On October 21, 1987, the New York Times ran a front page story about the practice of “punitive psychiatry” in what is now Russia.

A political dissident recently released from a Soviet psychiatric hospital said today that the habitual use of punitive psychiatric treatment in the Soviet Union remained unchanged despite recent criticisms of such practices in the Soviet press.  (Barringer, 21 Oct 1987, p. A1)

Yet this coverage only repeated the gist of a story that had been published in Time ten years before.

Since the late ’50s, when Khrushchev announced that “there are no political prisoners, only persons of unsound mind,” the Soviets have relied on tame psychiatrists to label troublemakers insane. 

Despite decades of supposed progress, however, it now seems as though very little in Russia has changed.

Last week, continuing the trend of repetition, The Daily Telegraph revealed that Soviet-era punitive psychiatry is alive and well.

Naked and with her hands and feet bound to the corners of a metal bed covered by a rubber incontinence sheet, Larisa Arap eyed with quiet defiance the doctors who wanted to declare her mad.

It was a futile gesture. The men in white coats standing over her were bitter adversaries.

Unfortunately, despite the grim details provided in sketching the plight of our contemporary hero, this new piece provides little in the way of historical context.

The practice of “punitive psychiatry”, perfected by Nikita Khrushchev in the aftermath of Stalin’s Great Terror as a more palatable way of dealing with political dissidents, was once thought to have been buried with the Soviet Union.

It has none of the depth of the twenty-year-old New York Times story.  The result, regrettably, is that a shocking statistic was overlooked.

in 1985, 1,923 of every 100,000 Soviet citizens were registered as having psychiatric disorders, indicating that more than 5 million in the country have such disorders. (Barringer, 21 Oct 1987, p. A7)

And if the parallels between these two stories hold, as the latest coverage implies, it would have been important to ask what that number is today.

Furthermore, the contemporary implication (that Arap’s diagnosis was sanctioned by the Kremlin) is made clearer by the earlier observation that many of the patients in 1985 had been incarcerated as a result of political maneuvering.

Dissidents assert that the K.G.B. runs the system — an accusation supported by the fact that the Ministry of Internal Affairs controls the 18 special psychiatric hospitals.

…said Aleksandr Podribinek, who has written a book on Soviet psychiatric practicse.  “Psychiatric abuse is the result of bad politics, not bad psychiatry.  To stop abuse, we have to change the politics.” (Barringer, 21 Oct 1987, p. A7)

The omission of a key diagnostic term in the latest coverage — “sluggish schizophrenia” — was therefore an implicit barrier to further examination.  Fortunately, this oversight is easily remedied.

For those wishing to look further into this story, to examine whether events are indeed repeating themselves, we offer the following resources as a sort of annotated introduction to the larger historical puzzle.

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Sluggish schizophrenia.

• Merskey, H. & Shafran, B.  (1986).  Political hazards in the diagnosis of “sluggish schizophrenia.”.  British Journal of Psychiatry, 148, 247-256.

Contends that there have been several aspects to the discussion of the abuse of psychiatry for political purposes in the USSR and that the concept of sluggish schizophrenia is virtually limited to the USSR and some other East European countries and may contribute to the misdiagnosis of Democrats as psychiatric patients. Recently, a number of articles have appeared in the Soviet literature relating the diagnosis of sluggish schizophrenia or slowly progressive schizophrenia to affective disorders, especially hypomania. Soviet publications on this theme from 1980 to 1984 are discussed, together with their relationship to questions on the abuse of psychiatry.

See also:

• Brown, J. V.  (1987).  Peasant survival strategies in late imperial Russia: The social uses of the mental hospital.  Social Problems, 34(4), 311-329.

Examines the social functions of the asylum in late imperial Russia, based on analysis of asylum annual reports and related documents for the years 1880-1896. Seasonal variations in patient admissions and discharges suggest that the use of asylums fluctuated according to the requirements of the peasant economy, that the asylum fulfilled essentially the same functions for workers and patients, and that while the asylum remained a powerful and coercive means of social control, the beleagured peasant population incorporated the institution into its desperate strategies for survival.

