The relationship between state and society remains an ever-present theme in research on the German Democratic Republic (GDR).Footnote 1 In the 1990s, following the opening of the archives, research began to move away from a theoretical presupposition, present in the study of totalitarianism, which argued that decisions by the state unilaterally shaped developments in the GDR.Footnote 2 Research conducted in the last decade or so has highlighted instead the interaction between the rulers and ruled. This has given rise to concepts such as durchherrschte Gesellschaft (thoroughly-ruled society), which assumes that all areas of society were fundamentally subject to the same all-encompassing, top-down form of rule; and the Diktatur der Grenzen (dictatorship of limits), which, in contrast to the previous concept, recognizes that the rule of the state and of the dominant Socialist Unity Party (SED) encountered certain limits on its power in everyday life. Additional concepts, such as Fürsorge-/Erziehungsdiktatur (welfare/educational dictatorship), take into account the existence of, and tensions between, the dictatorial aspects of the regime, on the one hand, and supposedly benevolent, emancipatory ones, on the other. Social historians who devised and employ such concepts have pointed to the pronounced aspiration of the GDR as a welfare state, exemplified by its healthcare system and its guarantees of full employment.Footnote 3 Whereas most social historians considered the ways in which the regime attempted to build consensus in support of its rule, some, including ones inspired by the “new cultural history,” have focused on ordinary East Germans and their everyday life. As a consequence, the newer scholarship does not focus on purely top-down processes any more. On the contrary, some studies heavily stress the importance of subversive action that tested the state's claim to complete power while, at the same time, contributed to the stability of the regime.Footnote 4 Many of these works concentrate on various aspects of everyday life, such as domesticity or friendship.Footnote 5
The present article combines a number of these approaches by focusing attention on a classical subject of institutional history: psychiatry. Asylums in the GDR were state-run establishments, as was the case in other socialist regimes—where, especially in the Soviet Union and Rumania, the state was known for its extensive political abuse of such institutions.Footnote 6 As Sonja Süß has pointed out, the SED regime did not systematically abuse its asylums. In fact, as the following investigation demonstrates, the East German state was, surprisingly, not interested in involuntary psychiatric commitments at all: it eschewed responsibility for procedures related to involuntary commitment, instead leaving it to “society” to decide which individuals should be committed—often against their own will.
Questions about psychiatric commitment—including ones about who was to be committed and for how long—serve in the following investigation as a prism for viewing the relationship between state and society more generally. The frequency of, and procedures governing, forced hospitalizations are particularly revealing of how the East German state's right to intervene in citizen's lives—and the reach of such intervention—shaped society. Involuntary commitment not only determined an individual's freedom, autonomy, and life opportunities, but also reflected societal understanding of health and illness, security, “normality,” and “morality.” Compulsory admissions are well suited as probes to test power structures, especially in a dictatorship. Occurring at the border between the private and public, they involve interaction among families, official actors (e.g., police, court officials, health authorities, psychiatric institutions, and hospitals), as well as others who could initiate the commitment process, such as neighbors, landlords, teachers, and acquaintances.
The first two parts of this article, which focuses on the years 1949 to 1963, make the argument that, early in the history of the GDR, negotiations about psychiatric hospitalizations took place with little direct input from the state or its apparatus. This finding suggests the value of reviving the concept of Vergesellschaftung (socialization)—a useful concept discussed briefly in the 1990s but then not pursued—with regard to particular state sectors.Footnote 7 Ralph Jessen proposed the term to describe areas in which the SED regime had shown little interest and that thus needed to be—at least unofficially—compensated for by society.Footnote 8 It turns out that most involuntary psychiatric hospitalizations were carried out without patient consent. Yet, these were not involuntary commitments in a legal sense. The judicial arm of the state (i.e., the courts and their executive arm—in this case, the police) only rarely participated in such decisions. Neither state nor party organizations, nor the Ministry for State Security (Stasi), was involved, and the police were only consulted in cases involving violence. This is surprising in light of evidence regarding the political abuse of psychiatry in Nazi Germany and the Soviet Union.Footnote 9 In contrast to their counterparts in these authoritarian regimes, authorities in the GDR did not throw their weight around to intervene in forced involuntary commitments. This is not to say that the East German state did not intercede in certain circumstances, or that there were no cases of political abuse whatsoever.Footnote 10 But, in general, the regime avoided outright political intervention—even as it failed to protect individuals, often the weakest members of society, from arbitrary admissions. The point is that, during the early years of the regime, the process of forced hospitalization generally took place independently of state control.
Decisions regarding involuntary psychiatric commitment were initially made, for the most part, in a “pre-medical” context, i.e., it was often primarily the family that decided whether to commit the patient. Members of the patient's wider social circle, such as landlords, neighbors, and work colleagues, could also contribute to such decisions. In these cases, it was facility physicians—who, at the time, were often quite critical of the state—who officially admitted such patients.Footnote 11 The latter were ultimately at the mercy of their environment and their surroundings in this unregulated process. Admissions practices, which involve highly consequential decisions about security and freedom, are commonly understood to be an area of activity that falls under the purview of the state—whether the state is a dictatorship or not—and it is generally defended as such. In the GDR, by contrast, where admission practices came under the purview of “society,” i.e., non-state actors, this independence from the state was particularly noteworthy.
