Research note: Mental health in Germany ca. 1900

Arwen Schepers and Daniel Gallardo Albarrán. Show Author details

Motivation

After the Covid-19 pandemic, its impact on mental health has received substantial focus, a sign of how important this part of general health care has become in the last decades. However, this was not always the case. The emotional aspect of individuals’ health became more prominent in 1900. To illustrate this, this post focuses on Germany that was a leading country in some respects concerning the awareness of mental health and it turned the discipline of psychiatry into a medical profession rather than a way of thinking.

Nosology

Unlike regular medicine, psychiatrists did not have a proper classification of diseases (nosology). One of the reasons was because of the seclusion of asylums and the limited exchange of knowledge. This created difficulties for the profession to be taken seriously by others in the medical field, as their knowledge basis and actions seemed less scientific. An additional complication happened when teaching psychiatry, since there were different ideas about the nature of mental illnesses and a consensus had not emerged yet. 

A predominant theory was introduced by Neumann, who argued that there was only one mental disease and that everything they observed were different stages: he called this the ‘Einheitspsychose’. This theory resulted in sooner admittance in asylums, as he claimed there were no different diseases, but the reaction time of the psychiatrists. Kahlbaum, on the other hand, criticised the Einheitspsychose. Instead, he proposed an elaborate framework that, in the end, was never used. Griesinger advocated a different system as well. He wanted to reduce the patriarchal nature of asylums and remove the focus on the asylum as treatment in itself, to focus on techniques that saw madness as a mental disease. In the end, none of these caught on and Einheitpsychose remained the preferred theory. 

The asylum

The first asylums in Germany were placed into existing buildings, such as abandoned churches. As these were often found in the countryside, this meant that the first asylums were placed in a rural setting. This was considered beneficial, as people first had to get back to nature and simplicity to recover. 

While psychiatrists believed that patients would recover the best in facilities placed in rural surroundings, they also considered asylums in the city ill-equipped to help patients. According to them, patients needed seclusion from family and society, before they could start to heal. The admittance and seclusion into the asylum was considered the best form of treatment and often it was considered more important than the therapy applied to patients by psychiatrists. At the same, not everyone agreed with this approach. Griesinger, a German psychiatrist, advocated letting people in their own environment and not admitting them in asylums, especially if that involved long term hospitalization.

Patients were divided according to their gender or faith as well as the progression of a particular disease and the behaviour of the patient, as measured by their cleanliness and tendency to create disruption. Another distinction related to their funding, since they could operate with different sources of funding (public, private or a mixed of both).

How did the overall society perceive the care patients received in asylums? Sometimes, not so well. After public scandals, such as the Mellage trial involving a person who had been wrongfully admitted to an asylum (see here), the fear that one might be unjustly incarcerated increased. This made some people with actual mental problems more reluctant to ask for help. Private clinics had some aura of secrecy surrounding them, sometimes because their patients belonged to the bourgeoisie or the aristocracy. 

Overcrowding

From 1860 onwards there was a problem of overcrowding in mental asylums. While the population in Prussia grew by 48 percent from 1880 to 1910, the number of patients in psychiatric hospitals increased by more than 400 percent (from 27.000 to 143.000). Due to a large number of chronic patients, the asylums turned more into custodial facilities than therapeutic ones. According to psychiatrists, this suggested that Einheitspsychose  was a spreading disease in Germany and that more facilities needed to be build. In some cities this was indeed the case, but the moment the new asylums opened they were already filled with patients.

Overcrowding was not seen as a failure by the discipline, since they explained it as a consequence of rising population and the modern urban environment. But their approach did contribute to more admissions, since they insisted that asylums were the best places for people with mental issues. The sooner they were admitted, the better treatments could work. On top of this, if people were diagnosed too late and they could no longer be cured, they had to remain in the asylum. 

Though overcrowding problems were structural, private asylums suffered somewhat less due to the fees that had to be paid for admission. They also profited from the government, which paid them to admit patients from public institutions in an attempt to relieve some of their pressure. Another way to release some of that pressure involved relying on confessional asylums. These no longer focused on treating the patients, but rather on care and, as such, they were only suited for incurable patients.

To solve the overcrowding conditions of asylums, new ones were built. We can see this in the figure below, which shows increasing numbers of institutions, although in some cases (e.g. Aachen, Düsseldorf or Hannover) were not enough given the rapid population growth of German cities. Consequently, beds per 100.000 residents, generally, went down at the turn of the 20^th century.

Conclusion

The first asylums were placed in rural settings, which led to the isolation of both patients and psychiatrists. This made it harder for patients to reintegrate in society. For psychiatrists, the distance made it difficult to confer with colleagues. A result of this seclusion was the lack of nosology, which created room for a theory, Einheitspsychosis, arguing that all mental illnesses were the same, but with different symptoms. This meant that anyone showing any signs of mental distress could be admitted, which paired with the low rates of patients leaving the asylums, created overcrowding in urban environments. Some new asylums were built, but population growth largely exceeded those investments in some places. 

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• Engstrom, E. J. (2019). Clinical Psychiatry in Imperial Germany. In Clinical Psychiatry in Imperial Germany. https://doi.org/10.7591/9781501723940
• Goldberg, A. (2002). The Mellage Trial and the Politics of Insane Asylums in Wilhelmine Germany. The Journal of Modern History, 74(1). https://doi.org/10.1086/343366
• Rössler, W., Riecher-Rössler, A., & Meise, U. (1994). Wilhelm Griesinger and the concept of community care in 19th-century Germany. Hospital & Community Psychiatry, 45(8). https://doi.org/10.1176/ps.45.8.818
• The data from the graphs was taken from the Statisches Jahrbuch Deutscher Städte.

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