Fifty Years of Political Abuse of Psychiatry

Ethics, Medicine and Public Health (2015) 1, 44—51

Available

online at ScienceDirect

www.sciencedirect.com

DOSSIER ‘‘ABUSE’’ /Studies

Fifty years of political abuse of

psychiatry — no end in sight

50 ans de maltraitance politique par la psychiatrie — pas de ﬁn en vue

R. van Voren

Human Rights in Mental Health-FGIP, Postbus 1956, 1200 BZ Hilversum, The Netherlands

Received 5 September 2014; accepted 7 December 2014

Available online 4 April 2015

KEYWORDS Summary In October 1989, the General Assembly of the World Psychiatric Association (WPA)

Medical ethics; accepted the Soviet psychiatric association back conditionally, after having been forced to

Human rights; leave the organization six years earlier because of systematic abuse of psychiatry for political

International law; purposes. Three weeks later, the Berlin Wall came tumbling down, and in 1991, the Soviet Union

Political repression; itself ceased to exist. However, over the past years, an increasing number of reports on the

Soviet Union internment of political activists in former Soviet republics made people realize that 25 years

after the decision of the WPA, political abuse of psychiatry still has not been eradicated. Using

psychiatry as a means of repression has been a particular favorite of totalitarian regimes with

a communist State ideology. Cases have been reported from other countries as well, including

Western democratic societies, yet nowhere else has it been developed into a systematic method

of repression. While probably the overwhelming majority of Soviet psychiatrists were unaware

that they had become part of a perﬁdious system to treat dissenters as psychiatrically ill on

the orders of the Party and the KGB, there is also ample evidence that the core group of

architects of the system knew very well what they were doing. When the USSR disintegrated,

the practice of using psychiatry against political opponents virtually ceased to exist. What came

in its place, however, was a very disturbing collection of other forms of abuses, including human

rights abuses due to lack of resources, outdated methods of treatment, lack of understanding

of human individual rights and a growing lack of tolerance in society. Starting this century, the

number of individual cases of political abuse of psychiatry has increased, in particular, over the

past few years in Russia, Belarus and Kazakhstan. The issue of Soviet political abuse of psychiatry

had a lasting impact on world psychiatry. It triggered the discussions on medical ethics and the

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.jemep.2014.12.001

Psychological and legal interventions for domestic violence 45

professional responsibilities of physicians (including psychiatrists), resulting in both national

and international declarations and ethical codes that address the interface between human

rights, professional responsibilities of physicians and medical ethics.

MOTS CLÉS Résumé En octobre 1989, l’Assemblée générale de l’Association mondiale de psychiatrie

(WPA) acceptait le retour conditionnel de l’Association psychiatrique soviétique, après avoir

Éthique médicale ;

été forcée de quitter l’organisation six ans plus tôt pour abus systématique de la psychiatrie à

Droits de l’Homme ;

des ﬁns politiques. Trois semaines plus tard, le mur de Berlin s’écroulait, et en 1991, l’Union

Loi internationale ;

soviétique elle-même cessait d’exister. Cependant, au cours des dernières années, un nombre

Répression politique ;

croissant de rapports sur l’internement de militants politiques dans les anciennes républiques

Union soviétique

soviétiques faisait prendre conscience que, 25 ans après la décision de la WPA, l’utilisation de

la psychiatrie à des ﬁns politiques était loin d’être éradiquée. Cette utilisation de la psychi-

atrie comme moyen de répression a été particulièrement appréciée des régimes totalitaires

d’obédience communiste. Des cas ont aussi été signalés dans d’autres pays, y compris dans

les sociétés démocratiques occidentales, mais nulle part ailleurs n’ont été développés comme

méthode systématique de répression. Bien que sans doute l’écrasante majorité des psychiatres

soviétiques ne savaient pas qu’ils étaient devenus partie d’un système pervers pour traiter les

dissidents comme malades mentaux sur les ordres du Parti et du KGB, de nombreuses preuves

montrent que les architectes du système savaient très bien ce qu’ils faisaient. Lorsque l’URSS

s’est désintégrée, l’utilisation de la psychiatrie contre les opposants politiques a pratique-

ment cessé d’exister. À sa place, cependant, une série troublante d’autres formes d’abus, des

violations des droits de l’homme dues au manque de ressources, des méthodes dépassées de

traitement, un manque de compréhension des droits humains individuels et une baisse crois-

sante de tolérance dans la société. Depuis quelques années, le nombre de cas individuels de

maltraitance politique en psychiatrie a augmenté, en particulier en Russie, en Biélorussie et au

