Atlas›Domain XVI · Historical, discredited & harmful›Guide 060
Guide XVI-060

Nazi euthanasia (Aktion T4)

Philipp Bouhler, Karl Brandt1939Germany (Berlin)
A 31 · L 51 · M 1824 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the history follows the United States Holocaust Memorial Museum (USHMM) Holocaust Encyclopedia article on the Nazi "euthanasia" programme (English edition, last edited 17 March 2026), the USHMM and Harvard Law School Nuremberg Trials Project accounts of the Doctors' Trial, the USHMM account of the 1945 Hadamar trial, and the German psychiatric association's (DGPPN) 2010 statement. The clinical work in sections 2 to 5 is the psychotherapist's own and is marked [synthesis] where it is general practice.

This is not a therapy. It was a secret state programme of murder. Under National Socialism, doctors, nurses and administrators selected and killed disabled children and adults in institutions in Germany, Austria and occupied territories from 1939 to 1945. The word "euthanasia" was used as a euphemism; the victims were described as "life unworthy of life" and as a hereditary and financial burden [source: USHMM, Nazi "Euthanasia" Program]. The centralised operation, code-named Aktion T4 after its Berlin office at Tiergartenstraße 4, killed people in six centres from January 1940 to August 1941; killing continued in decentralised form in hospitals and institutions until the end of the war. Historians estimate about 250,000 people were killed in all phases [source: USHMM]. The DGPPN states that the overwhelming majority of German psychiatrists in its predecessor organisations took part in or lent scientific legitimacy to forced sterilisation and murder [source: DGPPN, Schneider speech 2010].

The psychotherapist meets this history in descendants of the murdered, in families with silenced or falsified stories of a relative who "died in an institution", in disabled clients and clients with psychiatric diagnoses for whom it shapes trust in care, in descendants of staff and bystanders, and in the profession's own history. Change in this work, as understood here, comes through acknowledgement, restoring a murdered person's place in the family's history, bringing silence and shame into speech at a pace the client sets, and turning private grief into remembrance [synthesis; the themes of shame, taboo and intergenerational trauma are named in Posey 2013, publisher description].

2. Framework

Historical phases (outline, for orientation)

  • 1933 onward: forced sterilisation. The DGPPN states that more than 360,000 people were forcibly sterilised under the 1933 law and more than 6,000 died as a result [source: DGPPN 2010].
  • 1939: the children's programme. Planning began in spring and summer 1939 under Philipp Bouhler (head of Hitler's Private Chancellery) and Karl Brandt (Hitler's personal physician). A Reich Interior Ministry decree of 18 August 1939 required doctors, nurses and midwives to report newborns and young children with signs of severe disability. From October 1939 parents were pressured to place children in special "children's wards" that were in fact killing sites; the age range was later extended to 17. USHMM gives a conservative estimate of at least 10,000 children killed [source: USHMM].
  • Autumn 1939: authorisation. Hitler signed a secret authorisation, backdated to 1 September 1939, to protect participants from prosecution [source: USHMM].
  • January 1940 to August 1941: Aktion T4. Registration forms disguised as statistical surveys were sent to hospitals, psychiatric institutions and care homes; panels of three medical assessors, many of them well regarded, decided on the basis of the forms who would be killed. People were transported to six killing centres: Brandenburg an der Havel, Grafeneck, Bernburg, Sonnenstein (Pirna), Hartheim near Linz, and Hadamar. Families were sent urns and falsified death certificates. T4's own internal count was 70,273 people killed in the six centres between January 1940 and August 1941 [source: USHMM].
  • August 1941: public protest and the halt. The killings became an "open secret". Bishop Clemens August Graf von Galen of Münster denounced them in a sermon on 3 August 1941; in late August 1941 Hitler ordered the centralised operation stopped [source: USHMM].
  • 1941 to 1945: decentralised killing. The children's programme continued, and from August 1942 killing resumed in hospitals and institutions under local direction, by lethal medication and deliberate starvation, extending to older patients, people injured in bombing, and foreign forced labourers [source: USHMM]. In Pomerania, West Prussia and occupied Poland, SS and police units killed about 30,000 patients by autumn 1941; in occupied Soviet territories patients were murdered by SS and auxiliary police [source: USHMM].
  • Link to the Holocaust. USHMM describes the programme as a "dress rehearsal" for genocide: the ideology was extended to Jews and Roma, T4 killing technology was later used against Jews, and T4 personnel were assigned to the Operation Reinhard camps at Bełżec, Sobibór and Treblinka [source: USHMM; see also Friedlander 1995].
  • 1945 to 1947: trials. The Hadamar trial before a US military commission (8 to 15 October 1945) concerned the killing of 476 Soviet and Polish forced labourers; a German court in Frankfurt tried 25 Hadamar staff in early 1947 for the deaths of about 15,000 German patients [source: USHMM, The Hadamar Trial]. In the Doctors' Trial (United States v. Karl Brandt et al.; indictment 25 October 1946, judgment 19 August 1947, sentences 20 August 1947), "euthanasia" was one charge [source: Harvard Law School Nuremberg Trials Project].
  • After the war: silence and late recognition. The DGPPN describes collective denial, a leading T4 figure working under a false name as a court expert in the 1950s, exclusion of the forcibly sterilised and of "euthanasia" victims' families from the federal compensation law (BEG), and the sterilisation law not formally outlawed until 2007. The DGPPN apologised in November 2010 [source: DGPPN 2010]. The Bundestag decided in November 2011 to create a memorial at Tiergartenstraße 4, opened on 2 September 2014 [source: Stiftung Denkmal]. On 29 January 2025 the Bundestag unanimously recognised people with disabilities and mental illness murdered under National Socialism, and victims of forced sterilisation, as victims of the Nazi regime [source: Jüdische Allgemeine, 30 January 2025].

