SEARCH

SEARCH BY CITATION

Preface

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

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.

Family background

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

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.

But to enter a university, one had to be a member of the National-Socialist Party, which I was not. In the summer term of 1944, I enrolled for medicine at the University of Munich with a fake National Sozialistische Deutsche Arbeiterpartei – NSDAP – membership number. My intention was to switch to chemistry as soon as the war was over. Shortly before the end of the war, in February 1945, as Propaganda Minister Goebbels declared that Germany had to be defended at the ‘alpine fortress’, I was drafted for the Waffen-SS located in Garmisch. I burnt that conscription order. The head nurse of a Munich hospital run by a Catholic order organized for me a job as a nursing aide at a military hospital for shot injuries of the lung. The hospital was first located in Nymphenburg, but later moved to the former Insane Asylum Schönbrunn (Schwachsinnigen Assoziationsanstalt Schönbrunn) near the city of Dachau.

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.

Professional training as a psychiatrist

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

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.

A sidestep on the way to psychiatry

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

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).

image

Figure 1. The author and his wife, Dr. Wiltrud Häfner-Ranabauer, performing a cabaret song (Courtesy of H. Häfner).

Download figure to PowerPoint

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.

image

Figure 2. Prof. Ernst Kretschmer (1888–1964), chairman of the Department of Psychiatry and Neurology of the University of Tübingen (1946–1959), father of the ‘constitutional theory’ and the leading German psychiatrist of his time (Source: 123people.at).

Download figure to PowerPoint

He was not a charismatic orator, but one of the few psychiatrists who in those days regarded genetic and neurobiological factors as associated with mental phenomena. In his research on the sensitive delusion of reference (sensitiver Beziehungswahn), he showed how delusional illness, triggered by traumatic events, develops from certain personality traits, which match the illness like a key fits into a lock. Erik Strömgren stated about Ernst Kretschmer:

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.

image

Figure 3. Prof. Kurt Schneider (1887–1967), chairman of the Psychiatric Department of the University of Heidelberg (1946–1955) and an influential psychopathologist.

Download figure to PowerPoint

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.

image

Figure 4. Prof. Walter Ritter von Baeyer (1904–1987), chairman of the Department of Psychiatry of the University of Heidelberg (1955–1972) and a pioneer of the mental-health care reform in Germany (Courtesy of H. Häfner).

Download figure to PowerPoint

Academic career

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

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.

Planning and establishing the Central Institute of Mental Health

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

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.

In contrast, Walter von Baeyer in Heidelberg (Fig. 4), to whose department I had moved in 1958, was easy to convince of my plans. The two areas of activity assigned to the planned Institute were:

  1. Implementing and running a model of community mental-health care, including the provision of modern modes of therapy, early intervention, after-care and rehabilitation; the model should be capable of serving as an international showcase.
  2. Providing psychiatric research and research training in cooperation with the partner disciplines: child psychiatry and adolescent psychiatry, psychiatry of the elderly, psychosomatic medicine and psychotherapy, clinical psychology, biomathematics, biochemistry, psychopharmacology and imaging techniques. Molecular genetics was still in its infancy.

These plans received the support of the German Council of Science and Humanities for the first time in 1969.

Excerpts from the ‘Statement of the Council of Science and Humanities on the establishment of a “German Institute for Mental Health”’ of 10 May, 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.

image

Figure 5. Central Institute of Mental Health, Mannheim, in 2012 (Courtesy of the CIMH Public Relations Unit).

Download figure to PowerPoint

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 day-centre. On the lookout for a suitable building, we also had to visit the former Castle Hotel above the Castle of Heidelberg. The building was absolutely unsuitable. Nevertheless, the local association of the hotel and restaurant owners protested to the State Parliament. In the local press, articles appeared describing how psychiatric patients would soon be strolling in striped clothing in the Castle's gardens, thus undermining tourism. The neighbours of the next property we visited threatened us with lawsuits to claim compensation for the lost value of their properties. At long last, we managed to find a suitable building. The problems we had been encountering ceased to exist, after I had invited some of our patients and the neighbours, a prominent lady writer and an art historian, for a cup of coffee. Several years later, we could erect the CIMH building at the centre of Mannheim without any protest.

After the independent Social-Psychiatric Department had been established in Heidelberg (1965) and I had been appointed to the chair of psychiatry at the Mannheim Faculty of Medicine (1968), the developments we had initiated in Heidelberg from 1960 on grew a decisive step towards an exemplary network of integrated mental-health services. I set up a community-psychiatric unit in Mannheim. Its aim was to help plan and establish complementary mental-health services and to provide support and consultation for such services. Later, I managed to convert the position of the head of the Community-Psychiatric Unit into an academic position to increase its weight.

With the support of the Executive Board of the Mannheim University Hospital and the State Ministry of Science, I had succeeded in setting up an outpatient psychiatric service, a 24-h emergency service at the hospital's Departments of Internal Medicine, three inpatient psychiatric wards with a total of 55 beds and, with the professorships, in establishing university-level teaching. In addition, I still had at my disposal the Social-Psychiatric Department with its staff and facilities in Heidelberg. Prof. von Baeyer and the University of Heidelberg Faculty of Medicine had ‘lent’ them to me until we could move into the CIMH building [6]. In doing so, he essentially contributed to the developments that finally led to the establishment and opening of the CIMH.

Creating a functioning system of modern psychiatric services practically from the scratch in a mere 15 years had been hard work, but we had finally succeeded. All this had been made possible by the tireless commitment of an excellent staff on all levels, among them my wife, Dr. Häfner-Ranabauer, a psychologist. The precursors of the services set up in Heidelberg and Mannheim permitted us to finally move with our patients into the new building from April 1975 on. We had enough qualified doctors, nurses, social workers and psychologists in our staff to guarantee a proper functioning of our Department of Psychiatry and Psychotherapy.

