The Geneva Psychiatry 1980’s Crisis
Psychiatry and Antipsychiatry
Edited by François Ferrero
1. The Psychiatric Sectorization in France and in Switzerland
I will try to show why the Sectorization in France did not appear by chance and that it was an important and original experience, far from certain caricatures made out of it.
Evolution of the psychiatric hospital after the birth of the asylum
Throughout the 19th century many innovative experiences were developed in the field of psychiatry, in France as elsewhere. For instance, Morel (1809-1873) defended an unconstrained psychiatry, following the English movements of no restraint and open doors. In 1841 Falret (1794-1870) created the first post-treatment institute for women (foyer de post-cure), then in 1868 the first external consultations in Sainte-Anne, as Magnan (1835-1916) did at La Salpêtrière. Nevertheless, at the end of the 19th century, asylums were so overwhelmed that creating additional asylums, called "Landfill Asylums," was considered. On average, there was one doctor for 600 or even 1,000 patients. Many official reports all mentioned the catastrophic situation, but changes did not happen. Among these reports, one by Maurice Dide (see below) in 1926 is devoted to the catastrophic situation of asylums in the department of Haute-Garrone.
From the end of the 19th century, some successful experiences emerged to open the asylums, one in a non-academic environment in Ville-Evrard with Marandon de Montyel between 1888 and 1907 and another one in Bordeaux in the academic sphere of Emmanuel Régis (1855-1918) starting in 1902. Sensitive to Freudian ideas, Régis was appointed in 1907 to the mental illnesses chair at Sainte-Anne. However, it was Gilbert Ballet (1853-1916) who gave the widest visibility to this movement by opening a service at the Hôtel-Dieu in 1904 and theorizing about these questions. He presented a first assessment of this experience in La Presse Médicale (Ballet 1906) specifying that he possessed two rooms with 14 beds and a nurse for two patients during both day and night - figures which would be staggering nowadays. His great rival, Edouard Toulouse (1865-1947), a doctor of the Seine asylums, was one of the main architects of the dissemination of prophylaxis ideas in mental health and the founder of the French League for Mental Hygiene in 1921 (which became in 1966 the French League for Mental Health). In 1922 he turned the Henri Rousselle service in Sainte-Anne (Paris) into an open service and created a dispensary in order to treat the sick outside the asylum. Essentially relying on a social and scientific approach, he strived to transform the conditions of psychiatric practice and insisted on the need to integrate all these new discoveries in neurology and psychology. He was also concerned with legal issues by challenging the 1838 Act (Law) which prevented the creation of open services.
It has to be noted that as early as 1917 the Americans played a very important role, thanks to the Rockefeller Foundation, in developing a system of dispensaries for fighting tuberculosis throughout France. Many outpatient psychiatric clinics (Centres Médico-Psychologiques) used these dispensaries.
However, at the same period psychiatry and society in France and elsewhere were much more sensitive and preoccupied by eugenics ideology. This ideology promoted the theories of degeneration and the fantasy of an alleged danger of decline of the race due to physical deformities or mental disorders. Such ideas largely predominated and were validated by the highest scientific authorities such as Alexis Carrel (Nobel Prize winner for Medicine in 1912), Gaëtan de Clérambault and Edouard Toulouse. All three suggested this policy was needed to protect the French race. These racist and eugenic ideologies culminated later in the Nazi euthanasia program.
In the 1930s the Popular Front developed the Mental Hygiene Movement, recognized the profession of the psychiatric nurse, and replaced the term Asylum with Psychiatric Hospital. Appropriate financial resources would, unfortunately, not be obtained and the situation would even be compounded by the 2nd World War.
Influence of some Scientific Societies
The Medico-Psychological Society was founded in 1852, which undoubtedly makes it one of the oldest societies of psychiatry. It still publishes the Medico-Psychological Annals. As for the Society of Psychiatric Evolution founded in 1925, it has for a long time gathered progressive psychiatrists and has given its name to a renowned journal, L’Evolution Psychiatrique.
