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No. 71 Swiss Pioneers in Science and Medicine |
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E. Heim It is truly extraordinary that in the last third of the 19th century and the first half of the 20th century, scientists from such a small country as Switzerland – which only made up a tenth of the German-speaking world – influenced developments in psychiatry so profoundly. There were two main reasons for this imbalance. First, a fertile scientific environment: medicine in German-speaking countries was making great advances and renowned worldwide. In 19th century Europe, positivism was the leading school of thought in medicine. In psychiatry, this meant mental disorders were seen as a result of neuropathological processes. Proponents of this belief included Westphal, Meynert and Wernicke.1 The German neurologist Wilhelm Griesinger (1817-1886) is also grouped together with this trio of scientists, albeit somewhat unfairly. He was the first to posit a connection between psychiatric processes and altered brain structures. He was, however, far ahead of his time in that he believed in multi-dimensional psychiatry, in which symptoms not attributable to organic disease (and thus considered to have a psychological origin) were considered of etiological importance. As professor of internal medicine in Zürich, he made psychiatry an independent discipline with a specially designed hospital, the university clinic Burghölzli, which would become the setting for many key events that followed. The second factor that positively influenced the development of Swiss psychiatry was the country's new political order. In 1815, a sovereign state with a modern constitution (1848) was formed. With the accompanying liberal thinking and feelings of social responsibility, the idea of open and humane treatment of psychiatric patients found fertile ground. In addition to research and teaching, psychiatry at the university level made the treatment of patients at university facilities mandatory (in contrast to the situation in Germany). This fusion of academic theory and clinical practice allowed psychiatrists to make detailed observations of the course of an illness and the effects of treatment. This rich environment went on to produce some of the most extraordinary thinkers ever seen in the field of psychiatry. The talents and vision of the key players described below brought about revolutionary changes that are still felt by psychiatrists today. From Anatomy to Psychiatry
Auguste Forel (1848-1931) was a true polymath – he made a name for himself in neuroanatomy, psychiatry and the reform movement. After his early retirement, he turned his attention to his childhood hobby of studying ants, a field in which he would achieve an international reputation. Like many psychiatrists of the 19th century, he began his career in the neuropathological laboratory,1 specifically in anatomical research of the brain. Forel dedicated himself to these studies under the supervision of Bernard von Gudden, who would later become the first director of Burghölzli. Thanks to their collaborative invention, the microtome, they were able to dissect most regions of the brain. Forel did extensive research on the organization of the tegmentum with its complex fibrillary and nuclear structures: he was the first to describe the zona incerta and the so-called H fields that still bear his name (campus Foreli).2 Moreover, his anatomical descriptions of neurons have led him to be considered as a co-founder of neuron theory – the topic of his professorial thesis. At the age of only 30, Forel became director of Burghölzli and was instrumental in helping it achieve international acclaim. Correlating his knowledge of the brain with psychiatric processes and recognizing the importance of meaningful work for mental health, he created holistic treatments for his patients, including occupational and milieu therapy. His work with the mentally ill also led him to become an effective social reformer. Confronted with alcohol-addicted patients every day, he decided to abstain from drinking although he had never been a tee-totaler before. He was committed to informing the public about the dangers of alcoholism and, in 1880, he opened a special clinic for alcohol dependency (today called the Forel Clinic). A few years later he was active in establishing a Swiss chapter of the International Order of Good Templars, which aimed to support the prevention of alcoholism. This period coincided with his writings on eugenics, which from today's perspective would seem racist, but were in fact suggesting a way to halt the spread of genetic defects (especially addiction-related ones). As a free thinker and socialist, Forel was very far from the views of later proponents of racial hygiene in the Nazi era, but was often quoted out of context by them. Although Forel succumbed to many falsehoods in questions pertaining to race, these should in no way be equated with racism. Throughout his life, he remained critically and steadfastly opposed to discrimination and prejudice, including antisemitism. Forel worked just as passionately on social topics. His widely acclaimed book Die sexuelle Frage (The Sexual Question) published in 1904 was translated into several