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Social psychiatry in the making
Practices at Heidelberg’s Psychiatric University Clinic in the 1960s and 1970s

The Psychiatric and Neurological University Clinic in Heidelberg developed into a pioneering location for psychiatric reform from the early 1960s and, along with Frankfurt, into a leading centre of social psychiatric research and practice in the Federal Republic of Germany. The literature on Heidelberg social psychiatry, written mainly by those affected themselves, focuses on the reform programmes. It emphasises the importance of the work of the leading psychiatrists inside and outside the clinic and states that social psychiatry no longer played a significant role in Heidelberg when the reformers left in the 1970s. In contrast, this chapter takes a praxeological approach. It analyses the social psychiatric practices in the Heidelberg Clinic in the 1960s and 1970s using medical records, annual reports, administrative files and the written records of the medical and nursing staff. The analysis reveals that, in the 1960s, the implementation of the social psychiatric reforms in everyday clinical practice took longer than the publications of the senior physicians imply, and sometimes met with resistance. In addition, the freedom that the reformers gave their employees meant that they were also able to implement their own ideas. In the 1970s, social psychiatric practices continued without normative guidelines – or in spite of them – and were strongly influenced by internal traditions and the spirit of the times. The employees had wide scope for action within which they made independent decisions. All in all, patient care at Heidelberg was much more influenced by social psychiatry in the 1970s than in the 1960s.

In the Federal Republic of Germany, psychiatric reform began rather late compared to other Western countries. It took until the 1960s for a broad theoretical and practical critique of psychiatry to begin here. And it was not until the Psychiatry Enquete of 1975 1 that outpatient care structures were strengthened and a reform process initiated, which remains incomplete to this day. In contrast, in Canada, the USA, the Netherlands, Great Britain and Scandinavia, social psychiatric reforms in this regard had already been adopted fifteen years earlier (Kersting, 1998; Kersting, 2003).

The Heidelberg psychiatrists Walter Ritter von Baeyer (1904–87), Heinz Häfner (1926–2022) and Karl Peter Kisker (1926–97) were among the key figures in the reform of psychiatry in the Federal Republic of Germany. As early as 1965, they wrote a memorandum entitled ‘Urgent Reforms in Psychiatric Health Care in the Federal Republic of Germany’, in which they made criticisms that psychiatric hospitals in the Federal Republic were underfunded, that there was a shortage of personnel and rigid clinical hierarchies, and that there were no rehabilitation pathways. As a way out, they proposed the establishment of 250 ‘psychiatric community centres’ with inpatient wards, night and day clinics, outpatient clinics and rehabilitation services. Most of these demands were taken up by the Psychiatry Enquete. This recommended nationwide reforms, which were largely implemented step by step in the years that followed (Häfner, 2003).

Baeyer, Häfner and Kisker worked at the Psychiatric University Clinic in Heidelberg. 2 Baeyer was clinic director from 1955 to 1972, Häfner and Kisker were his senior physicians. Since its foundation in 1878, this clinic, located in the oldest German university town, has been considered one of the most renowned psychiatric institutions in Germany. From the early 1960s, it developed into a pioneering location for psychiatric reform and, along with Frankfurt, into the leading centre of social psychiatric research and practice in the Federal Republic (Rotzoll, 2012: 135). At that time, Heidelberg formed a model institution in which a ‘reform before the reform’  3 took place (Häfner, 1979: 154; Schmuhl, 2003: 15).

The literature on social psychiatry in Heidelberg in the era of the clinic director Walter von Baeyer, written mainly by those involved themselves, focuses on reform programmes and the high importance of senior psychiatrists and political developments. 4 It emphasises the early establishment of social psychiatry in Heidelberg in the early 1960s as well as the broad impact of the Heidelberg experiment in the Federal Republic. This occurred, on the one hand, through the staff members who moved to other places of activity and built up social psychiatry there, and on the other hand, through Baeyer, Kisker and Häfner, who were very committed to psychiatric reform and had developed national and international scientific and political networks. Finally, it is claimed that various personnel and structural changes and political events put an end to this heyday of social psychiatry in Heidelberg at the beginning of the 1970s. The decisive factors considered here are the exit of two key figures of the reforms, Kisker and Häfner, the departure of the Department of Social Psychiatry from Heidelberg for the neighbouring city of Mannheim twenty kilometres away, the anti-psychiatric agitation of the Socialist Patient Collective (SPK) in the Heidelberg Clinic in 1970–71 and the change in the directorship from Baeyer to the more conservative Werner Janzarik in 1973 (Häfner, 1979: 154; Pross, 2017: 50). 5

In contrast, this chapter focuses on practices in the clinic and how these evolved. It analyses the social psychiatric practices in the Heidelberg Clinic in the 1960s and 1970s using medical records, the annual reports of the Department of Social Psychiatry from 1968 to 1974, administrative files, and written records of the medical and nursing staff. By doing so, social psychiatric practice is not reduced to the question of the extent to which the social psychiatric ideas of the leading figures were implemented in the clinic. Rather, the focus is also on those social psychiatric practices in Heidelberg which cannot be explained by the leading physicians’ guidelines. In a psychiatric clinic, as in other institutions, everyday practice in some areas is only loosely linked to normative instructions, or completely independent of them, and has its own rules and routines which influence clinic staff and patients in their actions (Weick, 1995: 10). 6 Besides, the clinic staff, below the management level, also made use of their scope for action in everyday treatment and were in turn guided here by their own ideas and interests.

In addition to analysing the senior doctors’ social psychiatric ideas and goals, this chapter also examines the organisation of work in the Department of Social Psychiatry and in the psychiatric clinic as a whole. In this way, insights into effective structures and the scope of action can be gained, to which one would not become attentive by the sole investigation of the implementation of social psychiatric goals. Through this, the functioning of the Department of Social Psychiatry, but also the embedding of the influential Heidelberg figures in this setting, becomes visible. And finally, patient records are used in this chapter to analyse when and to what extent psychiatric treatment changed for patients.

