. Instead, I was assigned to ‘alternative war service’, for example, working on farms, painting lane markings on streets, working in railway transportation and cleaning up after air raids. These tasks in a variety of settings were a useful experience I could later profit from as a psychiatrist. In January 1943, I was drafted as an air force helper, but discharged from military service in the November of the same year because of an otitis media associated with severe complications. In March 1944, I finished school with A-levels. Five years into the war in 1944, medicine offered the only possibility to begin university studies. At the beginning of the war, several hundred chronically ill and disabled patients, mostly people with mental retardation or cerebral palsy, including many children and adolescents, lived at this nursing home for the mentally and bodily ill, founded by a Catholic order and run by a priest. Nearly one in two patients fell victim to ‘euthanasia’ between 1940 and 1945. (Der Spiegel 21/1978 in the author's translation) After its partial closure as an asylum, Schönbrunn became an auxiliary hospital and began to take over functions from the Nymphenburg-based hospital in the summer of 1944, because the latter was increasingly at risk of being bombed. Schönbrunn hence became a military hospital for patients with lung shots. Because of a shortage of doctors, I was ordered as a young medical student at the Schönbrunn hospital to help provide outpatient medical care for the population. The encounters with the parents and siblings of the mentally disabled patients who had been taken away for being killed confronted me with the crime committed on the sick and disabled and the agony this caused to their families. The Nazi regime's murderous programme robbed some 260 000 ill and disabled persons of their lives 1. Thirty-four psychiatrists, most of them in leading positions, had actively participated as experts in sealing these patients’ fate. Numerous other people working at psychiatric institutions had been involved in a more passive way 2. For a list of the T4 experts and a list of experts participating in children's euthanasia see: http://de.wikipedia.org/wiki/T4-Gutachter. After the war, the situation in Germany was utterly disastrous: I was one of the rare young men who had survived National Socialism and the war suffering only modest consequences (deafness on one ear). There were many of us survivors who felt a need to contribute not only to the material, but also the moral reconstruction of Germany. The crimes of the National Socialist (NS) system had hit the mentally ill and disabled particularly hard. After the war, surviving patients at the institutions had to suffer intolerable conditions. Nowhere did there seem to be such an urgent need for material and moral reconstruction as in psychiatry. I gave up my intention to become a chemist, stuck to my studies of medicine at the University of Munich, finishing them in 1950 with a state examination and a doctor's degree. My naive intention of those days to initiate a reform of mental-health care and to contribute to re-establishing research in that field had grown into a vocation. To supplement my medical studies I had began to study psychology and philosophy in 1946, taking a doctorate in philosophy in 1951. I wrote my doctoral thesis about: ‘Philosophical anthropology in the works of Max Scheeler and Arnold Gehlen’. I was supervised by Prof. Alois Wenzel, who had a chair of philosophy at the University of Munich. In 1948, I started the experiments required for my doctoral thesis in medicine at the University of Munich Psychiatric Department. In those days, psychiatric inpatient care, exclusively custodial in type, consisted predominantly of ‘bed treatment’, introduced by Clemens Neisser in 1890 and enthusiastically welcomed by Kraepelin. My doctoral thesis in medicine, a work of rather rudimentary science, dealt with physical changes as indicators of clinical improvement following electro-convulsive therapy. My supervisor, Prof. Georg Sterz, was chairman of the Department of Psychiatry and Neurology of the University of Munich. Before the advent of psychotropic drugs in the late 1950s, there were only few effective treatments available in psychiatry. As a result, only a small proportion of patients could be discharged. To calm down agitated patients, opiates, chloralhydrate and barbiturates were used. But I also witnessed how patients were forced to undergo the quite painful extended warm bath, sometimes over several days. Sometimes, paralytic dementia was still treated by malaria inoculation, a method introduced by Wagner-Jauregg (1922), a Nobel Prize winner (1927). As a medical student, I was once sent to fetch a carefully packaged tube containing malaria-infected blood for ‘therapeutic’ purposes from the driver of a train arriving from Vienna at the Munich Main Station. Depression was treated with opium, acute psychosis with electro-convulsive therapy, which was initially administered without a muscle relaxant or a short anaesthesia. Acute symptoms frequently improved rapidly, but lasting effects usually failed to materialize. On Thursdays, a bus used to bring patients selected as incurable to Eglfing-Haar, a local mental hospital with a capacity of over 4000 beds and situated at the gates of Munich. The atmosphere was one of powerlessness, the patients’ situation hopeless. All this resulted sometimes in resignation, sometimes in aggressive protest. If