At first glance, this would seem to confirm the findings of more recent research trends about the GDR, which, following the initial popular and scholarly emphasis on the supposed omnipresence of the dictatorial regime, began to uncover spheres that were not completely infiltrated by the dictatorship, such as love, intimacy, and friendship.Footnote 12 Upon closer inspection, however, it turns out that the case of psychiatric commitment was slightly yet significantly different. Whereas the regime did, in fact, target areas such as love and sexuality—especially as fertility politics became a battleground in the Cold War—it did not develop any interest in psychiatry.Footnote 13 Families essentially adapted to this situation by filling the vacuum created by this lack of political involvement. This Vergesellschaftung of psychiatric commitments was not an instance of Eigensinn—to use the popular term coined by Alf Lüdtke—much less an act of resistance, because members of society did not have to—in fact, did not—push for such agency when it came to psychiatric commitment.Footnote 14
It is also important to note that an otherwise interventionist state essentially neglected the welfare of psychiatric patients. There were three main reasons for this. First, the practice of medicine tended, in general, to be given more room for maneuver than other areas. Anna Sabine Ernst has shown, for example, that theoretically ambitious political attempts to implement the Pavlov doctrine and other Soviet-style psychiatric innovations were unsuccessful.Footnote 15 Second, psychiatry, in particular, was arguably a lower priority in the medical sector because mental illness was not contagious and thus seemed to pose less of a threat. The third and most important reason reflected the fact that the socialist welfare state concentrated primarily on the workforce—which was not surprising given the regime's self-identity as a worker's state.Footnote 16 Psychiatric patients were often not able to keep a job, or became long-term inmates who could not contribute to national output. It is likely that this was a reason for limited funding for asylums, and also a reason why psychiatry seemed peripheral to the concerns of the SED state more generally. At any rate, from an ideological perspective, especially during this early period, socialism was supposed to heal society from “capitalist” psychological illnesses.Footnote 17
The third section of this article considers the extent to which the so-called Vergesellschaftung of hospital admissions practices prompted admitting families, as well as those from the individual's immediate social milieu, to act and reason in a manner independent of state and ideological interests. To that end, this section engages Michel Foucault's well-known argument that psychiatric care reflected ideological, organizational, and economic conditions, such as the central role—in the case of the GDR—that state-owned enterprises played in the daily life of the workforce.Footnote 18 Indeed, even though the state did not directly intervene in processes of commitment, those processes reflected both organizational and rhetorical changes in the early GDR. In the first place, admissions by company physicians mirrored organizational changes, i.e., because company physicians sometimes admitted patients to asylums in the GDR, their professional opinion and the perception of the patients’ coworkers became crucial in this process. At the same time, state-owned companies played a role in the decision to discharge patients: hospitals contacted them before releasing a patient to ensure that he or she would be integrated back into the workforce. A release became highly unlikely if such cooperation seemed to be lacking.
Secondly, admissions point to the influence of working-class propaganda. As we shall see, patients’ families took advantage of official labor rhetoric, successfully using it to strengthen their position vis-à-vis medical experts. Their suggestions and demands shed light, in fact, on prevailing power structures in the GDR, for their decision-making authority in this realm allowed families to intervene in areas normally involving medical expertise. The point is that psychiatric admissions did not take place in a space free of politics, even though they did take place in a space free of direct government intervention.
The findings in this article about the practice of psychiatric hospitalizations in early East Germany are largely based on an analysis of five hundred psychiatric patient files from three different institutions: the psychiatric facilities at Rodewisch and Großschweidnitz in Saxony, and the Greifswald Psychiatric and Mental Hospital (Greifswalder Universitäts- und Nervenklinik), which was part of the Greifswald university hospital.Footnote 19 These three facilities were not strictly representative of all psychiatric institutions in the GDR, of course, but they did exhibit typical characteristics of such institutions and more or less covered the spectrum of mental health care at the time. All three admitted men and women, provided care to large districts, and served urban and rural areas. The rural location of Rodewisch and Großschweidnitz did not mean that their patients were predominantly from the countryside, however. The former was responsible for providing care to Karl-Marx-Stadt (Chemnitz), for example, and the latter admitted patients from Dresden. Greifswald, an urban hospital, cared for patients from that city, as well as from the rural Baltic Sea coastal region. The geographically remote locations of Rodewisch and Großschweidnitz reflected the belief, prevalent at the time the two clinics were founded in the late nineteenth century, that the “mentally ill” would have a better chance of recovery in a secluded rural setting.Footnote 20 The two asylums were located in Saxony, yet served very different catchment areas: Karl-Marx-Stadt was a “socialist” city (i.e., more secular, working-class, and centered around state-owned enterprises), whereas Dresden was more socially traditional.Footnote 21 In addition, all three hospitals belonged to different Bezirke (districts) after the administrative reform of 1952. As a result, each worked with different public health departments (Gesundheitsämter) and police authorities. Given these differences, the similar hospitalization practices in these three districts suggest a more general pattern of psychiatric admissions that held across early East Germany as a whole.
