1. Ueckermünde and its dark past
In Ueckermünde I meet a former employee, who was employed in the institution from 1939 and now looks after the graves in the cemetery. I would like to know where the children were murdered. She looks at me in astonishment: “No children were murdered here,” she says. “The deportations were terrible, and many starved to death, but children were not killed. This is the first time I’ve ever heard that.”[1]
Ueckermünde, a small seaside resort town on the bank Stettiner Haff, has been distinguished in the past as being family and senior friendly.[2]This small town has become a tourist attraction due to its restored old town and proximity to the water. However, in terms of history, the town has also been the scene of several chapters of the darkest history.[3]In 1875, “the oldest of the Pomeranian provincial insane asylums (Provinzialirrenanstalten)” opened in Ueckermünde.[4]During the Nazi era, cruel crimes against humanity were committed there.[5]For the targeted killing of disabled children, the Nazis established the “Children’s Department” in 1941.[6]The crematorium, built in 1940, was used for the disposal of the many fatalities.[7]Today, a memorial recalls the atrocious crimes which took place on what are now the grounds of the AMEOS clinic.[8]These dark shadows have clung to the city despite its idyllic location.
1.1 Psychiatry in Ueckermünde: a historical overview
As a human rights activist, Ernst Klee was known for his critical reporting and attitude towards psychiatric institutions in the former GDR. In 1991, he educated the public about the abuses perpetrated in these institutions. Ueckermünde Psychiatric Hospital was one of many institutions that became tragically infamous for its inhuman treatment of patients. Along with mentally disabled people, mentally ill people from the surrounding area were also housed there in huge dormitories without any regard for a need for privacy. Forced treatment with medication and confining non-conformists in cage beds[9]were part of everyday life in the psychiatric institution. The psychiatric ward was vastly overwhelmed with the task of caring for patients. There were only 65 beds available for patients with acute mental illness. The clinic had to provide care for a district with a population of 530,000.[10]
In 1993, in the documentary “The Hell of Ueckermünde – Psychiatry in the East”, Klee reported on the undignified housing of people with multiple disabilities who were in need of protection. Although Klee contributed to uncovering these violations of human rights, he was highly criticized for the way they were reported. He violated personal rights by revealing the film footage; however, this was the only way to make clear to the public the extent of the abuse committed which had been committed against human beings. Süß accused him of “blatant pessimism”[11]and stressed that the scenes shown in the film are a “burdensome legacy” of the psychiatric hospital Ueckermünde, which had “already been reformed”.[12]At that time, people with mental illnesses had long since benefited from the reforms that had been implemented.[13]
The report Zur Lage der Psychiatrie in der ehemaligen DDR(The Situation of Psychiatry in the Former German Democratic Republic), for which mainly East German “psychiatry experts” had been commissioned to work after the fall of the Berlin Wall, shows the extent to which attempts were made after 1989 to sweep the injustice committed against people under the carpet.[14]This states that the employees working in the psychiatric hospitals of the former GDR were highly motivated and not accountable for the circumstances and working conditions at the facilities.[15]This questionable insight, however, does not change the fact that those shown in the documentary were involved in destroying human lives.[16]Despite all criticism of Klee, the inhumane treatment in the aforementioned psychiatric hospital does not remain the only dark chapter in the history of psychiatry that has been poorly and inadequately dealt with. Klee did not paint a dark picture, but rather documented images that serve as a warning to future generations.
1.2 The stigma of people with mental illnesses
In an attempt to provide more progressive treatment for the mentally ill, the Rodewisch Theses[17]published in the 1960s were created to initiate reform efforts in the psychiatric wards of the former GDR. The aim was to counteract the public exclusion of mentally ill people and to promote positive developments in health care. For mentally ill people, for example, basic financial security was provided. An improvement in finances was possible for those affected, at least in agriculture.[18]Süß provides evidence of the success of the reforms with statements from the “professional living recollections of a doctor”[19]. A one-sided position without making reference to the patient’s perspective is adopted not only in their research reports but also in the vast majority of these reports in general. To what extent these lauded measures were beneficial for the lives of the patients cannot be conclusively answered due to insufficient research results.