In 1980, the CIMH was designated as a WHO Collaborating Centre for Research and Training in Mental Health, and it has been re-designated ever since. Over the following years, the WHO organized several international conferences at the Institute, issuing important recommendations (e.g. on ‘The future of Mental Hospitals’ on 2–5 November, 1976, on ‘Changing Patterns of Mental Health Care’ on 27 November to 1 December, 1978 in Cologne, ‘On the Standardization of the Nomenclature and Terminology in the Field of Mental Health’ on 28–30 April, 1980 and on ‘Research on Mental Health in the Elderly’ on 24–26 September, 1984) (Fig. 6).

image

Figure 6. Prof. Norman Sartorius, director of the WHO Mental Health Division (1977–1993), advisor in implementing community mental-health services and an initiator of numerous WHO conferences held in Mannheim (Courtesy of H. Häfner).

Download figure to PowerPoint

Under Prof. Brian Cooper's supervision, we organized international WHO training courses on psychiatric epidemiology. The WHO sent mental-health service planners from various countries (e.g. Luxembourg, Spain, Italy, Japan) to Mannheim to inform themselves about the principles and practice of mental-health services reform.

A statement of the national Council of Science and Humanities issued on 4 July, 1980 officially confirmed the early successes of our work: The Central Institute of Mental Health plays a vital role in psychiatric research in the Federal Republic of Germany….. The Institute is in the interest of national science policy and of supraregional significance. Four years later, an international expert commission wrote (27/28 Sept., 1984): In only a few yearstime the Institute has developed into a leading, internationally recognised centre for psychiatric-epidemiological research.

Mental-health care reform – progress towards the creation of the National Expert Commission

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

The lack of effective therapies has already been mentioned. Psychotherapy seemed to offer a chance. But in those days, systematic and thorough training in psychotherapy in Germany could only be obtained in psychoanalysis. Almost all leading psychiatrists in Germany, however, rejected psychoanalysis and saw themselves confirmed by K. Jaspers's [9] negative view. This did not deter me from gaining a proper training. I completed my training in psychoanalysis under the auspices of Alexander Mitscherlich and Margarthe Mitscherlich-Nielsen at the Department of Psychosomatic Medicine in Heidelberg and later at the Sigmund Freud Institute in Frankfurt. But psychiatry always remained my profession and, thus, my aim was a broad arsenal of therapies. Put off by continued infighting – although it did not affect me personally – I later renounced my membership in the German Psychoanalytical Association.

Convinced that a mastery of psychotherapy was indispensable in psychiatry, I founded in 1962, in cooperation with Prof. Helmut Thomä and Prof. Walter Bräutigam, at that time senior physicians at the Department of Psychosomatic Medicine and the Department of General Medicine respectively, a training institute for psychotherapy in Heidelberg, the Heidelberger Institut für Tiefenpsychologie e.V. (Heidelberg Institute of Depth Psychology), which still exists. The institute operated under the auspices of the three departments. This was all preliminary work.

My most important contribution to reforming psychiatry probably was the creation of a 2-year social-psychiatric training course for experienced psychiatric nurses, beginning on 1 April, 1963. Nurses are the persons who spend most time with the patients and have the greatest influence on the atmosphere on the ward and on the patients.

Most of the nurses qualifying from these training courses assumed leading positions, thus, sharing their knowledge, experience and attitudes. This ‘specialist training course for psychiatric nursing staff’ is now officially recognized and offered at numerous mental-health centres in Germany.

My activities aimed at improving the mental-health care system and creating a research institute developed hand in hand. The simultaneousness of these efforts also became reflected in the fact that the official report of the National Expert Commission on Mental Health Care was completed within a few months of the CIMH's opening in 1975.

Soon after World War II, a decisive change of course had taken place in mental-health care policy planning in the Anglo-American countries, triggered by reports of the scandalous conditions at the large institutions. The objective, which was not attained everywhere, was to give up the practice of long-stay intramural treatment at mostly isolated large public mental hospitals and to move to an open system of needs-based integrated treatment in the patients’ communities under conditions similar to those enjoyed by somatic patients.

In the Federal Republic of Germany, this reform process started to unfold with a delay of 15 to 20 years (GB in 1945, USA in 1961) [6]. One reason probably was that in Germany one did not want to raise the issue of the National Socialists’ mass murder of mental patients [10]. The German Psychiatric Association (DGPPN) officially dealt with this dark chapter of history for the first time at its annual meeting in 2011.

Moving to Prof. Walter von Baeyer's department in Heidelberg in 1958 gave me the opportunity to join forces with my friend Prof. Caspar Kulenkampff, then senior physician at the Psychiatric University Hospital in Frankfurt, for developing a strategy for initiating a reform process in Germany, too (Fig. 7). We set up a discussion group for senior physicians working at neighbouring university hospitals, the so-called Rhine-Main Group. We met monthly, exchanging research results, policy plans and opinions. Caspar Kulenkampff, my Heidelberg colleague Karl Peter Kisker and I established at our respective sites of operation community-psychiatric services: after-care programmes, day hospitals and halfway houses.

image

Figure 7. Prof. Caspar Kulenkampff (1921–2002), chairman of the National Expert Commission on Mental Health Care and an influential promoter of mental-health care reform in Germany (Courtesy of LVR).

Download figure to PowerPoint

Prof. Caspar Kulenkampff, who had blazed the trail with some of his initiatives in Frankfurt, later assumed the chair of psychiatry at the University of Düsseldorf, thus becoming in charge of a large mental hospital Grafenberg. His predecessor was Prof. Panse, who ‘sent mentally disabled and mentally ill people to their deaths’ (11, P. 333) and despite this active involvement in the National Socialist murder programme, held his tenure until his retirement. From there, Prof. Caspar Kulenkampff moved to the Rhineland Regional Council. In his capacity as a State Councillor for Health, he initiated a reform of the local mental-health care system.