In the choice of facilities for this analysis, different hospital and facility types were also taken into consideration. Whereas Großschweidnitz and Rodewisch were sanatoria and nursing homes, the Greifswald University and Mental Hospital was not a long-term care facility, but instead admitted patients for diagnosis and short-term treatment. The hospitals and care facilities had psychiatric and neurological wards during this period, and both are considered in this article. But while the focus is on psychiatric disorders, it is not useful to draw a strict distinction between psychiatric and neurological illness, for few such disorders were diagnosed at the time exclusively using psychiatric or neurological criteria alone. Age-related diseases and epilepsy were both examples of medical problems that were considered to be on the threshold of psychiatry and neurology. But patients with “classic” psychiatric illnesses, such as schizophrenia, were also examined for neurological anomalies. This was especially true during the intake process: neurological and psychiatric exams were given upon admission to a hospital or institution, and it was not uncommon for there to be disagreement over which disease or illness was responsible for the psychiatric anomalies.
One final note about the sources: the individual files from Rodewisch were chosen by random selection, but this was not possible for Greifswald and Großschweidnitz. Of the medical records from the latter, the Saxon State Archive has only retained the files of patients whose surnames began with the letters G, O, R, or T. This is known as the GORT system, which was used for the Greifswald records as well. Even if one cannot strictly speak here of representativeness in the sociological sense, this sample, which took into account the ratio of men to women in each facility, clearly covers a broad spectrum of admissions.
Doctors and Families as Decision-Makers in the Realms of Security and Illness
Research on the relationship between psychiatry and the state in socialist dictatorships generally addresses the systemic state abuse of psychiatry. The Soviet Union and socialist Romania, for example, used their psychiatric facilities as a means of silencing dissidents and removing them from the public sphere.Footnote 22 In the early 1990s, Germany began to examine its own past regarding government abuse of psychiatric institutions under socialist rule. In 1990, a series in the weekly news magazine Stern on the Waldheim Clinic in Saxony ignited public interest regarding the political abuse of psychiatry. As a result, that topic became the initial focus of much research on psychiatry in the GDR after the Wende of 1989–1990. Sonja Süß’s seminal work published in 1999 maintains that, in contrast to the Soviet Union, there was no systematic political abuse in East Germany.Footnote 23 Since its appearance, the only other study to have dealt with the subject of involuntary commitment in the GDR is one by Sabine Hanrath, who examines involuntary hospitalizations at the regulatory level, and comes to the conclusion that there was a regulatory vacuum—i.e., a lack of legislation—until 1968.Footnote 24 Looking at how different actors influenced processes of psychiatric commitment, the following section looks at how that vacuum was filled, arguing that families and doctors became key players in decisions regarding hospitalizations.
In 1959 the medical director of Rodewisch Hospital, Dr. Rolf Walther, explained and defended procedures governing the initialization of hospitalization for psychiatric care in the GDR:
As always, every qualified physician must be able to admit mentally ill patients with a corresponding doctor's certificate. The next of kin have hitherto given consent to hospitalization and to necessary treatment for patients who are otherwise unable or unwilling to give their own consent. This procedure should be legally sanctioned. Forcible involuntary commitments are limited to relatively rare cases, in which the family is ignorant or uncooperative and seeks either to prevent or to end hospitalization prematurely, against medical advice. In addition to these cases are ones with patients who have no next of kin.Footnote 25
There were therefore few official forcible involuntary commitments in Rodewisch, and it was the police that usually carried out the relatively few cases to which Walther refers. This was a result of the Police Administrative Law of 1931, which remained in effect during the 1950s and 1960s, despite early attempts by the Soviet authorities and then by the GDR's Health Ministry to remove forcible hospitalizations from police authority.Footnote 26 In the 1950s, the police had people committed—men, in most cases—with the justification that the patient was extremely violent, and continued to pick up people who appeared violent or destructive in public. For example, the police brought Frank A. to Rodewisch in 1953 after he had smashed a shop window.Footnote 27
The term Zwangseinweisung (forcible involuntary commitment) always referred to officially enforced commitments and not to other forms of compulsion, such as those initiated by family members. In Rodewisch and, apparently, in other facilities as well (as Walther's statement suggests), patients were, for the most part, admitted against their will, without an official order for involuntarily commitment.Footnote 28 Next of kin and doctors played the main role in this process, which meant that family members and the patients’ other social contacts assumed a recognized position of authority in the early GDR, even if this was not legally sanctioned. At the same time, new regulations led to considerably more leeway for doctors. The position of facility director (Anstaltsleiter) brought with it a significant increase in status and authority, in fact. And the fact that the director had final say in admissions decisions was an entirely new development in the history of German psychiatric care. Prior to this, directors had not played such an important role.