• Krasnov, V. N.  (2005).  The development of biomedical ethics in Russian psychiatry.  Psychiatriki, 16(2), 120-125.

The development and practical application of modern ethical principles in Russian psychiatry is rather edifying from moral, professional and historic perspective. In the former Soviet Union there existed a well organized and regulated system of psychiatric care, built on territorial ground. One of the disadvantages of this system was its excessive centralization and this disadvantage is not completely overcome in modern Russian psychiatry. A more serious disadvantage was the lack of special law on psychiatric care in soviet psychiatry as this system was based on the principle of paternalism. In the ’70-’80s of the last century this system was found to be connected with misuse of psychiatry for political purposes. Political persecution was exchanged for psychiatric examination and hospitalization in psychiatric clinics. In the beginning of the ’80s the threat of exclusion of All-Union society of neurologists and psychiatrists from the World Psychiatric Association, because of opposition from international human rights organizations, led the All-Union Society to suspend its membership by itself. At the same time this painful process had its positive side: because of criticism from abroad and growing discontent among the majority of psychiatrists in the middle of the ’80s, that is during the period of changes (so called “perestroika”), work on the law in psychiatry has begun. In 1991 the Soviet Union fell apart and several other countries were formed (the former Union republics). Russia was the first country where the Law about psychiatric care was passed. In 1992 this Law was confirmed by the Parliament and took effect in January 1993. The obligatory registration of mentally ill in psychiatric centers was canceled. All assistance is given confidentially. In 1993 the membership of the Russian Society of Psychiatrists in World Psychiatric Association was completely restored. In 1994, the Russian Society of Psychiatrists accepted the Code of psychiatric professional ethics. In 1996, after the World Congress of Psychiatry in Madrid, the Russian Society of Psychiatrists accepted the Madrid Declaration. Of course, the rudiment of excessive centralization in patient mental health care still exists. The number of mentally ill who are disadvantaged in the public health system is growing, due to the difficulties of providing employment and adaptation in the settings of market economy, as well as due to a large reduction of sheltered jobs for mentally ill. Unfavorable conditions of living in many psychiatric clinics (rooms for many beds, lack of space and equipment) are serious ethical and legal problems. Expensive remedies remain unavailable to many patients, especially for out-patients. These problems are being actively discussed and part of them is being gradually solved.

• López-Muñoz, F., Alamo, C., Dudley, M., Rubio, G., García-García, P., et al.  (2007).  Psychiatry and political-institutional abuse from the historical perspective: The ethical lessons of the Nuremberg Trial on their 60th anniversary.  Progress in Neuro-Psychopharmacology & Biological Psychiatry, 31(4), 791-806.

Sixty years ago at the Nuremberg Trials, 23 Nazi leaders were tried as war criminals, in what was known as “The Doctors’ Trial”. This trial exposed a perverse system of the criminal use of medicine in the fields of public health and human research. These practices, in which racial hygiene constituted one of the fundamental principles and euthanasia programmes were the most obvious consequence, violated the majority of known bioethical principles. Psychiatry played a central role in these programmes, and the mentally ill were the principal victims. The aim of the present work is to review, from the historical perspective, the antecedents of the shameful euthanasia programmes for the mentally ill, the procedures involved in their implementation and the use of mentally ill people as research material. The Nuremberg Code, a direct consequence of the Doctors’ Trial, is considered to be the first international code of ethics for research with human beings, and represented an attempt to prevent any repeat of the tragedy that occurred under Nazism. Nevertheless, the last 60 years have seen continued government-endorsed psychiatric abuse and illegitimate use of psychoactive drugs in countries such as the Soviet Union or China, and even in some with a long democratic tradition, such as the United States. Even today, the improper use of psychiatry on behalf of governments is seen to be occurring in numerous parts of the globe: religious repression in China, enforced hospitalization in Russia, administration of psychoactive drugs in immigrant detention centres in Australia, and the application of the death penalty by lethal injection and psychiatric participation in coercive interrogation at military prisons, in relation to the USA. The Declaration of Madrid in 1996 constituted the most recent attempt to eradicate, from the ethical point of view, these horrendous practices. Various strategies can be used to combat such abuses, though it is uncertain how effective they are in preventing them.