Phases of the psychotherapist's work [synthesis]

Session number and length follow the client's needs and the setting; the phases below are a working structure, not a protocol [synthesis].

  1. Recognition and assessment. Goal: notice when this history is part of the presenting problem (a relative who "died in an institution" between 1939 and 1945, family silence, fear of hereditary illness, distrust of psychiatry), and assess current distress, risk and supports. Move on when the client has named what they want from the work and current safety is adequate.
  2. Safety, stabilisation and pacing. Goal: build capacity to approach painful material without overwhelm, and agree how history will be brought in (who reads records, when, with what support). Move on when the client can approach and step back from the material in session.
  3. Historical inquiry and documentation (client-led, optional). Goal: support the client, if they wish, in finding records through the Bundesarchiv and memorial sites, and in understanding what records can and cannot show. Move on when the client has the information they wanted or has decided to stop.
  4. Processing, grief and meaning. Goal: grieve a death that was hidden or falsified, work with shame, anger and inherited silence, and place the murdered relative back in the family story.
  5. Memory, commemoration and advocacy. Goal: support private and public remembrance and any advocacy the client chooses, including contact with memorial sites and victims' associations.
  6. Follow-up. Goal: plan for anniversaries, new archival findings and family events that may re-open the material.

3. Guiding principles

  • This was murder, not medicine. Use the sources' language: "euthanasia" is a euphemism for killing [source: USHMM]. Practical meaning: put "euthanasia" in quotation marks and do not let the euphemism soften the account.
  • The murdered were people, not categories. Practical meaning: use the relative's name and life story when the client offers it; do not reduce them to a diagnosis.
  • The client sets the pace of historical inquiry. Practical meaning: never push a client to request records or visit a memorial; offer, explain, and let them choose [synthesis].
  • No graphic detail. Practical meaning: describe what happened factually and briefly; do not read out or show graphic accounts; let the client decide how much they want to know [synthesis].
  • The profession's own history is part of the room. Psychiatrists selected and killed patients [source: DGPPN 2010]. Practical meaning: be ready for mistrust of mental-health professionals and treat it as understandable, not as resistance [synthesis].
  • Acknowledgement before interpretation. Practical meaning: name the injustice plainly before exploring the client's inner responses [synthesis].
  • Records can be false. Families received falsified death certificates with invented causes and dates of death [source: USHMM]. Practical meaning: prepare clients for documents that lie, and for gaps where files were destroyed [source: Bundesarchiv].
  • Disability is not the problem; devaluation was. Practical meaning: work from a disability-affirming stance and watch for, and gently name, internalised ideas that disabled lives are worth less [synthesis].
  • Heredity fears need medical, not therapeutic, answers. Practical meaning: where a client fears an inherited condition, explore the fear and route factual questions to a physician or genetic counsellor; never give medical advice [synthesis].
  • Even-handedness on present-day debates. Practical meaning: keep the historical facts clear without taking a side on contemporary end-of-life legislation; the DGPPN's commitment is to guard against ideology and value judgements in medical-ethics debates [source: DGPPN 2010; synthesis].
  • Descendants of perpetrators and bystanders also need help. Practical meaning: hold their shame and conflict without collusion or condemnation [synthesis].
  • Remembrance can be healing work. Practical meaning: treat commemoration, biography and contact with memorial sites as legitimate therapeutic goals if the client wants them [synthesis; Hadamar memorial invites relatives' documents and photos, source: Gedenkstätte Hadamar].
  • Avoid moralising. Practical meaning: let the facts carry the weight; do not preach [synthesis].
  • Multiple roles need care. Practical meaning: if you are asked to act as the family's researcher, memorial volunteer or spokesperson as well as therapist, consider APA Ethics Code Standard 3.05 (Multiple Relationships) [source: APA Ethics Code, https://www.apa.org/ethics/code].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis].