It is not known exactly how many unofficial, involuntary hospital admissions occurred, but we can be certain that the practice was widespread. In a position paper for the Health Ministry, a certain Dr. Fabian, the medical director at Rodewisch, determined that in 1959, 90 percent of his current patients had been admitted against their will.Footnote 29 The decision to hospitalize patients at Rodewisch was almost always left in the hands of families and doctors. The practice developed at Rodewisch—which stipulated that, in cases where any doubt existed, the family and the facility's doctors should be responsible for commitment decisions—was likely common in potentially all psychiatric admissions. This necessitated, however, abolishing the requirement that patients sign their own consent forms. Instead, the next of kin, rather than the patients themselves, invariably became the doctors’ preferred contact for discussing treatment. This did not represent a new practice, of course, because family members had long been responsible, by default, for speaking to doctors on behalf of relatives who were patients.Footnote 30 In light of the persistent struggle by psychiatrists to secure recognition of decisions they had made based on information provided by families—including in cases involving official forcible involuntary commitments—it is highly likely that the practice in Rodewisch was typical of admission decisions in the GDR as a whole.Footnote 31 As this suggests, an unofficial negotiation process thus developed to compensate for the regulatory vacuum in admission practices. The judiciary did not revisit the policy of forcible involuntary commitment until 1968, which meant that the determination of who needed, or did not need, treatment in a mental health facility usually remained in the hands of families and physicians.
The following four examples shed light on how civil involuntary commitments worked in practice. Each represents typical family constellations in which civil hospital admissions were decided without patient input or consent. In the first case, the patient was an adult woman, Petra Sch. (all names have been anonymized), whose parents were involved in the decision to have her committed. Other parties attempted to assert their interests, but, as we will see, only the family's input and the physician evaluations were ultimately crucial for the final decision—as was generally the case. In the second example, the patient's sister arranged for hospitalization and, in this case, the negotiation took place solely between family members and doctors. In the last two cases, families initiated hospital admissions of dependent family members: an underage child and an elderly man with dementia. This was not unusual, for minors and the elderly were completely dependent on decisions made by their next of kin.
In the case of Petra Sch., who suffered from epilepsy and had been hospitalized on numerous occasions in the early 1950s, it was her family and landlord, members of the local authority, i.e., the Gemeinderat (representing her hometown), and institutional physicians who were all involved—voicing very different concerns—in the decision to commit her for a third time. Petra Sch. was brought to Untergöltzsch with an acute epileptic seizure after a doctor had injected her with a sedative.Footnote 32 The patient's mother argued against a longer hospital stay and wrote to the facility to obtain her daughter's temporary release, which she hoped would serve as a trial period for a more permanent discharge. A temporary leave was granted and Petra Sch. was released into the care of her mother.Footnote 33 Shortly thereafter, the institution received a letter from the local town council, which argued forcefully that the patient was in dire need of institutional care. The letter recapped the admission order and then emphasized that the release of the patient was not in the interest of the admitting physician, the local town council, or the owner of the house in which she lived:
The admission of [Petra Sch.] proceeded at the prompting of the physician, Dr. N., who has been on holiday these last weeks. As soon as he returns, the admission forms will be sent to you. During its last meeting, the Municipal Social Commission of Raum [Saxony] fully addressed the [Sch.] case again because there is an application from the owner of the house where [she] lived, which requested that [she] no longer live in his house after her return from the hospital because she had already smashed window panes, etc. Because [her] condition is unlikely to improve significantly in the near future, and because the seizures recur regularly, we ask that she not be temporarily released, let alone discharged, after only a few weeks, especially since we have already had difficulties with the doctor, who, because of the risk, does not want to administer any more sedatives … while she is experiencing a seizure. We request your understanding and that you inform us of your decision in this matter.Footnote 34
The town council, the landlord, and the local doctor cited pragmatic reasons for a long-term commitment, which were related exclusively to disruptions to the normally smooth administration of town life. The director of the institution made a different argument in her written reply, while, at the same time, taking on the role of intermediary between the mother's interests and those of the town:
The above-named patient behaved in the last weeks of her stay here in a calm, collected, and unobtrusive manner, so that the request of the patient's mother was granted, and [she] was released on a trial basis on September 6, 1951, into her mother's care. At this point in time I had not yet received your letter of August 31, 1951. From a medical standpoint, it is correct to release, on a trial basis, a patient whose condition has considerably improved, especially when the family—as in this case—has assured diligent care and supervision. If concerns should arise on your part after review of the domestic conditions, the immediate return of the patient will be requested.Footnote 35
The doctor's medical arguments were not related to those of the town council, but she did not reject the council's concerns out of hand, allowing instead for the possibility of readmission should any doubts arise about the family's ability to ensure that Petra Sch. would not cause any disruptions. The doctor thus demonstrated the multifunctional role of the mental-health facility: providing medical opinion and treatment, as well as mediating, when necessary, between the family and the town.
There are several reasons why the admission process in this case was noteworthy. First, the proper procedure for civil involuntary commitment was not followed in this case: the patient was not subject to an official, forcible involuntary commitment; in addition, she was admitted without the proper admission forms. It is also striking that the patient's opinion in the matter was not mentioned in her medical records, even though the commitment was not involuntary. The facility doctor thus worked to mediate among all involved parties in this case—except for the patient. There are four ways in which the admission of Petra Sch. was nevertheless typical of the manner in which many admissions proceeded that were not official, forcible involuntary commitments—yet, in which the patients were in some way incapacitated and thus stripped of the right to make their own decisions. First, and of particular significance, it was ultimately the doctors and family members who made the decision about a long-term hospital stay. Second, other parties attempted to influence the decision. This was not necessarily irrelevant, as this example suggests: it was the actions of the local doctor that had led to hospital admission in the first place. The local doctor's role was nevertheless largely inconsequential when it came to the decision to keep the patient in the facility. Third, the patient was barely—in this case, not at all—involved in the decision. Finally, the arguments and reasoning of the local municipality were purely pragmatic in nature.