Credit for the political breakthrough goes to Walter Picard, a CDU member of Parliament. Visiting mental hospitals in Hesse he had become painfully aware of the unspeakable misery of psychiatric patients. At the advice of his nephew Manfred Bauer, assistant doctor at Kulenkampff's former department, Picard turned to Kulenkampff and me. That was the beginning of an exceptional cooperation. On 7 April, 1970, Walter Picard gave an important speech to the national Parliament, which he had written on the basis of his experience, our proposals and my 1965 memorandum. After expert hearings, the Parliament commissioned the Federal Ministry of Health to set up a National Expert Commission on Mental-Health Care with the aim of collecting data on the current state of mental-health care in Germany and of drafting proposals for its improvement. Kulenkampff was appointed chairman of the Commission, and I became vice-chairman. ‘Ex officio’ members of the Commission's Executive Committee were the president of the German Psychiatric Association, one representing the 11 states and one representing the Federal Ministry of Health. The commission had initially 19 members representing various mental-health professions.

In 1973, the year in which data were collected for the Expert Commission's preliminary report, both the mental-hospital buildings and the way patients were managed there, were intolerable almost everywhere. More than 60% of the patients stayed for more than a year, around 30% for 10 years or more. About 40% of the patients were in rooms with more than 10 beds, often with just one washbasin to share [12].

In its final report, the Expert Commission recommended that the hospital-centred system be replaced by an integrated system of community care [13]. We had already implemented in Mannheim a model of such a network comprising inpatient and outpatient services, a day centre and complementary services for crisis and emergency management, therapy, after-care and rehabilitation.

The Commission's work and its recommendations, submitted to the Federal Minister of Health on 25 November, 1975, had an enormous impact on mental-health care in Germany. They triggered a change of attitude among the staff of psychiatric services and even influenced public opinion favourably. This success was also attributable to the overall political atmosphere in Germany at that time. The ‘generation of 1968’ and the coalition government of the Sozialdemokratische Partei Deutschlands (SPD) (Social Democratic Party) and the Freie Demokratische Partei(Free Democratic Party) led by Willy Brandt in 1969 gained increasing influence on political and social culture. Traditional attitudes and institutions stood under criticism and made it easier to dismantle old structures, not least at large mental hospitals. New interest for disadvantaged and excluded groups in society helped to bring the blight of the mentally ill into public awareness. But the 1968 revolt also had some unfavourable effects.

It was in this atmosphere of overall enthusiasm that mental-health professionals founded the ‘Mannheimer Kreis’ (Mannheim Circle) on 29 May, 1970, and the ‘German Association of Social Psychiatry’ on 18 December, 1970. Both organizations supported, though in very different ways, the reform of mental-health care. Prof. Asmus Finzen, who later became chair of social psychiatry at the University of Basel, and Dr. Rainer Flöhl, the science editor of the ‘Frankfurter Allgemeine Zeitung’, promoted the cause of the mental-health reform in public.

On 18 January, 1971, Walter Picard founded the ‘Aktion Psychisch Kranke’ (Action for the Mentally Ill) in Bonn with Kulenkampff and me as further founding members. Its aim was to vigilantly accompany the implementation of the Expert Commission's recommendations and to create for the mentally ill an influential political lobby not linked to any particular political party. And this is just what the association has become, thanks to Walter Picard's design of a balanced representation of the political parties. Walter Picard was appointed the association's first chairman. The ‘Aktion Psychisch Kranke’, also under its later long-term chairman, Prof. Heinrich Kunze, has effectively supported the cause of the mentally ill and influenced policy decisions in the field of mental-health care.

Research initiatives

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

The fact that I had scrapped my plans of studying chemistry and turned to psychiatry did not diminish my interest in the systematic, solid basis of research and clinical practice. In postwar psychiatry, unsecured convictions and speculation abounded. Some ‘schools of thought’ – in Germany, there were two in those days (Tübingen and Heidelberg) – had developed binding orthodoxies. I regarded as one of the most urgent tasks in psychiatry as a scientific discipline to secure the independence of thinking and to create a scientific basis for the therapies offered. For this reason, I kept a healthy distance to these two schools. I was lucky to always find competent partners for my research work. Its success has essentially depended on their contributions.

One of the prerequisites for being entrusted with the task of establishing a research institute and for obtaining funds for that purpose was the applicant's sufficient research competence. During the Munich years, I had published on my research into the functioning and failure of the frontal brain areas, into regulatory disturbances caused by hypothalamic lesions and later, together with F. Vogel and K. Diebold in Heidelberg, into myoclonus epilepsy (Unverricht-Lundborg), to give a few examples. For the latter work, we received the Michael Foundation Prize. I also wrote a book on psychotherapy (1956), which was influenced by my study of philosophy. I had interviewed 240 concentration camp survivors for a research project conducted together with von Baeyer and Kisker in Heidelberg on the psychiatric effects of concentration camp imprisonment [14]. Those interviews were an experience that can hardly be put into words.