Kazakhstan. La question de la maltraitance politique de la psychiatrie soviétique a eu un impact

durable sur la psychiatrie mondiale. Il a déclenché des discussions sur l’éthique médicale et les

responsabilités professionnelles des médecins (y compris les psychiatres). Il en a résulté des déc-

larations à la fois nationales et internationales et des Codes d’éthique pour déﬁnir l’interface

entre les droits, les responsabilités professionnelles des médecins et l’éthique médicale.

Introduction After Athens, developments succeeded each other in

a rapid succession. The USSR disintegrated; former Soviet

Twenty-ﬁve years ago, in October 1989, the General Assem- republics became independent and in all of them new

bly of the World Psychiatric Association (WPA) met in Athens psychiatric associations appeared. Most of them became

with one main item on the agenda: the abuse of psychiatry members of the WPA within the next years. By the time the

for political purposes in the USSR and the question whether General Assembly of the WPA convened in Madrid in August

the Soviet association should be allowed to rejoin the orga- 1996, a dozen new associations had joined this international

nization or not. Six years earlier, it had withdrawn from body. Political abuse of psychiatry seemed to be a matter of

membership when it became clear it would otherwise be the past, now only a matter of research for historians and

expelled because of Soviet psychiatry having been turned political scientists.

into a systematic tool of repression. But now, times had However, over the past years an increasing number of

changed: the USSR was opening up, political prisoners were reports on the internment of political activists in former

being released in large numbers and the Soviets claimed the Soviet republics led to a resumed interest in the issue of

abuse had come to an end. A large team of investigators sent the abuse of psychiatry for political purposes [2]. The fact

by the US State Department did not conﬁrm this claim alto- that all these years these abuses were a frequent and ongo-

gether [1], but the winds of change called for leniency and ing practice in, for instance, the People’s Republic of China

thus the Soviets were allowed back conditionally. Coinciden- [3], did not alert the world that this perversion of medical

tally, yet very symbolically, the General Assembly took place science had not come to an end. Rather, it was reports on

the day that GDR-leader Erich Honnecker resigned from his individual cases of such abuses in former Soviet republics

position, and it would be only three weeks until the Berlin such as Belarus, Kazakhstan and Russia [2,4], which made

Wall came tumbling down. people realize that 25 years after the World Congress in

46 R. van Voren

Athens, political abuse of psychiatry still had not been erad- are followed as in the case when the person would be sen-

icated. tenced to a term of imprisonment. Only in case of short-term

hospitalizations, these procedures are sometimes bypassed,

in particular, when the internment is somewhere in the

provinces and carried out to ‘‘scare’’ a person into submis-

Why psychiatry?

sion or to settle an old dispute with a local authority.

At the same time, declaring a person mentally ill pro-

According to the deﬁnition of the foundation Human Rights

vides a perfect opportunity to dismiss political or religious

in Mental Health — FGIP (formerly the Global Initiative on

beliefs, as they are the product of an ill mind and do not

Psychiatry), ‘‘political abuse of psychiatry refers to the mis-

have to be taken seriously. In particular, in the case of opin-

use of psychiatric diagnosis, treatment and detention for

ions that threaten the prevalent or only-correct ideology (or

the purposes of obstructing the fundamental human rights

religion), authorities ﬁnd that such a way out is especially

of certain individuals and groups in a given society. The

welcomed, as one can maintain the view that there is no

practice is common in, but not exclusive to, countries gov-

opposition and one has full support of the population. As

erned by totalitarian regimes. In these regimes, human

Soviet leader Nikita Khrushchev stated in 1959: ‘‘a crime

rights abuses of those politically opposed to the state are

is a deviation from the generally recognized standards of

often hidden under the guise of psychiatric treatment. In

behavior frequently caused by mental disorder. Can there be

democratic societies, ‘whistle blowers’ on covertly illegal

diseases, nervous disorders among certain people in Commu-

practices by major corporations have been subjected to the

1 nist society? Evidently yes. If that is so, then there will also

political misuse of psychiatry.’’