The Paris Psychoanalytic Society was founded in 1926 by Marie Bonaparte, René Laforgue and others, along with two Swiss psychoanalysts, Charles Odier and Raymond de Saussure. It still publishes the Revue française de Psychanalyse (French Journal of Psychoanalysis). The Institute of Psychoanalysis had to cease its activities during the War and several of its members joined the active Resistance.
From the Resistance to the Liberation
Jean Garrabé evokes the memory of Professor Joseph Levy-Valensi (1879-1943), who was deported and died in Auschwitz. Among the countless victims of the Nazi regime, there were psychiatrists who, like Levy-Valensi, had been persecuted because of their Jewish origin or their political opinions.
One of them, Maurice Dide (1873-1944), son of a pastor, Dr (PhD) of Letters and Medicine and excellent violinist, joined the "Combat" movement, was arrested in 1943 and deported to Büchenwald where he died the following year. He is known to have described Passionate Idealism, Chronic Hallucinatory Psychosis (with Gassiot in 1918) and Athymormy, (with Guiraud in 1922). His name is cited by Edward Shorter in his Historical Dictionary of Psychiatry (Shorter 2005).
"The Asylums of Death: 40,000 victims in Psychiatric Hospitals during the Occupation"
In 1952 Dr Daumézon mentioned this drama in the Esprit journal (see below). Thirty years later, Dr Bonnafé prefaced Dr Max Lafont's thesis, "Smooth extermination" which describes what happened at the Vinatier asylum where 3,000 patients died. This doctoral thesis would, however, be published with great difficulty and would almost go unnoticed. This tragedy finally came out of oblivion in 1987 with the publication of an article by Dr Claudine Escoffier Lambiotte in the French newspaper Le Monde bearing the provocative title above. Today, historians estimate that up to 50,000 patients were victims of cold, hunger and other deprivation in psychiatric hospitals between 1940 and 1944.
The Vichy Government had, however, been made aware of the situation since the beginning of this drama and the Medico-Psychological Society devoted its session to it on October 27, 1941. Drs Dublineau and Bonnafé presented there a communication on the catastrophic consequences of nutritional deficiencies in asylums, but this information had to be kept secret for obvious political reasons.
For Dr Lucien Bonnafé the memory of this tragedy as well as other war-related events suffered from a form of collective amnesia. Nevertheless, we can uncover multiple indications of the influence that these dramas had on a whole generation of psychiatrists whether they had experienced them either directly or through the experience of their family or friends.
Psychiatrists committed themselves very early on to the Resistance movements, hiding Jews and Resistants in asylums and sometimes showing engagement with tremendous courage. Among others, Dr André Hammel (1894-1965), also a pastor, would be recognized as a "Righteous" with his wife. He was one of the pioneers of Institutional Psychotherapy. Or the Drs Paul Balvet, Lucien Bonnafé and François Tosquelles at Saint Alban Hospital in Lozère. Tosquelles was a Spanish Resistant fluent in German who knew of Herrman Simon’s book (1929) calling for a reorganization of the asylums (Simon 1929).
Saint Alban, originally a fortress, is located on an isolated plateau and was transformed by a brother of the Congregation of Saint John of God in order to admit psychiatric patients. The asylum was repurchased by the State and became a major place of the Resistance where artists like Tristan Tzara, Paul Eluard and his wife Nusch would take refuge. Thanks to a few doctors who had the courage to transgress the law by deciding to let the patients out with the aim of helping the farmers in the fields, they suffered much less from the lack of food than elsewhere. Gaston Ferdière did the same in Saint-Denis and Henry Ey in Bonneval. Saint Alban has thus been one of the cradles of the Institutional Psychotherapy movement.
As for Dr Paul Sivadon, director of the Ville Evrard hospital in Neuilly sur Marne, east of Paris, he had seen his sister, survivor of Ravensbrück, return in absolute physiological and moral distress. Precious testimony from his daughter teaches us that, despite the frequent insurmountable difficulties in putting into words such an indescribable experience, Dr Sivadon and his sister have spoken a great deal about it. These exchanges on the concentration camp life would have a decisive influence on the continuation of his commitment to psychiatry and, with some colleagues, he created the "disalienating" movement. The stories of survivors encouraged many psychiatrists to engage in a radical transformation of the psychiatric hospitals project.