The chapter will first investigate what patient treatment looked like in the Department of Social Psychiatry in the 1960s and 1970s. It will then explore to what extent social psychiatric approaches were implemented in other wards of the Heidelberg Clinic during this period. In closing, the significance of personnel changes in the clinic, political events and the parting of ways with the Department of Social Psychiatry in the 1970s, will be examined.

The development of the Department of Social Psychiatry in Heidelberg

Karl Peter Kisker and Heinz Häfner, supported by the clinic director Walter Ritter von Baeyer, pushed for the expansion of social psychiatric facilities and treatment methods at the university clinic from 1960 onward, inspired by the international reform debates and based on Anglo-Saxon models. The most important institutional innovation was the establishment of the first two rehabilitation wards in the Federal Republic in 1960, which were housed in pavilion-style buildings that had been completed shortly before. Each pavilion had twelve beds for women and twelve beds for men, divided into rooms with two to four beds.

Statistical information is available on the patients admitted there from 1968 to 1973. 7 Most patients were quite young, the average age being under 30 years. The duration of treatment averaged four to six weeks for patients who came to the ward for the first time; for multiple admissions, which were primarily crisis interventions, the treatment time was much shorter. The medical records show, however, that significantly longer stays of half a year were not uncommon. 8

Table 3.1

Diagnoses in the rehabilitation wards 1968–73

1968 1970 1971 1972 1973
Schizophrenic disorders 70 62 58 59 33
Manic-depressive disorders 39 17 13
Neuroses 29 28 51 38 32
Other diagnoses 24 35 22 46 28
Total recorded 162 142 144 143 93

Jahresbericht, 1968: 21; Jahresbericht, 1970: 19; Jahresbericht, 1971: 33; Zweijahresbericht, 1973: 59–60.

The number of patients admitted hovered around 150 before dropping to 93 in 1973 due to the impending move of the ward to Mannheim in 1974 accompanied by Häfner's appointment to the chair of psychiatry there. Barely half of the patients had schizophrenic disorders; other frequently represented diagnoses were manic-depressive disorders and neuroses. The men's pavilion was managed by Kisker, the women's pavilion by Häfner. Here, for the first time in the Heidelberg Psychiatric University Clinic, there were no isolation rooms and closed areas and the dormitories were only used at night. The group rooms were shared by male and female patients and therapies and activities were also mixed. 9

The rehabilitation wards were joined by a small night clinic with an initial total of twelve beds, which opened as the first transitional facility between inpatient and outpatient treatment in 1962 in the basement rooms of the pavilions and was expanded to seventeen beds by 1968. In 1965, the newly established institutions were merged into the Department of Social Psychiatry and Rehabilitation, headed by Häfner. The first goal of this new department was research and teaching, and the second was psychosocial treatment of patients and aftercare for outpatients (Rotzoll, 2012: 138). The great importance of research is particularly evident in the interdisciplinary special research division Social Psychiatry, which had been located in Heidelberg since 1968, as well as in the high number of scientific guests who came to Heidelberg for study visits from Germany and abroad. 10

In the second half of the 1960s, the department expanded by establishing transitional facilities outside the hospital grounds, following the US concept of community mental health centres. 11 The integration of patients into the urban space was seen as an important component in dealing with psychosocial problems, and the solution to such problems was not sought solely by optimising and disciplining the individual, but also in designing the social environment. Thus, in 1966, a day clinic for twenty people was established in Heidelberg's city centre, and in 1968, in cooperation with services provided by the Church, the first transitional home, with eight living areas, was built in the Heidelberg neighbourhood of Rohrbach. 12 In addition to the institutional innovations, outpatient aftercare was established on the ward for a gradual, psychiatrically accompanied and stable return to life outside the clinic. After discharge, outpatient consultation hours were offered and the newly created ‘patients’ club’ of the ward with cultural community activities was open not only for inpatients but also for discharged patients. Furthermore, cooperation was established with the social services of the city of Heidelberg and non-profit organisations, and a lay helpers’ association for discharged patients was set up (Häfner, 1979: 155).

Sociotherapy

The sociotherapy practised in Heidelberg emphasised the importance of social influences on the development and chronification of mental illness, especially in the areas of socialisation, work and living. The first pillar of the social psychiatric therapy process was the treatment of mental illness during hospitalisation in the framework of a ‘therapeutic community’, a concept developed in the early 1950s by the British psychiatrist Maxwell Jones (Jones, 1953). 13 The ‘therapeutic community’ included the entire therapeutic staff and all patients who were supposed to support each other in their therapeutic process. The environment thus created was intended to be therapeutic and was considered more important than individual therapeutic measures. The focus of treatment was that psychiatrists, psychologists, nurses and social workers consciously talked to patients about underlying difficulties and conflicts rather than individual symptoms. In this way, the affected person should learn to understand their symptoms as the product of these difficulties and inner conflicts, and to communicate and discuss them in one-to-one conversations or in groups. The administration of psychotropic drugs and the use of electroconvulsive therapy was done cautiously. They were primarily seen as a prerequisite for acutely psychotic or depressed patients to become capable of communication and thus receptive to the decisive therapy, the community and the activation programmes of the department (Häfner, 1966: 90–1).

In the medical records, the treatment methods on the pavilion ward in the 1960s clearly stand out, since here the focus was not on medication and electroconvulsive therapies as in most of the other wards, but on the psychotherapeutic forms of treatment and social learning processes described above. For each patient, the doctor decided whether medication was necessary, showing a particular reluctance to use electroconvulsive therapies, which was even more pronounced than that for medication. 14 In the epicrisis of most medical records, group therapy as well as the activation programme and the therapeutic community were highlighted as primarily promoting healing (see also Häfner, 1969: 90).

