At the outset of her study, Stefanie Coché asks why and how people have been committed to psychiatric institutions and what their commitment says about German society in the 1940s and 1950s. In search of answers to these questions, she argues that admissions practices involved the interaction of a variety of actors, each with its own specific claims and jurisdictions. She deploys a power-centred analysis to explore the diversity of agents and historical contexts that were in play on the threshold of psychiatric institutionalisation.
In adopting this perspective, Coché takes aim at a longstanding bias within German psychiatric historiography that has tended to interpret hospitalisation simply as an exercise in medically sanctioned state repression. An entire generation of psychiatric historians dating back to the 1970s and 1980s has been heavily invested in this narrative and it continues to exert powerful influence within the field. The cost of telling these one-sided stories of state repression has been to elide or misinterpret the influence of other actors, especially of patients and their relatives, but also of psychiatric professionals. In attempting to redress this bias, Coché’s research does not so much discount the role of the state as re-evaluate it in relation to the significance of ‘local knowledge and power relations in social microcosms’ (p. 15). And this re-evaluation results in remarkable findings that contradict several long-held and widely propagated historiographic dogmas.
On the face of it, Coché’s task is made all the more challenging – and potentially rewarding – by the fact that she attempts to compare psychiatric institutionalisation in three distinct political regimes: East, West, and Nazi Germany. But she hastens to point out that hers is not a comparison of nation states, but rather an ‘inter-societal’ (p. 20) comparison. The study exploits the perspective of patients and relatives, their social environments, regulations and medical discourses, as well as medical practices in conjunction with six psychiatric hospitals in different parts of Germany. It deploys four analytic categories that were common across these hospitals and nation states: (1) power and agency in admissions practice, (2) disease and diagnosis, (3) security and danger, and (4) work and performance (Leistung). Coché devotes a chapter to each of these categories.
To reinforce her larger agenda of a ‘socio-cultural approach to the history of science’ (p. 36f), Coché defends her use of hospital patient records as historical sources and appeals for both a functional and hermeneutic analysis of them. She argues that because madness was not ‘constructed’ and ‘attributed’ (p. 296) entirely within the asylum itself, but rather on its threshold, a strictly functional analysis of patient records is inadequate and that therefore non-institutional actors must likewise be taken into account with the aid of hermeneutic techniques. Coché believes that this dual approach is necessary in order to bridge the gap between ‘internalist’ psychiatric histories of medical/hospital practices on the one hand, and socio-cultural histories of patients’ subjectivities and marginalisations on the other.
Coché finds that, in all three political systems, psychiatry as an institution was unable to steer hospital admission decisions. It was not doctors or even judges, but rather non-institutional actors (including patients themselves, neighbours and, especially, family members) who drove decisions about hospitalisation. At least as far as psychiatry is concerned, Coché’s findings effectively demolish as an artifact and ‘illusion’ (p. 303) Lutz Raffael’s widely and enthusiastically cited notion of a ‘scientization of the social’.Footnote 1 Furthermore, and contrary to the enormous attention that historians have paid to race and gender issues, Coché finds that, in all three political systems, work was a far more significant factor in the construction of boundaries between health and illness or normalcy and deviance. This was the case not just for patients themselves and their ‘social microcosms’, but also for psychiatrists and state authorities. Even in cases of involuntary commitment, Coché finds that families continued to exert influence. Although in Nazi Germany the attitudes of families and the state were often more closely aligned, in East Germany the state was largely absent from decisions about involuntary commitment. Rejecting the concept of a ‘Durchherrschung’ of east German society, Coché draws on Ralph Jessen’s notion of the ‘Vergesellschaftung’ of the state to explain how families and doctors, rather than state officials, dominated the decision-making process. By contrast, in West Germany that process was much more informed by notions of individual rights. All of this leads Coché finally to the conclusion that psychiatric hospitals were first and foremost ‘instruments of social self-regulation from below’ and, as such, characteristic of the ‘adaptation of social microcosms to the processes of modern rationalization’ (p. 312).
Two critical notes are worth mentioning. First, Coché’s book is an academic dissertation and as such is an unnecessarily over-differentiated account that too often sacrifices narrative force on the alters of comparison and analytic consistency. More importantly, however, Coché’s focus is limited to admissions practices. She rightly argues that studying psychiatric institutionalisation can open a window onto societal norms of health, security, deviance, etc. But there is more to be examined than just this front-end of the story. What goes entirely untold is the back-end of people actually being discharged from psychiatric institutions and the hardly less profound significance of the ‘local knowledge and power relations in social microcosms’ (p. 15) that govern their social (re-)inclusion. Had Coché examined these back-end practices, she likely would have found that psychiatrists had a much more decisive role to play than they did for admissions. In any case, until we develop analytic tools and, above all, historical narratives that are robust enough to recount both the front and back ends of this story, our understanding of the complex relationship that the book’s title purports to explain – i.e. that between psychiatry and society – will remain inadequate.
These criticisms aside, Coché’s book is an impressive piece of historical scholarship. It is both a welcome contribution and an important corrective to those histories that for too long have been over-invested in critiquing psychiatric institutions and portraying them as instruments of state repression.