4.1 Building the therapist's own historical literacy

  • Purpose / when: Before working with a family affected by this history, or when it first comes up. Clients should not have to teach their therapist the basics.
  • Steps: (1) Read the USHMM encyclopedia article and the DGPPN 2010 statement. (2) Learn the outline: the 1939 children's programme, T4 from January 1940 to August 1941, the six centres, the August 1941 halt, decentralised killing to 1945, and postwar trials and silence [source: USHMM; DGPPN 2010]. (3) Learn what archives hold (section 4.7). (4) Note your own reactions, including any family connection to this history, and take them to supervision.
  • Example language (illustrative): "I know the outline of what happened, and I'll be honest when I don't know a detail. We can find out together if that helps."
  • Watch for: Over-reliance on memory or popular accounts; using graphic detail to show knowledge; your own distress. Working: you can follow the client's references without needing them explained, and you correct no one unprompted.

4.2 Recognising when the history is present

  • Purpose / when: At intake and throughout. The history often appears indirectly.
  • Steps: (1) Listen for cues: a grandparent, great-aunt or uncle who "died in an asylum" or "of pneumonia" in an institution between 1939 and 1945, especially in Germany, Austria or annexed and occupied territories; a death certificate with a vague cause; a family that never spoke of a relative; fear of hereditary illness; strong distrust of psychiatry; relatives who were forcibly sterilised. (2) Note these cues without jumping to conclusions. (3) Ask open questions (4.3). (4) Hold the possibility lightly until the client or the records confirm it [synthesis; pattern of falsified certificates, source: USHMM].
  • Example language (illustrative): "You mentioned your great-uncle died in a hospital during the war and no one talks about him. Would you like to tell me what you know?"
  • Watch for: Imposing the history on a family that has no such link; missing it because it is framed as an ordinary death. Working: the client feels the topic is speakable here.

4.3 Assessment of family history and its present effects

  • Purpose / when: Once the history is named, to understand what it means for this client now.
  • Steps: (1) Ask what the client knows, how they learned it, and what remains unknown. (2) Ask how the family talked, or did not talk, about the relative. (3) Explore present effects: grief, shame, anger, fear of illness or of psychiatry, effects on relationships or decisions about having children. (4) Assess current mental state, functioning and supports. (5) Screen for suicidal thoughts as part of routine risk assessment (4.21). (6) Ask what the client wants from therapy regarding this history: understanding, records, grief, family repair, remembrance, or none of these [synthesis].
  • Example language (illustrative): "What would you like to be different, if anything, about how this history sits with you and your family?"
  • Watch for: Assuming the history is the main problem when the client came for something else. Working: a shared, client-owned goal.

4.4 Mapping the family with the gap visible

  • Purpose / when: To make silence and absence visible and discussable, when the client wants a structured picture of the family.
  • Steps: (1) Draw a family map (genogram) with the client. (2) Mark the murdered relative clearly as a person, with a name if known. (3) Mark who knew, who kept silent, and who was told what. (4) Mark other affected people (for example, a forcibly sterilised relative). (5) Reflect on patterns: secrets, shame, roles [synthesis].
  • Example language (illustrative): "Let's put her on the map, here, where she belongs. What do you notice when you see her there?"
  • Watch for: Overwhelm when the absence becomes visible; pace and pause. Working: the client speaks about the relative more freely.

4.5 Factual, non-graphic psychoeducation

  • Purpose / when: When the client wants to understand what happened, or holds inaccurate beliefs (for example, that the relative's death was natural, or that only a few people were killed).
  • Steps: (1) Ask what the client already knows and wants to know. (2) Give a brief outline in plain terms: a secret state programme; selection by doctors from registration forms; transport to killing centres or killing in institutions; falsified death notices; at least 70,273 killed in the centralised phase and about 250,000 in all phases [source: USHMM]. (3) Leave out graphic detail; offer reputable reading (USHMM, memorial sites) for those who want more. (4) Check understanding and feelings after each piece [synthesis].
  • Example language (illustrative): "From what historians have documented, families were often sent a death notice with an invented cause and date. So the certificate you have may not be accurate."
  • Watch for: Shock, dissociation or flooding; information given faster than the client can take it in. Working: the client can hold the facts and their feelings together.

4.6 Stabilisation and pacing before and during historical inquiry

  • Purpose / when: Before the client requests records, reads files or visits a memorial, and whenever material overwhelms.
  • Steps: (1) Agree signs of overwhelm and a way to pause. (2) Practise grounding and self-soothing strategies the client already finds helpful. (3) Plan who will be with the client when records arrive, and when they will read them (for example, not alone late at night). (4) Agree that the client may bring documents to session to read together. (5) Schedule follow-up after any planned exposure to the material [synthesis].
  • Example language (illustrative): "When the archive replies, would you rather open it with someone you trust, or bring it here unopened so we can look at it together?"
  • Watch for: Avoidance that keeps the client stuck versus avoidance that is wise pacing; let the client lead. Working: the client approaches the material and recovers afterwards.