Then, like today, people with mental illnesses had to contend with prejudice. The patients “treated” in Ueckermünde were known to the public in smaller cities and were marginalized in society. Since 1990, data has been available that allow conclusions to be drawn about the public’s perception of people with mental illness. The study tends to show greater disapproval of people who are treated for alcohol abuse or who suffer from schizophrenia.[20]
In the debate about discrimination and exclusion, the public hardly receives any information about the fates of those who have had to undergo coercive measures in psychiatric institutions due to mental illness. The media only occasionally provide information about crimes committed by acutely ill individuals admitted to psychiatric institutions. In this context, no reference is made to the difference between “criminal accommodation under the Criminal Code (StGB) and public accommodation under mental health or accommodation laws.”[21]In the minds of the people, a distorted image of the affected group of people is created.[22]Not only external influences such as media coverage, but also the lack of understanding in the social and family environment exacerbate the pressure on those affected. In addition, the structural discrimination[23]and stigmatizing views[24]that can even find their way into the medical profession make the recovery process more difficult in some places.[25]
This also illustrates the imbalance in the balance of power between doctors and their patients.[26]People who have been caught in the mills of medical assessment can become more often victims of the arbitrariness of those in positions of authority, as the case of Gustl Mollath has revealed.[27]
The primary aim of this article is to raise public awareness of people’s fates and to discuss a topic that is not sufficiently addressed by the population and the media. This “making visible” is based on the guidelines of the Disability Policy Guidelines, which call for the timely implementation of the objectives set out in the UN Convention.[28]
2. About Elisa
Elisa was born in 1966 in Neubrandenburg in what is now Mecklenburg-Western Pomerania, where she grew up with her mother. Due to her lack of any school qualifications, Elisa’s mother mainly worked as an unskilled worker. This resulted in her placing Elisa in preschool immediately after her birth. Elisa took on responsibility at an early age and supported her mother with contacting the authorities. At 16, shortly before graduating from high school, Elisa attempted to publicly found a party. In order to push this through, she met regularly with three followers in the restaurant Gaststätte Kranich. In Neubrandenburg, this locality was considered a shady meeting place, which did not prevent Elisa from publicly altering political statements in the writings of Marx and Engels. This circumstance led to her being forced into psychiatric treatment in the local psychiatric hospital in Ueckermünde. […]
In Ueckermünde, the processing and procedures for dealing with patients behind closed doors at different times and in different political systems are far from complete. Since there are hardly any documented testimonies of patients formerly treated in Ueckermünde, we will now present the first findings and interpretations of Elisa’s history, which are dealt with in more detail in subsequent articles. Elisa was a lifelong friend of Judi Klein and is a main character in my book “The Voices of Those Remaining”.
2.1 Comments on Elisa
Elisa’s development might have been influenced by her mother’s choice to place her in preschool. Due to the GDR’s program for childcare in preschools,[29]the research literature proves that an individual’s personal development was restricted from the outset because of the “right to control the individual” policy [30]
[…]
Indoctrination continued in the socialist school through the teachers, whose political philosophy was based on Marxist-Leninist teaching.[31][…]
Elisa’s early separation from her mother […], the assumption of responsibility for the regulations of official affairs that began with literacy, and the identity conflict in her youth, which led to a conflict with the political system of the GDR, did not prevent her from developing a critical attitude towards the dictatorship. After only a few days of being banned from the Kranich restaurant, Elisa was admitted to a psychiatric ward in Ueckermünde.[32][…]
The exclusion associated with the stay in a psychiatric hospital, which was not only carried out in her own family by her brother on her mother’s side, but also the public stigmatization in the social environment of her hometown prevented her from returning to the life she had dreamed of.
After her stay in the psychiatric clinic in Ueckermünde, she was initially prevented from continuing her schooling. […] In addition to this, she was also denied any further training.
She was only allowed to work in agriculture for a minimum subsistence income, which she was never able to cope with until her death in 2002. The inadequate training of the educational and psychiatric-psychological staff in Neubrandenburg after 1989 […], which was to be counteracted with the opening of the Clinic for Psychiatry and Psychotherapy in 1993 […], also did not bring about the desired success for Elisa.