you did not distance yourself – what most colleagues did – the situation on the ward for agitated patients was difficult to bear. In the early 1950s, first reports on the horrifying conditions at the state mental hospitals in the U.S.A. began to surface. They boosted calls for closing down the snake pits. In Germany, these calls entered public awareness at a much later stage. In 1948, the German Mark was introduced. The economy began to flourish, but my father's business was in trouble after its Munich headquarters had been destroyed during the war and an alternative warehouse in the countryside had been looted. I had to lend a hand to get the business thriving again. As a student, I had worked for a year, in 1948/1949, selling fabrics to garment manufacturers, mail-order companies and department stores. I made more money for the family business during that period than I did later in the medical profession. The experience I gained and the connections I built to leading figures in the economy proved useful for my later activities in the mental-health policy field. One of the joined stock companies, for which I was working, offered me the post of an assistant to its board of managers. The conviction that, if necessary, I would be able to earn my living by other means, too, later gave me a certain sense of independence in my medical profession. After receiving my licence to practise medicine, I did a year of internal medicine, worked two months at a private practice in a Bavarian mountain village and finished my doctoral thesis in philosophy. That was a busy time. After completing the doctorate in philosophy I took up, at the advice of my supervisor, Prof. Georg Sterz, my first position in psychiatry at Prof. Ernst Kretschmer's department in Tübingen. On the very first day, my new boss sent me to the department's cabaret team, led by Dr. Kluge, a talented colleague, guitar player and text writer. From that day on, I was to pursue my cabaret career wherever I could find suitable partners at the departments (Fig. 1). Later, after the Zentralinstitut für Seelische Gesundheit [Central Institute of Mental Health (CIMH)] had been established, on the occasion of the so-called south-western autumn symposia, which we used to organize together with our colleagues from Konstanz (Rudolf Cohen), Freiburg (Mathias Berger) and Zurich (Jules Angst) in the wine region of the Palatinate, we enjoyed many a fascinating cabaret contest with our co-organizers and their highly talented teams. Prof. Kretschmer put me in charge of the ward for agitated women. But I had great trouble understanding the wailing of the depressed peasant women from the Swabian Alb. I asked Prof. Kretschmer to assign me first to the neurological ward where language played a minor role. But he refused and gave me a colleague with an equally good mastery of both the Swabian dialect and the German language to help me. In those days, Ernst Kretschmer was the leading German psychiatrist (Fig. 2). His theory of constitution, based on the notion that there are continuous transitions between personality traits and psychosis in association with body types, had been entered even in school books. From Eugen Bleuler, it was only a short step to Emil Kraepelin and especially Ernst Kretschmer, whose “Körperbau und Charakter” and “Der sensitive Beziehungswahn” I still regard as fundamental contributions to psychiatry. (3, p. 153) Ernst Kretschmer even treated delusions by psychotherapy, demonstrating an in-depth understanding of the patients’ state. He had established training courses in psychotherapy. All that was a revelation to me who suffered under psychiatry's incapacity to offer effective treatment. What I was less enthusiastic about was Kretschmer's hypnosis therapy, grandiosely called ‘fractional active hypnosis’. In 1953, Prof. Kurt Schneider had invited me to give a lecture at the Psychiatric Department in Heidelberg (Fig. 3). That was unusual. In his view, the way I understood transitions between personality and psychosis was due to inadequate training, which, he regretted to say, was quite frequent at the Tübingen Department. The colleagues in Tübingen, in turn, looked down upon Heidelberg, criticizing that what they practised was merely normative psychiatry consisting in endless descriptions of symptoms – they called it ‘pea-counting’ – and characterized by lack of innovative research. In 1954, I left Tübingen for the University of Munich Psychiatric Department, again at Prof. Sterz's recommendation, but against Ernst Kretschmer's energetic advice. My intention was to qualify there as a lecturer. After Ernst Kretschmer, Kurt Schneider and Erwin Strauss had declined, Kurt Kolle, a psychiatrist in private practice, had finally been appointed to that chair. My plan of post-doctoral studies did not work out in Munich, because Prof. Kolle and I could not agree on the topic. Instead, I did an intensive two years of neurology, which back then was part of psychiatry. I temporarily supervised a rather poorly equipped neurologic–neurosurgical intensive care unit, treating ascending paralysis in poliomyelitis with an ‘iron lung’, and in Kraepelin's tradition set up a psychodiagnostic laboratory at the Department. Prof. Kolle, sitting on Kraepelin's old oak chair – the legs of which he had had extended by blocks of wood – used to open the daily morning conference by reciting several lines from Goethe's poetry, while we stood there listening to him. I learnt from him how not to manage