4.7 Supporting archival research

  • Purpose / when: When a client wants to find out what happened to a relative.
  • Steps: (1) Explain what exists: the Bundesarchiv holds about 30,000 patient files from the centralised phase in record group R 179; about 40,000 further files are considered destroyed; names, dates of birth and last institution are indexed online in the invenio system; access is allowed for research and for next of kin with a legitimate interest [source: Bundesarchiv]. (2) Explain that these files do not record the final days or dates of death; the memorials at the six former killing centres hold death lists and are the contacts for that [source: Bundesarchiv]. (3) Mention that some memorials, such as Hadamar, search their own databases for relatives free of charge, subject to data protection, and offer meetings with staff [source: Gedenkstätte Hadamar]. (4) Help the client decide whether, when and how to inquire; the client makes the request. (5) Prepare them for no result, partial results, or distressing results (4.6) [synthesis].
  • Example language (illustrative): "The federal archive holds some of the files and the memorial sites hold others. Whether you look, and when, is up to you."
  • Watch for: Raising hopes of a full file; the client feeling they have failed the relative if nothing is found. Working: the client feels in charge of the search and its pace.

4.8 Preparing for and debriefing memorial visits and meetings

  • Purpose / when: When a client plans to visit a memorial site (one of the six centres, the Tiergartenstraße 4 memorial in Berlin) or meet memorial staff.
  • Steps: (1) Explore hopes and fears. (2) Plan support, timing and an exit plan. (3) Suggest bringing documents and photos if they wish; Hadamar notes this helps link a face and life story to a name, and accepts originals or copies for preservation [source: Gedenkstätte Hadamar]. (4) After the visit, review what happened, what was learned and what was felt [synthesis].
  • Example language (illustrative): "What are you hoping to find there, and what are you afraid of finding?"
  • Watch for: Grief that arrives days later; anniversary reactions. Working: the visit is experienced as an act of remembrance, not only as distress.

4.9 Working with ambiguous, disenfranchised and delayed grief

  • Purpose / when: When the client grieves a relative whose death was hidden, falsified or never mourned, sometimes generations later.
  • Steps: (1) Acknowledge that this grief was denied a place, by the state's deception and often by the family's silence [synthesis; deception, source: USHMM]. (2) Invite the client to tell what they know of the person's life, not only the death. (3) Explore grief for what was lost to the family: the person, the truth, and later the family's ability to speak. (4) Consider symbolic acts the client chooses: a letter, a ritual, marking a grave or a date [synthesis]. (5) Where faith is part of the grief, explore it with cultural humility; the DSM-5-TR category "Religious or Spiritual Problem" (Z65.8) may apply where the difficulty centres on faith ICD-10-CM Z65.8 (Unbound Medicine); the DSM-5-TR wording is [uncertain].
  • Example language (illustrative): "She was never properly mourned. It makes sense that the grief is arriving now, with you."
  • Watch for: The client feeling they have no right to grieve someone they never met. Working: grief moves, and the relative becomes a person in the client's mind.

4.10 Working with shame, stigma and inherited silence

  • Purpose / when: When shame about the relative's illness or disability, or about the family's silence, is present. The publisher's description of a study of descendants names shame, anger and taboo as themes and describes the history as intergenerational trauma [source: Posey 2013, publisher description].
  • Steps: (1) Name shame as a common response to a history in which victims were labelled "unworthy of life" [synthesis; label, source: USHMM]. (2) Separate the relative's condition from the crime done to them. (3) Explore where the silence came from: fear, stigma, the absence of recognition (families of "euthanasia" victims were long excluded from compensation, per the DGPPN). (4) Explore what the client wants to do with the silence now [synthesis].
  • Example language (illustrative): "The shame belonged to those who did this, not to her and not to your family. But I can see how it got passed down."
  • Watch for: Moralising the family's silence; rushing to resolve shame. Working: the client can speak of the relative without lowering their voice.

4.11 Breaking family silence: family conversations

  • Purpose / when: When a client wants to talk with relatives about the history, or a family requests joint sessions.
  • Steps: (1) Clarify the client's goal and the likely responses of others. (2) Rehearse opening the topic. (3) In joint sessions, agree ground rules and each person's right to pause. (4) Allow differences in readiness; not everyone has to know or speak. (5) Where children are present, adapt to age and obtain their assent as well as parental consent (4.20) [synthesis].
  • Example language (illustrative): "You might start with something like: I found out something about Great-aunt's death, and I'd like to tell you if you want to hear it."
  • Watch for: Conflict, blame, or a relative who insists the death was natural. Working: the topic becomes speakable, even if views differ.

4.12 Fears about heredity and illness

  • Purpose / when: When a client fears that a relative's diagnosis will "come out" in them or their children, or carries the programme's idea of a "hereditary burden".
  • Steps: (1) Name the history of this idea: the programme presented victims as a genetic burden [source: USHMM]. (2) Explore the fear and its effects (for example, on decisions about children). (3) Do not give medical or genetic information; route factual questions to a physician or genetic counsellor. (4) Help the client separate a real health question from the inherited devaluation [synthesis].
  • Example language (illustrative): "That's a medical question a genetic counsellor can answer properly. Here, can we look at what this fear has been doing to you?"
  • Watch for: Giving reassurance you cannot back; reinforcing stigma. Working: the client's decisions are their own, not driven by the inherited idea.