• Smulevich, A. B.  (1989).  Sluggish Schizophrenia in the Modern Classification of Mental Illness.  Schizophrenia Bulletin, 15(4), 533-539.

The concept of latent schizophrenia was developed by E. Bleuler (1911) and was further promoted in the studies of a number of research psychiatric schools of Europe, the United States, Japan, and other countries. In Soviet psychiatry, there is a long-established tradition of studying “soft” forms of schizophrenia (Kerbikov 1933; Rozenshtein 1933; Brukhanskii 1934). In the systematics of schizophrenia, developed by Snezhnevsky (1969) and his colleagues, sluggish schizophrenia is viewed not as an initial (prodromal) stage of schizophrenia, but rather an independent diagnostic category characterized by a slowly progressive course, subclinical manifestations in the latent period, overt psychopathological symptoms in the active period, and then by a gradual reduction of positive symptoms, with negative symptoms predominating the clinical picture during patient stabilization. Studies are reviewed examining the relationship of constitutional and genetic factors to the clinical manifestation of sluggish schizophrenia. Finally, the importance of methodological considerations and an examination of divergent factors in the U.S. and Soviet concepts of schizophrenia are presented.

• Windholz, G.  (1985).  Psychiatric commitments of religious dissenters in Tsarist and Soviet Russia: Two case studies.  Psychiatry, 48(4), 329-340. 

Considers 2 cases of psychiatric commitment from 2 historical periods in the USSR, the czarist regime and Stalin’s rule. Both Ss allegedly claimed to be Jesus Christ; they were neither charged nor exiled but were diagnosed as paranoiacs and committed involuntarily. It is suggested that the present commitment of dissenters in the USSR may be based on a psychiatric judgment, although political factors may also be relevant.

• Windholz, G.  (1999).  Soviet psychiatrists under Stalinist duress: The design for a “new Soviet psychiatry” and its demise.  History of Psychiatry, 10(39, Pt 3), 329-347.

Described the development of the “New Soviet psychiatry” in the 1950s. A Scientific Session of the USSR Academy of Sciences and the USSR Academy of Medical Sciences met in 1950 in Moscow to comply with the order of Josef Stalin. Its purpose was to institutionalize the theory of higher nervous activity of Ivan Pavlov, which considered psychiatric and neurotic syndromes in terms of the dynamic localization of the brain’s functions. The Session decreed that annual scientific conferences should be held to consider problems related to Pavlovian physiology. At the 1951 meeting, psychiatrists V. A. Giliarovskii, M. O. Gurevich, and A. S. Shmar’ian were condemned for adhering to anti-Marxist ideology and to Western psychiatric theories. The accused psychiatrists recanted. After Stalin’s death in 1953, psychiatric hospitalization was used as a means of suppressing dissent. However, beginning in the early 1990s, following the dissolution of the Soviet Union, Russian psychiatrists began attempts to align themselves with Western mainstream ideas.

-JTB.

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30 August 2007

Interest in this story has prompted an update, to provide some additional context to the discussions regarding abuse.  These general histories are appended below.

General Histories.

• Kanas, N.  (1992).  Psychiatry in Leningrad (St. Petersburg).  Psychiatric Annals, 22(4), 212-220.

Reviews the history of Soviet psychiatry, beginning in 1862 with the first Russian psychiatric society and followed by the founding of the Bekhterev Institute in 1907. Psychiatric abuse began with the advent of Stalinism in the early 1930s. Recently, much has been written about Soviet psychiatry, especially in terms of human rights violations and the inappropriate use of nosology to hospitalize political dissidents. However, since the 1930s, there have been coexisting points of view with that of the dominant Moscow school, principally represented by the Leningrad school. Psychiatry in Leningrad is more interpersonally oriented, interested in psychotherapy, and tighter in its conceptualization of schizophrenia. Current practices in biomedical treatment, individual psychotherapy, and group and family therapy in the Soviet Union are also described.

• Korolenko, C. P. & Kensin, D. V.  (2002).  Reflections on the past and present state of Russian psychiatry.  Anthropology & Medicine, 9(1), 51-64.