languages. With this, he contributed in a more pragmatic way to the public perception of sexual problems than Freud's early writings did. He supported the sexual equality of men and women, the decriminalization of concubinage and unrestricted use of contraceptives. Through the secularization of law, he wanted a 'reasonable' regulation of the sexual question, and in doing so became a leading pioneer of sexology. In the late Victorian Age his views naturally resulted in fierce protests and resistance, especially from religious leaders, but Forel would not give up. It was only after many years of fighting and as a consequence of a stroke that he became milder and more tolerant; in 1920 he even joined the Bahá'í faith as he was impressed by its reconciliatory beliefs. Forel also devoted a significant part of his research efforts to consolidating and publicizing hypnosis, authoring the first textbook on the subject. His book Der Hypnotismus oder die Suggestion und die Psychotherapie (Hypnotism or Suggestion and Psychotherapy) was printed in several editions and was widely circulated. His student and later successor Eugen Bleuler contributed an article to the second edition, entitled 'Two Hypnotized Hypnotists', in which he described in a humorous but scientific manner how he and Forel hypnotized each other. Additionally, Forel founded the Internationale Gesellschaft für Medizinpsychologie und Psychotherapie (International Society for Medical Psychology and Psychotherapy), which was one of the first organizations in the field. As with most brilliant minds, Forel gives the impression that he must have lived more than one life. At barely 50 years of age, he stepped down as director of Burghölzli to dedicate himself to ant research.3 Two of Forel's students became prominent specialists in psychiatry: Adolf Meyer and Eugen Bleuler. Adolf Meyer (1866-1950) is not usually associated with his Swiss heritage, as he emigrated to the USA after his training. He worked at several psychiatric institutes before he became a professor at Johns Hopkins University from 1913 to 1937. Familiar with psychoanalysis, he developed his own psychodynamic theory of personality termed 'psychobiology', which was closer to the neopsychoanalysis of Sullivan, Horney and others. He became famous in the USA for being a pioneer of medical and psychiatric didactics, which were still held in high regard after World War II.4 The Divided Mind
Being the founder of the 'Zürich School', Eugen Bleuler (1857-1939) assumes a special place in the history of psychiatry. He saw disease in an integrative way – giving equal consideration to findings from the natural sciences and the new methods of psychoanalysis. Bleuler shared his teacher Forel's conviction that alcoholism was a social evil, one that he too had to combat. This may also have been the reason why he held on to Forel's misguided views about eugenics.1 Bleuler was not even 30 years of age when he became the director of the mental hospital in Rheinau in 1886, where he devoted his life exclusively to his patients. He spent his days with them, made observations and kept countless notes on their behavior. This allowed him a completely different level of access to their suffering than was typical. In 1898, after he succeeded Forel at Burghölzli, he further developed his observations and introduced the concept of 'schizophrenia' (lit. 'split mind') to depict the inner conflict and the division of the consciousness. His interpretation was based on the psychological concept of 'association' (here referring to the links between psychological functions); 'dissociation' on the other hand is seen as segregation within the thought process. His use of terms such as autism and ambivalence also found acceptance in the clinical world.5 Bleuler was successful in combining psychoanalysis with psychopathology – a feat accomplished by neither Kraepelin nor Freud. From psychoanalysis, he gained a dynamic understanding of how disorders correlate with life history. Bleuler's enthusiasm for and openness to psychoanalysis sustained its development. In 1904, he was the first university teacher to begin correspondence with Freud and take him seriously. He was also the first person outside Vienna to embrace psychoanalysis and, while keeping a critical distance, encouraged his colleagues and students to explore it. When Bleuler, however, recognized a certain orthodoxy in the psychoanalytic movement, he decided to leave the international association, nevertheless he remained a proponent of the discipline in public, which Freud greatly appreciated.6 Partly because of this view, Bleuler attempted to have medical psychology implemented into the medicine curriculum in order to better train students in the doctor-patient relationship.4 His ideas about 'depth psychology', a term coined by him to take into account the role of the unconscious, referred not only to the mentally ill but also to human behavior in general. His students, especially Jung and Binswanger (see below), developed this approach further according to their own ways of thinking. Becoming Oneself