4.13 Working with descendants of perpetrators, staff and bystanders

  • Purpose / when: When a client discovers or suspects that a relative worked in the programme (as an assessor, physician, nurse, administrator or driver) or knew of it.
  • Steps: (1) Acknowledge the weight of the discovery without condemnation or excuse. (2) Separate the client's responsibility (none for the past) from their choices now. (3) Explore conflicting feelings: love, horror, shame, anger, loyalty. (4) Support any wish to research, acknowledge or make amends, for example contact with a memorial site, at the client's pace. (5) Be alert to secondary splitting in the family [synthesis]. Context: the Hadamar trials show that nurses and administrators as well as physicians were tried [source: USHMM, The Hadamar Trial].
  • Example language (illustrative): "You can love your grandfather and also be horrified by what he took part in. Both can be true."
  • Watch for: Collapse into guilt; minimising ("he had no choice"); the therapist's own judgement leaking in. Working: the client can hold the facts without self-condemnation.

4.14 Disabled clients and disability history

  • Purpose / when: When a disabled client learns about or is affected by this history, or when present-day devaluation of disabled lives echoes it.
  • Steps: (1) Ask what the history means to the client. (2) Name the programme's core idea, that some lives were "unworthy of life" [source: USHMM], as the injustice. (3) Explore present-day experiences of ableism and how the history colours them. (4) Offer links to disability-led organisations and to memorial education, if wanted. (5) Ensure your own practice is accessible [synthesis].
  • Example language (illustrative): "Hearing about this history can make today's comments about disabled people land much harder. Has that happened for you?"
  • Watch for: Treating the client as a symbol rather than a person; over-identification by the therapist. Working: the client feels respected and less alone with the meaning of the history.

4.15 Clients with psychiatric diagnoses: trust in care

  • Purpose / when: When a client in psychiatric care, or with a family history of institutionalisation, is frightened of hospitals, diagnoses or professionals because of this history.
  • Steps: (1) Acknowledge that psychiatrists selected and killed patients [source: DGPPN 2010]. (2) Explore what the client fears and what they need to feel safe. (3) Explain current rights and consent procedures in plain language where you know them, and encourage questions to the treating team. (4) Never advise starting, stopping or changing a medicine; refer questions to the prescriber. (5) Support the client to bring a trusted person to appointments [synthesis].
  • Example language (illustrative): "Your fear has real roots. Let's think about what would help you feel safer with your care team, and what questions you'd like to ask them."
  • Watch for: Defending the profession; dismissing fears as symptoms. Working: the client engages with care on more informed, safer terms.

4.16 Links with the Holocaust and other targeted groups

  • Purpose / when: When the client's family history also involves Jewish, Roma, Polish or Soviet victims, or forced labourers, or when the client wants to understand how the programme connects to the Holocaust.
  • Steps: (1) Offer the historical link as USHMM states it: the programme as a "dress rehearsal", extension of the ideology to Jews and Roma, and T4 personnel later assigned to Operation Reinhard camps [source: USHMM; Friedlander 1995]. (2) Explore how layered persecution shaped the family. (3) Respect differing community memories and avoid ranking suffering [synthesis]. Note: the 1945 Hadamar trial concerned 476 Soviet and Polish forced labourers [source: USHMM].
  • Example language (illustrative): "Your family was hit by more than one strand of the same machinery. Where would you like to start?"
  • Watch for: Competitive suffering in families or communities. Working: the client has a coherent account that holds all the strands.

4.17 Remembrance, biography and commemoration

  • Purpose / when: When the client wants to honour the relative privately or publicly.
  • Steps: (1) Explore what remembrance would mean to the client. (2) Options include writing a short life story, gathering photos and documents, sharing them with a memorial site [source: Gedenkstätte Hadamar], visiting the Tiergartenstraße 4 memorial, whose guiding idea is "Remembering means commemorating and informing" [source: Stiftung Denkmal], or marking a date. (3) Support the client to decide whom to involve. (4) Review afterwards [synthesis].
  • Example language (illustrative): "What would you want people to know about him, apart from how he died?"
  • Watch for: Remembrance used to avoid grief; pressure from relatives. Working: the client feels the relative has been given back a place.

4.18 Creative and expressive approaches

  • Purpose / when: When words are hard, or the client already uses art. A study of descendants used art making throughout [source: Posey 2013, publisher description].
  • Steps: (1) Offer, do not require, drawing, writing, collage or other media. (2) Keep the focus on the client's own expression, not on depicting violence. (3) Reflect together on what emerges. (4) Store work safely and respect the client's wishes about it [synthesis].
  • Example language (illustrative): "If it's easier, you could show me what this feels like on paper rather than in words."
  • Watch for: Graphic imagery that retraumatises; performance pressure. Working: new feeling or meaning becomes available.

