Online reports – Society – From the insane prison to the psychiatric revolution

Prologue: In the spring of 1977, I was researching a series of articles for the young “Basler Zeitung” about the conditions in the Liestal psychiatric clinic. No detail has stuck in my mind as clearly as this one. When I called the then head doctor Arnold Tschudin for a statement and greeted him with “Hello, Mr. Tschudin,” he cut me off: “Doctor Tschudin!” Apparently not very experienced in dealing with the media, the head of the clinic had apparently failed to notice that journalists in professional dealings did not mention doctoral titles either verbally or in writing.

The reprimand was insignificant, but it seemed to me like an unexplained confirmation of the research I had compiled with Ruth Buser: the articles were entitled “Too little help for 'hopeless cases',” “Hierarchy paralyzes cooperation,” and “Waiting for urgent reform.”

Brain surgery is intended to provide “calm”

The series (picture) documented, among other things, the case of a 14-year-old boy who the hospital doctors had diagnosed with oligophrenia (feeblemindedness). They wanted to help the young patient find “peace” with a brain operation. The operation was only omitted because of his poor general condition. After being transferred to an anthroposophical living and working community, the “hopeless case” became a “normal person”.

Other aspects included the strict hierarchical structure, which led to tensions because doctors were reluctant to reveal their medical secrets and were generally averse to close contact with nursing staff, or the shortage of staff, which meant that patients had to be “literally processed”.

controversy

The reactions to the series of articles were controversial: some were in favour or in complete favour from the circles of nurses and patients, but rejected by the head physician Arnold Tschudin. The recently published, over 200-page book by the sociologist Lukas Ott on the “History of Psychiatry in the Canton of Basel-Landschaft” shows that Tschudin allegedly asked his political superior, Health Director Paul Manz (SVP), to clearly reject the “unobjective, polemical and French newspaper articles”.

The former Reformed pastor Manz, at the time the undisputed “strong man” in the Basel-Landschaft government, actually initially supported his chief psychiatrist.

Manz also expressed this position when the then SP district councillor Angeline Fankhauser, as a result of the series of articles, proposed a psychiatric reform in the “canton's own institutions” and fundamental innovations in a postulate: the inclusion of nursing staff in therapy decisions, outpatient clinics with a regional focus and external therapeutic living and work options. These goals must be taken into account in the foreseeable election of Tschudin's successors.

Media reports trigger psychiatric reform

Manz was prepared to accept the postulate, but “not because she believed that the clinic was not doing a good job with the resources available,” as the book states. At the time, there seemed to be a state of uncertainty. The district council's environmental and health commission also felt “uneasy about the clinic,” but felt “not competent” to have a say in questions of psychiatric care. So it remained unclear for some time whether there would actually be any movement in state psychiatry.

Today, author Ott, former mayor of Liestal and head of cantonal and urban development in Basel for a few months, comes to the conclusion that the three-part report in the “Basler Zeitung” and subsequent research by the “Beobachter” on the forced psychiatric treatment of a 67-year-old man from Pratteln, who was picked up at his front door by the police “like a serious criminal”, were the triggers of the most fundamental psychiatric reform that the Basel region had ever experienced.

Change of heart for the health director

The reform director was, of all people, the somewhat media-sceptical government councilor Manz, who underwent a spectacular change of course: reading over a dozen books on the goals and forms of psychiatric care as well as discussion impulses from his son Andreas, who had come into contact with social psychiatric institutions in the USA.

The result of the change of heart: As requested by parliamentarian Fankhauser, the government elected the progressive Basel psychiatrist Theodor Cahn as the new chief physician on December 1, 1978. It was he who, together with co-chief physician Jakob Christ (he set up the external psychiatric services), paved the way for social psychiatry in the Basel region. In November 1980, the government presented a new “psychiatry concept” that envisaged a reduction in the number of beds, the abandonment of the most questionable forms of therapy, the strengthening of pre- and post-care in crisis interventions and the child and adolescent psychiatric service.

New chief physician without white medical uniform

The radical paradigm shift was also visually evident. Chief physician Cahn refused to wear the white coat, and soon after, nursing director Emil Rämi also wore civilian clothes while at work. Clinic administrator Rolf Müller also joined the management's efforts to see patients as partners: he persistently built a zoo on the land that had become available. He did his part to open up the clinic by organizing public events, jazz matinees and art exhibitions.

The history of Baselland psychiatry, which Ott traces chronologically and using many unknown sources, begins in 1854 with the establishment of a “lunatic ward” in the new cantonal hospital. The new building replaced the former “infirmary”, which had been run as a “poor and invalids' home, hospital and insane asylum, a multifunctional collection camp for all marginalized people” (according to editor Hans-Peter Ulmann, the soon-to-retire CEO of Baselland Psychiatry).

Oppressive piece of social history

Both the documentation of the everyday life of the “sick” – characterized by military punishment, oppression and the most austere living conditions – and the beginnings of the newly emerging medical discipline, which seem helpless from today's perspective, also at times prove to be an oppressive piece of social history: the helplessness and aggressiveness of society in dealing with people who – dependent on the help of others – did not conform to the prevailing norm in one way or another.

It is a merit of this exciting and at the same time distanced commissioned book that it not only acknowledges in detail the positive professional, structural and institutional developments, but also the critical and sometimes very problematic approaches with which mental medicine is trying to develop itself according to the model of Trace and error which paved the way for development.

These included brain operations as well as forced sterilizations, electroshock therapies initially carried out without anesthesia or experiments with psychotropic drugs in the “Hasenbühl” sanatorium and nursing home in Liestal, which opened in 1934 – practices which, according to author Ott, were “also common practice elsewhere”, but which could not be carried out “better”.

“Contract killer” managed to escape

The spectacular escape of Bengt Salvèn from the supposedly escape-proof extension in 1975 caused a stir and was not a reference to the clinic at the time: the Swede was supposed to commit a contract killing in Ziefen (which, however, did not entirely succeed). After his arrest in Liestal, he was interned as a pretrial detainee in the psychiatric clinic that had opened a year earlier on the orders of the governor's office. This measure raised questions not only about the security of the building, but also about the internment of criminals in psychiatric institutions in general.

The last representative of the old school was the head doctor Arnold Tschudin, who specialized in the Rorschach test. This is how an assistant doctor at the time experienced him, but he qualified it to OnlineReports: “He got along, was decent with us, led the sessions well and had a good feel for the patients.” The later family doctor cannot say how Tschudin behaved towards patients and nursing staff: “There were no visitors from the head doctor.” The consultation hours were “short and sweet.”

Massive expansion of the range of products on offer

Since the major reform in the 1980s, which was noticed nationwide, psychiatric care has never been the subject of public criticism, despite certain setbacks. This is due to the development of numerous new services: AIDS and drug counseling centers, residential homes, experiments with spiritual healing, work integration and much more.

Social psychiatry emerged from the practice of preservative psychiatry, with the focus on the therapeutic environment and reintegration, as the book's title suggests: “You go in to come out again.” But even today, psychiatry has not come to an end. The publication, which would have deserved a reader-friendly typesetting and the odd numerical graphic, shows that the search for the correct therapeutic and social way of dealing with mental illness continues.

Lukas Ott: “You go in to come out again.” Schwabe-Verlag. Basel 2017.