Analyzes 3 periods of Russian psychiatry: before 1917, during the Soviet period, and after the fall of the Soviet Empire. The section on Russian psychiatry before 1917 considers the biomedical model in psychiatry which was transferred from somatic medicine without recognizing the difference in the character of signs and symptoms. Mechanisms of mental disorders were analyzed predominately from the position of the “physiology of superior nervous activity.” The 2nd section considers ideological concepts which influenced the development of Soviet psychiatry. Psychological approaches to diagnosis, treatment, and explanation of the mechanisms of development of the disorders were prohibited and excluded. Clinical orientation was directed towards the disclosure of the symptoms, syndromes, and nosologies according to oversimplified interpretation of psychiatric terminology. Psychiatrists developed a specific mentality and skills in detecting symptoms of psychopathology in every consulted person. The last section reviews the situation in contemporary Russian psychiatry. Its development continues to be influenced by “negative” aspects inherited from the Soviet era, particularly the hyper-diagnosis of schizophrenia. However, psychological approaches are revived.

• Veltischev, D.  (2003).  Past and present of psychiatric care in Russia.  Psychiatria Danubina, 15(1-2), 69-71.

Presents a brief overview of the historical development and current status of psychiatric care in Russia. The spiritual treatment of psychiatric patients at monasteries during the 1500s, the origins of psychiatric hospitals in the 1700s, the development of a psychiatric care system in the 1800s and 1900s, and current issues in psychiatric care delivery in Russia are chronicled. The contributions of psychiatrists and researchers to the development of psychiatry in Russia are also identified.

See also:

• Bonnie, R. J.  (2001).  Semyon Gluzman and the unraveling of Soviet psychiatry.  Journal of the American Academy of Psychiatry and the Law, 29(3), 327-329.

Discusses the life and work of Semyon Gluzman, a Ukranian psychiatrist. The article discusses Soviet psychiatric repression, Soviet policy towards psychiatry, and its place in the world of psychiatry. Over the past decade, Dr. Gluzman has continued to be at the center of the struggle for democratization in Ukraine and has been an inspiration to reformers in other formerly totalitarian countries and to their friends in the West. He founded the Ukranian Psychiatric Association in 1991 as an independent voice and established a commission to review complaints about civil rights violations by mental health authorities.

• Kuznetsov, Y. M., Shamrey, V. K., & Vale, M. (Trans).  (1997).  Some sociophilosophical sources of Russian psychiatry.  International Journal of Mental Health, 26(2), 5-9.

States that recent changes in Russian society have strengthened Western influence on the development of the science and practice of psychiatry. In addition to the inputs of the East and the West on the development of the social-philosophical conditions of a humane attitude toward the mentally distressed, it is stated that the development of Orthodox humanism had considerable influence on the foundations of Russian psychiatry. This humane attitude is also said to derive from the upheavals people underwent in Russia. It is concluded that, in contrast to the Western system of psychiatric care, the Russian system developed at a higher humanistic level from the very beginning as a result of the traditional Orthodox orientation of the Russian people. The psychiatrists P. D. Shipulinskii, I. M. Balinskii, I. P. Merzheevskii, and V. M. Bekhterev are discussed.

• Mohr, P., Füredi, J., Swingler, D., Bitter, I., Gheorghe, M. D., et al.  (2006).  A historical overview of psychiatry in selected countries of Central & Eastern Europe.  Socijalna Psihijatrija, 34(1), 3-8.

The paper reviews the history of psychiatry in several countries of Central and Eastern Europe (CEE): Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Russia, Slovakia, and Slovenia. The first asylums for mentally ill in the region were founded in the 16th century (Poland). A German influence, impact of Russian psychiatrists, or French inspiration can be detected in some countries. The great tradition of psychiatry in this part of Europe is evidenced by the number of national psychiatric organizations and specialized journals. The development of psychiatry in CEE has in many ways reflected various historical twists. The nations of the region share a common past, an uneasy current period of transition from totalitarianism to democracy and the future as either novice or ascending members of the European Union.

-JTB.