4.19 The profession's own history: reflective practice and teaching

  • Purpose / when: For the therapist's own development, team training, and when clients raise the profession's role.
  • Steps: (1) Study the DGPPN 2010 statement: psychiatrists' participation, post-war denial, the apology to victims and relatives, the independent historians' commission, and the society's commitments [source: DGPPN 2010]. (2) Know the Doctors' Trial outline: 23 defendants; "euthanasia" charged against Karl Brandt, Viktor Brack, Waldemar Hoven and Kurt Blome; Blome acquitted, the other three convicted; seven death sentences in the trial overall [source: Harvard Law School Nuremberg Trials Project; USHMM]. (3) The Nuremberg Code was set out in this trial's judgment [source: The Nuremberg Code, from Trials of War Criminals before the Nuremberg Military Tribunals, Vol. 2 (US Government Printing Office, 1949), reproduced by the US Army Medical Research and Development Command]. (4) Reflect in supervision or team learning on how professional authority, obedience and ideology enabled harm, and what safeguards matter now [synthesis].
  • Example language (illustrative): "Members of my own profession took part in this. I don't take that lightly, and you're welcome to ask me about it."
  • Watch for: Defensiveness, or excessive self-disclosure that shifts focus to the therapist. Working: clients experience the therapist as honest about the field's past.

4.20 Children and young people in affected families

  • Purpose / when: When children are part of family work, are learning about the history at school, or are disabled.
  • Steps: (1) Obtain parental consent and the child's assent appropriate to age. (2) Share history at an age-appropriate level and without graphic detail. (3) Watch for distress, particularly in disabled children who may identify with the victims. (4) Follow local safeguarding, mandatory reporting and child-protection routes if any present-day concern about a child's safety arises [synthesis].
  • Example language (illustrative): "Long ago, some people did very wrong things to people who were ill or disabled. It was wrong, and it's not how people are treated now. You can ask me anything."
  • Watch for: Children carrying adult distress; secrecy demands. Working: the child can ask questions and is not frightened about their own safety.

4.21 Suicide-risk assessment and crisis planning

  • Purpose / when: When distress, grief, shame or isolation is high, or after distressing archival findings.
  • Steps: (1) Ask directly about suicidal thoughts as part of standard risk assessment. (2) Assess intent, plans, history and protective factors. (3) Build a safety plan with the client, including people to contact. (4) Lethal-means counselling, where relevant, covers safe storage and removal only. (5) Give crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland); local crisis services elsewhere. (6) Follow safe-messaging principles: no method detail, no glamorising [synthesis].
  • Example language (illustrative): "Sometimes when people learn something this painful, they have thoughts of not wanting to be alive. Has anything like that been on your mind?"
  • Watch for: Risk rising around anniversaries, archival replies or family conflict. Working: the client knows what to do and whom to contact in a crisis.

4.22 Advocacy and recognition

  • Purpose / when: When a client, family or service wants to pursue recognition, research or public remembrance.
  • Steps: (1) Share the facts: families of "euthanasia" victims and the forcibly sterilised were long excluded from the compensation law [source: DGPPN 2010]; on 29 January 2025 the Bundestag recognised both groups as victims of the Nazi regime and called for more research and a project to secure patient records [source: Jüdische Allgemeine]. (2) Point to the victims' association listed by the Tiergartenstraße 4 memorial as a partner, the Association of "Euthanasia"-Harmed and Forcibly Sterilised Persons [source: Stiftung Denkmal]. (3) Support the client's chosen advocacy without taking it over. (4) Check any current entitlements with the relevant authorities; they may have changed [uncertain].
  • Example language (illustrative): "Would it matter to you to be part of something wider, like the memorial or the victims' association?"
  • Watch for: The therapist's own advocacy agenda; role confusion (APA Ethics Code Standard 3.05). Working: the client's advocacy is self-directed and sustaining.

4.23 Duties when a colleague or institution devalues or abuses disabled people

  • Purpose / when: When the therapist encounters, in the present, a colleague or institution neglecting, abusing or denying care to disabled or psychiatric patients, or using language of lives "not worth living" in care decisions.
  • Steps: (1) Document what you observed, factually. (2) Raise the concern through the institution's safeguarding or clinical-governance route. (3) Where needed, report to the relevant regulator, professional body or adult- or child-protection authority under local law. (4) Seek supervision and, if necessary, legal or professional advice. (5) Never take part in or supervise such practice [synthesis].
  • Example language (illustrative, to a colleague): "I'm concerned about how this patient's care is being decided. I'd like us to take it to the safeguarding lead."
  • Watch for: Pressure to stay silent; retaliation. Working: the concern is formally recorded and acted on.