a department. My conviction to be able to earn my living elsewhere, too, helped me through this tough period. In 1957, the president of the German Psychiatric Association (DGPN), Prof. Jürg Zutt, and his deputy, Heinrich Scheller, who were attending a conference in Munich, invited me for breakfast at their hotel. Well informed about what was going on in Munich, they paved the way for my further career. I decided to go to Heidelberg. On 1 June, 1958, I began as an assistant doctor at the University Psychiatric Department under Prof. Walter von Baeyer. In Heidelberg, Prof. Kurt Schneider, von Baeyer's predecessor, invited me a couple of times for tea at his house. Kurt Schneider, who was highly educated in philosophy and in his later days enganged in studying religious-philosophical questions, was interested in hearing about my work and the ideas I entertained. Although he did not always agree, he was prepared to discuss matters intensively. In 1960, I finally qualified as a lecturer in psychiatry at the Faculty of Medicine. Fifty years later, my thesis was translated into Italian and a new edition appeared in 2011 4. Von Baeyer, who had suffered from the National Socialist racial laws, had managed to survive the NS regime and the war as a military doctor. He became a paternal friend to me (Fig. 4). He was exceptional in his liberal views, ethical mindset, sense of responsibility and open-mindedness towards innovation. Thanks to his unselfish support, I was able to develop in Heidelberg the plan for the CIMH and to establish there its precursor. Having completed my post-graduate studies I was offered the chair of clinical psychology in 1962 at the newly created subsidiary of the University of Munich in Augsburg. I declined it. In 1965, I was appointed professor and head of the Social-Psychiatric Department at the Psychiatric Department in Heidelberg. In 1967, I was offered the newly established chair of psychiatry at the Mannheim Faculty of Medicine of the University of Heidelberg. The contract stipulated that this chair, to which I was appointed on 1 April, 1968, be associated with the position of the director of the ‘German Institute for Mental Health’ – that is what I called it back then – ‘on the condition that it is established’. However, at that point that was just pie in the sky. First, a new building had to be erected, a state foundation (of the State of Baden-Württemberg) created as the Institute's financing authority and the statutes defining the Institute's tasks adopted by the State Government and Parliament on 8 April, 1975. On 26 June, 1975 the Institute's Supervisory Board appointed me director of the Central Institute of Mental Health Foundation – supra-regional research institutes were officially called central institutes – and chairman of its Psychiatric Department. I held that position until my retirement on 1 October, 1994. In 1978, I was offered a chair of psychiatry at the University of Bern, which would have permitted a thoroughgoing reform of the local mental-health care system. In that context, a Berne-based group of activists for alternative psychiatry wrote me a very unfriendly letter. The revolutionary unrest, which, for many years, had caused trouble at the University of Heidelberg, and my passion for skiing were further reasons why that offer, afterall, seemed quite attractive to me. However, after consulting with my family and trusted colleagues, I decided to stay in Mannheim. And, given the good working conditions at the Institute, I was never to regret that decision. The Berne chair was then offered to my senior physician Wolfgang Böker, who accepted it. In the first two decades following its foundation, members of the CIMH received offers for a total of 28 chairs of psychiatry, psychiatry of the elderly, clinical psychology, biomathematics and for pharmacology and toxicology in Germany, Switzerland and Australia. Three chairs of psychiatry and one of biomathematics in German-speaking Switzerland have been or still are held by former members of the CIMH staff. But there were also offers for academic positions that, in hindsight, I should have accepted. Except for an active membership in the university's Great Senate during the severe student unrest (from 1968 to 1973), as we had to join forces to keep the university functioning, I never ran for the office of a dean or, despite energetic invitations, for that of the rector of the University of Heidelberg. Nonetheless, I have been awarded the Great University Medal and the Golden Medal of the Mannheim Faculty of Medicine. I also shunned the chairmanship of the national Council of Science and Humanities, the presidency of the German Psychiatric Association, of which I am now an honorary member, and some other comparable international positions, not counting the years I was member of the Executive Committee of the European Psychiatric Association. One or two of these positions would certainly have flattered my ego. But it was right to let these positions go, because I already had an enormous workload and, given my inclination to do a good job, I would hardly have been able to put enough time into the duties these positions required. In 1981, Prof. Michael Shepherd invited 12 ‘distinguished psychiatrists’ to outline ‘the nature and implications of their own discipline’ in a volume entitled ‘Psychiatrists on Psychiatry’ 5. Despite being just a colourful collection of personal views, mine included, the book has attracted a lot of interest and been