Vienna was the world capital of psychoanalysis in the early 1900s, stimulating a burgeoning interest in the mind. Yet, these intellectual movements would be supplanted by state-sponsored repression after Nazi Germany's annexation of Austria in 1938 (the Anschluss). Vienna's Steinhof Hospital for psychiatric patients encapsulated these conflicting paradigms, providing a venue first for enlightened aspirations and subsequently for physician-assisted atrocities. As Vienna hosts the 2023 World Congress of Psychiatry, we wish to highlight Steinhof's poignant legacy, which should serve to reinforce the importance of compassion and human rights in contemporary care.

Founded in 1907, Steinhof represented psychiatric ideals circulating around fin de siècle Vienna and beyond.^{Reference Topp1} The hospital was predicated on modernist plans following consultations between the architect Otto Wagner (1841–1918) and other stakeholders.^{Reference Topp1} Wagner's schemes promoted symbiotic connections between mental health and architecture, challenging conventional prison-like settings; notably, only 50 years before Steinhof's foundation, patients were routinely held in chains in Vienna's Narrenturm (mad tower).^{Reference Glass2}

Wagner sought to create conducive therapeutic environments by combining functionality with aesthetics. To that end, Steinhof's pavilions comprised light, open spaces, supplemented by an Art Nouveau style that even extended to the window bars.^{Reference Glass2} Steinhof's location atop hills overlooking Vienna was intended to promote well-being and healing, as were its formal gardens.^{Reference Glass2,Reference Regal and Nanut3} Further, the complex contained a theatre and a church specifically designed for psychiatric patients; today, the latter remains as a striking example of Catholic Art Nouveau. In the ensuing years, Steinhof received acclaim from visiting physicians for these progressive features.^{Reference Topp1}

However, post-Anschluss, Steinhof was implicated in the Nazi's T4 programme, a campaign of involuntary euthanasia for individuals with mental and physical disabilities (lebensunwertes Leben – ‘life unworthy of life’). This resulted in the transportation of approximately 3000 Steinhof patients to killing centres in 1940. Thereafter, Steinhof housed children with mental health disorders in an institution named Am Spiegelgrund.^{Reference Glass2} Here, psychiatrists would provide evaluations involving measures of physical and mental health and socioeconomic factors, somewhat prefiguring the comprehensive nature of contemporary functional capacity assessments. During this process, those children considered to be lebensunwertes Leben per Nazi ideology were euthanised.^{Reference Neugebauer and Stacher5}

Harrowingly, over 750 child patients were murdered in Am Spiegelgrund. Others suffered fatal consequences from inhumane experimental procedures, including pneumoencephalographies, electroshock therapy and forced overdoses.^{Reference Thomas, Beres and Shevell4,Reference Neugebauer and Stacher5} Death certificates were fabricated, and families would be requested to pay for their child's ‘care’.^{Reference Thomas, Beres and Shevell4} Nazi defeat saw Am Spiegelgrund's closure and punitive measures enacted for several psychiatrists complicit in the atrocities.^{Reference Neugebauer and Stacher5} Yet, according to Neugebauer and Stacher, one of Am Spiegelgrund's directors, Heinrich Gross (1915–2005), continued to study victims’ brains long after this, even obtaining funding grants.^{Reference Neugebauer and Stacher5} Equally, many psychiatrists who conducted assessments would also continue practising post-war. Only in the 21st century were the children's remains buried and a memorial established (Fig. 1).

Fig. 1 Art Nouveau theatre and Spiegelgrund memorial. 2007. Muesse. Reproduced under a CC-BY license.

In modern contexts, we encourage psychiatrists and others to visit Steinhof and consider how a symbol of progressive approaches became a venue for physician-assisted abuses; given global authoritarian trends, such reflections may be increasingly resonant. For us, Steinhof's dual legacy offers a timely reminder of lessons from psychiatric history, reinforcing the necessity of professional and ethical principles underpinned by morality, dignity and human rights.