What She Left Behind by Ellen Marie Wiseman (Book Review)

Screen Shot 2016-01-12 at 10.53.06 PMWhat She Left Behind

By Ellen Marie Wiseman

This book is composed of two interweaving stories. Clara, a woman who lived in the 1930s was committed to a mental institution against her will based on her wealthy father’s unhappiness about her Italian immigrant boyfriend and her refusal to marry the rich guy that her father picked out for her. The other story is about a current day teenager named Izzy who is a foster child of Peg and Harry after having lived with several previous foster parents since her mother unexplainably murdered her father. Peg is working on a museum project examining newly discovered suitcases of belongings of former patients (including those of Clara) of a now closed psychiatric facility, in order to gain some understanding of their lives. Izzy helps out with this project and finds the diary of Clara and becomes interested in her life.

Being a psychiatrist, I was initially drawn to this book with the idea that I would gain some insight into the lives and treatments of psychiatric patients living in the first half of the twentieth century. This was the case and it included vivid description of the treatment that was done at that time such as ice baths, insulin shock therapy and electroconvulsive therapy (ECT).

Although I never worked in a state hospital, when I toured them in the late 1960s, such treatments except occasional ECT under humane conditions were things of the past. As far as the possibility of someone spending most of their life committed to a mental institution based on the word of her father when she clearly did not have a mental illness, I would like to think that this would not have been possible. Certainly, in modern times from my experience someone being hospitalized against their will would have to go through a legal hearing with the patient being assigned an attorney if they don’t have one. Once in a hospital with treatment with modern-day medicines (which were not really available until the 1950s) most mental illness can be put at least in temporary remission with such treatment. Today, there would be reviews by multiple doctors with no mandate to keep the person in the hospital against their will unless they were a danger to themselves or others due to a mental illness. I would hope that nothing like Clara’s situation could occur today. Obviously, I can’t speak for every state hospital in the United States and certainly things were different in the 1930s.

There was another aspect of Clara’s case was particularly disturbing to me in that the psychiatrist in charge of her care was depicted as a mean, cruel, selfish man who was mainly responsible for Clara’s lost life. I felt it was an unfair indictment, which suggested all psychiatrists of that time might have been of the same cloth. I understand that the author has the creative choice to develop characters in whatever fashion she chooses. I probably would not be complaining if the character were a dishonest lawyer who did unsavory things in the interest of an interesting storyline but nevertheless, I felt that this book was stigmatizing my profession.

There was particular theme of this book, which also had a special interest to me. Three characters in the book were driven to try to understand their early origins. Izzy, understandably could not fathom why her beloved mother murdered her father. This ultimately led her to empathize with a schoolmate who had some parental trauma. It contributed to her mission to find Clara’s daughter who was essentially separated from her at birth, and hand over her mother’s diaries so she could know about her mother’s story. Clara’s daughter led a life of yearning to know what happened to her mother and Clara similarly went through life wanting to know what happened to her daughter. This is a variation of a theme, which I have seen played out in many people’s lives as well as in some interesting movies. Persons, sometimes separated at birth or when they are quite young often yearn to know their biological parent or parents with whom they may have had no relationship for decades. I have reflected on the psychodynamics of these issues in an earlier posting in this blog. Therefore, I was particularly interested to see how they played out as major motivating factors in the characters in this book.

I believe the author Ellen Wiseman has created an intriguing story that will hold the interest of the reader whether or not you come from a psychiatric background.


Nazi Extermination of Mental Illness

IIn 1922 Alfred Hoche a German psychiatrist co-authored a document demanding the extermination of persons he believed were a burden to society. In 1933 Adolph Hitler followed up on this by introducing obligatory sterilization of people with diseases he believed to be inheritable including mental retardation, schizophrenia, affective psychosis, and alcoholism. In July 1939 a plan was developed with the assistance of leading psychiatrists for the extermination of this group of people. Torrey and Yolken in their analysis of the literature believe that the entire population of people with schizophrenia (between 220,000 and 295,000 people) living in Germany at the time were either sterilized or killed. After the invasion of Poland the systematic murders of patients in various psychiatric hospitals were carried out. There are reports of only two psychiatrists who chose to stay with their patients and both perished. This plan to eliminate schizophrenia did not succeed probably because it is not entirely a genetic disease. We should never forget those whose lives were taken during this time and how and why they they were killed.

Year End Reflection on Those Taken From Us

There are certain times of the year such as religious holidays, anniversaries and the New Year where I find myself reflecting on those people who are no longer with us. As we come to a new year and the end of the first decade of the 21st century that is one of those times. As a son, I think about my parents which leads me to remember other relatives and dear friends who have died and whom I miss. As a Jew I think of the Holocaust and the extermination of millions of people who were murdered because they were  born Jewish. I know history is filled with other similar events which have occurred even in the recent past and may approach the evil nature and magnitude of Hitler’s work.