The care of her mother, who was suffering from Parkinson’s due to the use of neuroleptic drugs,the daily struggle against the staff of the Steg counseling center, who vehemently wanted to place her mother in a nursing home for the elderly,[33]the lack of understanding in their own relationship and the desperateness of their situation at that time, made the hopelessness in their lives overwhelm them. […]
Elisa was forced to follow a path through life that consisted of heteronomy and exclusion. Elisa profited as little from the such highly praised reforms postulated by the Rodewisch Theses[34], and later followed by the Brandenburg Theses as other people treated in the aforementioned clinic. […] The structural discrimination in Neubrandenburg by the staff had begun in GDR era and continued after 1989.[35]Elisa was strong enough for others, but in the end, she did not have enough reserves left over for herself. […]
Elisa’s lifeless body was found in her mother’s apartment. She had fastened a plastic bag around her head. She left a goodbye note written in shaky handwriting on the card addressed to her mother for her 60th birthday. On this card Elisa also asked for forgiveness from her former partner and Judi Klein.
Just one day after Elisa’s suicide, employees at the Steg cleared out her apartment. Judi’s attempt to counter this failed. Two days after Elisa’s death, her mother was transferred to a nursing home for the elderly, an action which Elisa had fought against for so long.[36]
2.2 UN Special Rapporteur on Torture Juan E. Méndez
With regard to the problems that exist in German psychiatric institutions, reference should be made to the statement made by the UN Special Rapporteur on Torture, Juan E. Méndez, who in 2013 declared compulsory drug treatment without the patient’s consent to be torture under certain circumstances.[37]According to Méndez, such psychiatric forced treatment must be immediately stopped.[38]
Instead of approaching this discourse, Rolf Schmachtenberg, who is responsible for the interests of disabled people in the Federal Ministry of Labour and Social Affairs, stated in the presence of the Federal Commissioner for Disabled Persons, Verena Bentele[39]: “There is no concept of torture in Germany. The Federal Government does not share the view of the Special Rapporteur.”[40]
Such a statement made by a person with major political responsibility is unacceptable for our society. If issues that already have no social reality in the public eye are not even taken seriously by the German Federal Government due to a lack of expertise and the expertise of political leaders, we are far from being a society that aims to be open to everyone, in spite of the reorientation in psychiatric-psychotherapeutic practice, the dedicated commitment of numerous people and the support of various organizations.
Despite legal regulations, improper treatment of patients and the misuse of the responsibilities of on-site nursing and medical staff in psychiatric institutions cannot be ruled out. It is fitting not to disregard the fact that changes in the law in recent years, in particular the basically obligatory appointment of a procedural guardian in connection with commitments under the Psych-KGs[41]of the Federal States (Länder) or of commitments under the German Civil Code (Bürgerliches Gesetzbuch) in connection with the provision of commitments, have led to a strengthening of the rights of the individuals concerned in commitment procedures.[42]Since 2012, the requirements for forced treatment have been anchored in the German Civil Code.[43]Nevertheless, mistreatment and abuse of power in psychiatric institutions cannot be ruled out.
The reasons for improper treatment and possible misuse of responsibility are complex. Excessive demands and stress on the part of the medical personnel can lead to an increased probability of misdiagnosis, as the time required for in-depth examinations is too short for the individual fates of those affected. If there are no other regulatory authorities, a misinterpretation of the treatment may continue and consequently lead to a non-medically indicated administration of drugs, in particular neuroleptics. If this medication has no therapeutic purpose and is administered against the will of the person concerned, the UN Special Rapporteur Méndez states that torture has occurred.
In addition, excessive demands, time pressure and attending to too large a number of patients also lead to an increased probability of indifference and insensitive behavior towards those concerned, which would amount to an abuse of a position of responsibility. The person concerned is subject to the system of psychiatry and the individuals acting within it and their decisions and remains at the mercy of the will of others. It is likely to be virtually impossible for the persons concerned to prove improper treatment at a later time.
3. A plea for clarification
In recent years, the scholarly and public treatment of psychiatry in Ueckermünde has been rather one-sided and limited to the documentary “The Hell of Ueckermünde – Psychiatry in the East”, in which the suffering of people with multiple disabilities is depicted. The hell of Ueckermünde was to remain a warning example for all eternity. Numerous projects to improve psychiatric practice and care have been initiated by the State Association of Social Psychiatry.[44]
After 1993, the premises of the former Christophorus Hospital and today’s AMEOS Clinic were partially redesigned and staff increased or restructured.