After publishing the study, I was invited by the Association for Research in Nervous and Mental Diseases to give a lecture on ‘Psychosocial changes following racial and political persecution’ in New York in 1969. The lecture was chaired by Fritz Redlich, Yale, and officially commented on by some of the leading U.S. psychiatrists: Erich Lindemann (chairman, Department of Psychiatry, Harvard University), Ernest Gruenberg (New York University), Theodor Lietz (Yale), Dr. Lawrence Kolb (chairman, Psychiatric Services New York, NY), Jürgen Ruesch (San Francisco, CAL), Bertram S. Brown (director, NIMH, Bethesda) and Morton Kramer (NIMH). I have listed these names, because they reflect the fact that this was the first time our research work had been recognized abroad. The connections built there to Dr. Redlich paved the way for the later sponsorship of the CIMH by the Psychiatric Department of Yale University and for the two consultation visits Prof. Lindemann from Harvard paid to Mannheim.

A nationwide study covering 10 years and conducted together with Wolfgang Böker, who later became chair of psychiatry in Berne, and Anne Schmitt on crimes of violence committed by mentally ill individuals [15] followed. The aim of the study was to assess the actual risk of violence of mentally ill persons, because it served as an argument for keeping them behind lock and key. The result was that, in sum, the risk of violence of the mentally ill did not exceed that of the age- and sex-matched general population. In certain groups of illness and measured by certain factors of risk and resilience, the risk was either higher or lower. A third study, conducted in 1965 together with Helga Reimann, later chair of sociology in Augsburg, was an epidemiological and urban-ecological study of the population of Mannheim [16]. It also yielded data for assessing the need for mental-health services in the region.

Simultaneously with or after these three large-scale projects, I undertook several smaller studies. Special attention was attracted by the study conducted together with Armin Schmidtke. It yielded first-ever reliable evidence for the precipitation of suicidal behaviour by model learning from a television series [17, 18].

The German Research Foundation (DFG) granted us funds for a 13-year Special Research Branch (SFB: 116 Psychiatric Epidemiology), conducted together with colleagues in Mannheim and Munich from 1 January, 1973 to 31 December, 1986. The SFBs are an instrument of funding high-standard research conducted by successful interdisciplinary cooperations. Thanks to the research projects mentioned and the Special Research Branch we were able to attract to the CIMH accomplished scientists and to train young scientists for its research staff.

Towards the end of the funding period (1985), an international expert commission certified that we had helped re-establish psychiatric–epidemiological research in Germany.

In 1987, after an interim period of 1 year, a second Special Research Branch (SFB 258: Indicators and models of risk for the origin and course of mental disorders) was launched. It was funded by the German Research Foundation until 31 December, 1998.

Initially, I served as the speaker for the SFBs (Fig. 8). To relieve my workload – I was then in charge of both the Institute and its Psychiatric Department – I later handed this position to Prof. Martin Schmidt, chairman of the CIMH Department of Child and Adolescent Psychiatry, but continued as his deputy in a successful, conflict-free cooperation during the second SFB period through completion in 1998.

image

Figure 8. The author presenting a scientific lecture (Courtesy of H. Häfner).

Download figure to PowerPoint

With experienced scientists lacking, establishing psychiatric research was no easy task. The German Research Foundation granted us funds for visiting scientists. We succeeded in inviting the epidemiologist Prof. Brian Cooper from Prof. Michael Shepherd's team in London and biomathematician Prof. Theodor Gasser from the University of Zurich. In addition, we set up exchange programmes with the Institute of Psychiatry in London and Yale Department of Psychiatry in New Haven. In the first years of the CIMH, four physicians and/or psychologists went to the Institute of Psychiatry in London and two to Yale for at least 3 months. In turn, one colleague from London, one from Ireland and a professor from Yale came to the CIMH for a year each to support us.

In 1987, I launched with two permanent (Wolfram an der Heiden, Kurt Maurer) and several temporary research team members the large-scale ABC of Schizophrenia Study, which is about to be completed. We explored in detail the prodromal stage and early course of schizophrenia. On the basis of the results from this project funded by the Federal Ministry of Research, we developed a two-stage early recognition instrument for clinical practice [19, 20] in cooperation with the teams of Prof. Klosterkötter (Cologne), Prof. Maier (Bonn), Prof. Möller (Munich), Prof. Gaebel and Prof. Wölwer (Düsseldorf). The instrument provides the prerequisite for early intervention. In the ABC Study, we confirmed the sex difference in age at schizophrenia onset on the natural and treated course of the disorder [21], its transnational and transcultural validity together with Munk-Jørgensen et al. [22] on data from the Danish case register and with A. Jablensky and N. Sartorius on data from the WHO ten-country study [23, 24]. We showed that a social explanation was unlikely and finally discovered, together with W. Gattaz, that biology provided an explanation: there was a protective effect of oestrogen, mediated by a sensitivity reducing effect on D2 receptors [25]. When we compared the prodromal stages of schizophrenia with those of unipolar depression, we found a high degree of similarity [26]. We analysed and compared the medium-term (5-year) and long-term (homogenized: 11.2- year = 136-month) course of schizophrenia and the courses of its symptom dimensions [27]. The result was that the depression dimension is the most frequent in the course of schizophrenia. These are just a few from the trove of results this study has yielded, some of which have entered textbooks.

In 2004, I gave a celebratory lecture at the Heidelberg Academy of Sciences and Humanities, which triggered an unbelievable echo in the media [28]. The lecture led to a large-scale interdisciplinary research project entitled ‘The biography and illness of Ludwig II, King of Bavaria (1845–1886)’. The project was conducted together with Prof. P. Kirchhof (constitutional law expert) and Dr. F. Sommer (historian) and funded by two major research foundations, the Fritz Thyssen Foundation and the Robert Bosch Foundation. The results have been published [29]. In cooperation with my colleagues from the Heidelberg Academy, I also organized four symposia on research into health issues and ageing in the period from 1999 to 2011. The symposia were sponsored by the Robert Bosch Foundation, and their proceedings have been published [30-33].