E. Torrey Fuller
E. Torrey Fuller

People with Schizophrenia Also Targeted by Hitler

As as a psychiatrist,  I also find myself  reflecting at these times on the systematic murder by the Nazi’s  of people because they had a mental illness! This addition to my personal memorial list is relatively new to me since I only recently became aware of the details of Hitler’s systematic singling out mental disease,  especially schizophrenia due to recent writing of E. Fuller Torrey, Robert Yolken and others. Yes,  I had  known how the Nazi’s in their attempt at racial purity were targeting other groups in addition to the Jews but I did not appreciate how people with Schizophrenia were being especially chosen. I was originally alerted to this piece of history by an article in Psychiatric News by Mark Moran in November of this year which also referred to an article by Torrey and Yolken in the September 2009 issue of the Schizophrenic Bulletin

Psychiatrist May Have Given  Birth to this Plan

Alfred Hoche
Alfred Hoche

Some further review turned up  additional information which suggested that Hitler’s thought process on this may have had it’s roots in events that occurred in 1922. At this time the psychiatrist Alfred Hoche and the lawyer, Karl Binding, published a document titled “Extermination of Life Unworthy Creatures” , using that ominous term for the first time and demanding extermination of persons who constituted “a burden” to the society, ravaged by World War I. They argued, in this document, that excessive humanitarian ideas be abandoned in the interest of what they called  “the higher state morality” implying that the existence of an individual is worthless if unfitting to the interest of society.  Shortly after Adolf Hitler took power in 1933, an act was passed, translated as Act on Preventing an Inheritable Burdened Progeny” The act introduced the obligatory sterilization of persons suffering from inheritable diseases, including, among others, mental retardation, schizophrenia, affective psychoses, epilepsy, and alcoholism. Implementation of the act, associated with the sterilization of approximately 350,000 persons in Germany, induced a wide discussion during which only the Catholic Church expressed a negative attitude toward the act.

Physicians Including Psychiatrists Participate in Extermination Plan

The next stage was the elimination of these people as well as the Jews. The approach to the Jews is well documented. However how Hitler utilized physicians including psychiatrists to approach the eliminations of psychiatric patients was not as well understood at least by myself. In July of 1939, an agreement between Hitler, the Reich Chancellory head, Lammers and the leader of the Reich’s physicians, Dr. Leonardo Conti, resulted in the formation of a strictly secret commission for the extermination of patients, directed by Philip BouhIer and called T4 (according to its official address at Tiergartenstrasse 4, in Berlin). The commission included, among others, recognized professors of psychiatry and neurology: Carl Schneider from Heidelberg, Paul Nitsche from Halle, Werner Heyde from Wurzburg. The commission was to choose methods of extermination (at the beginning carbon monoxide was used) and provide opinions on the lists of patients submitted for extermination by psychiatric hospitals, using official questionnaires. This occurred two months before the invasion of Poland. Apparently gold fillings were removied from the teeth of the deceased and used to partially pay for this program. Torrey and Yolken in their analysis of the data estimate that between 220,000 and 295,000 people with schizophrenia were either sterilized or killed which according to them represented all of those people with schizophrenia living in Germany at the time.

Extermination Plan Continued After the Invasion of Poland

After attacking Poland in September, 1939, the Germans began in the very same month a systematic murder of patients in Polish psychiatric hospitals that were situated in the captured parts of the country. The action of murdering these patients  took a similar course in all psychiatric hospitals.HItler The schedule was typical of Nazi mass crimes, followed a specific plan, and was performed scrupulously. After taking control of a hospital under a German director, no patient could be released from the hospital under threat of the death penalty. All the patients were counted and transported out in lorries to an unknown destination. Each transport was accompanied by armed soldiers from special SS detachments, who returned without the patients after a few hours. The patients were said to be transferred to another hospital, but circumstances showed that they had been killed.

In October, 1939, approximately 1,000 patients (children and adults) of the psychiatric hospital in Owinska, near Poznan, began to be transported out in an unknown direction. At the same time, a chapel and a rich, 100-year old medical library were destroyed. The hospital was turned into SS barracks and burned at the end of war. Extermination of patients from the hospital in Owinska requires special attention since on that occasion for the first time new methods for the mass killing of people were implemented. Investigations conducted after the war by the Commission for Examination of Nazi Crimes demonstrated that the special Gestapo unit  took care of the patient evacuation. The patients, dressed only in worn clothes, were transported out in lorries, each lorry accommodating 25 patients and some armed SS men. Distressed and protesting patients were quieted with injections of narcotics. According to witnesses, the lorries drove first toward Poznan where the patients were crowded into an old fort.  Each of the bunkers accommodated approximately 50 persons. The gates were sealed up with clay, and carbon monoxide was fed into each bunker, killing the patients within 10-20 minutes. Corpses of the murdered patients were dragged out by a group of prisoners of the fort, and other prisoners transported them and buried them in a forest close to Oborniki.