The therapeutic discussion rounds were supplemented by an activation programme with occupational therapy, joint leisure activities, the patients’ club and daily ward meetings of doctors, nursing staff and patients, in which mainly organisational issues were dealt with. Behind this was the therapeutic conviction that all these measures would reduce the pathological symptoms and promote social skills (Häfner and von Zerssen, 1964).

However, the patient files reveal the darker side of this therapeutic community, especially in the early years. There are entries that some patients found it too noisy and restless, others suffered from not being taken seriously by more highly educated patients or being ridiculed for their problems. In 1962, a doctor noted in the case of a male patient: ‘The patient's marked lack of talent gives his fellow patients, who virtually conspire among themselves for this purpose, repeated opportunities to amuse themselves at his expense. Apart from that, the patient is exposed to the no less unpleasant influence of some of his fellow patients.’  15

The second pillar of the social psychiatric therapy process was the rehabilitation of the patients – i.e. the psychiatrically accompanied, gradual return of the patients to self-determined living outside the clinic – for which the transitional facilities described above were seen as crucial aids, and to employment. Transitions between rehabilitation facilities were fluid in this regard. For example, on 27 September 1963 clinic director Baeyer and the senior physician Walter Bräutigam reported on the transition from an inpatient stay to the night clinic as the first transitional facility:

Overall, the combination of relative freedom and the possibility of being attached has proved very successful. After returning from the night clinic, the patients seek out the familiar community of the ward at evening meals and home discussions, they also remain in contact with the doctors they know, and in most cases they also continue to receive medication support. 16

Professional rehabilitation was provided on the one hand by work therapy, and on the other hand by supervision of the job search in the open labour market. Work therapy was thus clearly distinguished from occupational therapy (Beschäftigungstherapie), which was also offered. Whereas in occupational therapy patients were free to choose their activity, work therapy aimed to enable patients to test themselves at experimental workplaces inside and outside the clinic, which were oriented towards their former profession (Böker, 1966; Dörner and Plog, 1999: 83–4). For this purpose, they were mainly employed in the technical and administrative departments of the university hospital and, depending on the activity, were instructed by nurses, technical and administrative staff (Häfner, 1966: 90).

The high significance of the British model of ‘industrial units’ in the work therapy efforts of the Department of Social Psychiatry is particularly evident in the fact that in 1964 a printing shop was set up for the patients of the pavilion to produce forms for the needs of the clinic. From 1968, an ‘industrial rehabilitation unit’ also existed in the corrugated cardboard factory in nearby Wiesloch, where six to eight patients did paid part-time work. A minibus took the patients to their place of work, accompanied by nursing staff (Dörner and Plog, 1999: 83; Rotzoll, 2012: 140–1). The reference ‘corrugated cardboard in the morning, occupational therapy in the afternoon’ was since then often recorded in the medical files. Housewives, office workers and students were also employed in the corrugated cardboard factory, often as an intermediate step before they started work according to their training. 17 When patients complained about this, it was emphasised that the work was primarily intended to get them used to a workload under real conditions and that they should consider the time in the corrugated cardboard factory as part of the therapy. 18

Heinz Häfner emphasised in 1966 that after the initial medical consultations with the patient, the therapeutic staff discussed all observations and findings together and used this to develop an individual treatment plan, which was then negotiated with the patient by the head physician of the department (Häfner, 1966: 90). However, neither the corresponding plans nor a discussion of treatment were documented in the medical records until the end of the 1960s. For the most part, the sociotherapeutic programme was merely mentioned in general terms without describing individual psychotherapeutic treatment strategies. A typical doctor's letter reads: ‘The patient participated in our comprehensive sociotherapeutic programme throughout his inpatient stay, which included group psychotherapy, individual therapy, occupational and work therapy, and meetings.’  19

It is only in the medical records of the 1970s that individual therapy plans and the formulation of a therapy goal increasingly appear. 20 Often, the documentation reveals that the therapy plan was justified to the patient and that details were negotiated with him or her. For example, a patient who was hospitalised in 1972 and 1974 for ‘paranoid ideation and suspected psychosis’ received a three-month treatment plan in 1974, divided into the three sections ‘planned diagnostic measures’, ‘medication’, and ‘sociotherapeutic goals’. The last is elaborated as:

Connecting with groups, promoting hobbies (linoleum cutting, photography), reducing feelings of unworthiness, reducing paranoid fears, professional reintegration. Restriction of pedantry. Prepare detachment from mother. Training of contact skills, possibly reestablish relationship with youth friend. Participation in games in the ward. Training of work ability; especially speed. 21

One patient diagnosed with ‘neurotic development with obsessive depressive features’ in 1975 had among the treatment goals to be achieved: ‘Promoting sociability in the context of group therapy, training assertive behaviour, and encouraging greater independence and personal responsibility.’  22

Another innovation was that the progress reports in the 1970s increasingly described routines that governed interaction on the social psychiatric ward. For example, it was now reported that the actual condition of the patients was made visible for all on the ward by equipping each patient with a red, yellow or green cardboard sign. The assignment of these signs was made at the ward meetings and could be discussed. The granting of freedoms and the rules for living together were regulated via these signs. Only patients with a green sign were given free exit. Patients with red signs were considered unstable and in need of special care. The other patients were asked to pay special attention to them. 23

New roles for psychiatrists, nurses and social workers

The Heidelberg reformers saw a new understanding of roles and an expansion of the training of psychiatrists and nurses as central to the social psychiatric tasks and establishment of a ‘therapeutic community’. The idea was to build a therapeutic team in which different opinions counted, in which nursing staff were trained in social psychiatry, and social workers also played an important role. The psychiatrist's role was to tie these threads together (Häfner et al., 2011: 197).