be offences that are characteristic for people with abnormal

A key question is why authorities resort to the intern-

minds [ . .]. To those who might start calling for opposition

ment of political or religious dissenters, or other types of

to Communism on this basis, we can say that [. . .] clearly

‘‘bothersome citizens’’, in mental hospitals. On the basis of

the mental state of such people is not normal’’ [7].

thirty-ﬁve years of research and involvement in combating

If we look at the full picture, we see that using psy-

such practices, I have come to the conclusion that in most

chiatry as a means of repression has been a particular

cases, it is a combination of expedience and ideology.

favorite of totalitarian regimes with a ‘‘socialist’’ or com-

Physicians, who are educated in an all-encompassing

munist State ideology. Cases have been reported from other

absolutist system without the possibility to get to know con-

countries as well, including Western democratic societies

trasting views and opinions (as was the case in the Soviet

[8], yet nowhere else has it been developed into a system-

Union) can be convinced that the utilitarian goal of the pre- 2

atic method of repression. An explanation might be found

scribed treatment is correct and that the ‘‘patient’’ needs

in the fact that totalitarian socialist states claim to focus on

to be ‘‘adjusted’’ to the demands of general interest. Also,

the establishment of the ideal society, where all are equal

the dominance of certain scientiﬁc paradigms (e.g. in which

and all will be happy, and where a monist view of reality

psychiatry is exclusively a medical, neurobiological disci-

is dominant: we all see the same, think the same and thus

pline) with the accompanying vocabulary (subversive views

act the same. Those who are against this viewpoint must

are symptoms of a mental disorder) and treatment goals

be suffering from a mental disorder. Even worse, the fact

(disciplining and ‘‘adjusting’’ the victim to the prevailing

that one dares to go against an omnipresent ideology and an

political discourse) make it very difﬁcult to allow an alter-

all-powerful state is in itself already suspicious and a sign of

native approach to exist.

madness. Thus, even in the Soviet Union of the 1970s, where

Also, one should not forget that hospitalizing bothersome

many were not happy, only few continued to believe in the

people is a particularly convenient method because hospi-

State ideology, and society was far from ideal; many psy-

talization has no end, no set term, and thus, if need be,

chiatrists still believed that those who dared to turn against

people can be locked away forever, or as long as the person

the regime must have been suffering from a mental illness.

continues to have ‘‘wrong ideas’’ and remains a problem

How else could they explain to themselves that a dissident

to the existing power structure. Interestingly, in the USSR,

was willing to give up his/her own future as well as that of

there seemed to be a correlation between the ‘‘severity’’ 3

their partners and children [9]?

of the ‘‘crime’’ and the length of hospitalization. People

Yet while probably the overwhelming majority of Soviet

who would normally be sentenced to at least seven years

psychiatrists were unaware that they had become part of

in a camp usually spent at least seven years in a psychi-

a perﬁdious system to treat dissenters as psychiatrically ill

atric hospital, while hospitalization would be shorter if the

accusations concerned lighter violations of the law [5].

One might think that such practices also exclude the

need to have a lengthy pre-trial investigation and a both- 2

The authors put ‘‘socialist’’ on purpose between quotation

ersome court case, but this is in fact almost never the case:

marks in order to stress that socialism as proclaimed by totalitarian

dictatorial or totalitarian regimes tend to be very metic- states, e.g. China or North Korea is fully incompatible with social-

ulous in administrating and documenting their repressive ism as perceived in democratic societies. However, a discourse on

acts (e.g. the detailed administration of the Nazi camp sys- these matters falls outside the boundaries of this contribution.

tem [6]), and thus in many cases the same legal procedures One of the psychiatrists the author worked with in Ukraine in the

1990s had been a regional Party organizer in Vinnitsa, and was in

the years 1985—1991 convinced that Gorbachev was suffering from

The full text of the relevant position paper can be obtained from ‘‘sluggish schizophrenia’’ because of his reform plans. Only when

FGIP: write to P.O. Box 1956, 1200 BZ Hilversum, The Netherlands, Ukraine became independent in 1991, she realized that this was not

www.gip-global.org. the case.