Windows on the world

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

Over the years, I became increasingly involved in issues of science, medicine and research policy. I acquired the knowledge required for these tasks through personal contacts with leading figures in various disciplines, by participating in various working groups and committees of the WHO and, last but not least, by undertaking lecture tours, attending congresses and visiting a number of countries. Contacts and experience accumulated over the years, for example by organizing and attending smaller research meetings, by travelling to guest-lectureships at universities in the USA, Canada, Australia, the former USSR, Japan, the People's Republic of China, Taiwan, Hongkong, Denmark, Sweden, Finland, Italy, Spain, Hungary, Austria, Switzerland, Bulgaria and the former Yugoslavia and Czechoslovakia.

From 1976 to 1980, I was member of the WHO European Advisory Board for Biomedical Research. During this period, I learnt how research works in very different political systems. In 1975, I was appointed member of the Committee on Medicine of the German Council of Science and Humanities. In that capacity, I participated in drafting the recommendations on medicine. In 1977, the president of the Federal Republic of Germany appointed me a full member of the Council of Science and Humanities, extending the appointment in 1980 for another 3 years. This Council, which counts among its members the Federal and State Ministers of Research, the Federal Ministers of Finance and Internal Affairs as well as an equal number of selected scientists and a few leading figures of public life, is the most important advisory body on higher education and all types of state-funded research in Germany. In 1979, I was elected chairman of the Council's Scientific Commission. In the last 3 years of my membership, which ended in 1983, I also chaired the Committee on Medicine.

During my years on the Science Council, I made the acquaintance of a number of leading scientists from various disciplines, of several leading politicians and of civil servants working at the Federal Ministry of Research and at state ministries. During my tenure as chairman of the Scientific Commission, I was in part responsible for producing expert assessments on research institutions and medical faculties and for issuing recommendations on clinical and dental research, to mention but a few examples.

At the CIMH, which back then was and still is reliably financed by the State Government of Baden-Württemberg, we expanded our counselling in the field of mental-health services planning. In these activities, I was assisted by Wulf Rössler, currently chair of psychiatry at the University of Zurich, and Wolfram an der Heiden. I finally passed these tasks on to Prof. Hans-Joachim Salize, now head of the CIMH Research Group for Mental Health Services Research.

Over the years, my friend John Wing, chairman of the WPA Section Committee on Psychiatric Epidemiology, and I organized a series of excellent research conferences. The first international symposium on psychiatric epidemiology in Mannheim was organized in cooperation with the WHO and the German Psychiatric Association (1972) [34]. On this occasion, I suggested to my colleagues Prof. Erik Strømgren (Aarhus) (Fig. 9) and Prof. Wing (London) (Fig. 10) that we should set up a small European action committee on psychiatric epidemiology. This was the birth of a creative triumvirate in both scientific and cultural terms. We organized further European research symposia at regular intervals. In 1976, a European symposium took place in Mannheim [35]. Further European meetings of similar sort followed in Aarhus/Denmark, Opatija/Croatia and Copenhagen. In 1981, our committee joined the EPA (then called AEP) as the first Section Committee (on Epidemiology and Social Psychiatry). In 2002, I placed the Committee's chair in the hands of Prof. Munk Jørgensen.

image

Figure 9. Prof. Erik Strømgren (1909–1993), chairman of the Department of Psychiatry of the University of Aarhus and an active promoter of mental-health care reform on the international stage (Courtesy of H. Häfner).

Download figure to PowerPoint

image

Figure 10. Prof. John Kenneth Wing, chairman of the Social Psychiatry Research Unit, Institute of Psychiatry, London, on the occasion of receiving an honorary doctorate of the Mannheim Faculty of Medicine of the University of Heidelberg on 28 March, 1977 (Courtesy of H. Häfner)

Download figure to PowerPoint

1966 was the year I founded an international research journal for the growing field of psychiatric epidemiology. With the support of my research friends I managed to set up an international team of editors and to convince Dr. Heinz Götze, managing director of the Springer-Verlag (Heidelberg), of our project. The first issue of the journal called ‘Social Psychiatry and Psychiatric Epidemiology’, which still continues to be successful, appeared in 1966.

In the recent decades of my professional career, I have frequently been invited to act as an academic advisor, for example, on issues such as funding priorities in medical research and the reorganization of medical faculties and university hospitals in Germany. Several German and foreign faculties have asked for my opinion on candidates for professorial appointments or on doctoral theses. A special case was the participation in a commission of inquiry of German research institutions and involved universities. In a self-cleansing effort of the scientific community, the commission's task was to investigate a particularly severe case of forged data published in leading international scientific journals. The fraud had been committed by a very renowned medical scientist. Over a course of 8 years, a considerable number of junior scientist had been involved more or less extensively. A group of cancer researchers were accused of having systematically forged laboratory data between 1992 and 1996 and of having stolen ideas and results from other researchers on a large scale [36, 37]. The images of the institutions and persons involved suffered severe blows. Several academic titles had to be withdrawn.

A long-term research policy task I was in charge of until 2003 was handed to me by the Federal Ministries of Research and Health in 1993 in the aftermath of Germany's reunification: I was chosen to chair the national body of experts appointed to coordinate the re-establishment of public health in research, academic teaching, health care provision and public administration. Before 1933, Germany had done pioneering work in the field of social medicine and public health, but after the leading figures had emigrated and the programmes become laden with ideology, the field had collapsed. We succeeded in launching promising developments in some of the old and new states.

Stumbling blocks

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References

An example of the resistance first psychiatric facilities met with in urban residential areas was the experience described with our first day hospital. But problems may also arise from rivalry between colleagues, particularly if carried out by unfair means. My first experience of that sort was the disappearance of a finished paper and its copy from my hospital desk by night. The electronic age had not yet begun. After I had written a letter to my rival's secretary, threatening to file a complaint, the manuscript came back via express mail.