Carl Gustav Jung (1875-1961) was the most famous student of the Bleuler School. Impressed with Jung's talent, profound education and scientific interest, Bleuler brought him into contact with Freud in 1907. After their first encounter Jung became so fascinated with Freud and his teachings that he began to neglect his clinical duties in favor of his research. Thus, Bleuler asked him to resign from the clinic in 1908. After doing so, Jung became more active in psychoanalytical research. The analytical psychology he developed had almost as large an international audience as Freud's psychoanalysis. He adopted the term 'complex' to refer to an unconscious set of feelings and beliefs, and had his own ideas about the unconscious, to which he later added the term 'collective unconscious'. His education in the humanities enabled him to view psychological processes in a new light. He saw symbols found in artwork, fairytales, mythology and dreams as the key to understanding the unconscious. He coined new terms like 'archetypes', 'anima/animus' and 'shadow'. Spirituality as found in mythology, Gnosticism and religion was an important source of self-discovery for him: Werde der Du bist ('become who you are') summarized his ideas of individuation. Becoming oneself was for Jung not only a therapeutic goal, but a personal one, achieved only after dealing with internal and external conflicts.4 Freud's teachings had a major impact on Jung in the short time that they worked closely together. They shared the idea of an unconscious, to which access is provided through dreams, and felt that childhood development has a great impact on the adult psyche. They held each other in such high regard that Freud nominated Jung to be the first president of the new International Psychoanalytical Association. Freud asked Jung to accompany him on speaking tours in the USA, appointed him as an editor and saw him – his most important non-Jewish student – as his future successor and protector of the psychoanalytical movement. Nevertheless, the importance Freud placed on childhood sexuality, the omnipresence of the Oedipus complex and the idea of a libido that was purely sexually orientated were themes Jung could no longer support. He parted ways from Freud in 1913, setting off many lasting conflicts in their field. It was very hard for Freud to overcome his deep disappointment, as he had hoped Jung's international contacts would bring him out of his intellectual isolation. Jung, on the other hand, fell into a deep inner crisis after the loss of Freud's spiritual-fatherly support.7 However, Jung stepped back from his professional activities and developed his own theories further. He embarked on a journey to discover inner truth that was unique in the history of science. He immersed himself in an incessant stream of inner fantasies and images, which would later help form his theories. His process of finding inner truth lasted for more than a decade and was recorded by Jung in a book, Liber Novus.8 This mysterious 'red book' (the leather cover was red) slowly became known among Jung devotees, but his heirs withheld it from the public. It was not until 2007 that Jung's grandson agreed to have the book published. It turned out that the book was not a collection of autobiographical notes, but rather numerous symbolic sketches and texts, which were only of limited interest to the wider public. In his papers and books, Jung comes across as sensitive and introverted. There was, however, another side to him, a 'homo politicus', which was very active in the organization and expansion of psychotherapy in its early days – a talent which had been utilized by Freud. While in later life Jung insisted he was not interested in starting any 'schools', in the mid-1920s he was very much involved in the congress movement, serving as vice-president of the Allgemeine Ärztliche Gesellschaft für Psychotherapie (General Medical Society for Psychotherapy). When one of the co-founders, Ernst Kretschmer, resigned in protest against the restrictions placed upon them by the National Socialists, he encouraged Jung (as a representative of a neutral country) to found another society, the Internationale Allgemeine Ärztliche Gesellschaft für Psychotherapie, which Jung agreed to do in order to protect persecuted Jewish colleagues. Despite this, he simultaneously began to cooperate with the institute of Matthias Göring (a relative of a senior Nazi). Additionally, it was found that some of his writings contained racist views. So, although he tried to maintain contacts for scientific discourse on an international level, his political views posed problems for him in the 1930s as well as in the post-war era.4,7In 1985, the American historian Geoffrey Cocks came to the conclusion that although Jung showed a naive enthusiasm for the National Socialists, he was never active in supporting them in their political goals. Prominent Figures Three other prominent Swiss psychiatrists who also completed at least part of their training at Burghölzli should be mentioned: Ludwig Binswanger, Hermann Rorschach and Medard Boss.
Hermann Rorschach (1884-1922), who died from a surgical complication at the age of only 38, was seen as the promising star of Swiss psychiatry. Under Bleuler's supervision, he wrote a dissertation about the processes of perception. However, it was his ink blot test (see image) – perhaps the psychological test that is most well-known to non-professionals – that would go on to make him a household name.