The hospitalizations of forty-six-year-old Walpurga R., who was admitted to Großschweidnitz nine times between 1947 and 1956, were typical for less complicated cases involving only the family and doctors.Footnote 36 It was Walpurga's live-in sister who initiated most of her hospital admissions, where she received various diagnoses, such as “reactive depression,” “endogenous depression,” and “schizophrenia.”Footnote 37 Regardless of the precise medical diagnosis, the visits to the doctor were precipitated by situations that Walpurga's sister described as no longer sustainable or acceptable. She claimed, for instance, that, prior to her sister's commitment in 1947, Walpurga R. had refused food out of fear that she could be poisoned.Footnote 38 In 1953 the patient's sister explained that she could barely communicate with her because she was now hearing voices.Footnote 39 Walpurga only stayed in the facility for a few weeks each time, until physicians and the sister agreed that the symptoms had subsided to the point that she could once again live with her sister.
As noted earlier, minors and the elderly were completely dependent on the decisions made by their next of kin. Many of the commitments in these cases proceeded in a manner similar to the following two examples involving Karin F. and Albin H., who were both subject to civilly enforced admissions. As different as these two cases may otherwise be, both involved a domestic situation that proved to be a crucial factor in the decision to seek inpatient care, whether on account of increased care expenses and effort, or in connection with violent behavior.
Karin F. came to Großschweidnitz in 1958 at the age of thirteen. Since childhood, she had suffered from a “spastic paresis in her hips.”Footnote 40 Her parents explained that her care was becoming ever more expensive as the paralysis worsened. The patient's mother had first turned to the local polyclinic, which referred them to the board of specialists at the Großschweidnitz hospital. It was there that the mother spoke out in favor of her admitting daughter, and the doctors agreed: “Inpatient care would be advisable here. This is not possible, however, due to lack of space—at least for the next few months. In the interim we can only make a note of this case and come back to it in due course.”Footnote 41 Shortly thereafter, Karin F. was indeed admitted to inpatient treatment, but three weeks later, after her spasticity had improved, she was released at the request of her parents.Footnote 42 In this case, the patient's parents and the physicians at Großschweidnitz had made the decision for inpatient treatment, whereas the patient herself was ambivalent about being admitted.Footnote 43 There were, however, also cases in which doctors and next of kin admitted patients who were decidedly against that course of action—as in the case of seventy-one-year-old Albin H. in 1958. Albin H. lived at the time with his son, who wanted to have his father admitted after he had not only begun wandering the apartment building at night but also physically attacking his son and other tenants.Footnote 44 The elderly man vehemently objected to admittance, but because his son and the physicians felt otherwise, he was admitted to the facility against his will—without his commitment being considered a forced admission, because neither the police nor the judiciary was involved. This was no exception: available evidence suggests that it was, in fact, common practice for families and doctors to decide to have patients admitted against their will, regardless of the potential patient's age or sex.
Against this background, the following section discusses what these findings mean for our understanding of the complex relationship between state and society in the early GDR. Many studies have shown that totalitarian or “semi-totalitarian” models and concepts, such as durchherrschte Gesellschaft, do not provide a nuanced analysis of that relationship—not least because they deny or at least underestimate autonomous action on the part of society.Footnote 45 As we shall see, even the more moderate concept Diktatur der Grenzen only partially helps to explain processes of psychiatric commitment; the neglected term Vergesellschaftung fits much better in this context.
Interpreting Psychiatric Commitment without State Intervention
The central role that families and doctors played in making decisions about involuntary commitment does not fit some of the more common characterizations of the SED dictatorship, which tend to assume that freedom of action was indeed possible in the GDR, but stress that such freedoms must be understood in relation to the structures of dictatorial rule. After all, government agents supposedly infiltrated even those areas of daily life that were at least partially autonomous.Footnote 46 Accordingly, it would not be possible to conceive of any part of life in the GDR as not somehow related to the dictatorship. The problem is that such an approach only partially characterizes and accounts for the actual practices of psychiatric admissions. With that in mind, the following section explains why psychiatric admission practices challenge useful concepts such as Eigensinn and Diktatur der Grenzen, suggesting, in turn, that involuntary hospitalizations can be better understood as a Vergesellschaftung of state-run process.Footnote 47 To be sure, negotiations among families, doctors, and members of the patient's social milieu took place “at the margins of the basic structure” of the dictatorship, where areas for maneuver existed for “ordinary” Germans, as suggested by Thomas Lindenberger's concept Diktatur der Grenzen.Footnote 48 However, in the case of psychiatric commitment, this was not a result of Eigensinn on the part of patients or families, i.e., they did not press for the right to act autonomously in this context.