The initiatives taken by some influential colleagues against my mental-health reform efforts were more severe in kind. After my ‘memorandum’ had been published, a health politician at the ministerial level (name not disclosed for reasons of privacy) tried to persuade the head of the division in charge at the Federal Ministry of Health to withdraw the funds granted to me for studying acts of violence committed by the mentally ill. In the course of this large-scale research project, I gained insight into all the large mental hospitals in the Federal Republic of Germany. The civil servant in question informed me correctly about this request and refused to intervene.

A further behind-the-scenes attempt to prevent me from carrying out a major research project occurred just a few years ago. Again, there was a prominent colleague who told me what was going on, thus disclosing the unfair machinations.

In 1966, in the context of the heated debate following the publication of my ‘memorandum’, Prof. Panse, Düsseldorf, wrote a letter to my supervisor, Prof. von Baeyer. After the war, Panse had got a chair of psychiatry and even been elected president of the German Psychiatric Association despite having contributed to the National Socialist mass murder programme in a leading position [11]. It was not until 2011 that the German Psychiatric Association (DGPPN) stripped its former president of his honorary membership. The response Prof. von Baeyer wrote on 30 June, 1966, shows what Panse had had in mind:

… I am not a person who is inclined to use provocative language. But I can understand when younger representatives of our discipline, and especially those who cannot be denied to be highly talented and accomplished scientists, are not afraid to do so. In such cases I prefer to come to their rescue, defending them against the criticism. And this is what I would like to do in Dr. Häfner's case, too […] I cannot actually see any reason why Dr. Häfner should not stay in charge, after data collection [for the project on crimes of violence of mentally ill individuals] has progressed so well at the other centres and Dr. Häfner […] has done an excellent job.» [38].

Prof. Jürg Zutt, a reform-oriented Executive Board member of the German Psychiatric Association, told me around the same time that a representative of traditional mental hospital psychiatrists on the Board had submitted a proposal to exclude me from the Association because of my ‘agitation against psychiatry’. The proposal was rejected.

Trouble was also caused by the very heterogeneous anti-psychiatry movement. Against the backdrop of an increasing popularity of the sociopsychological labelling theory [39], Thomas Szasz called for the abolishment of psychiatrists, more or less. Ronald D. Laing [40] and David Cooper [41] even regarded the mentally ill as healthier than the healthy. They classified psychotic phenomena merely as ‘unusual’ experiences, which normal people tended to suppress.

The strongest influence was exerted by Franco Basaglia with his demand for a ‘democratic psychiatry’ [42]. He fiercely criticized the inhumane, prison-like conditions at Italian mental hospitals and their ‘pathogenic’ effects on the patients. His criticism was received enthusiastically in many countries. Basaglia demanded that, to close them down, mental hospitals should be stopped admitting new inpatients, and, instead, general hospitals should provide 15 beds each for acutely ill psychiatric patients. This demand, written down in Italy's law ‘Nr. 180’ (adopted in 1978), confronted the WHO with the question whether to adopt this model, too. The WHO set up an international committee of experts, which met in Cologne in Basaglia's presence and partially under my chairmanship (WHO Working Group on Changing Patterns in Mental Health Care, Cologne, 27 November–1 December 1978). On behalf of the WHO the British psychiatrist Dr. Douglas Bennet (London) had visited the mental hospitals in Gorizia and Trieste/Italy, which had purportedly been closed down, and submitted a sobering report on Basaglia's reform efforts. The committee expressly recommended the closing down of the obsolete public mental hospitals, but only in conjunction with a simultaneous creation of suitable programmes and facilities for the patients in need of psychiatric treatment and/or support in the community.

A severe crisis, which was to upset me considerably, occurred in Heidelberg in February 1970. It was caused by the ‘Sozialistisches Patientenkollektiv’ (Socialist Patients’ Collective; SPK). Founded by an assistant doctor of the University of Heidelberg Psychiatric Department and grown into a radical political movement, the SPK declared that …capitalism is the real disease, and any type of existing illness can be subsumed under it: from a broken arm to kidney stones to prenatal brain damage (43, p. 116). The ill were called upon to turn the illness into a weapon [44]: The system has made us ill, so let us deal the sick system the deathblow [44]. The SPK described its objectives in its response to the Board of Directors of the University of Heidelberg dated 20 July, 1970: On its scientific basis – patient monitoring – the SPK has worked out the following results:Therefore, the SPK must set itself the objective of retrieving illness from the governing classes, who have turned it into capital, because it only produces more capital and illness. The aim is to abolish the sick capital or the capitalistic sickness and to halt the capitalistic process of exploitation and wear and tear or turn that process around. A foreign word for this process moving in the opposite direction is revolution [45]. The SPK likened our reform efforts to the National Socialists’ euthanasia programme: Community psychiatry is a continuation of the patient killings [46]. The Institute we were planning was also harshly criticized: Mr. Häfner is planning to set up a ‘German Central Institute of Mental Health’…. The SPK called it; The new Central Institute of Mental Eugenics and Euthanasia [46].This utopian ideology attracted a surprisingly large number of proponents. After the activists had occupied the offices of the Administrative Director of the Heidelberg University Hospital and of the Rectorate in the early summer of 1971, the University's Rector and Board of Directors agreed to grant the SPK two buildings to host their ‘work’ and an annual budget of 200,000 German Marks. The majority of the Senate, however, raised serious concerns and the Minister of Education refused approval. After serious conflicts, the Rector and the Medical Faculty appointed three experts each to assess the question whether the SPK should be admitted under the university's roof. But the arguments presented by the experts were highly contradictory. The majority of the Senate appointed me as chief expert. They followed my recommendation to withdraw what the Rector and the Board of Directors had granted. A highly shortened and distorted version of my arguments was immediately published in the left-wing journal ‘Kursbuch’ [43]. The SPK had installed interception devices in the meeting room.