Nevertheless, it is well-known that up until the 2000s a questionable complex therapeutic program was in place. This consisted, among other things, of shared accommodation for people with mental and physical disabilities in the socialist prefabricated building Haus 40.[45] For the latter group of people, this dilapidated building still serves today as a dormitory, located across from the Morgenstern preschool, which is in front of or behind the sports field of the prison, depending on the perspective in question. The website of the AMEOS Clinic for Psychiatry and Psychotherapy in Ueckermünde proudly boasts of a 140-year tradition.[46]Critical visitors to the website may well ask themselves what tradition means from the point of view of the clinic?
To this day, the public has not been informed about the whereabouts and further state of health of the people shown in the documentary by Ernst Klee. There is also no detailed information about the professional career of the staff depicted in Klee’s documentary. Many of the patients who received psychiatric treatment at this location during the GDR era and years after the fall of the Iron Curtain, important contemporary witnesses, have not yet been asked about their experiences with the medical staff. Psychiatric abuse of power in this institution as well as in other similar clinics in the former GDR was hardly mentioned in official reports and mainstream media after 1993.[47]
Therefore, even today it is advisable to carry out a precise and transparent examination of the treatment methods at the “closed” clinic at Ueckermünde and in other psychiatric institutions.
To ensure a systematic review of the past, the research work should address patients formerly treated in Ueckermünde with qualitatively and quantitatively oriented survey procedures. Collaboration in an interdisciplinary research group seems to be significant for ensuring a realistic depiction of what really took place. The role and interaction of medical, educational and psychological specialists with patients as well as the relationships between psychiatry in Neubrandenburg and in Ueckermünde must be examined in detail. At this stage, the political role of the physicians working in outpatient clinics in Neubrandenburg, their connections to psychiatry in Ueckermünde and the resulting treatment of their patients, both during the GDR era, after the Reunification and well as today, should be examined in more detail. In addition, the patient’s perspective on the successes and failures of the Psychiatric Clinic in Neubrandenburg, which opened in 1993, the Social Psychiatric Services and other support facilities for the mentally ill should be included. For example, research into the psychosis group founded in 1994, the role of personnel retrained in the urgent procedure for mentally ill individuals, and the possible abuse of power in these positions could be investigated. The processing of cases related to abusive treatment in the psychiatric wards of the former GDR must not be forgotten. It is only in an informed society that people who depend on psychiatric-psychotherapeutic support can feel safe in crisis situations.
Dr. Christian Discher
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5. Author portraits:
Judi Klein
Judi Klein writes about her life in her books. They are the memories of an injured soul whose voice was not heard during her childhood. In the form of poems, memoir and excerpts from medical records, the reader gains insights into the inner life of a woman who was labeled a “schizophrenic” at a young age. The lack of understanding in her environment, a closed, defensive attitude in her family and among the doctors led her down a path she could not leave of her own accord for a long time. Judi Klein willingly confronts the public and binds a readership that wants to look behind the façade of socially excluded people. Today Judi Klein uses writing to try to come to terms with the trauma of the past. Judi Klein and Christian Discher share a deep and long-lasting friendship.
Dr. Christian DischerDuring his stay in the psychiatric ward in Ueckermünde in 1997, the doctors and psychologists stated that Christian Discher had below average intelligence. The medically documented stigma made it impossible for him to return to his old life. As a result of the forced medical treatment, which robbed him of his ability to express himself for one and a half years and severely restricted him physically, he was helplessly at the mercy of the medical staff. After the suffering described in his book “The Voices of Those Remaining”, he turned his back on his old hometown and went to a special clinic in West Germany to overcome the trauma he had experienced. He studied French and English and wrote his doctoral thesis in linguistics with a focus on migration. His studies led him to Paris and Dublin. Now a qualified university lect
[1] Klee (1993:12).
[2] Cf. Walther, Gerd (mayor) http://www.ueckermuende.de/index.html.
[3]Focal points of German psychiatric history on human dignity: Cf. Dieckhöfer (1996).
[4]Bernhardt (1992: 2) quoted n. Klee (1993:11).
[5]Klee (1993:11) reports more than 3000 fatalities, while other sources now estimate 3556. In addition, there were 889 deportations within the framework of the “T4” murder of the sick campaign. Tremper quoted n. http://www.links-lang.de/presse/14287.phpDie Toten Kinder von Ueckermünde (The Dead Children of Ueckermünde).(2014).