translated into several languages. At my retirement on 30 September, 1994, I gave up all my medical positions to make it easier for my successor to step in. I continued to lead the Special Research Branch 258 until the end of 1998 jointly with Prof. Martin Schmidt. I have continued working in charge of my Schizophrenia Research Group, established in 1985, with two excellent colleagues, Dr. Kurt Maurer and Dr. Wolfram an der Heiden, and a number of scientists who were members of our team for limited periods of time, e.g. Anita Riecher-Rössler, professor of psychiatry and chairwoman of the Psychiatric Outpatient Department of the University of Basel, Wagner Gattaz, professor of psychiatry and chairman of the Laboratory of Neuroscience of the Department and Institute of Psychiatry at the University of Sao Paulo, Prof. Armin Schmidtke, head of the Department of Clinical Psychology at the Clinic for Psychiatry and Psychotherapy of the University of Würzburg, Wulf Rössler, professor of clinical and social psychiatry and chairman of the Department for Social and General Psychiatry at the University of Zurich and Martin Hambrecht, professor of psychiatry and chairman of the Department of Psychiatry and Psychotherapy at the Elisabethenstift Hospital in Darmstadt. My small staff is funded in part by the Ministry of Science, Research and the Arts of the State of Baden-Württemberg. The CIMH gives me office space and equipment. The German Research Foundation funded the Age, Beginning and Course (ABC) of Schizophrenia Study for 25 years until 31 May, 2012, and there are still interesting data left for analysis. The Federal Ministry of Education and Research has financed several accompanying studies. Those are privileged conditions for a scientist of my age. In Germany, there are currently two major national research institutes for psychiatry, the Max Planck Institute in Munich and the CIMH in Mannheim. Both were planned in times of scarcity, Emil Kraepelin's Munich-based Institute during World War I in 1916/1917, the CIMH after World War II 6. After the war in 1945, not only mental-health care, but also psychiatric research in Germany were in a shambles. International connections and the trust of the population in psychiatry had been lost. There was a lack of academic teachers and young scientists willing to pursue their careers in psychiatry. This was one of the motives behind my wish to help restore psychiatric research. A proper means for that purpose seemed to me the creation of an institute with the resources to pursue sophisticated research and offer research training in psychiatry. The chairman of the University of Munich Psychiatric Department (Prof. Kurt Kolle), where I had worked for 4 years, had sense neither for such ‘unrealistic’ plans nor for methodologically high-standard research. These plans received the support of the German Council of Science and Humanities for the first time in 1969. The current situation in mental-health care in the Federal Republic of Germany requires urgent reform…. It must be stressed that although the Institute's tasks in the field of inpatient and outpatient care and its advisory functions are focused on practice, at the same time they also intensively serve the purpose of research and training….’The establishment of the model institute is urgently recommended. The Institute will contribute to closing the gap between social psychiatry in the Federal Republic. Attempts to attract public and political interest failed at first. The first step to that end, but at the same time also intended to help initiate a mental-health care reform, was the visit Prof. von Baeyer, my Heidelberg colleague and senior physician K.P. Kisker and I paid to the Federal Minister of Health, Dr. Elisabeth Schwarzhaupt, in Bonn on 16 July, 1964. On this occasion, I also presented her my plans for the Institute. She was sympathetic to our cause and gave us some advice. In the following year, in 1965, I published a supplemented version of my presentation, co-authored by W. von Baeyer and K.P. Kisker, and sent some 1000 copies to key figures all over Germany. This ‘memorandum’ reported on successful reforms adopted abroad and described Germany's outdated mental-health care system, which I called ‘a national emergency’ 7. The article called for a reform of mental-health care in our country. But this memorandum, too, which according to F.-W. Kersting (professor of history at the University of Münster), a historian, already anticipated the recommendations later issued by the parliamentary expert commission, achieved no visible effect 8. In 1971, the next Minister of Health, Käthe Strobel, submitted to the national Parliament a motion for funding the Institute as a model institution. But, because in Germany health policy lies in the responsibility of the states, all the Federal Ministry could do was to offer a prospect of funding part of the costs of creating a model of modern mental-health care. We should have secured the support of our ‘host state’ first. But the Lord Mayor of Heidelberg, where the first steps towards establishing the Institute had already been taken, had denied his support, and so had the Minister of Education and Culture of the State of Baden-Württemberg. We had to set up a private operating base to be able to pursue our plans. On 1 July, 1965, Prof. von Baeyer and I founded in Heidelberg a private Association of Sponsors. We succeeded in inviting influential people from politics, science and industry as