Soon after that, a female student from the SPK wrote an open letter before committing suicide. She accused the SPK of having offered her only political indoctrination while she had been seeking treatment. Flyers branding me murderer of the young lady were distributed. ‘Suicide=murder’ was painted in big black letters on the wall of our private house. The Minister of Education, Prof. Hahn, the Rector, who, following the Senate's decision, had withdrawn the agreement with the SPK, and I were convicted for murder by the SPK vehmic court ‘Volksgericht’ (People's Court). My wife, our little son and I were placed under police protection for three months. In the following years, several terrorists of the second generation emerged from the SPK.

Life in Mannheim had remained quite peaceful during the days of chaos in Heidelberg. At our Heidelberg Department, only a few colleagues had staged scattered protests. A small group, professing radical ideas of freedom, abused heroine, which led to a tragic death of a doctor. This experience and the difficulty of containing ensuing lapses worried me considerably. At the Institute, a group of activists from the radical ‘Kommunistischer Bund’ (Communist Federation) continued to fight against the directorate and the trade union. Luckily, a few years later, these difficult times were a thing of the past.

These are only a few examples of the unpleasant experiences we made. In such critical situations, friends and partners are needed who have the decency and courage to step in to defend one's cause even against resistance. My Heidelberg supervisor, Prof. Walter von Baeyer, has always remained a model for me.

There is one more important event to recount after this murky chapter of my chronicle. In the spring of 2011, Andreas Marneros, professor emeritus of psychiatry in Halle, and his wife, Prof. Anke Rohde, invited a handful of savvy and sympathetic friends from various walks of life with their spouses to attend an ‘Aristotle-Symposium’. We met at the site of the philosopher's school in Macedonia and in the unbelievably rich tombs of Philip II, father of Alexander the Great. We stayed at a charming hotel in Naoussa, listening to and presenting lectures, each one from his field of wisdom. Andreas Marneros commented on the presentations from Aristotle's point of view and the perspectives of other great Greek forbears of our European culture. This event had been organized to mark the retirement of an academic teacher from his highly successful professional life in his second home country, Germany. For us guests, it was a most enriching and gratifying experience.

This is where my recollections from my professional life end. As mentioned, they are just a tiny selection of the events that could have been recounted. Many a pleasant encounter with friends and colleagues must remain unmentioned. It is a pity, but nothing can be done about it.