Indeed, the shadow of the concentration camps had made the asylum environment unacceptable as it had become evident that nothing could be more similar to a camp than an asylum.
Invention of the Sector (1950-1960)
The psychiatric Sectorization was born mainly because of the war and a double refusal:
· Refusal of the segregation of the mentally ill and the asylum system which could evoke the concentration camps and,
· Refusal to exclude the sick from society.
The original idea consisted in entrusting responsibility for the mental health of a given population, around 60,000 inhabitants, to a team ensuring both hospital operations and monitoring of patients within the population of the Sector.
The immediate post-war period hoped for a radical transformation in the organization of the psychiatric care system. The context was then particularly favorable: De Gaulle had just created Social Security; he personally supported these reforms, and the medical community was sensitive to the significant problems of psychiatry. Several think tanks then laid the foundations for a new psychiatric assistance. One of them gathered around Julian de Ajuriaguerra in Sainte-Anne. It advocated an approach including prevention, cure, aftercare, and rehabilitation in the community and was concerned with protecting mental health.
In an eloquent sign of this favorable context, psychiatrists received the support of their medical colleagues during the National Mental Health Days of 1945 and 1947. The president of these Days was also a renowned neurologist, Professor François Lhermite. Other meetings helped change the situation, such as the "Bonneval Seminars" (Colloques de Bonneval) organized in 1946 around Henri Ey.
The idea of Sectorization would have been raised for the first time during the National Mental Health Days in 1947. A resolution indeed required a national plan to set up psychiatric establishments in each "geographic sector" in order to offer the population both care and rehabilitation possibilities (this notion of geographic sector would be the source of many misunderstandings in the future and would often reduce Sectorization to an ordinary geographic division). This resolution also requested for these establishments to be located in the vicinity of other hospital units, including general hospitals. The aim was thus to ensure the penetration of the psychiatrist in the activities of the general hospital and of the various specialists in the psychiatric establishment.
Unfortunately, the situation evolved in the wrong direction due to multiple disagreements between psychiatrists, administrative and political officials or between psychiatrists themselves. The condemnation of psychoanalysis by the communist party would also generate a great disturbance.
Meanwhile, the number of hospitalized patients continued to increase whereas the human and material resources did not follow at the same pace. The Esprit journal published in 1952 an issue entitled "Misery of Psychiatry." This indictment describes the absence of care due to a lack of financial resources and workforce and the appalling promiscuity in which patients and caregivers lived in totally overcrowded hospitals (Le Guillant and Bonnafé 1952). They describe this reality under the title "The patient's condition in the psychiatric hospital" and accuse the administrative and political powers of failing to assist persons in danger and of opposing any change.
An important paper had already been published by Daumézon and Bonnafé to support the necessity to reform the psychiatric system (Daumézon and Bonnafé 1946).
In the midst of this great psychiatric misery, a first "experimental" Sector, benefiting from a semi-private status, opened its doors in the 13th arrondissement of Paris in 1954. It operated for 10 years without possessing a mental hospital. Its founders, Drs Philippe Paumelle, Serge Lebovici, René Diatkine and Paul Claude Racamier, were psychoanalysts.
Unfortunately, as it is often the case, these beautiful ideas would take time to be concretized and would only be partially realized.
Ministerial circulars only granted official recognition to the Sectorization in 1960, thanks to the strong support of few brave officials. This decision would nonetheless arouse much resistance from both the administration and psychiatrists. Following the events of 1968, these previous circulars would be taken up in a ministerial decree in 1972, but it was only in 1985 that the Sectorization would finally become the reference model of public psychiatry in France.