From the beginning, the leading figures of Heidelberg social psychiatry emphasised the high therapeutic relevance of the nursing staff, who spent most of the time with the patients and shaped the treatment environment. Here, they referred to concepts from the USA, where the nursing staff were given a key position in sociopsychiatric treatment (Häfner et al., 1965: 108–9). In the reformers’ view, psychiatric nursing in Germany had until then been limited to a purely custodial function and care for the physical well-being of the patients. This applied to the asylums as well as to the university clinics, including the Heidelberg Clinic. The reformers’ distrust of the older nursing staff in Heidelberg is particularly evident from the fact that, in the mid-1960s, senior physician Karl Peter Kisker appointed a medical student to work as an assistant nurse on the closed ward he headed (Männer Gartenhaus), to covertly observe the role of the nurses. Together they published his report under the accusatory title ‘The Masters of the Clinic’. The report emphasised the nurses’ custodial attitude, their superficial subservience to the physicians, their therapeutic inaction and their undermining of modern therapeutic measures, as well as the violence they exerted (Hemprich and Kisker, 1968). It was an impetus for the nationwide reform movement, but led to heated debates in the Heidelberg Clinic as to whether such actions and the resulting publication were disloyal or justified by the abuses (Pross, 2017: 42–3).

In the sociotherapeutic wards, too, the psychiatrists complained in the early days that the nuns and lay nurses working there initially had a custodial attitude and only insufficiently fulfilled the required new understanding of their roles and the new and diverse tasks. They observed with concern that the nursing staff had difficulties with the younger and more intelligent schizophrenic patients who expressed criticism and questioned their authority in group discussions. And they criticised that nurses reacted to the new system with anxiety, aggression and jealousy about the close therapeutic contact between patients and doctors (Rave-Schwank and Kallinke, 1973; Rotzoll, 2017: 108–9).

In the women's pavilion in Heidelberg, Häfner therefore established a pilot project in April 1963. For the first time in Germany, a social-psychiatric oriented two-year specialised training for fully qualified female nurses with eight places was introduced. In the following years male nurses and social workers could also participate (Rave-Schwank and Kallinke, 1973; Rave-Schwank and Lersner, 1974). Because of the initial difficulties, Häfner made an effort to recruit new nurses for the specialised training instead of the experienced nursing staff who had been working there until then. Young, freshly trained nurses, especially those with high school diplomas, were to be moulded for the new tasks (Häfner et al., 1965: 108–9).

The medical records of the department contain reports by student nurses about individual patients and their dealings with them, which they had to write as part of their training. These reports reveal their intention to respond to the patient, to take on not a maternal but a comradely role, to help and to stimulate. 24 The medical records also show how nurses were given a more and more important voice in ward responsibilities as well as within communication and in writing the medical history. Already, at the end of the 1960s, nurses occasionally wrote parts of the medical history. 25 From 1972, the medical records contained sheets in which the nursing staff entered their observations about the patient as well as treatment measures as a standard feature. In the 1972/73 annual report, this innovation was justified. A new chart scheme had been introduced in which each professional group was to enter its observations about patients as well as intended and achieved measures, thus making these measures easily available and verifiable for the other staff members and ensuring the closest possible information flow between team members. 26 In the 1970s, it came to pass that nurses sometimes even wrote the ‘doctor's letters’. For example, the medical file of a patient contains a letter dated 1972 from a nurse in the pavilion ward in which he took over communication with out-of-town physicians and reported to a resident from Mannheim about the patient on behalf of the director. The file contains the assistant physician's reply letter, in which he addressed the nurse directly – a procedure that would have been unthinkable in the past due to deeply rooted professional thinking. 27

The third pillar in the sociotherapeutic treatment and rehabilitation of mentally ill patients was formed by social workers, who were accorded an important role, especially in the reintegration of patients into their social and professional environment. Here, too, the USA, England, but also Scandinavia and France, served as models, where care sectors, communal treatment centres and psychiatric social work had existed since the 1950s. The Heidelberg Department of Social Psychiatry had two female social workers from 1966, whereas in the Federal Republic of Germany social work only increasingly found its way into clinical psychiatry after the Psychiatry Enquete of 1975 (Brückner and Kersting, 2021). Their main task was to arrange work for the patient awaiting discharge that was appropriate for their capacity and social behaviours. The social worker first consulted with the doctor, who gave their own opinion on the case and provided her with psychiatric and sociopsychological data. Then she contacted the patient and their family to find out what the patient wanted, but also to make them aware of their integration problems and to motivate and support them in finding a job. If this did not lead to clear results, the social worker organised psychological assessments for the patient at the Psychological Service of the Heidelberg Labour Office. 28 In addition, the social worker assisted the patient during the initial period of integration into their new workplace (Dörner and Plog, 1999: 58–60). Finally, she made regular home visits to support the family and broaden their understanding of the family member with a mental illness. 29

The medical records of the 1960s and 1970s show the important role played by social workers. For example, the medical record of a 17-year-old schoolgirl who had excelled in competitive sports before her admission to the social psychiatric ward in 1968 reports:

Since the patient seemed to have little interest and was not able to go to grammar school or to obtain the Abitur, efforts were made to initiate a change of profession. The social worker looked for a job where the patient would be involved in sports. After this job seemed to be secured to some extent and because of pressure from the parents, the patient was discharged. 30

