Why a history of psychiatry?

Pointing out the relevance of the history of psychiatry in the decade of the brain may seem anachronistic given the fast pace at which empirical knowledge of neurobiology is gained and that the future stands at the centre of scientific and public attention.

The picture often painted of modern psychiatry as a discipline that steadily converges on the current status of basic research and aims to implement it in clinical research and everyday life is not incorrect; yet it does not mirror the entire reality of our discipline. It is for good reason, unlike in all the other medical fields, that our literature has known and widely discussed an — albeit mainly polemic — counter-discipline, i.e. ‘antipsychiatry.’ It was likewise for good reason that Littlewood dubbed psychiatry “the most self- doubting speciality” of all medical disciplines,¹ and that psychopathologically oriented authors like Janzarik² and Sass³ have spoken of a crisis in psychopathology, or in psychiatric diagnosis; that is to say, not just in a peripheral area of psychiatry, but in a very central one.

Thus, we are discussing the very concept of psychiatry itself. Despite the seemingly unifying formula of the decade of the brain, psychiatry remains a complex field, both in research and in the clinic, empirically as well as theoretically. In the end, it makes little difference if one speaks only of a postmodern variety — or tangle — of theories, or of a veritable identity crisis in the field. What matters much more is that, regardless of an author’s scientific and theoretical position, the fundamental questions of what psychiatry is, what constitutes mental health and illness, and what diagnosis and therapy are cannot be ignored. The tasks set for psychiatry here can only be tackled by including and making use of the current (and future) knowledge of its history.

Studies on the history of psychiatry can and must show how interwoven are all the various ramifications of psychiatry, be they scientific, biological, anthropological, socio-scientific, or psychodynamic. In addition, they are all necessarily characterised by certain theoretical assumptions regarding the human being. These interconnections as such are not the problem, but they can become a hindrance for scientific progress if disregarded and if the actual work carried out is not included as part of the background. Lack of such self-criticism inevitably gives rise to the notorious, dogmatic, one-track distortions of our discipline. By employing concrete examples, psychiatric history can make these — at first sight fairly abstract — relations become very much alive, and thus bring scientific theory close to the empirical everyday of science. One need think only of the careful work involved in treating such widely dissimilar approaches as the (nowadays usually underrated) ‘romantic’ psychiatry of the early 19th century, its diametrical opposite the materialistic ‘brain psychiatry of the late 19th century, and the ‘anthropological’ psychiatry of the 20th century, which was closely linked to certain (existential) philosophical concepts, and has lately fallen into disuse.

The demand thus put to psychiatric history — and also as a call for our own self-appraisal — must therefore be to question current opinion and to replace it with hard scientific data. In all likelihood, the ubiquitous uncritical-palliative, or plain superficial name-dropping, often in form of an historical introduction, has decisively contributed to psychiatric history being seen more as a fringe discipline by the rest of the scientific community. It is therefore in the interest not only of psychiatric history, but also of psychiatry as a whole, to undertake a careful and comprehensive acquisition of data concerning the life and the work of its influential authors. Particularly striking examples of the lack of such unbiased visions are the biographers of Emil Kraepelin — although interest in his work and person has risen noticeably in the wake of neo-Kraepelinianism, some publications remain either uncritically devotional or, less often, opposed out of prejudice (e.g. Braceland⁴, and Güse and Schmacke⁵).

All that has been said about the history of psychiatry shows the need for a scientific treatment of the darkest time of German psychiatric history, the period of Nazi rule. This requires a careful analysis of developments from the mid-19th century until 1933, especially regarding the development and shaping of the degeneration theory against the backdrop of social Darwinism and eugenics, as well as their modification and implementation by the Nazis. Differentiating matters in such a way will prevent rigid thought patterns that are met with even today. There are many such examples, two of which I think are particularly important. In the debate about the person and the work of Alfred E Hoche, consideration of only his uncontested merits in clarifying psychiatric concepts of illness, and ignoring the treatise Die Freigabe der Vernichtung lebensunwerten Lebens (Legalising the Extirpation of Unworthy Life) which he co-authored with the well-known professor of jurisprudence K Binding in 1920,⁶ is just as unacceptable as the hasty and prejudiced dismissal of Emil Kraepelin as a mere forerunner of racist Nazi perversions of psychiatric practice, while disregarding his wealth of ideas which influence diagnosis and research even today.

Otherwise, when dealing with the history of psychiatry in Nazi Germany, there is still much to be caught up with in empirical research. Above all, a more comprehensive examination of patient files in psychiatric clinics and archives of other institutions are needed for data that will give a sharper and more comprehensive picture of historical fact.

Finally, I would like to address two aspects of the historical research of psychiatry which are often underestimated. The first one concerns the results of psychiatric historical investigation. These are by no means art for art’s sake, as they impinge not only on the historical, but also on current psychiatric research. Thus, the steadily growing knowledge of the person and work of Emil Kraepelin will without a doubt influence the many, and powerful, psychiatric researchers and clinicians who have lately taken to labelling themselves neo-Kraepelinians. Analogies could be drawn to many other historical figures and concepts in our field.

We now come to the second aspect. As welcome as it surely is that a growing group of clinical and practising psychiatrists take an interest in the history of their discipline, it must be made evident just as unequivocally that historical psychiatric research is not a matter of “a few hours after work”, but very labour-intensive and time-consuming. This is not to say that it should be left entirely to medical historians, since historical and current psychiatric knowledge are without question the requisite for a more profound discussion of the subject. Hence, efficient research is best achieved through a combination of the cooperation of psychiatrists and medical historians. Beyond that, psychiatric historical research, like every other scientific discipline, needs an international web of researchers and contacts, an aim we have moved closer to in recent years, thanks in no small part to the inception of several specialised journals and societies, such as the journal History of Psychiatry and the European Association for the History of Psychiatry (EAHP). In this context the section on the History of Psychiatry of the World Psychiatric Association (WPA) should also be mentioned for trying to develop the above-mentioned web by sending out regular newsletters and organising regional and international conferences.

Thus, the scientific field of the history of psychiatry has two focal points: one, the methodically solid and comprehensive research of the history of psychiatric institutions, of their patients, and of those who worked there and, inseparable from the first, the conceptual-historical facet, i.e. the historically grounded scientific-theoretical analysis of perennial fundamental questions in psychiatry which are necessarily linked to philosophical premises. Only through a convincing scientific investigation of these issues will the history of psychiatry be perceived as the up-to-date field relevant to the clinical everyday, which it is, by virtue of the subject of its research. Psychiatry definitely is, of all medical disciplines, the one most reliant on history.

ACKNOWLEDGEMENT

Thanks are due to A Rodón for translating and editing the manuscript.

REFERENCES

Littlewood R. From disease to illness and back again. Lancet 1991;337:1013-1015.
Janzarik W. Die krise de psychopathologie. Nervenarzt 1976;47:73-80.
Sass H. Die krise der psychiatrischen diagnostik. Fortschr Neurol Psychiat 1987;55:355-360.
Braceland FJ. Kraepelin, his system and his influence. Am J Psychiatry 1957;113:871-876
Güse HG, Schmacke N. Psychiatrie zwischen bürgerlicher revolution und faschismus. Band 1. Kronberg: Athenäum, 1976
Binding K, Hoche AE. Die freigabe der vernichtung lebensunwerten lebens: ihr mass und ihre form. Leipzig: Hirzel, 1920

Professor Paul Hoff
Technical University of Aachen (RWTH) Department of Psychiatry and Psychotherapy Aachen, Germany

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