In the 13th arrondissement, as I knew it in the mid-1970s, everything seemed different: management was collegial and the administration which had agreed to relinquish its power loyally supported the project. The relationships between professionals, patients and their families were incomparably simpler, more welcoming and direct than anything I had seen so far. Yet, this organization would immediately arouse distrust and hostility and would be rejected by most of the officials responsible for psychiatry in France and abroad, in particular by the heads of the University Services. Sectorization was perceived as a danger because it challenged the powers and the traditional hierarchical organization. It redefined the role and responsibilities of psychiatrists and asked them for a change in their way of working. They needed to learn how to meet patients and their families outside the hospital, go into the community and collaborate with a multidisciplinary team enjoying great autonomy. This adventure has been remarkably described by Paul-Claude Racamier in a collective book, Le Psychanalyste sans divan (The Psychoanalyst without a couch) (Racamier, Diatkine, Lebovici and Paumelle 1993).
Sectorization, which was generalized in France, poorly matched the original project and an important work published in 1975 was even entitled History of Sector psychiatry or the impossible Sector (Fourquet, Murard, Lamarche-Vadel and Préli 1975). Indeed, real power had been quickly transferred to the administration and the budget was still managed by the hospital of the Sector, which represented a considerable obstacle to the development of out-patient services and other facilities in the community. Setting up an organization charged with ensuring continuity of care under the responsibility of a psychiatrist accountable for a hospital-ambulatory team encountered many difficulties.
From an academic point of view, it is likely that this organization, strongly influenced by psychoanalysis which gave priority to the social and community aspects of psychiatry, could appear as a threat to education and research budgets. Besides, the organization was not very interested in scientific research. Today, I understand a little differently the letter published in the newspaper Le Monde by significant university leaders; it is rather an illustration of this distrust than real support to the director of the Bel-Air Clinic (Ferrero 2018).
It is also interesting to note that Pierre Pichot, who mentions Henry Ey in his remarkable book One century of Psychiatry, ignores deliberately (or maybe unconsciously?) all the colleagues involved in the Sectorization movement (Pichot 1983).
After Lausanne and Zurich, Geneva risked becoming the 3rd University Department of Psychiatry in Switzerland, out of a total of five, to choose Sectorization. Unlike France and so many other countries, Switzerland did not have to face the ordeals of World War II. The Federalist system which gives the Cantons a large degree of autonomy made it possible to develop medical and psychiatric services of often high quality in each Canton. The same phenomenon occurred for Sectorization: Switzerland did not have to follow the guidelines of a single model and was able to adapt to different contexts. These reforms would most often take place smoothly, except in Geneva, as we have seen before. Sectorization would be done in close conjunction with academic psychiatry and not against it. This is undoubtedly what enabled it not to lose contact with the academic world and the research’s requirements. In Geneva, we tried to adapt Sectorization to academic psychiatry. We developed specialized outpatient clinics and programs for different problematic areas such as geriatric psychiatry, drug abuse, bipolar disorders, borderline personality disorders and a psychiatric unit in the University General Hospital for dual diagnosis, etc. From my point of view, these patients were not being treated effectively enough in the sector system.
Sectorization, like any model of healthcare organization, has also shown its limits. Caught in multiple contradictions, it did not meet some unrealistic expectations, it did not make it possible to suppress psychiatric hospitals nor remove the complexity of psychiatric problems and their care. From my point of view, Sectorization, at least as it was originally thought in the 13th arrondissement and sometimes elsewhere, has represented an extraordinary field of experimentation. Its generalization has been difficult and has remained largely unfinished for economic, political, and ideological reasons.
The proliferation of debates and new ideas it sparked will attract doctors and other professionals of often remarkable quality to psychiatry. Like others before them, they will try to help psychiatry get rid of a long deadly history. Sectorization has represented a kind of revolution through this proposal to shift the center of gravity of psychiatry from the hospital to the community and by organizing care and prevention as close as possible to where patients live, in their environment and with their families (Chanoit and de Verbizier 1987).
Sectorization has also helped give voices to patients, their families, and caregivers. By radically questioning practices characterized by a most often frozen, overwhelmed, and neglected hospital system, it has played a role which, in certain respects, echoed the achievements of Pinel and the founders of the asylum system at the end of the French Revolution. Those who criticize it seem to me to forget that Sectorization was designed, above all, for a minority of patients - the most difficult and most severe mentally ill patients, those whom academic psychiatry has too rarely considered as its priority.