The medical records reveal that the nursing staff were heavily involved in social work alongside the social workers – for example by organising patients’ clubs, working in day and night clinics and providing telephone services and home visits. Even the psychiatrists invested a great deal of time here and took an active part in providing organisational support for the rehabilitation of their patients. They discussed the patients’ future career plans with them in detail and took care of night clinic or day clinic placements, ‘sheltered’ jobs and places in residential homes. They also encouraged patients to come regularly to outpatient aftercare and to the patients’ club and wrote them letters or made phone calls if they did not show up. 31

The importance of social psychiatry throughout the clinic in the 1960s

The sociopsychiatric pavilion wards in the Heidelberg Clinic were an exception in the 1960s because a sophisticated sociotherapeutic ward programme was practised and here, for the first time, a gradual path out of the clinic was organised and supervised. In contrast, in the other psychiatric departments until the end of the 1960s, after inpatient treatment, which in most cases took place on the same ward from beginning to end, patients were usually discharged home and handed over to the care of the attending, resident doctor. If the treatment was not successful, they were transferred to a psychiatric asylum. Follow-up care, if it occurred at all, was provided by the treatment ward or polyclinic.

Nevertheless, social psychiatric approaches were not limited to the Department of Social Psychiatry at the clinic in the 1960s. This was primarily due to the initiative of committed assistant doctors, who were given great freedom by the clinic director Baeyer. For example, in the late 1960s Christiane von Held and Uwe Genkel established a therapeutic community in the open men's ward, Männer Ruhe, with Baeyer's approval, and held daily ward meetings there (von Held and Genkel, 1974). Wolf Dieter Wiest, then assistant physician at the clinic, describes the spirit and the atmosphere of the 1960s in his memoirs:

The Heidelberg Clinic was like a powder keg of ideas … At that time, the day and night clinics came into being, and every younger psychiatrist took psychotherapeutic care of schizophrenics who had been abandoned earlier. The time when psychopathological phenomena were merely observed and catalogued seemed to be gone forever.

(Wiest, 2000: 91)

At the Psychiatric Polyclinic, new social-psychiatric services were introduced as early as 1964 and 1965 by the senior physicians Karl Peter Kisker and Dieter Spazier. They included group therapy as a new treatment method. Whereas until then the focus had been on diagnostics, psychiatric-neurological counselling and administration of medication to outpatients, individual psychotherapy and group therapy were now also offered. It is noteworthy that, in the polyclinic, social workers acted as co-therapists alongside psychiatrists. Furthermore, a patient club and social counselling were offered. Behind the reforms was the view that, as long as community-based treatment centres did not exist, the traditional polyclinics should fill the therapeutic gap between isolated hospital psychiatry and mental health practice (Kisker et al.,1967). These services were expanded by Spazier and his assistant doctor Wolfgang Huber, who launched the Socialist Patient Collective (Pross, 2017). After the SPK was thrown out of the clinic in 1970, the social-psychiatric services at the polyclinic were further developed by Helmut Kretz (Baeyer, 1977: 31).

It was essential for the spread of social psychiatric approaches at the Heidelberg Psychiatric University Clinic that Heinz Häfner and Walter Bräutigam offered psychotherapeutic training and supervision at the end of the 1960s, which all physicians and the social workers who conducted group therapy were required to undergo (Pross, 2017: 283). In addition, many Heidelberg physicians went to the US for several months to learn social psychiatric methods, and in doing so benefited from the close-knit, international network of the Heidelberg Clinic. 32

Nevertheless, the importance of social psychiatry for the Heidelberg Psychiatric University Clinic, especially in the 1960s, should not be overestimated. In 1970, von Baeyer supervised a dissertation on the eighty-seven inpatient curative procedures carried out at the clinic from 1959 to 1965, which served to maintain or restore the patients’ ability to work and earn a living and the costs of which were borne by the social insurance funds. The dissertation says about ‘sociotherapy’: ‘Since its implementation was not one of the clinic's tasks, only corresponding suggestions could be recorded, but not the measures themselves’ (Kemmerich, 1970: 5–6). A little later it is written that sociotherapeutic suggestions would have included changes in the housing situation, a change of job or retraining, for which the clinic physician would make recommendations in the final report. However, general practitioners, independent social workers, employment and housing offices, etc. were supposed to take care of their implementation. Altogether, sociotherapeutic suggestions were only made in fifteen of eighty-seven cases (Kemmerich, 1970: 73–4).

The significance of personnel changes, political events and the departure of the Department of Social Psychiatry in the 1970s

According to the narrative of the clinic psychiatrists of the time, at the beginning of the 1970s various personnel changes, political events and the departure of the Department of Social Psychiatry for Mannheim put an end to social psychiatry in Heidelberg (Häfner, 1979: 154; Pross, 2017: 50 with further references). Kisker was appointed to the Hanover Medical School in 1966 (Beyer, 2016). Since 1968, appointment negotiations had been underway for Häfner to become the chair of psychiatry at the Heidelberg University Medical Faculty in Mannheim, which had been founded in 1964. In this context, his Department of Social Psychiatry was split off from the main clinic and became part of the Faculty of Clinical Medicine in Mann­heim. The wards and all research projects were moved to Mannheim in 1974, first to a temporary facility, then in 1975 to the newly opened Zentralinstitut für Seelische Gesundheit (Central Institute for Mental Health). This institute performed supraregional research and training tasks in the field of social psychiatry and organised psychiatric care for the Mannheim population according to the principles of a community mental health centre (Häfner and Martini, 2011: 92–4, 122–4).