[6] Bernhardt (1992: 85ff.) quoted n. Klee (1993:218). “Hans Hefelmann, official of the Führer’s Chancellery who he was responsible for organizing the children murders, recalled in his statement dated November 9, 1960 that the children’s department had been in an institution “in the western part of the lagoon, northwest of Stettin” (Js 148/60, GStA Franfurt/Main).
[7] Cf. Bernhardt (1992: 72) quoted n. Klee (1993:11).
[8]Cf. http://www.links-lang.de/presse/14287.php.
[9]Pictures of cage beds: accessible online at https://www.flickr.com/photos/96964423@N03/14961252944/in/photostream/.
[10]Cf. Klee (1991).
[11]Süß (1999:82).
[12]Süß (1999: 82).
[13]Cf. ibid. (1999:81).
[14]Cf. Klee (1991).
[15]Cf. The Situation of Psychiatry in the Former GDR – Review and Recommendations. Commissioned by the Federal Ministry of Health. (1991:4).
[16]“From the ruling dictatorship of the former GDR with the corresponding awareness of authority the poverty of the patients in the large psychiatric hospitals can also be deduced. This was made possible by a subservient attitude, as well as by the unclear legal situation of the committed. However, ultimately it was also made possible due to the background of general indifference.” Haas (1994:3).
[17]Cf. Süß (1999:73) Rodewisch Theses: accessible online at: http://www.skh-rdewisch.sachsen.de/fileadmin/user_upload/rodewisch/pdf/Publikationen/Rodewischer_Thesen_1963.pdf.
[18] Cf. Klee (1991).
[19] Süß (1999:73).
[20]“In 2011, respondents expressed a stronger desire for social distance from people with schizophrenia than two decades earlier. …[…] In 2011 as in 1990, people with alcohol dependence faced the strongest rejection, followed by people with schizophrenia and those with depression […]”Angermeyer et al. (2013:3).
[21]Discher (2015).
[22]On the Stigmatization and Stereotyping of Mentally Ill People: Cf. Rüsch et. Al (2004).
[23]“Structural discrimination describes the negative consequences for mentally ill people resulting from imbalances and injustices in social structures, political decisions and legal regulations.” Rössler (2004:854).
[24]“Public stigmatization consists of three elements – stereotypes, prejudices, and discrimination – relating to a power gap between members of the general public and the stigmatized minority.” Rüsch et al (2004:5). [Original bold].
[25]Cf. Rüsch et al (2004:5).
[26]Cf. Riggenbach (2009 :134).
[27]“If one sees in humankind nothing but a mixture of social or biological forces, then the concepts of guilt and punishment lose all meaning, as they are meaningless when applied against a machine. Just as a broken computer is not brought to justice and not punished, but repaired, it also becomes “necessary” to repair a person who stops working according to the official program. There are special psychiatric hospitals for exactly this purpose. This conclusion is so inevitable that even an early materialist like Weitling, a forerunner and teacher of Marx, painted the picture of a future society “of freedom and harmony,” in which there would be no more legal proceedings and no more trials, in which rather all those “possessed by wicked passions” would be put into hospitals and the “incurable” would be kept on special island colonies. This is a typical utopia dreamed up by a terrible phantom. How much scarier is the utopia that created real life? In the (still small) model it shows us what awaits us in the not too distant future. A taste of this is given when psychiatrists, obviously in all seriousness, explain to compulsorily admitted “patients” that their religious beliefs or their critical attitudes towards life, their “lack of social adaptation,” as doctors say, are a clear symptom of mental illness. […] Schafarewitsch, Igor (1978) quoted by Weinberger; Dieckhöfer (2015). http://www.psychiatrie-und-ethik.de/wpgepde/.
[28]On the 10 disability policy guidelines: Cf. http://www.berlin.de/imperia/md/content/balichtenberghohenschoenhausen/behinderten/10bpl.pdf?start&ts=1432796667&file=10bpl.pdf. This reflects the concerns formulated in the UN Convention on the Rights of Persons with Disabilities. It elevates the rights of the disabled “to the basis and standard of political action and provides the legal framework.” DIFM (2013:4) “According to the Convention, disabled people should be able to make use of human rights on an equal footing with others.” DIFM (2013: 12).
[29]Israel (2008).
[30]Israel (2008) http://www.psychoanalyse-aktuell.de/321+M54b1f5bf267.0.html?&tx_ttnews.