2. Some Characteristics of Switzerland relevant to Psychiatry
At this point, it could be useful to briefly describe some of the originalities of the Swiss political organization and its influence on psychiatry. I hope it will also contribute to a better understanding of my answer to Shorter.
- Switzerland was never a centralized State, but a Confederation of Cantons, which was progressively built between 1291 and 1815, piece by piece, that is to say, Canton by Canton. Every Canton has his own Government including a ministry of health, teaching, security, or economy etc. The advantages are numerous for the health care system, too: the Canton is not only responsible for guaranteeing access to care for its population, but also for its organization. Thanks to this system, politicians remain in close contact with the population. The question of whether to increase the power of the Federal Government is a matter of continuous discussion, not only through numerous votes following an initiative or a referendum. The main point is to reach a broad consensus.
- In line with this organization, every Canton has its own General Hospital and, with very few exceptions, its own Psychiatric Hospital. The majority of these were created between 1835 and 1900. This explains why Switzerland had never huge Psychiatric Hospitals.
- Since the second half of the 19th century, five Cantons have a Medical Faculty: Geneva, Lausanne, Bern, Basel, and Zurich; the five Medical Directors of these faculties were also appointed Chair of Psychiatry at their respective University.
- As early as 1888, psychiatry was included as a mandatory domain for the federal final exams and for receiving the title of MD.
- Nearly all psychiatric hospitals are recognized as centers for postgraduate training. This responsibility was never delegated exclusively to the University Hospitals.
- All psychiatrists are members of the Society of Psychiatry - now the Swiss Society of Psychiatry and Psychotherapy. The advantage is to promote close contacts between psychiatrists working in different settings, such as public services, universities, private practice or in private psychiatric clinics.
- A long tradition of continuity exists between the hospitals and the outpatient clinics, as well as between university departments and Cantonal or private hospitals.
- Some of these hospitals had an international reputation: Kreuzlingen with Ludwig Binswanger, Münsingen with Max Müller, Münsterlingen with Roland Kuhn, etc.
- Medical Directors usually received their training in foreign countries, e.g.,
Eugen Bleuler (1857-1933) was not only trained in Zürich with August Forel, but also in Paris with Charcot, and in London and Munich with von Gudden. His first position as Medical Director was at the Zürich Psychiatric Cantonal Hospital Rheinau, and not at the University Hospital. Bleuler was the first Medical Director at the famous Burghölzli who was able to speak Swiss German with his patients. Most of the previous Medical Directors, who came often from Germany, were speaking only Hoch Deutsch (high German taught in schools).
Carl Gustav Jung (1875-1961) was trained in Zürich with Eugen Bleuler, in Paris with Pierre Janet and Alfred Binet and in London before coming back to Zürich and receiving his title as adjunct Professor at the University in 1904.
Ludwig Binswanger (1881-1966) was trained at Burghölzli with Bleuler and Jung, and in Lausanne and Heidelberg before taking the responsibility of the Bellevue Clinic in Kreuzlingen, (Thurgau), a clinic owned by his family.
Hermann Rorschach (1884-1922) was trained in Neuchâtel, Zürich, Bern, and Berlin. His first important position was at the Münsterlingen Klinik (Thurgau). He then moved to the University Hospital Waldau in Bern and became finally Adjunct Medical Director at the Cantonal Psychiatric Hospital in Herisau (Appenzell).
This list, which could be much longer, shows that Swiss Psychiatrists were influenced by different schools.
The goal here is to provide an understanding of at least three characteristics of Swiss Psychiatry: first, the absence of a unique School of reference; secondly, its great diversity, enriched by many influences and traditions; and thirdly, its continuous exchange between Cantonal and University Hospitals.
The Swiss organization allows me to explain why Shorter’s comment is inappropriate. The ongoing investigation of potential ethical problems in drug trials by Roland Kuhn has nothing to do with a Swiss centralized political decision. It is exclusively the responsibility of the Thurgau Canton where the Münsterlingen Psychiatric Hospital is located and where Roland Kuhn was the Medical Director.