There were at least three reasons why psychiatric admissions in the GDR became a process remote from the state. In the first place, the state hardly advanced any legal claims to such authority before 1968. Sabine Hanrath attributes this regulatory vacuum—which allowed for a great deal of leeway at the grass roots—to the relatively strong position of East German psychiatrists, who were able to assert their own interests in the GDR to a much greater extent than their counterparts in the Federal Republic could.Footnote 49 This may have been related to the power they enjoyed because of their small numbers: many medical experts had left the Soviet zone of occupation and the GDR in its early years, and the regime may have tried to prevent further the emigration of medical experts by granting them greater room for maneuver in their profession.Footnote 50 Second, given the absence of legislation regulating psychiatric commitment, it would have been possible for different government actors to step in to fill this regulatory vacuum. Yet, this was not the case in the GDR. Neither the police—as had been the case in the Third Reich—nor state security agencies (as in the Soviet Union), nor the judiciary (as in West Germany), showed any initiative in this area.Footnote 51 Third, state intervention was especially difficult because admissions decisions were in no way a foregone conclusion with a predictable outcome, i.e., they could not be pushed along certain paths by systematic state penetration into society at the grass-roots level, including by the many sociopolitical institutions that existed in East Germany, such as youth and women's organizations.
An intertwining of “state power, the exercise of rule, and fragmented society”—in the sense of Lindenberger's Diktatur der Grenzen—did not play a role in most psychiatric admissions, then, even if they were, admittedly, the result of interactions between institutions (e.g., hospitals, facilities, and polyclinics) and society.Footnote 52 This meant, on the one hand, that psychiatric admissions were largely free from political intervention, which is why East German patients were not normally admitted for reasons of political nonconformity—and thus not subject to systematic political abuse. This implies that patients were, by and large, deprived of any state-sponsored protection. As a result, they were exposed to the arbitrariness of their social milieu, since there was no external authority that would review the legitimacy of the admission. Members of that milieu took extensive advantage of the room for maneuver that they enjoyed but had not wrested from state authorities. On the contrary, members of the patients’ immediate social milieu had been left with no other option than to take the initative for psychiatric commitments, in cooperation with medical experts. In the GDR, then, it fell to “society” to secure the working of the psychiatric sector, which the state largely neglected.
As suggested, this specific constellation cannot properly be explained by the concepts Diktatur der Grenzen or Eigensinn. Rather, the idea of a Vergesellschaftung of what was elsewhere a responsibility of the state offers a more suitable characterization of psychiatric admission procedures in the GDR. The point of Ralph Jessen's neglected concept is to identify the ways in which East German society itself compensated for the absence of state regulations in certain areas such as involuntary hospitalizations—rather than focusing on ways in which the state influenced society, or the ways in which ordinary Germans acted in a way that could be desribed as eigensinnig.Footnote 53 Questions that usually arise in discussions about individual autonomy under a dictatorship, and that usually focus on efforts to struggle against the strictures of the regime by any means possible, did not apply when it came to matters of admissions practices.Footnote 54 Moreover, the system of involuntary hospitalizations apparently worked so well during the first two decades of the GDR that the legal regulation introduced in 1968 essentially adopted the existing approach.Footnote 55 As a result, the Vergesellschaftung of the psychiatric sector in the 1950s and 1960s became entrenched during the later years of “really-existing” socialism in the 1970s and 1980s.
Indirect and Unintentional State Influences on Hospitalizations
The “socialization” of psychiatric admission practices should not suggest that the regime had no influence in this area, i.e., that this was a space entirely free from official interference, a special niche removed from politics. In fact, socialist ideology, political rhetoric, and economic factors all influenced in various ways the argumentation underlying admissions decisions, which suggests that the SED regime affected such decisions in an indirect, yet nevertheless profound, way. At the same time, the suggestions and demands of patients’ families reveal a great deal about power structures in the GDR, for the extent to which families could successfully intrude in areas of medical expertise was a result of the decision-making authority they enjoyed in this sensitive area. The general framework created by the state was thus as important for the relationship between medical experts and laypersons as it was for the institutionalized care of patients.
The reasoning behind patient admissions is also instructive for what it reveals about socialist standards of equality, as well as for the role that labor played in the construction of a healthy self-image in the so-called Workers’ and Peasants’ State.Footnote 56 In accordance with labor propaganda, as well as with official doctrine about equality, families occasionally demanded improvements for their loved ones, who were not only patients but also provided actual labor while confined to the institutions. Correspondence between family members from the 1950s reveals, in fact, that the rights they demanded were specifically derived and invoked from the fact that patients also worked there. In an extended exchange of letters with Rodewisch, for example, one mother used this strategy to ensure better treatment for her daughter.Footnote 57 She repeatedly pointed out in her letters that her daughter should be treated better because, after all, she was working in the institution. For example, the mother specifically referred to her daughter's labor contribution when complaining that her daughter had (the daughter claimed) been overpowered and kicked in the abdomen by four other people in a fit of rage:
One could simply make the argument that she is ill and therefore not to be believed. As her mother, I know my daughter and it is very unfortunate that she is mostly in her right mind and only suffers from seizures. I know from a reliable source that my daughter is very hardworking and compliant. That is also suggested by the fact that she gets up early every day and does the laundry and other work as well. I certainly have no complaint about this, because such ill people need distractions that contribute to their recuperation. Yet, at the same time, she should be offered some diversion by granting her more freedom of movement, which would be more fitting to her condition.Footnote 58
The argumentative strategy that the patient's mother adopted was significant for its remarkable appropriation of labor rhetoric. It does not merely rest on abuses in the facility; rather, it invokes her daughter's right to “good” treatment because of her willingness to work and because of her exemplary work performance. Whether done intuitively, from personal conviction, or deliberately as a strategic tool, the mother decided to invoke state doctrine about labor and equality to advance her pragmatic concerns and obtain better treatment for her daughter. As this example suggests, the appropriation of socialist rhetoric and reasoning sometimes affected areas of everyday life in which the rulers and the ruled did not directly meet. In this case, it involved a somewhat heated written exchange between members of the nursing staff and the patient's mother—which supports scholarly claims that the SED dictatorship was based, in part, on “social acceptance,” as well as on “political and cultural creativity.”Footnote 59 Regardless of her motivation, and regardless of whether the mother supported or rejected the system or was simply indifferent to it, she used established phrases (Floskeln) from the official party line in order to advance the interests of her family.