members. On 3 November, 1965, Mannheim's Lord Mayor, Dr. Reschke, offered me the prospect of a building plot and support by the city's Councillor of Health and Social Affairs, Dr. Hans Martini, and by the city's construction authority. We decided to build the institute in Mannheim. In late 1965, we elected Dr. Hans Martini on the Executive Board of our Association as the representative of the city of Mannheim. The close cooperation with Dr. Martini as a member of the Association's Board laid a further foundation for the success of my plans. In 1966, the State of Baden-Württemberg established in Mannheim the Second Faculty of Medicine of the University of Heidelberg. This increased the chances for the Institute. I managed to negotiate with the University of Heidelberg and the responsible State Ministry of Education and Culture that the new chairs planned to be created for psychiatry, psychotherapy and psychosomatic medicine and child psychiatry and adolescent psychiatry would be held by the chairmen of these departments at the Institute. They as well as the heads of the research units qualified as lecturers would be appointed in cooperation with the university. The departments would be funded by the CIMH Foundation alone. In this way, I succeeded in securing that the Institute would be independent, but fully responsible for research, teaching and providing university hospital services in the field of psychiatry at the new faculty. The possibility of taking a doctorate and qualifying as a lecturer offered the scientists working at the Institute an opportunity to pursue academic careers. In late 1964, I managed to get the deputy secretary-general of the newly founded Volkswagen Foundation (1962), Dr. Rudolf Kerscher, interested in the project. I submitted our first application on 9 March, 1965, and the Foundation granted the Association on 2 July, 1966 120 000 German Marks for planning purposes and on 18 November, 1969 start-up funding to the tune of 7.55 million German Marks to cover construction and furnishing costs. This considerable financial support from Germany's biggest science foundation prompted the federal and the state governments, too, to jump on the bandwagon. The national Council of Science and Humanities, after I had submitted them a detailed account of how we planned to proceed, recommended in that same year a rapid beginning of the construction work. But it was not until 10 November, 1971 that the Federal Minister of Research invited us to sign a financing agreement. In accordance with the recommendations of the Science Council the Federal Government agreed to cover two-thirds and the State of Baden-Württemberg one-third of the construction and furnishing costs that exceeded the sum granted by the Volkswagen Foundation. On 8 February, 1972, the State of Baden-Württemberg agreed to cover the operating costs as well 6. After a construction permission had been obtained on 30 March, 1972, the Minister of Education and Culture put the Association of the Sponsors of the Institute and hence, the members of its Executive Board, the lawyer Dr. Hans Martini and the psychiatrist Heinz Häfner, in charge of supervising the construction and furnishing of the Institute. With the support of architects and excellent staff, we were able to accomplish this unusual task. On 1 April, 1975, the Institute's administrative unit, technical services and research units moved into the new building. All this sounds as if it was a straight run to the goal (Fig. 5). But, in fact, there were many obstacles on our way. From 1965 to 1975, the year when the CIMH finally opened, we revised our plans several times. With the money from the Volkswagen Foundation for planning purposes, we undertook fact-finding missions to comparable research institutions and mental-health facilities, the first together with Prof. von Baeyer to the U.S.A and Canada (1966). A representative from the National Institute of Mental Health (NIMH) described us the U.S. community mental health policy and demonstrated several model programmes supported by the government. Research at the CIMH was organized on the model of the Institute of Psychiatry in London. The Psychiatric Department of Yale Medical School in New Haven (USA) served as a model for community psychiatry and also for the CIMH's building and furnishings. In 1967, to gain further information, I undertook a well prepared visit to the U.S.A. together with Prof. von Baeyer and the Lord Mayor of the city of Mannheim, Dr. Reschke, and some of his senior staff members. Prof. Fritz Redlich, chairman of the Psychiatric Department, later dean of Yale Medical School, showed us the research facilities and the community-psychiatric service centre. This demonstration convinced the Lord Mayor about a key objective of our plan: to erect the Institute at the city centre and close to the other university hospitals. Members of our planning staff were supported by colleagues from Switzerland, the Netherlands, Austria, Denmark and Sweden, for which we are greatly indebted to them. Prof. Michael Shepherd, who held the first-ever chair of psychiatric epidemiology, and John Wing, professor of epidemiology and social psychiatry, both from the London Institute of Psychiatry, provided us with valuable advice over longer periods of time. After I had declined the invitation to the chair in Munich/Augsburg in 1965, the State Government of Baden-Württemberg granted me 1 million German Marks for buying a property to establish a psychiatric