The events surrounding the Socialist Patient Collective were also significant according to this narrative, as they influenced the mood in the clinic towards reform projects. The SPK, the first patient-organised body in Western Europe, was founded in 1970 by Wolfgang Huber at the Heidelberg Psychiatric Polyclinic and joined by several hundred patients before its dissolution in 1971. It was influenced by the student movement and anti-psychiatric ideas. It denounced the social psychiatric approaches at the psychiatric clinic as completely inadequate and acted particularly against Häfner and Baeyer. Nevertheless, many of the clinic's assistant doctors initially sympathised with the SPK, which saw itself also as a therapeutic community and wanted to make ‘a weapon out of illness’ with the goal of revolutionary change in society. After the conflict with Baeyer escalated and the SPK was expelled from the clinic, a small part of the group increasingly became violent and was put on trial as a criminal association (Pross, 2017: 173, 183, 399).

The change in the directorship from Baeyer to Werner Janzarik, who directed the clinic from 1973 to 1988, is described according to this narrative as the end of the reform era. Within the Heidelberg Clinic, classical psychopathology was seemingly once again the primary scientific interest (Mundt, 2001: 368–9; Bonah and Rotzoll, 2015: 283). Moreover, Janzarik himself declared his election to be politically motivated. The faculty had wanted clear structures and responsibilities to be reintroduced in the clinic, which had become ‘unhinged’ as a result of the anti-psychiatric excesses (Janzarik, 1979: 13). When he took over as director, he set himself the goal of reorganising the clinic. One of his measures was not to renew the contracts among the assistant and senior physicians of the reformist wing, about fifteen people, despite public protests by the assistant doctor committee (Pross, 2017: 152).

As a result, the social psychiatry built up by the reformers would apparently no longer play a role in Heidelberg. A contemporary witness who was an assistant doctor in the psychiatric clinic at the time described the subsequent period: ‘The Heidelberg Clinic then continued to be exposed to the controversial discussions of anti­psychiatry without a social psychiatry that might have absorbed some of the concerns of antipsychiatry.’  33

However, the processes described did not mean the death of social psychiatric care of Heidelberg patients in the 1970s. First, some of Heidelberg's social psychiatric facilities, which were spread throughout the city, did not close until much later, despite the relocation of the Department of Social Psychiatry to Mannheim in 1974; for example, the day clinic was not moved until 1982. 34 Second, there was close cooperation between the Heidelberg Clinic and the Central Institute for Mental Health in Mannheim in the 1970s, as the staff still knew each other personally and were aware of the respective specifics of the care structures, so that patients from Heidelberg were often referred to this institute and vice versa. 35

Third, open wards continued to operate in the pavilion buildings after the move. 36 Here, a special emphasis was placed on psychotherapy and group activities, which speaks for a certain continuity. The frequent long stays, which can be detected up to the 1980s, point in the same direction. For example, a patient diagnosed with ‘schizophrenic psychosis’ stayed here for several months in 1975 and for more than a year in 1981. 37

Fourth, in Heidelberg, the Psychosomatic Clinic compensated to some extent for the psychotherapeutic treatment in the Department of Social Psychiatry, in both inpatient and outpatient form. In 1968, Walter Bräutigam, who had previously worked closely with Heinz Häfner, had become director of Heidelberg's Psychosomatic Clinic. This clinic had already been established in 1950 as the first of its kind in Germany and was part of the university hospital, but it existed independently of the psychiatric clinic. From the beginning, both inpatient and outpatient psychoanalytic treatment was offered at the Psychosomatic Clinic, which was directed by Alexander Mitscherlich until 1968. While Mitscherlich saw the social psychiatric activities of Baeyer and his staff as competing with the Psychosomatic Clinic services and the relationships were not without conflict, 38 the cooperation between the Psychosomatic Clinic and the Department of Social Psychiatry intensified significantly under Walter Bräutigam. The Psychosomatic Clinic also received a new orientation. Not only did the number of beds increase from eight to twenty-four, the psychotherapeutic services also expanded. The infirmary was now organised as a therapeutic community, and therapies offered included classical psychoanalytic individual therapy, analytical group therapy and depth psychology-based individual and group therapy. 39 In addition, non-verbal group procedures such as concentrative movement and design therapy were offered. The inpatient individual and group therapies were subsequently continued on an outpatient basis (Bräutigam, 1986: 138–9).

Fifth, the split from Häfner's Department of Social Psychiatry was counterbalanced by the fact that social psychiatric ideas can be traced throughout the psychiatric clinic in the 1970s. Analysis of the medical records reveals that there was an uptake of psychotherapeutic methods and an increase in communal activities on all wards in the 1970s. For the first time, medical records from beyond the pavilion documented individual psychotherapies. 40 Even on the closed ward Frauen Wache, ward meetings were held in 1972. 41 And for 1975, there is evidence that even on the closed ward Frauen Gartenhaus, sometimes no medication was given at all, and individual and group psychotherapy was carried out instead. 42

On all wards, psychiatrists were increasingly concerned with the social needs of their patients. Nurses and social workers were given important roles in this area. 43 The importance attached to social rehabilitation and outpatient follow-up increased continuously throughout the 1970s. The medical records show that it was becoming more and more common for patients to be admitted first to a closed ward and then to an open ward, whereas previously patients had almost always stayed in one and the same ward from the beginning to the end of their hospitalisation. Thus, cooperation between the wards increased to a great extent. Moreover, transitional wards and outpatient aftercare services were expanded. For example, in 1972 there was outpatient group psychotherapy in the main clinic, 44 and in 1975 there were patient clubs on various wards, as well as several therapeutic residential homes that were directly related to the clinic. 45 An important role was played here by the ‘Heidelberger Werkgemeinschaft’ (Heidelberg Working Group), which was founded in 1973 to set up and expand ‘night clinics, day clinics, residential homes, shared apartments, jobs protected from competition, occupational therapy workshops, lay help circles, training opportunities for caregivers and previously untrained personnel’ in the Heidelberg area. This association was independent of the Heidelberg Psychiatric University Clinic, but many employees of the clinic were active on a voluntary basis. 46