Ludwig Binswanger (1881-1966) was born into a family of psychiatrists, his grandfather was the founder of Bellevue, a well-known psychiatric clinic on Lake Constance. After his initial training at Burghölzli, Binswanger became the director of Bellevue for almost half a century. This institute had a reputation for the close communal life its patients, doctors and members of the Binswanger family shared, and Binswanger's networking made it Europe's center of intellectual thought. Prominent figures from both science and the arts were regular guests. Binswanger was the first to combine psychotherapy with existential analysis in an attempt to give psychopathology a new epistemological foundation. In 1941, influenced by the existential philosophy of Heidegger's Sein und Zeit (Being and Time), he created the term Daseinsanalyse for his approach. He saw it not so much as a therapeutic method, but as another scientific way of understanding people who live in their 'own' world, connected to others important to them and with whom they form a 'common' world. Regardless of whether a person is sick or healthy, one's unique 'existence' should be respected (see box). In his publications Binswanger applied his theories mainly to schizophrenic and manic-depressive psychoses. Binswanger always kept an attitude of critical distance concerning psychoanalysis. Nevertheless, he maintained a lifelong and good relationship with Freud, who respected Binswanger's philosophical stance, even though Freud pointed out that he saw his own roots firmly planted in the natural sciences.9 After World War II, there was a split between Binswanger and his students. Those who followed Medard Boss (1902-1990) sought out ways to treat patients which were more therapeutic in approach and less epistemological. With support from Heidegger, the 'Zürich School of Daseinsanalyse' grew and developed. This school of thought is still taught today and views its approach as a synthesis of Freudian psychoanalysis, Jung's analytical psychology and existential philosophical findings. Boss, however, also deserves to be mentioned in another light. As a result of the political turmoil and war of the 1930s and 1940s, professional discourse naturally suffered as scientists were unable to meet each other. A few far-sighted colleagues began to re-establish contacts and organized conferences after the war, which among other things tried to grapple with its psychological effects. As Switzerland was spared from this war, it played a crucial role. Boss was instrumental in these efforts and sought to establish an organization to succeed the Internationale Allgemeine Ärztliche Gesellschaft für Psychotherapie. This led to the foundation of the important umbrella organization for European national psychotherapy organizations – and later others from all over the world – known as the International Federation for (Medical) Psychotherapy (IFP), which is still active today.4,7 After the Pioneers As mentioned above, it seems somewhat surprising that such a small country like Switzerland could contribute so much to a medical area in such a short time period. Perhaps it is also surprising that no comparable developments have been made since World War II. This needs to be viewed in the light of specific post-war socio-cultural conditions, but could also reflect a general trend. Three socio-cultural trends became evident after World War II. Europeans were suffering from personal losses, trauma and material scarcities, and for many people the restrictions of living as part of a collective had become unbearable. The rapid growth of existentialism, which called for a self-reliant individual, had a major effect on psychiatric practice – boosting support for psychotherapy in general, and existential analysis and psychoanalysis in particular. Developments in the USA and England were influenced heavily by emigrants from Europe – many of whom were Jewish – trained in psychoanalysis. They dominated the field, taking over the academic world step by step until hardly any key position in psychiatry or psychotherapy was filled by someone who was not a psychoanalyst. It was not until the 1960s that the tide turned in favor of the community mental health movement and other newer developments. The third development was political in nature. The socialist countries of eastern Europe decided Pavlovian behaviorism should be the dominant approach. A final yet crucial trend – not only seen in Swiss psychiatry or medicine, but through the whole of science – is that the course of scientific research is no longer determined by outstanding individuals, but rather by teams or even academic centers. The time of the individual pioneer seems to be over – a development which is not necessarily a disadvantage for science. Nevertheless, this should not stop us looking back at the trailblazers within our disciplines, such as the ones described in this article, and draw inspiration from their lives and many achievements.
Related Articles Auguste Forel: Seeing Utopia in an Ants Nest The Case of Ellen West: Triumph or Tragedy? Gazette 69: Mind and Body Translated from German by Alan Tootle.  Edgar Heim University of Bern Prof Heim was co-chair of the Department of Psychiatry at the University of Bern from 1977 to 1994 and President of the International Federation for Psychotherapy from 1988 to 1998. |
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Auguste Forel: Seeing Utopia in an Ants Nest P. Lavender Auguste Forel was a leading neuroanatomist and psychiatrist, but humans were not his only study subjects. He was fascinated by ants and may even have seen parallels between their tiny but complex worlds and our own societies.
From the age of 11, Forel was enthralled by these creatures, devoting all his summer vacations to their study. In 1874, at the age of 25, he published his monumental monograph Les Fourmis de la Suisse (The Ants of Switzerland), which earned him several awards and even lavish praise from the great Charles Darwin, who wrote to Forel: 'I have now read the whole of your admirable book and seldom in my life have I been more interested by any book.' Over his lifetime Forel would amass a collection in which more than 6,000 species were represented. He described 3,500 new ant species and, based on his profound knowledge of their anatomy, proposed a new taxonomy. His magnum opus, however, was a beautifully illustrated five-volume treatise on the social world of ants, printed between 1921 and 1923, and which is still considered a major contribution to the field. Right up to his death in 1931 at the age of 83, Forel remained active as a private scholar in his fields of interest – ant research and the promotion of social welfare.