References

  1. Top of page
  2. Preface
  3. Family background
  4. Professional training as a psychiatrist
  5. A sidestep on the way to psychiatry
  6. Academic career
  7. Planning and establishing the Central Institute of Mental Health
  8. Mental-health care reform – progress towards the creation of the National Expert Commission
  9. Research initiatives
  10. Windows on the world
  11. Stumbling blocks
  12. References
  • 1
    Häfner H. Comment on E.F. TORREY and R.H. YOLKEN: “Psychiatric Genocide: Nazi Attempts to Eradicate Schizophrenia”. (Schizophr Bull. 2010, 36(1), pp. 26–32) and R.D. STROUS: “Psychiatric Genocide: Reflections and Responsibilities”. Schizophr Bull 2010;36:450454.
  • 2
    Roelcke V, Schneider F. Psychiater im Nationalsozialismus – Täterbiographien. (Editorial). Nervenarzt 2012;83:291292.
  • 3
    Strömgren E. Erik Strömgren. In: Shepherd M, eds. Psychiatrists on psychiatry. Cambridge: Cambridge University Press, 1982:152169.
  • 4
    Häfner H. Psicopatici. Translated into Italian by Luciano Del Pistoia from HÄFNER H (1961) Psychopathen. Daseinsanalytische Untersuchungen zur Struktur und Verlaufsgestalt von Psychopathien. Rome: Springer Verlag, 2011. GIOVANNI FIORITI Editore.
  • 5
    Shepherd M, ed. Psychiatrists on psychiatry. Cambridge: Cambridge University Press, 1985.
  • 6
    Häfner H, Martini H. Das Zentralinstitut für Seelische Gesundheit. Gründungsgeschichte und Gegenwart. München: C.H. Beck, 2011.
  • 7
    Häfner H. (unter Mitarbeit von W. v. Baeyer und K. P. Kisker). Dringliche Reformen in der psychiatrischen Krankenversorgung der Bundesrepublik. helfen und heilen 1965;4:18.
  • 8
    Kersting F-W. Der lange Schatten des NS-Krankenmords. Psychiatriereform und «Vergangenheitsbewältigung» in der Bundesrepublik 1955–1975. In: Oehler-Klein S, Roelcke V, eds. Vergangenheitspolitik in der universitären Medizin nach 1945. (Pallas Athene Band 22). Stuttgart: Franz Steiner Verlag, 2007:361386.
  • 9
    Jaspers K. Allgemeine Psychopathologie, 9th edn. Berlin Heidelberg: Springer-Verlag, 1965.
  • 10
    Roelcke V, Schneider F, eds. Psychiater im Natiionalsozialismus. Der Nervenarzt 2012;83:291336.
  • 11
    Forsbach R. Friedrich Panse, etabliert in allen Systemen. Nervenarzt 2012;83:229336.
  • 12
    Zwischenbericht der Sachverständigenkommission. Bundestagsdrucksache 7/1124 vom 19.10.1973.
  • 13
    Bericht über die Lage der Psychiatrie in der Bundesrepublik Deutschland. Zur psychiatrischen und psychotherapeutisch/psychosomatischen Versorgung der Bevölkerung. Bonn: Deutscher Bundestag, 1975. DRS.7/4201.
  • 14
    von Baeyer W, Häfner H, Kisker KP. Psychiatrie der Verfolgten. Berlin, Göttingen, Heidelberg: Springer, 1964.
  • 15
    Häfner H, Böker W. Crimes of violence by mentally abnormal offenders. Cambridge: Cambridge University Press, 1982.
  • 16
    Häfner H, Reimann H, Immich H, Martni H. Inzidenz seelischer Erkrankungen in Mannheim 1965. Soc Psychiatry 1969;4:126135.
  • 17
    Häfner H, Schmidtke A. Die Vermittlung von Selbstmordmotivation und Selbstmordhandlung durch fiktive Modelle. Nervenarzt 1986;57:502510.
  • 18
    Schmidtke A, Häfner H. The Werther effect after television films: new evidence for an old hypothesis. Psychol Med 1988;18:665676.
  • 19
    Maurer K, Häfner H. Early recognition inventory ERIraos: development, structure, results (Abstract). Acta Psychiatr Scand 2002;106(Suppl 413):19.
  • 20
    Rausch F, Maurer K, Häfner H. ERIraos: Ein zweistufiges Früherkennungsinventar für Psychosen. Früherkennung und -intervention bei schizophrenen Störungen. neuro aktuell 2010;8:1925.
  • 21
    Häfner H, Riecher A, Maurer K et al. Geschlechtsunterschiede bei schizophrenen Erkrankungen. Fortschr Neurol Psychiat 1991;59:343360.
  • 22
    Löffler W, Häfner H, Fätkenheuer B et al. Validation of Danish case register diagnosis for schizophrenia. Acta Psychiatr Scand 1994;90:196203.
  • 23
    Hambrecht M, Maurer K, Sartorius N, Häfner H. Transnational stability of gender differences in schizophrenia? An analysis based on the WHO Study on determinants of outcome of severe mental disorders. Eur Arch Psychiatry Clin Neurosci 1992;242:612.
  • 24
    Hambrecht M, Maurer K, Häfner H. Gender differences in schizophrenia in three cultures. Results of the WHO collaborative study on psychiatric disability. Soc Psychiatry Psychiatr Epidemiol 1992;27:117121.
  • 25
    Häfner H, Ehrenreich H, Gattaz WF, Louza MR, Riecher-Rössler A, Kulkarni J. Oestrogen – a protective factor in schizophrenia? Current Psychiatry Reviews 2006;2:339352.
  • 26
    Häfner H, Maurer K, Trendler G, An Der Heiden W, Schmidt M, Könnecke R. Schizophrenia and depression: challenging the paradigm of two separate diseases – a controlled study of schizophrenia, depression and healthy controls. Schizophr Res 2005;77:1124.
  • 27
    Häfner H. Psychose, Depression und manische Symptomatik – Leitsyndrome eigener Krankheiten oder Kontinuum? In: Möller H-J, Müller N, eds. Schizophrenie – Zukunftsperspektiven in Klinik und Forschung. Wien: Springer, 2010:330.
  • 28
    Boyes R. Mad king was just crazy about palaces. The Times 2004;June 30: 1 (see also p. 19 of the same issue).
  • 29
    Häfner H. Ein König wird beseitigt. Ludwig II. von Bayern (1st edn, hardback). München: C.H. BECK, 2008 (paperback edn 2011).
  • 30
    Häfner H, ed. Gesundheit – unser höchstes Gut?. Berlin Heidelberg: Springer-Verlag, 1999.
  • 31
    Staudinger U, Häfner H, eds. Was ist Alter(n)?. Berlin, Heidelberg: Springer-Verlag, 2008.
  • 32
    Häfner H, Beyreuther K, Schlicht W, eds. Altern gestalten – Medizin, Technik, Umwelt. Berlin, Heidelberg: Springer-Verlag, 2010.
  • 33
    Kielmansegg P, Häfner H, eds. Alter und Altern – Wirklichkeiten und Deutungen. Berlin, Heidelberg: Springer Verlag, 2011.
  • 34
    Wing JK, Häfner H, eds. Roots of Evaluation. The epidemiological Basis for Planning Psychiatric Services. An international Symposium held at Mannheim on July 26–29, 1972. London: Oxford University Press, 1973.
  • 35
    WHO Regional Office for Europe. The Future of Mental Hospitals. Report on a Working Group. Mannheim, 2–5. November, 1976 (document ICP/MNH 019 II: 1976).
  • 36
    Abbott A. Fraud claims shake German complacency. Nature 1997;387:750.
  • 37
    Schiermeier Q. Gene therapist accused of fraud to seek redress in German court. Nature 1997;389:105.
  • 38
    Archives of the University of Heidelberg. von Baeyer's estate, Rep. 63.
  • 39
    Szasz T. The social reaction to deviances. In: Weinberg SK, ed. The sociology of mental disorders. Analyses and readings in psychiatric sociology. Chicago: Aldine Publishing Company, 1967.
  • 40
    Laing RD. Phänomenologie der Erfahrung. Frankfurt: Suhrkamp, 1969.
  • 41
    Cooper D. Psychiatrie und Anti-Psychiatrie. Frankfurt: Suhrkamp, 1971.
  • 42
    Basaglia F. Die negierte Institution oder die Gemeinschaft der Ausgeschlossenen. Ein Experiment der psychiatrischen Klinik in Görz. Frankfurt am Main: Suhrkamp, 1971.
  • 43
    Roth J. Psychiatrie und Praxis des Sozialistischen Patientenkollektivs. Kursbuch 1972;389:107120
  • 44
    SPK Patient Information Nr. 1.
  • 45
    SPK leaflet of 20 June 1970.
  • 46
    SPK Documentation III (AStA Kassel).