The fact that social psychiatric approaches continued to gain in importance and that no rollback can be detected in the Heidelberg Clinic can be explained on the one hand by the establishment of internal clinic routines which were continued. That the wards came into closer contact with each other helped spread these practices. On the other hand, since the 1970s at the latest, social psychiatric approaches were implemented in many places in the Federal Republic of Germany, more opportunities for exchange were created, and the will arose on a broad basis to advance social psychiatric reforms in psychiatry. The reform mood was shaped by a particular zeitgeist, embodied by the social-liberal government that Willy Brandt had launched in 1969 under the title ‘Reforms dare’. The atmosphere was influenced by the social movements (student, women's, ecology and peace movements) with their anti-authoritarian critique of society, in which an increased awareness of ‘the social’ and of human and civil rights was immanent (Schmiedebach and Priebe, 2004: 469). Important books critical of psychiatry appeared in German during this period, notably Michel Foucault's Madness and Society (1969), Franco Basaglia's L’istituzione negata (The institution denied, 1971), R. D. Laing's The Divided Self (1972), and Erving Goffman's Asylums (1973). One of the best-known German works, which strongly influenced the public debate, was Frank Fischer's 1969 book Irrenhäuser: Kranke klagen an (Lunatic asylums: Patients accuse) in which he denounced the miserable and inhumane everyday life in institutions that he, a Germanist and historian by training, had experienced for eight months as an auxiliary nurse in five psychiatric hospitals (Fischer, 1969).

In 1970, the Mannheim Circle and the German Society for Social Psychiatry (DGSP) were founded. It was not only psychiatrists who participated; nurses, caregivers, social workers, occupational therapists, physicians, psychologists and sociologists who worked in psychiatric clinics or connected institutions were also involved. The founding of the Aktion Psychisch Kranke (Action for the Mentally Ill) in 1971 by members of all parliamentary groups in the German Bundestag and committed professionals from the field of psychiatry was also an important vehicle for the formation and institutionalisation of the psychiatric reform movement. As early as 1972, 1,200 participants came to the social psychiatry conference in Bethel. The Mannheim Circle and the DGSP had become a kind of mass movement within psychiatry, whose credo was formulated by Klaus Dörner in 1972 in reference to a sentence by Max Fischer (1919) as follows: ‘Psychiatry is social psychiatry or it is no psychiatry’ (Dörner, 1972: 8).

Conclusion

The analysis of social psychiatric practices at the Heidelberg Clinic in the 1960s and 1970s on the basis of medical records, administrative files and records of the medical and nursing staff showed, on the one hand, the impressive achievement of the leading reformers Walter von Baeyer, Heinz Häfner and Karl Peter Kisker in creating a model institution of German social psychiatry in Heidelberg in the 1960s. On the other hand, in addition to the leading psychiatrists, the increasing relevance of other actors with their own ideas and interests and of routines and procedures, which did not coincide with the guidelines from above, came to the fore, whereby there were clear differences in their importance between the 1960s and 1970s.

In the 1960s, social psychiatric practices in Heidelberg were very much shaped by the senior doctors and the structural reforms they initiated. However, their scope within the Heidelberg Psychiatric University Clinic was largely limited to the Department of Social Psychiatry, with its transitional facilities, diverse forms of therapy (individual and group psychotherapy, work and occupational therapy) and intensive ward life with daily meetings and multiple leisure activities organised by the patients themselves. At that time, on most of the other wards of the clinic, the focus of treatment was primarily on medication and electroconvulsive therapies. Social psychiatric approaches were practised only on some other open wards and in the polyclinic from the 1960s.

The Heidelberg psychiatrists who initiated the social psychiatric reforms drew a large part of their assertiveness from the fact that they had clear objectives in mind through an orientation towards Anglo-Saxon models. They explicitly referred to the US model in their attempt to establish a Community Mental Health Centre and to give nurses a key position in social psychiatry. Great Britain served as a model for the therapeutic community and for ‘industrial rehabilitation units’. For the important role of social workers in social psychiatry, the Heidelberg reformers cited the USA and Great Britain, but also Scandinavia and France as models.

Another finding regarding the 1960s is that the implementation of Heidelberg's social psychiatric reforms in everyday clinical practice often took longer than the publications of the senior physicians would suggest. In addition, the freedom that the reformers gave their employees allowed them to pursue and implement their own ideas. This led to reform initiatives by assistant doctors and, in the case of Wolfgang Huber, who founded the Socialist Patient Collective at the polyclinic in 1970, to his complete withdrawal from staff management at the end of the 1960s.

As far as the significance of the reformers for social psychiatry in Heidelberg is concerned, the situation in the 1970s is clearly different. The medical records show that social psychiatry in Heidelberg had not lost its importance in everyday clinical life with the departure of Häfner, Kisker and the Department of Social Psychiatry, the events surrounding the Socialist Patient Collective and the change of director from Baeyer to Janzarik in the 1970s. There is no evidence of a break in the trend. The complaint of many doctors involved about the disappearance of social psychiatry was mainly about the lost spirit of reform in the clinic and the decline in social psychiatric research. In the 1970s, however, patient care at the Heidelberg Psychiatric University Clinic was even more influenced by social psychiatry than in the previous decade. On the one hand, this is due to the fact that the Department of Social Psychiatry was still being set up at the end of the 1960s and it was not until the 1970s that individualised therapies were increasingly described in the medical records. On the other hand, in the 1970s, patients in all departments of the psychiatric clinic increasingly benefited from psychotherapeutic services, a changed doctor–patient and nurse–patient relationship and continuously expanded support for reintegration into society. Heidelberg's transitional facilities increased overall in the 1970s. The day clinic did not move to Mannheim until 1982 and the residential homes and sheltered workplaces were mainly run and expanded by the Heidelberger Werkgemeinschaft, founded in 1973. This organisation was independent from the clinic, but, nonetheless, many employees of the psychiatric clinic were active in it.