Some modern-day researchers discern links between Forel's studies on the highly structured behaviors of ants and his thoughts on the human world. André Parent, professor at the department of psychiatry and neuroscience at the University of Laval (Canada), notes that Forel made insightful observations on the neural control of sensory and instinctive behaviors common to both humans and insects. Parent speculates that: 'Detailed studies of animal societies that are so rigidly organized as ants must have played a role, at least unconsciously, in shaping his opinions about birth controls, education, sexuality, etc.' Charlotte Sleigh, senior lecturer in the history of science at the University of Kent (England) and author of the 2004 book Ant, is more forthright, believing that Forel's psychiatry and myrmecology were completely interwoven. She says: 'He took ants as a model for what humans could achieve: social harmony, eugenic reproduction, the lot.' Sleigh suggests that Forel's most important theory was that the human learning process echoes the evolutionary path taken by ants, which over thousands of generations had acquired useful behaviors that were laid down as habits or instincts. 'This showed how humans too – notably alcoholics – could be re-educated out of their harmful behaviors and into new, socially useful habits,' she says, but adds: 'Do I personally think this is valid? Not at all.' Forel appears to have admired the orderly nature of ant societies, an admiration that could have found expression in his ardent pacifism and internationalism. More disturbingly, Forel may have drawn on the highly structured world of the ant to determine a 'naturalized' system of ethics, which he then applied to humans. 'A dangerous thing,' Sleigh says, 'where nature's supposed is dictates a human ought.' Sleigh sees a link between Forel's thinking and later evolutionary psychologists who would use 'natural' behaviors in our ancestors to explain human behaviors today. In 1978, the Swiss National Bank honored the memory of Forel on its 1,000 franc banknote. Its design reflected Forel's passion for myrmecology, with the reverse side given over to an image of three ants and a cross-section of an anthill. In the wake of renewed debate over Forel's ideas on eugenics, the note was withdrawn from circulation in 2000. Related Articles Matters of the Mind: The Impact of Swiss Psychiatry The Case of Ellen West: Triumph or Tragedy? Gazette 69: Mind and Body Paul Lavender is an editor of the Karger Gazette |
| The Case of Ellen West: Triumph or Tragedy? P. Lavender Anorexia nervosa is still one of the most prominent eating disorders, but the therapeutic approach has definitely changed over the last hundred years: Whereas Binswanger still based his treatment on a strictly psychodynamic ground, it nowadays calls for a more comprehensive approach, including cognitive-behiavoral techniques. It is nevertheless interesting to look almost 10 decades back at a different therapeutic culture. In 1923, psychiatrist Ludwig Binswanger discharged Ellen West, a deeply troubled anorexic patient, from his sanitarium. He was fully aware that she was at high risk for suicide, which she duly committed shortly after. Twenty years later Binswanger published her case to support his Daseinsanalyse – and he described her death as a successful treatment outcome. Binswanger's fusion of psychotherapy and existential analysis demanded an individual's 'existence' be respected. For him, diagnostic labels were less important than understanding a patient's existence and experiences from their own perspective. This approach was made famous by the case of West, who used writing and poetry to vividly describe her inner turmoil. When she came under Binswanger's care she weighed only 92 lbs (41 kg). Previous therapy had failed and she had twice tried to commit suicide. She seemed unable to relate to herself as a real person, writing in one of her diaries: 'I am isolated. I sit in a glass ball. I see people through a glass wall. I scream but they do not hear me.' Despite becoming physically healthier, the suicide attempts continued. Eventually, she and her husband were given the choice of a closed ward and expected deterioration of her condition, or release. They chose release. She immediately felt better, ate happily, spoke to her husband, and wrote letters to friends. Then she took a lethal dose of poison. Though West's fate was tragic, Binswanger did not see it as a failure. As David Lester commented in the Psychoanalytic Review, Binswanger believed that 'only in her decision for death did she find herself and choose herself. The festival of death was the festival of the birth of her existence.' Questions will always remain about whether West could have avoided suicide had she been treated differently, and today opinion is divided over whether Binswanger's approach created a reasonable outcome for the patient, or was a case of psychic homicide. Related Articles Auguste Forel: Seeing Utopia in an Ants Nest Matters of the Mind: The Impact of Swiss Psychiatry Gazette 69: Mind and Body Paul Lavender is an editor of the Karger Gazette |
 © 2010, S. Karger AG, Basel. All rights reserved. |