Another characteristic of the correspondence between family members and mental health facilities was the demanding tone that families sometimes adopted. The families did not only seek advice (which was also commonplace in the Federal Republic) but also—in fact, far more often—offered their own suggestions for treatment when formulating enquiries about a patient's potential admission to a facility, the length of his or her stay, and whether he or she could be temporarily released.Footnote 60 Correspondence between Rodewisch and the mother of Annegret M. offers one example of such interactions. Annegret M. was an adult woman admitted to Rodewisch for the fifth time in 1953.Footnote 61 That March, her mother opined in a letter that she did not find it good that her daughter was “shocked so often,” requesting instead that the medical staff consider whether she might fare just as well without shock-therapy treatment.Footnote 62 As this suggests, the patient's mother, who considered bringing her daughter home, believed herself competent to give her opinion on the course of the illness and its treatment: “As much as I would like to come pick up my daughter, I also worry that she would need to return soon. Has there been any improvement to speak of? Could it be that the summer heat affected her illness?”Footnote 63 The treating physician, a certain Dr. M., replied two weeks later that they had tried to do without the electric-shock therapy but could not because the patient had become too angry and “hysterical.”Footnote 64 Following further correspondence about a temporary release over the Easter holidays, the mother contacted the doctor again in June with fresh concerns:
Would it be at all possible for you to permit my daughter … to leave the hospital grounds every now and then—only as her condition allows? I think that she is mostly in her right mind. … It must contribute to improvement if the patient has something to look forward to. I know that it might be a difficult decision to make because my daughter had once tried to escape years ago. In my view one cannot always be so strict, and it would perhaps be appropriate to ease the monotony of institutional life a bit, especially since my daughter keeps herself busy there.Footnote 65
The doctor replied to these suggestions by noting that Annegret M. had already been regularly leaving the hospital grounds for many weeks, together with one of her fellow patients: “It is also very important to us to treat our patients according to their own particular needs, and we are happy when the mental condition of the ill allows us to grant them greater freedoms.”Footnote 66
Such correspondence, which was not unusual, suggested the changed role from pre-1945 practices that families now played in the admission process. As mentioned earlier, power relations had shifted for involuntary admissions. Officials committed very few patients; instead, it was family members and doctors who took and carried out the decision to admit adult patients against their will. According to the medical director of Rodewisch, this procedure was used to commit about 90 percent of his patients through the end of the 1950s.Footnote 67 The patient's entire hospital stay, including the length of stay and the admission itself, was based on the wishes of the family and the approval of the doctor. The conclusions drawn by Udo Schagen and Sabine Schleiermacher about the development of health care in the GDR—that, “in spite of the abolition of the physicians’ previous organizational strength and power, based on professional standards, the hegemony of medical thought in all questions of health and illness [remained] astonishingly unbroken”—is only partially valid with regard to psychiatric admissions. It is true that psychiatrists were able to strengthen their relative position of power vis-à-vis other institutional actors, whether it be the police or municipalities.Footnote 68 Yet, when it came to non-institutional players involved in hospital admissions, laypersons often had a self-assured attitude in the GDR, including a belief in their right to make interpretations of a highly specialized, medical nature.
A more tangible change in the East German practice of admitting psychiatric patients resulted from regime efforts to restructure the health care system. Such endeavors were not specifically aimed at the mental health sector, yet managed to change admission practices significantly. The GDR adopted many elements from the Weimar Republic, while also incorporating demands articulated by the labor movement since the imperial period.Footnote 69 In the course of restructuring the heath care system, certain changes had an impact on mental health admissions, even if the changes were not specifically meant to affect the psychiatric field. The practice of factory physicians admitting patients took hold in the 1950s, a direct consequence of changes in the GDR's political and economic framework. In such cases, patients often went to the hospital directly from work, accompanied by their colleagues. It was the latter, in fact, who often made the initial statements for the heteroanamnesis—a much different situation than was the case when the referring individual was a member of the patient's family or the primary-care physician.