4.24 Responding to denial, minimisation or devaluing views in the room

  • Purpose / when: When a client minimises the killings, repeats "burden" arguments, or expresses devaluing views of disabled people.
  • Steps: (1) Stay calm and curious; explore where the view comes from. (2) Offer the documented facts without lecturing [source: USHMM]. (3) Name your own position briefly if needed. (4) Keep present-day end-of-life debates separate from the historical crime; do not take sides on current legislation [synthesis].
  • Example language (illustrative): "Historians document that this was a secret programme of murder that families were lied to about. I'm curious what you've heard that suggests otherwise."
  • Watch for: Rupture; escalation; your own anger. Working: the client engages with the facts, even if views remain.

5. Handling problems

The problems below are the psychotherapist's own synthesis [synthesis] unless a source is given.

  • No records found. About 40,000 central files are considered destroyed [source: Bundesarchiv]. Response: prepare the client for this in advance; explore what not knowing means; suggest the memorial sites' own death lists and databases as a further route [source: Bundesarchiv; Gedenkstätte Hadamar]; support grief for the lost information itself.
  • Records that contradict family accounts or each other. Death certificates were falsified [source: USHMM]. Response: treat discrepancies as expected; help the client hold uncertainty; memorial staff may help interpret records.
  • Overwhelm after reading files or visiting a site. Response: return to stabilisation (4.6); slow down; reduce exposure; reassess risk (4.21); consider pausing historical inquiry.
  • Stuck in grief or rumination. Response: shift from the death to the person's life (4.9, 4.17); explore what keeps the loop going (guilt at "moving on", loyalty); consider whether a remembrance act would mark a transition.
  • Family resistance or conflict. Relatives may refuse to discuss or deny the history. Response: respect the client's limits and those of others; work on what the client can do alone; avoid triangulation; return to joint work later if wanted (4.11).
  • Client "resistance" that is distrust of the profession. Response: name the profession's history openly (4.15, 4.19); invite the client's terms for safety; do not interpret mistrust as pathology.
  • Non-adherence to agreed plans (for example, not making an archive request). Response: treat it as information about readiness; explore ambivalence; reaffirm that the client may choose not to search.
  • Ruptures. Triggers include the therapist's nationality or profession, an ill-judged comment, or using the euphemism without quotation marks. Response: acknowledge, apologise for the specific misstep, explore the impact, repair.
  • Discovering a perpetrator in the family mid-therapy. Response: slow down; see 4.13; screen for shame-driven risk; offer extra sessions if feasible.
  • Exposure to graphic material online or in media. Response: help the client choose reputable sources (USHMM, memorial sites) and limit exposure; process what was seen.
  • Present-day bioethics debates arousing the client. Response: help the client separate the historical crime from current debates; the therapist does not take sides on current legislation (4.24).
  • Disabled client identifying with victims and feeling unsafe. Response: name the difference between past and present while acknowledging present ableism; strengthen supports; consider disability-led peer support (4.14).
  • Child or vulnerable adult at risk in the present. Response: follow safeguarding and mandatory-reporting routes without delay (4.20, 4.23).
  • Therapist vicarious trauma. Response: supervision, limits on graphic reading, peer support, and attention to any personal or family connection.
  • Multiple roles. The therapist is asked to research for the family or speak publicly. Response: consider APA Ethics Code Standard 3.05; clarify roles or refer the research task to memorial staff or archives.

Harm account

What was actually done

From 1939 to 1945, the National Socialist state ran a secret programme to kill people with mental and physical disabilities, described by its organisers as "life unworthy of life" [source: USHMM]. Philipp Bouhler, head of Hitler's Private Chancellery, and Karl Brandt, Hitler's personal physician, led the planning; Hitler's secret authorisation was backdated to 1 September 1939 [source: USHMM]. A decree of 18 August 1939 required reporting of disabled newborns and young children, who were then killed in special children's wards; at least 10,000 children were killed [source: USHMM]. From January 1940, adults selected by panels of medical assessors from registration forms were transported from hospitals and care homes to six killing centres: Brandenburg an der Havel, Grafeneck, Bernburg, Sonnenstein (Pirna), Hartheim and Hadamar. T4's own count was 70,273 killed there by August 1941 [source: USHMM]. Families were deceived with urns and falsified death certificates [source: USHMM]. After public protest, including Bishop von Galen's sermon of 3 August 1941, the centralised operation was halted in late August 1941; killing continued in a decentralised way in hospitals and institutions until 1945, and patients were also murdered in occupied Poland and Soviet territories [source: USHMM]. Historians estimate about 250,000 people were killed in all phases [source: USHMM]; the DGPPN gives at least 250,000 to 300,000 [source: DGPPN 2010]. At Hadamar alone about 15,000 people were killed [source: USHMM, The Hadamar Trial]. Personnel and killing technology from the programme were later used in the Operation Reinhard camps [source: USHMM].

