Everything under Control?

Psychiatric Medical Records Shed Light on the Relationship between State and Society

How do the state and society decide what is psychologically “normal”? How are ideas of normality reflected in official procedures? The historian Stefanie Coché has examined the practice of committing patients to psychiatric institutions in the “Third Reich,” in East Germany and in West Germany by looking at more than 1,400 medical records. She found out that states abused their power in ways different from what we might assume.

by Silke Feuchtinger

Under duress, a young man is taken to a psychiatric ward. He is incapacitated and ultimately his will is broken by medications and operations. From then on, he is submitted to a tortuous system of arbitrariness, humiliation and imprisonment. There is no escape – society, the state and medicine are too closely entwined. Films such as One Flew Over the Cuckoo’s Nest with Jack Nicholson from 197 have significantly shaped the picture we have of psychiatry. Especially for the period before 1970 in Germany, many people project the image of an invasive and authoritarian system in which psychiatry and state power worked hand in hand – not only, but also related to the unjust regime of National Socialism.

The historian Dr. Stefanie Coché has examined this assumption by investigating the commitment practices of the three German states between 1941 and 1963. She looked at over 1,400 medical records in a total of six psychiatric institutions. “From the perspective of a historian, psychiatry is particularly interesting because it tells us something about the concept of what is considered to be ‘normal’,” says Coché. “Analyzing the commitment practices allows us to draw conclusions about the relationship between the state and society.”

Commitment is not a top–down process

Coché investigated the various medical histories by taking aspects such as age, gender, social environment, place of residence and course of disease into account. She also studied personal documents such as letters and diaries. In almost all cases, the historian was able to observe a complex negotiation process that preceded each commitment. “Psychiatry is quickly associated with coercion,” she explains. “That, however, is only a small part of the picture. The actual commitment process was usually more complex – regardless of whether it was in the Third Reich, the former German Democratic Republic or the old Federal Republic of Germany.”

Family members, friends and neighbors, doctors, police, teachers and jurists – they could all be involved in the process – in cases of both involuntary and voluntary commitment. “In cases of involuntary commitment, the state played a considerably more important role. However, this also very rarely occurred without extensive preliminary discussions,” explains Coché. This is also the case for the two examined dictatorships: “In most cases, with only few exceptions, people were not committed at the initiative of the state, but at the initiative of persons from their social environment.” Hence it would be incorrect to assume a top–down process.

Women with sexually transmitted diseases were forcibly committed

In these interactions among various actors, Coché sees the foundations for the emergence of notions of normality – even in a system as repressive as National Socialism: “The views on both sides determined one another. The ideology of the NS regime did not simply seep down into the population. Many people agreed with it from the beginning.” Using psychiatry for the purpose of state encroachment and abuse of power were thus rare. Moreover, this was not even necessary for the National Socialist regime to cement its unjust system: “The concentration camps could be used more effectively to ‘deal with disruptive factors’,” says Coché. “As we know, the abuse of power was limitless there.” In contrast, between 1941 and 1945, in almost all cases commitment to psychiatric wards came at the request of citizens – despite the fact that the brutal practices of these institutions, which included the murder of the mentally ill, were well known.

An important exception is a specific group of citizens: “The National Socialists saw women with sexually transmitted diseases as a huge threat to the military might of the Reich. Even without preceding discussions, they could be arrested and forcibly detained. In these cases, extensive abuse was committed by the state.” Men with STDs were not prosecuted – the concept of guilt and innocence with regard to the spread of venereal diseases was clearly gender-specifically motivated in the “Third Reich.”

Abuse by neglect

At the beginning of her research, Coché also suspected state abuse in East Germany. It seemed obvious that in the socialist country, similar commitment practices such as those perpetrated in Romania in the 1970s and 80s would be prevalent. To muzzle regime critics and suppress dissidents, the Romanian ruler Nicolae Ceaușescu often committed them to psychiatric clinics – under catastrophic hygienic conditions and without the chance of a fair trial. For the German Democratic Republic, Coché was unable to find one single comparable example: “The East German leaders were not really interested in psychiatry. For the regime, it was above all a cost factor. After it had moved away from the practices of National Socialism, a veritable vacuum of responsibilities ensued. Coché therefore sees an abuse of power in the state’s neglect. “A lack of regulation can also lead to a deprivation of rights. In East Germany, this meant that some patients who needed treatment were never admitted to psychiatric hospitals, while others were never released,” she remarks. Legal regulations did not come into place until 1968.

In the post-war era commitment practices reflect a society in turmoil

While during National Socialism the high number of female patients in psychiatric hospitals was striking, the medical records from East and West Germany are quite heterogeneous. “No particular group was affected more strongly than others. One topic that repeatedly comes up in both states in the context of psychiatry is productivity. Both the authorities and the patients themselves referred to their ability to work as a reason necessitating treatment in a psychiatric ward.” Commitment during the occupation period from 1945 until 1949 reflects a society in turmoil. Whether it was former concentration camp prisoners, prisoners of war, refugees or displaced persons – people’s experiences with the horrors of war affected commitment to psychiatric institutions and clinics: “During this period, there was a high demand for places in psychiatric wards, but medical care in general had to manage with a lack of personnel. As a result, entries in the medical records of those years are scarce,” explains Coché. This makes it almost impossible to draw conclusions about the fate of individual patients.
More detailed records only appear again after the founding of the Federal Republic of Germany. Until the psychiatric reforms of the 1970s, many measures were, however, not yet adapted to new standards. “For example, in West Germany involuntary commitment was only possible by court order. In reality, this was often not issued until after the event – when the patient had already been committed.”

Did Foucault miss the mark?

Aside from women with sexually transmitted diseases who were forcibly committed during the war and the situation of neglect in the German Democratic Republic, Coché did not find evidence of state coercion in any of the cases she examined. The written documents of patients also do not indicate forced commitment. There are, however, differences in the extent to which the state and psychiatry worked together. The orders of the state-run health authorities in the period of National Socialism, for example, were binding. East Germany, in contrast, preferred outpatient care, thereby passing on much of the responsibility to the patients themselves and their immediate surroundings. In West Germany, judicial rulings gained in importance – to protect both sides.

Overall, however, Coché is convinced that the influence of the state on psychiatric commitment is much smaller than has been assumed until now. The view of state and society shaped by Michel Foucault, according to which individuals are controlled by those in power through institutions, are formed and deliberately curtailed in their freedom, seems to fall short: “The role of the patient and his or her social surroundings is decisively more significant than that of the state,” Coché emphasizes. “Even if I suspected at the beginning of my research that the results could go in this direction, that the medical records would project such a differentiated picture surprised even me.” The historian could not discern a deliberate control system established by the state and its health care system in any of the three systems she examined. This shows that “normality” cannot be dictated from above.