Mental Health Care for the Mentally Handicapped in Germany

A.Sand u.Chr.Gaedt 1

Mental Health Care…….

Mental Health Care for the Mentally Handicapped in Germany[1]

A.Sand and Chr.Gaedt

The foundation of the Lebenshilfe - an organization serving the needs of non-institutionalized handicapped persons - in 1958 and the report of the Enquête commission to the Federal Government in 1975 (Psychiatrie-Enquête, 1975) were milestones in the movement to reform the care of persons with mental handicaps. The Enquête-Report dealt with the development of mental health care in the Federal Republic of Germany. One of its main conclusions was that separate facilities for psychiatric patients and mentally handicapped persons were urgently needed. This meant a break with the longstanding, but wrong tradition of interpreting mental disablement as a psychiatric illness and having the mentally handicapped admitted as patients to psychiatric institutions. Psychiatry had let itself be abused for too a long a time for the purpose of isolating mentally handicapped persons from the rest of society on the pretext of medical grounds. In this connection one should not forget the role psychiatry played in the euthanasia murders of Nazi Germany.

At the time of the Enquête-Report, approximately 94.200 mentally handicapped persons were residing in large-scale psychiatric institutions which, typical for that times, were not offering humane caring facilities. Following this report many efforts were made to achieve a separation from psychiatry. Since no binding nation-wide conceptions existed, the social agencies on the state level took their individual course of action, for example by discharging the handicapped into community-integrated caring facilities, by transfering them to newly established homes with a pedagogic philosophy, or by creating autonomous departments within the large-scale psychiatric institutions (Dreher et al., 1987, Theunissen, 1991)

The Lebenshilfe - an initiative of parents - was founded with the same purpose in mind. The establishment of this organization was a protest against the inhumane caring facilities in the psychiatric institutions which isolated persons from their environment. The examples set in other countries, especially Sweden, Denmark, the Netherlands and the United States, served as models. The Lebenshilfe developed rapidly. By 1990 ca. 130.000 mentally handicaped persons were being provided for in community-integrated facilities (Lebenshilfe, 1990).

Even before the reunification took place, the reformative movement had slowed down. At the time of reunification, there were still ca. 10.000 mentally handicapped persons residing in psychiatric institutions in the former FRG because appropriate alternatives were not available and the development of therapeutic-pedagogic wards left much to be desired (Theunissen, 1991). The Lebenshilfe organization is today far from having realized its objective to provide comprehensive care for all mentally disabled persons. One of the main barriers to this goal is that the federal allocation of funds for personnel is inadequate.

The struggle to "de-institutionalize" and to improve the living conditions for mentally handicapped persons has become harder due to the fact that five new states have entered the Federal Republic of Germany. At the present, we have no reliable statistics on the extent of the problem, but one can be assured that all energies and financial funds currently available for the care of the mentally handicapped are committed to improving the standard of care in the new states. Under these circumstances, new problems don't have the chance to be registered.

For this reason it is understandable that the issue of "dual diagnosis" does not play a significant role in Germany. For a long time this topic was taboo, a reflection of the strained relationship between psychiatry and pedagogy. Psychiatry tried everything it could to keep from being suspected again of assuming responsibility for something it was not authorized. It was too willing to accept the conceptions of the pedagogues, who interpreted every psychic disturbance in terms of behavior disorders resulting from isolation, labelling and misdirected adjustment processes. They were convinced that all problems could be solved by making the everyday living situation more normal, or depending on the case, by utilizing behavior modification techniques. In this process, feelings of omnipotence were passed on from the medical staff to the pedagogues.

This view has only been changing recently. It became too obvious that pedagogic conceptions could not meet the challenge presented by the problems of mentally handicapped persons with psychiatric illness. In the light of this development, the present shortage of personnel resulting from other factors becomes even more threatening. Psychiatry now is confronted with a demand for competent diagnostic and therapeutic services, a task it is not prepared for, neither on an in-patient nor on an out-patient basis, with a few exceptions. Even today a widespread if not prevailing assumption is that classical psychiatric disturbances do not occur in mentally disabled persons and that all disorders which can be classified as psychiatric can be attributed to organic brain damage. This explains why, as a rule, forms of therapy for the mentally handicapped are unimaginative even today.

Stimulated by the discussions concerning the issue of "dual diagnosis" in the United States (Szymanski et al., 1980, Matson et al., 1982, Stark et al., 1988) as well as the ideas coming over from the neighboring Netherlands (Dosen et al., 1990), a movement which is committed to a more differentiated view of diagnostic and therapeutic necessities in caring for this group of persons is emerging. But this movement has not yet attained any significance on a national level. The traditional professional associations of psychiatrists have not yet occupied themselves with this problem. As far as we know, there is no research work being done at any German university which is concerned with this issue. So there are only sporadic activities being initiated by a few institutions which are particularly affected by the problem. That explains why there is no systematically recorded information available, for example epidemiological data or information on a nation-wide network for mental health care or alternative models which we could present here today.

Neglecting this issue has serious consequences for the further development in the care of mentally handicapped persons. Because the large institutions furnish relatively good diagnostic-therapeutic services, they feel pressured to admit all those handicapped persons who cannot be cared for in a community setting. In this way, the road of normalization is blocked again for many disabled persons. Inhumane selections processes, believed to have been overcome a long time ago, are revived. So, the large institutions are turning into a reservoir for really difficult cases. Centers only for the care of the seriously handicapped are emerging in the form of a new "total institution". The "Neuerkerode Memorandum" (1991) has called attention to this fact and has gotten a good response nation wide.

Therefore, all efforts must be made to prevent this step backwards. The prime objectice is to build up diagnostic-therapeutic services for all mentally handicapped, in other words, also for those persons residing in a community-type setting. This can only become reality if the psychiatric and the pedagogic facilities find a new and intensive way to cooperate. Because of the exceptional circumstances at that time, we do not believe that the Federal Republic of Germany will take on an innovative role. On the contrary, impulses and ideas from other European countries will be necessary to get the development going in Germany. In this respect, we are very concerned about the efforts being made to found a European association, the goal of which is to improve the quality of life of persons doubly burdened with mental handicaps and psychiatric illness

Literature

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Dosen,A., van Gennep,A., Zwanikken,G.J. (Eds.)(1990). Treatment of

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Lebenshilfe Selbstdarstellung (1990). Bundesvereinigung der Lebenshilfe für gesitig Behinderte e.V. Raiffeisenstr. 18, 3550 Marburg, Germany

Matson, J.L., Barrett, R.P. (Eds.)(1982) Psychopathology in the Mentally Retarded. New York: Grune & Straton

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Theunissen,G.(1991) Aus der Psychiatrie in die Gemeinde - Konzepte zur Integration geistigbehinderter Erwachsener in der Bundesrepublik Deutschland. In: Böker,W. u. Brenner, H.-D. (Hrsg.) Geistigbehinderte in Psychiatrischen Kliniken. Berlin, Stuttgart,Toronto: Huber

[1] Mental Health Care for the Mentally Handicapped in Germany. Presentation at the World Psychiatric Association Regional Symposium Budapest. August 1991. Published in: Ital. J. Intellect. Impair./Riv. Ital.Disturbo Intellet.1992, 5: 21-24.