What it looked like, as USHMM describes it. Health authorities pressed parents to place disabled children in special clinics that were in fact killing sites, where staff gave the children lethal overdoses of medication or let them starve; the children's programme was later extended to young people up to 17 [source: USHMM]. Adults were selected from questionnaires sent to hospitals, psychiatric institutions and care homes that looked like routine statistical surveys, each reviewed by three doctors; the categories included schizophrenia, epilepsy, dementia, long institutional stays and non-German descent [source: USHMM]. Selected patients were taken from their institutions by bus or train to the killing centres, where they were gassed within hours of arrival in rooms disguised as showers [source: USHMM]. In the decentralised phase from 1942, patients in ordinary hospitals and institutions were killed mainly by overdoses and lethal injections, and many adults and children were deliberately starved; the killing spread to elderly patients, bombing victims and foreign forced labourers [source: USHMM]. Families received an urn and a death certificate with a false cause and date of death [source: USHMM]. Warning signs in a family history: a relative who died suddenly in an institution between 1939 and 1945, often soon after an unexplained transfer; a cremation urn sent to the family; and a stated cause of death that relatives never believed [synthesis].

Accountability was partial. In the 1945 Hadamar trial, a US military commission sentenced the chief administrator Alfons Klein and the male nurses Heinrich Ruoff and Karl Willig to death, the chief physician Adolf Wahlmann to life imprisonment (later commuted), and chief nurse Irmgard Huber to 25 years; a German court in Frankfurt tried 25 Hadamar staff in 1947 [source: USHMM, The Hadamar Trial]. In the Doctors' Trial, Karl Brandt, Viktor Brack and Waldemar Hoven were convicted on the "euthanasia" charge and Kurt Blome acquitted [source: Harvard Law School Nuremberg Trials Project].

How it caused harm

  • Death. Hundreds of thousands of disabled children and adults were murdered [source: USHMM; DGPPN 2010].
  • Deception of families. Falsified notices denied families the truth and the chance to mourn [source: USHMM].
  • Forced sterilisation. More than 360,000 people were forcibly sterilised, and over 6,000 died as a result [source: DGPPN 2010].
  • Betrayal by caregivers. Doctors and nurses, whose role was care, selected and killed patients; the DGPPN states that its predecessor organisations' members overwhelmingly took part or lent legitimacy [source: DGPPN 2010].
  • Long denial and exclusion. The DGPPN describes post-war denial, a leading perpetrator working as a court expert under a false name, exclusion of victims' families and the sterilised from compensation, and the sterilisation law not outlawed until 2007; formal parliamentary recognition as victims came only in January 2025 [source: DGPPN 2010; Jüdische Allgemeine].
  • Intergenerational effects. Shame, anger and taboo in descendants are described as intergenerational trauma [source: Posey 2013, publisher description].
  • A step toward genocide. USHMM describes the programme as a "dress rehearsal" for the Holocaust [source: USHMM].

Recognising it today

  • In family histories: a relative who died in a psychiatric hospital or care home between 1939 and 1945; a death notice with a vague cause or a distant place of death; an urn sent to the family; silence or shame around the person; a relative who was forcibly sterilised [synthesis; pattern, source: USHMM].
  • In records: a name in the Bundesarchiv R 179 index (invenio) or on a memorial site's death list [source: Bundesarchiv]; records whose dates and causes conflict [source: USHMM].
  • In clients: fear of psychiatry, fear of heredity, disenfranchised grief, or shame about a disabled or ill relative [synthesis].
  • In ideas: language describing disabled lives as burdens or as not worth living, which the programme used [source: USHMM]; denial or minimisation of the killings.
  • In institutions: neglect or devaluation of disabled or psychiatric patients in present-day care calls for safeguarding action (4.23) [synthesis].

What to do instead and how to help those harmed

  • Supported care: the DGPPN commits to humane, patient-oriented psychiatry, fighting stigma, and guarding against ideology and value judgements in medical-ethics debates [source: DGPPN 2010]. Present-day care of disabled people and people with mental illness rests on informed consent and rights; the psychotherapist upholds these and never takes part in coercive or devaluing practice [synthesis].
  • For descendants and relatives: client-led therapeutic work as in section 4; archival routes through the Bundesarchiv (R 179, next-of-kin access) and the memorials at the six former killing centres [source: Bundesarchiv]; the Hadamar memorial's free research service and meetings for relatives [source: Gedenkstätte Hadamar]; the Tiergartenstraße 4 memorial and information site in Berlin [source: Stiftung Denkmal].
  • Survivor and victims' organisations: the Association of "Euthanasia"-Harmed and Forcibly Sterilised Persons, listed as a partner of the Tiergartenstraße 4 memorial [source: Stiftung Denkmal].
  • Recognition and legal routes: the Bundestag's January 2025 recognition of these victims, with calls for research and preserving patient records [source: Jüdische Allgemeine]; check current entitlements with the relevant German authorities [uncertain].
  • Reporting duties today: where abuse or neglect of disabled or psychiatric patients is suspected now, use institutional safeguarding, regulators, professional bodies and adult- or child-protection services under local law [synthesis].
  • Crisis support: 988 (US); Samaritans 116 123 (UK and Ireland); local crisis services elsewhere.

Sources

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