Psychological and legal interventions for domestic violence 47

on the orders of the Party and the KGB, there is also ample monopoly of the Moscow School of Psychiatry led by Aca-

evidence that the core group of architects of the system demician Andrei Snezhnevsky. The diagnosis of ‘‘sluggish

knew very well what they were doing. schizophrenia’’ that became Snezhnevsky’s trademark pro-

vided a handy framework to explain ‘‘dissident behavior’’.

According to Snezhnevsky, schizophrenia was much more

prevalent than previously thought because the illness could

Political abuse in the (former) USSR

be present with relatively mild symptoms and only progress

later. In particular, the notion of sluggish schizophrenia

The development of political abuse of psychiatry in the

broadened the scope, because according to Snezhnevsky,

Soviet Union was very much facilitated by this totalitar-

patients with this diagnosis were able to function almost

ian Soviet environment mentioned earlier, which proved to

normally in the social sense. Their symptoms could resemble

be a perfect ‘‘micro-climate’’. Actually, what happened to

those of a neurosis or could take on a paranoid quality. The

psychiatry was in fact no different than the fate of Soviet

patient with paranoid symptoms retained some insight into

biology, where in the 1930s the teachings of Lysenko became

his condition, but overvalued his own importance and might

the only acceptable truth and all other views were literally

exhibit grandiose ideas of reforming society. Thus symp-

banned [10]. For decades, Lysenkoism ruled Soviet biology,

toms of sluggish schizophrenia could be ‘‘reform delusions’’,

and it took a major effort by leading scientists like the

‘‘struggle for the truth’’, and ‘‘perseverance’’.

nuclear physicist Andrei Sakharov and the biologist Zhores

Several scholars analyzed the concepts of sluggish

Medvedev to end the rule of Lysenkoism and bring Soviet

5 schizophrenia in the USSR, and scholarly work that focused

biology back into line with reality. However, this surgical

on this diagnosis. In July 1979, a Moscow psychiatrist, Etely

intervention never happened in psychiatry; in fact, the lead-

Kazanets, surprised the world with an article published in

ership of Soviet totalitarian psychiatry remains in power in

Archives of General Psychiatry [12]. Kazanets strongly criti-

Russian psychiatry to this very day. As a result of this combi-

cized the use of the diagnosis of schizophrenia in his country,

nation of factors, the political abuse of psychiatry, which

directly referring to the theories of the Moscow School of

initially mostly affected intellectual and artistic circles,

Andrei Snezhnevsky: ‘‘Particularly troublesome are cases of

grew into an important form of repression with approxi-

psychosis that lack the characteristic clinical progression of

mately one-third of the dissidents in the 1970s and early

schizophrenia. Some psychiatrists contend that a listing of

1980s being sent to a psychiatric hospital, rather than to a

6 the schizophrenias should include so-called transient, peri-

camp, prison or exile [11].

odic or time-limited schizophrenia, which manifests after

The main turning point was the year 1950, when the

exogenous stresses, but, during periods of transmission,

Pavlovian psychiatric school was declared as the ‘‘one and

leaves ‘hardly any changes in personality, . . . signs of psy-

only’’ acceptable one and all other views on psychiatry

chic weakness having been exhausted’ and can in fact follow

were outlawed. Some of the psychiatric leaders who did not

a relapse course.’’ Kazanets criticized not only the overly

adhere to Pavlov’s theories were even sent to the Gulag.

broad use of the diagnosis, of schizophrenia, but also the

In that year, at a joint meeting of the All-Union Neurologi-

fact that once a person had this diagnosis it was almost

cal and Psychiatric Association and the Academy of Medical

impossible to have this diagnosis revised: ‘‘This resulted

Sciences Pavlov’s behaviorism was enforced as the only

in long and unfounded retention of patients on the dispen-

acceptable ideology of mental health practice and research

sary list . . . Keeping these people on dispensary lists for long

in the Soviet Union. This resulted in a virtually complete

periods constitutes a real threat to their individual rights.’’