With Pierre Baumann, we have presented on the INHN website some “Preliminary notes on the official inquiry of the clinical research activities of Roland Kuhn” (Baumann and Ferrero 2017). An additional comment has followed the publication of the official report (2019).
3. Psychiatry and Politics in Geneva: History of an Ambivalent Relationship
The impact and consequences of the events of 1980 did not come out of the blue and deserve to be understood from a historical perspective, the local dimension of which is important. Indeed, if the history of Genevan psychiatry is often evoked by emphasizing certain personalities who have marked it, it is worth proposing another reading, centered on the ambivalent and sometimes conflictual relationship between psychiatry, politics, and society.
What can explain, for example, why this city, so receptive to the ideas of the Enlightenment, postponed for several decades any project to build an asylum?
Despite the commitment to build an asylum by some exceptional personalities such as Abraham Joly (1748-1812), sometimes considered by the Swiss a precursor to Philippe Pinel (1745-1826), Etienne Dumont (1759-1829) and Gaspard De La Rive (1770-1834), all early asylum proposals had been refused because the cost was considered too high. When the first asylum finally opened in 1838, the government entrusted its management to Dr Charles Coindet (1796-1876), a psychiatrist trained in Edinburgh, Scotland, and a member of an influential Geneva family. His dismissal 18 years later represented the first scandal in a series that struck the first four doctors in charge of psychiatry.
Coindet was dismissed in 1856 by a new radical government (which had overthrown the liberal oligarchy) on the pretext of the wrongful internment of a 14-year-old girl. He was replaced by Marc Olivet (1821-1897), a doctor without any psychiatric skills but close to the government, who then held the position for 35 years. In 1876, he became the first professor of psychiatry at the new Faculty of Medicine, although he had written nothing about psychiatry. Under his leadership, the asylum's reputation became so deplorable that he was eventually forced to resign in 1891following the murder of a patient by his cellmate.
The situation improved at the end of the 19th century thanks to the appointment of Joannès Martin (1851-1939), a doctor of Geneva origin who had benefited from the remarkable psychiatric training he acquired partly in Zürich with Auguste Forel (1848-1931). Martin introduced important transformations in the organization of asylum and its care, creating continuous observation rooms and developing treatments by clinotherapy that allowed him to reduce the use of restraint and isolation. In charge of the project of the new asylum “Bel-Air”, he was unfortunately forced to resign in 1899 because the government accused him of being responsible for the significant overrun of the construction costs of the new psychiatry hospital.
Rodolphe Weber (1866-1937), who succeeded Martin, was another young and talented psychiatrist who had a brilliant career and became dean of the Faculty of Medicine and then rector of the University of Geneva. After two-three years, however, he was confronted by the hospital’s powerful administrative commission that did not appreciate his liberal innovations and that systematically rejected his proposals such as, for example, his plan to create a specialized unit for criminal patients. He, too, became a victim of political conflicts and was forced to resign in 1924 following accusations made against his closest associate doctor by the socialist party, which wrongly accused him of being in the pay of a pharmaceutical establishment.
Considering the tormented careers of the first leaders of Geneva psychiatry over the course of almost a century, the reasons for dismissal or resignation are striking. Some classic ingredients that have underpinned the complex relations that psychiatry maintains with the political world and, more broadly, with society are ubiquitous:
· The question of freedom: when one will accuse another of exercising too much surveillance by referring to abusive internment or, on the contrary, not enough control, resulting in a murder.
· The relationship to money: in this austere city influenced by Calvinism, the authorities hesitated for years to build an asylum, to install heating or to implement the training of psychiatric nurses.
· A distrust of biological psychiatry: when one is suspected of being influenced by the pharmaceutical industry.
· And two subjects that can be found everywhere: interpersonal and ideological conflicts.
The Zeitgeist influences many decisions, with two remarkable exceptions during the first half of 20th century: a very modest influence of eugenic theory and the refusal of psychosurgery. Should the observation that society has tried to respond to the fears inspired by madness by the exclusion of the mentally ill patients or, at the opposite, by the negation of madness, be seen as a kind of an insoluble question?
March 31, 2022