In the 1970s, social psychiatric practices sometimes took place without normative guidelines – or in spite of them – and were strongly influenced by internal routines and by the spirit of the times. The analysis of the medical records shows that in this period, with regard to social psychiatric approaches, the dynamics of action within the psychiatric clinic were actor-bound, but not as hierarchically shaped as the institutional organisation envisaged, and the employees had a wide scope for action. Heidelberg social psychiatry of the 1970s is an example of a reform-oriented practice complex that shifted from the leading figures and representative structures to the lower levels through routinisation, where it developed and spread. This was favoured by the fact that within social psychiatry the scope for action of assistant doctors and non-medical staff was greater than in other areas of psychiatry.

Notes

1 The Psychiatry Enquete was a report on the situation of psychiatry in the Federal Republic of Germany, completed in 1975 by a commission of experts from all areas of psychiatry on behalf of the Bundestag.
2 Until 1969, the clinic was connected to the neurology department and was called the Psychiatric and Neurological University Clinic. In 1969, the Neurological and Psychiatric clinics became independent.
3 The quote comes from Kersting, who refers to innovative models in the Federal Republic of Germany before the Psychiatry Enquete (Kersting, 2004: 271).
4 One exception is Maike Rotzoll's study, which uses administrative files to trace the structure of social psychiatry in Heidelberg. Rotzoll (2012).
5 Cf. the section ‘The significance of personnel changes, political events, and the departure of the Department of Social Psychiatry in the 1970s’.
6 See also the reflections by Marietta Meier in Chapter 8.
7 Bibliothek des Zentralinstituts für Seelische Gesundheit, Mannheim, Jahresberichte der Sozialpsychiatrischen Klinik am Klinikum der Universität Heidelberg [Annual reports of the social psychiatric clinic at the Heidelberg University Hospital], 1968–73 (henceforth Jahresbericht, Zweijahresbericht). Jahresbericht, 1968; Jahresbericht, 1970; Jahresbericht, 1971; Zweijahresbericht, 1973.
8 For example Psychiatrische Universitätsklinik Heidelberg, Aktenmanagement (henceforth referred to as PA), Heidelberg, Medical records from 1962, 1968, 1972, 1975, women 62/243, men 62/94.
9 Jahresbericht, 1969: 5.
10 Jahresbericht, 1969: 33; Jahresbericht, 1970: 15–16, 35–6.
11 Jahresbericht, 1969: 4.
12 Jahresbericht, 1969: 140–1.
13 The concept of the therapeutic community is also highly significant in the case studies by Despo Kritsotaki, Katariina Parhi and Henriette Voelker in Chapters 1, 5 and 10.
14 Cf. in particular PA women 62/217.
15 PA men 62/92; see also PA men 68/202.
16 Universitätsarchiv Heidelberg (henceforth UAH), Heidelberg, Rep. 49/367, Operation of the Psychiatric and Neurological Clinic, Day and night clinic 1962–68, Prof. Dr. W. v. Baeyer/PD Dr. Bräutigam on 27 September 1963 to the administration of the clinical university institutions.
17 See for example PA women 68/299.
18 See for example PA women 68/326.
19 PA men 68/133. See also PA men 68/219; PA women 68/411; PA women 68/417; PA women 68/440.
20 Early exceptions are PA men 68/167; PA men 68/211.
21 PA men 72/286. See also PA men 72/278; PA men 72/339; PA women 72/422.
22 PA men 75/281.
23 See, for example PA men 72/339.
24 This is particularly evident in PA women 68/474; PA women 68/326.
25 PA women 68/474.
26 Zweijahresbericht, 1973: 35–6.
27 PA women 72/335.
28 See for example PA women 68/268.
29 Jahresbericht, 1968: 8.
30 PA women 68/447.
31 See, for example, PA men 72/286.
32 Jahresbericht, 1969: 33; Jahresbericht, 1970: 12–13.
33 Eyewitness interview from 4 October 2012 by Christian Pross. Quoted in Pross, 2017: 50.
34 After the Heidelberg day clinic closed its doors, it took until the mid-1990s for a new day clinic to become operational in the city. Rotzoll, 2012: 144, 148.
35 See, for example, PA women 75/214. According to Maike Rotzoll, this changed in the following decades when the personal relationships no longer existed. Interview, 8 November 2021, with the Heidelberg psychiatrist and medical historian Maike Rotzoll, who had worked at the clinic since the 1980s.
36 These wards were now called ‘Station Pavillon-West’ and ‘Station von Gebsattel’.
37 PA men 75/201.
38 Baeyer's annoyance at Mitscherlich's attempts to limit and question the scope of competence of Baeyer's staff with regard to psychotherapeutic topics is particularly evident in a letter from Baeyer to Mitscherlich in 1964. UAH, Rep. 63, Estate of Prof. Walter v. Baeyer, 15–17, Letter from Prof. v. Baeyer to colleague Mitscherlich, 4 November 1964.
39 While psychoanalysis comprehensively tries to uncover and change the foundations of neurotic conflicts in the imprints of childhood, depth psychology-based treatment primarily deals with currently effective conflicts in the patient and in his or her relationships.
40 PA men 72/341 is particularly detailed.
41 See, for example, PA women 72/336.
42 PA women 75/290.
43 PA men 75/203.
44 PA women 72/312.
45 PA men 75/218; PA men 75/225.
46 UAH, Rep. 63/103, Heidelberger Werkgemeinschaft, Flyer [undated, 1973].

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Doing psychiatry in postwar Europe

Practices, routines and experiences

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