This should be altered, he concluded, ‘‘especially in persons

For instance, in 2001, Dr. Yakov Landau of the Serbski Institute who have made good social vocational adaptation’’ [12].

said on Polish television that ‘‘the organs (KGB) burdened us with The reaction of Kazanets’ employer, the Serbski Institute

very responsible work [. . .]. They expected us to do what they asked

us to do, and we knew what they expected.’’

In 1927, the Soviet newspaper Pravda published an article stating

that a young researcher Troﬁm Denisovitch Lysenko (1898—1976)

had resolved the food shortages in the Soviet Republic of Azerbaijan Andrei Vladimirovich Snezhnevsky, born in 1904 in Kostroma,

by growing peas during the winter season. The food shortage was graduated from the Medical Faculty in Kazan in 1925 and started

caused in the ﬁrst place by the massive re-allocation of labor force working in the psychiatric hospital in his hometown. In 1938—1941,

from agriculture to industry and threatened to expose the party he was senior scientiﬁc associate and deputy director of the Moscow

policy of rapid industrialization as shortsighted. Lysenko’s solution Gannushkin Psychiatric Research Institute. In 1947, he defended his

came at the opportune time to provide a rationale that allowed his dissertation on psychiatry for the elderly under the title ‘‘Senile

deceptive but highly desirable rendition of genetics to rescue the Psychoses’’. During the war, he was ﬁrst linked to a battalion and

party authority. Unfortunately, the price was disastrous, because then became chief psychiatrist of the First Army. In 1945—1950,

Lysenko’s solution was not only faulty but it also legitimated the he worked as a lecturer at the psychiatric faculty of the Central

abuse of science in the Soviet Union by placing the whole domain Institute for Continued Training of Physicians and for almost two

of research under the jurisdiction of the Communist Party. years (1950—1951) was director of the Serbski Institute. Until 1961,

This percentage is based in the ﬁles of the International Associ- he was head of the psychiatric faculty of the Central Institute for

ation on the Political Abuse of Psychiatry. However, the KGB itself Continued Training of Physicians. In 1962, he became head of the

reported higher percentages of ‘‘mentally ill’’ dissidents: for exam- Institute for Psychiatry of the Academy of Medical Sciences of the

ple, in a 1976 KGB document found in the Stasi archives, it is USSR, a position he held until his death on July 17, 1987. In addition,

reported that in 1973, a total of 124 persons were arrested for from 1951 onwards, he was chief editor of the Korsakov Journal

these crimes against 89 persons in 1974, in the context of which of Neuropathology and Psychiatry. In 1957, he became a candidate

it is important to note that 50% of these people were mentally ill. Member of the Academy of Medical Sciences, in 1962 a full member.

48 R. van Voren

in Moscow, was swift: Kazanets lost his job. His later fate is their statements and behavior.’’ However, others showed an

unknown. ‘‘extreme social dangerousness and [this formed] the foun-

In 1986, the Canadian psychiatrist Harold Merskey, dation of the recommendation for compulsory treatment in

together with neurology resident Bronislava Shafran, ana- a Special Psychiatric Hospital’’ [14]. A 1982 study by Serbski

lyzed a number of scientiﬁc articles published in the main psychiatrists Landau and Tabakova was chillingly direct:

Soviet psychiatric publication, the Korsakov Journal of ‘‘Previously conducted study of patients [by Landau and

Neuropathology and Psychiatry [13]. They took two sam- Tabakova] with delusions of reform showed that the content

ple years, 1978 and 1983, and found 37 and 27 articles of such delusional ideas extends beyond the realm of their

respectively that focused on schizophrenia. In these arti- interpretational relations, it always involved various aspects

cles, they concluded that ‘‘the notion of slowly progressive of the life of society as a whole . . . These patients wrote

schizophrenia is clearly widely extensible and is much numerous appeals and complaints to various organizations

more variable and inclusive than our own ideas of sim- . . The clinical aspects of the patients’ pathological state

ple schizophrenia or residual defect states. Many conditions as described above, coupled with their sense of psycholog-

which would probably be diagnosed elsewhere as depres- ical (‘offensive’) urgency, and, with their outwardly intact

sive disorders, anxiety disorders, personality disorders or and orderly behavior . . . determined the greatest degree of

hypochondria, seem liable to come under the umbrella of their social dangerousness and made it necessary to refer

slowly progressive schizophrenia in Snezhnevsky’s system’’ them to special psychiatric hospitals . . .’’ [14].