In any event, the initial information that was provided strongly determined the patient's fate, given that decisions about the patient's hospital stay were usually made quickly after intake, frequently even before the treating physicians were able to speak with the patient's next of kin. Among these early decisions was the patient's assignment to a ward. Since the hospitals themselves were divided into several units, this meant that new patients were immediately evaluated to determine whether they should be admitted to a “calm” (ruhig) or an “agitated” (unruhig) ward, whether they were “fit to work” (arbeitsfähig) at the institution, and whether they would be permitted to leave hospital grounds, e.g., in order to perform small errands. The admission of sixty-year-old Janosch Sch. to Untergöltzsch in 1950 by the company physician was a typical example of this process, as the first entry in his medical record suggests: “According to [the] attached medical certificate, patient was admitted by Dr. L.-C. Arrived directly from work accompanied by [his] colleagues. During intake, somewhat cool, calm, introverted. Supposedly exhibited sudden changes during work. Was constantly running in circles, which caused concern that he could run into the engine of the rotating machine.”Footnote 70 Such behavior and dangerous workplace situations were not peculiar to East Germany, of course, but the way in which the situation was handled was certainly GDR-specific, in many respects. More to the point, it underscored the sweeping changes ushered in by worker dependence, in almost all areas of life, on his or her place of employment. The fact that the patient did not return home first before reporting to the hospital—even though it was not an emergency situation, such as an attempted suicide or a violent episode—as well as the fact that he did not go to the hospital with a family member or relative, demonstrated the absolutely vital function assumed by the social environment of the workplace, even for existential decisions made during personal crises.Footnote 71
East German factories and employers also played a considerable role in the decision to discharge patients from psychiatric facilities, with psychiatrists and employers also working together closely, as was the case for admissions. Negotiations around Martin W.’s hospital stay provides a useful example. In 1949, the twenty-five-year-old was scheduled to be discharged from the Greifswald University and Psychiatric Hospital following treatment for an attempted suicide. At the suggestion of the city hospital in Stralsund, a doctor at the Greifswald University Hospital subsequently wrote to the Volkssolidarität (People's Solidarity Association) in Stralsund, Martin W.’s former employer: “The ward doctor at the city hospital Am Sund in Stralsund asked us to contact you before discharging the patient. They want to try to improve the patient's living situation and possibly find him a position at the Volkswerft (People's Shipyard). We are therefore asking if you would be able to do anything for our patient.”Footnote 72 The Volkssolidarität replied as follows: “We must unfortunately inform you that we have no further use for this patient. In spite of repeated promises not to make any more suicide attempts, [he] did make a further attempt. We consequently find that we no longer want to employ such weak-willed [willenlos] people.”Footnote 73 He did not, in other words, deserve employment. Moreover, his repeated suicide attempts ironically indicated that, from the point of view of the Volkssolidarität, he no longer had any value to society. The indignant response sounded almost as if it were meant as a punishment for a deliberate and malicious transgression against an organization that had once graciously helped him find work. Moreover, the locution perpetuated notions that had been firmly entrenched in the Nazi era and even earlier: in the early GDR, the “weak-willed” and “unwilling to work” (arbeitsscheu) were typical attributes used to describe so-called psychopaths.Footnote 74 On one hand, as this suggests, established and accepted beliefs about a person's ability to work were seamlessly integrated into the reigning discourse of the workers’ state. On the other, as we have seen, family members appropriated similar rhetorical models about the will and ability to work, but used them instead in the interest of the patient.
Conclusion
The foregoing analysis of the practice of psychiatric hospitalizations in the GDR leads to two surprising conclusions. The first is that there was hardly any direct state intervention in the process; indeed, the regime did not seem to have any interest in intervening. Why did the GDR, commonly considered to be an interventionist state, neglect the domain of psychiatry? One likely answer is that it focused on industrious workers, not on protecting weak citizens who were not economically productive. This is an important point, given that this was a regime known for the ways in which it tried to win legitimacy and bind people closer to the state through welfare measures. What we know about psychiatric admissions practices does not confirm, therefore, the popular concepts of a Fürsorgediktatur, a durchherrschte Gesellschaft, or a Diktatur der Grenzen. The neglected concept of Vergesellschaftung—in this case, the “socialization” of a responsibility that usually fell within the purview of the state—is more useful for understanding early developments in the GDR, at least in this realm. It is the only concept that helps us envision the possibility of an unwelcome social space separate from the state: psychiatry was not just safe from politics—it was indeed neglected by the state, which meant that responsibility fell to families and medical personnel. In sharp contrast to this, the Federal Republic introduced legislation for compulsory admissions to psychiatric facilities in the 1950s. There it was the judiciary—not doctors and families—that was in charge of involuntary hospitalizations. The latter also played a role, of course, but court decisions ultimately became decisive.Footnote 75
The second major finding of this article is that certain developments in the GDR had—wittingly or not—immediate and far-reaching consequences with respect to psychiatric hospitalization, and they manifested themselves in two ways. In the first place, families appropriated the regime's own rhetoric of labor and egalitarianism and used it to their own advantage, as well as to that of the patient. Besides their central role in the admissions process, medical laypersons were thus able to assert their position vis-à-vis the actual experts, i.e., the facility physicians. Family members regularly offered opinions about the doctors’ therapeutical approaches and choices regarding changes in the patients’ treatment, such as the ability to leave the facility for leisure activities. As this suggests, laypersons could thus successfully intervene in areas of psychiatric expertise, with medical experts merely reacting to such demands. In addition, as we have seen, company doctors referred employees for admission to institutional care directly from the workplace, and it was colleagues, rather than family members, who would then take on the important role of referral. The Vergesellschaftung of psychiatric commitment thus happened in a genuinely “East German” way, even though—in fact, arguably because—there was no direct intervention by the regime.