[31]Cf. Detjen (2007: 200).
[32]Süß also investigated the question of whether there had been systematic political abuse of psychiatric facilities in the former GDR. A report by the Saxon State Ministry for Social Affairs, Health and Family denies this abuse. Cf. quote from Süß (1999: 112) “The German Medical Journal (Deutsche Ärzteblatt), the official publication of the Federal Chamber of Physicians (BÄK) and the National Association of Statutory Health Insurance Physicians (KBV) similarly circulated such information. A similar statement was made by the World Association of Psychiatry in 1999. And similarly, the general public in Germany and internationally was appeased.” Weinberger (2009: 120). The Walter von Baeyer Society for Ethics in Psychiatry reported regularly on cases of political abuse in the psychiatric facilities of the former GDR, which met with little public interest. Cf. Weinberger (2009: 120). To what extent a schizophrenic condition was present before Elisa’s admission to Ueckermünde in 1982, which was frequently described by Elisa as forced treatment with restraining methods in cage beds, and whether this was a case of political abuse, cannot be assessed according to the authors’ findings. This would require a comprehensive investigation.
[33]Elisa told Judi in detail about the constant external influence exerted by the staff at the Steg.
[34]On the Brandenburg Theses: Cf. (1999:75).
[35]According to the authors, the structural discrimination in Neubrandenburg can be proven by the attempted intervention and intrusion of the pedagogical-psychological staff of the social psychiatric service into the private or intimate sphere. The aim was to achieve complete control over the lives of the mentally ill. In order to gain access to the living quarters, a popular means of sanction was to threaten the patient indirectly with “admission” to the hospital. Cf. Discher (2015c: 163). (Chapter Ms. Hässel).
[36]Judi Klein.
[37]“[…], medical treatments of an intrusive and irreversible nature, when lacking a therapeutic purpose or when aimed at correcting or alleviating a disability, may constitute torture or ill-treatment when enforced or administered without the free and informed consent of the person concerned.” Mendez (2013:4).
[38]“States should impose an absolute ban on all forced and non-consensual medical interventions against persons with disabilities, including the non-consensual administration of psychosurgery, electroshock and mind-altering drugs, for both long and short-term application. The obligation to end forced psychiatric interventions based on grounds of disability is of immediate application and scarce financial resources cannot justify postponement of its implementation.” Mendez (2013:5).
[39]“The more than 30-member delegation of the Federal Government was led by Gabriele Lösekrug-Möller, State Secretary of the Federal Ministry of Labour and Social Affairs. In addition, the spokespersons for the disabled, Kerstin Tack (SPD), Uwe Schummer (CDU) and Corinna Rüffer (Bündnis 90/Die Grünen) were present. http://www.diefachverbaende.de/files/fachthemen/2015-03-26-Kurzbeitrag-Genf-Staatenpruefung.pdf
[40]https://www.youtube.com/watch?v=vUkQpwjoh7M.
[41]For public law on commitment in Mecklenburg-Western Pomerania: Cf. §§ 11, 15 PsychKG M-V.
[42]For the commitment under supervision law Cf. § 1906 BGB Approval of the supervision court for the commitment: accessible online at: http://www.gesetze-im-internet.de/bgb/__1906.html.
[43]Klinkhammer (2013).
[44]Model projects of the Landesverband Sozialpsychiatrie can be found at http://www.sozialpsychiatrie-mv.de/PKP/index.html . Model Project Social Psychiatry (1998 – 2001), Model Project Communal Psychiatry (2002 – 2005), Model Project KoDE – Cost Reduction in Integration Assistance (2006 – 2008), Model Project Work and Employment TAB-MV (2008 – 2009), Model Project: “Living Longer in MV” (2009 – 2012).
[45]The treatment of patients in Ueckermünde is described in detail from the perspective of a seventeen-year-old in Discher’s “Die Stimmen der übrigbliebenen” (“The Voices of Those Remaining”) (2015).
[46]Cf. http://www.ameos.eu/1638.html.
[47]Zum Mißbrauch der Seelenheilkunde: Schaden für Einzelne. Gefahr für alle. (On the Abuse of Psychiatry: Harm to Individuals. A Danger to All.) Cf. http://www.psychiatrie-und-ethik.de/wpgepde/wp-content/uploads/2012/01/rb201001.pdf. Cf. Dieckhöher (2009).