On December 7, 1939, approximately 1,200 patients were transported out of the neighboring psychiatric hospital in Dziekanka, near Gniezno. Selection of the patients for the transport was made personally by the hospital director, Ratka, who had just changed his citizenship to German and put on an SA uniform. Later on, the hospital kept providing psychiatric services for patients of German nationality and also served other, peculiar aims. On orders from Berlin, the hospital was disguised to represent a place of burial of the exterminated patients even if most of them had never visited the hospital. Families of the patients were falsely informed that the patients being searched for were buried at the hospital cemetery, and the families were even charged for the care for these graves. After the war, it was found that the psychiatric hospital in Pruszkow near Warsaw played a similar role. Families of the murdered patients were referred to the hospital and told that their relatives had been brought to the hospital, but died natural causes.

The sanatorium in Koscian for neurological and psychiatric patients lost approximately, 500 patients who were murdered and the institution then appropriated for other purposes. Patients in psychiatric hospitals in Warta (approximately 580 patients), Gostynin (approximately 100 patients), and Choroszcz (564 patients) were shot in the neighboring forests while patients of Kochanowka hospital (approximately 540 patients), Nazi loading on trainnear Lodz were killed in the sealed lorries using engine exhaust. In the psychiatric hospital of Lubliniec, 194 children were killed with high doses of luminal. The existence of the psychiatric hospital in Kobierzyn, near Cracow ended on June 23, 1942. The hospital was surrounded by soldiers in helmets and SS uniforms, the patients were loaded into lorries and cattle trucks, and the patients were transported to Auschwitz to gas chambers. Severely ill patients were transported to the hospital cemetery and shot there. A total of 566 patients died in that action.

The above data that originated from individual hospitals do not unfor­tunately create a complete image of the extermination of patients. It is difficult to estimate, e.g., how many of the psychiatric patients in the hospitals died due to drastically lowered food rations. Systematic starvation increased the mortality of patients several fold. It should be mentioned that this statistic does not pertain to patients of German origin who were fed better. The numbers of known victims also fail to include crimes which have not been documented. At the end of the war, the Nazi authorities destroyed evidence of their own crimes, as they pulled back from the captured territories. In most cases, extermination of patients was executed with no preliminary formalities (in the Reich it was preceded by filling in of questionnaires) and unexpectedly. The data quoted above originated from hospital registers that escaped destruction or from secretly prepared lists of those patients who were transported out of the hospitals.

Most Psychiatrists Don’t Protest but Two Psychiatrists Chose to Stay with Their Patients

I apologize for somewhat wordy unpleasant detail of this blog but I felt the story had to retold. My source for much of the above detail which I have shortened comes from the previously mentioned reference  Project Inposterum.

Torrey made the  point of emphasizing how while psychiatrists played a leading role in these horrendous events, he is not aware of any protests against the policy from organized German psychiatry. He notes “if you wanted a bright future in Nazi Germany you would not be enhancing your prospects by saying “we shouldn’t be doing this.” However the above link  gives two instances in Poland where psychiatrists chose the path of staying with their patients. Dr. Józef Bednarz, (see date of 1932 in this link ) Director of the Psychiatric Hospital  in Swiecie in Wisla, who rejected the chance to escape, did not want to leave his patients, and was shot with them in November of 1939.

Grave of Dr. Halina Jankowska
Grave of Dr. Halina Jankowska

Dr. Halina Jankowska, the eminent psychiatrist, and her nurses on  August 23, 1944, during the Warsaw Uprising rejected the chance to leave their patients in the Hospital of Saint John of God and died with them in the ruins of the bombed hospital

How Did This  Extermination Effect the Future of Schizophrenia ?

Torrey and Yolken also make the point that the Nazi reasoning  for killing patients with schizophrenia was also founded on an erroneous notion that the disease was entirely genetic. In fact the number of existing cases or the prevalence of the disease after the war was low as expected, because of the killings.  However the incidence or number of new cases was high suggesting that factors other than genes played an important role in schizophrenia. Studies have  found that the incidence rate in Germany 20 years after the last patient was sterilized or killed were 2 to 3 times the rates in the US and England . It was postulated that the most likely explanation is that social conditions after the war produced environmental factor such as famine, illnesses  and poverty which led to an increase in new cases of schizophrenia

Of course what ever we can glean from the results of this horrible “experiment “ will never provide any justification for what was done. I do that believe that we are obligated to use  any data that emerges from this event to better help people in the future just as we can use the data from other unspeakable Nazi experiments on helpless victims  to make people’s lives better in the future. In doing so we need to never  forget those whose lives were taken including  why  and how they were killed.

May This Be A Good Year for All of You

While I chose to write the last blog of the year on a somber topic, I do want to also end with an optimistic greeting to all of you.  I appreciate the interest and encouragement that many of you have given me as I have undertaken this weekly blog . I know that there are many people who share my interest and concern about educating the public about all aspects of  mental illness.

I wish everyone of you a most Happy New Year.

Comments Are Always Welcome