[13]. In the mid-1990s, two leading psychiatrists who worked in

Soviet dissident and former political prisoner Semyon Snezhnevsky’s Research Center wrote an analysis, which at

Gluzman [14] carried out even more extensive research in their own request was never published and remained in the

the 1980s. In his analysis, he quoted a large number of archives of the organization Human Rights in Mental Health-

works by well-known associates of the Serbski Institute, and FGIP. Twenty years later, the text is still of great interest,

in some of these studies, the political ‘‘illness’’ was far and provides a unique insight into Soviet psychiatry, the way

from being camouﬂaged. While sitting in the Lenin Library the system managed to develop, and the central role Snezh-

in Moscow, he went step-by-step through Serbski Institute nevsky played in all of this. In their work, the authors put

publications, in particular analyzing dissertations and other the role and position of Snezhnevsky against the backdrop of

scientiﬁc studies by staff members. His results were no a totalitarian Stalinist society, where each and every branch

less shocking. In his analysis, he quoted a large number of society was dominated by one leader, one school, and

of works by well-known associates of the Serbski Insti- one leading force. The authors assumed that Snezhnevsky’s

10 11

tute like Margaretha Taltse, Yakov Landau, and Tamara school became the leading one simply because one or the

Pechernikova. In some of these studies, the political other direction in Soviet psychiatry had to fulﬁll that role,

‘‘illness’’ was far from camouﬂaged, for example, patients and the choice fell on Snezhnevsky. However, the willing-

who were considered to be ill because of ‘‘excessive reli- ness of Snezhnevsky to answer the ‘‘needs’’ of the Soviet

giosity’’ [14]. Another study quoted by Gluzman concludes: security organs undoubtedly played a signiﬁcant role in this.

‘‘compulsory treatment in an ordinary psychiatric hospital According to the authors, the political abuse of psychi-

may be recommended for patients with schizophrenia with atry started much earlier than is generally assumed: ‘‘it

delusional ideas of reform, who show a diminished level of started when the State used the paternalistic tradition of

activity and in whom we can observe a difference between Russian psychiatry and forced the psychiatrists to impose

a certain way of life on their patients.’’ The needs of the

patient became secondary to the needs of the state and its

‘‘planned economy’’, a subjugation that was in fact no dif-

The outcome of the article is also of importance today, when ferent than in other parts of Soviet life. The consequences

new victims of political abuse of psychiatry in Russia are diag-

were initially not far-reaching. For example, a doctor dis-

nosed as having a ‘‘personality disorder’’, which seems to have

charges a patient before treatment is actually completed,

replaced sluggish schizophrenia as the brand mark, e.g. in the case

not because the patient can go home, but because otherwise

of the members of the music group ‘‘Pussy Riot’’. And, not only

the patient stays away from work too long; this in turn could

in Russia does this aspect of Soviet psychiatry prevail. In Ukraine,

negatively affect the statistical success-rate of the mental

a researcher of the Kyiv Institute of Psychiatry was recently told

health institution itself, which contravenes the ‘‘interests

he was suffering from ‘‘reform delusions’’ when he suggested to

of the State’’. However, in the course of time this practice

the director of Dnepropetrovsk Special Psychiatric Hospital that the

institution was outdated and needed thorough reform.

Semyon Gluzman, born in 1946, was arrested in 1971 and spent

ten years in camp and exile for his ‘‘in absentia’’ diagnosis of Gen-

eral Pyotr Grigorenko. He currently lives in Kyiv, Ukraine, and is Anna Iosifovna Tabakova, associate of the Serbski Institute,

President of the Ukrainian Psychiatric Association. involved in the cases of, a.o., Yuri Shikhanovich and Ivan Yakhi-

Margarita Feliksovna Taltse, head of the Fourth (Political) movich.

Department of the Serbski Institute after Daniil Lunts (died 1977), Initially this unique book, titled ‘‘Psychiatry, psychiatrists and

involved in quite a few cases, including Yuri Shikhanovich, Ivan society’’, was to be published by Geneva Initiative on Psychiatry, but

Yakhimovich, Vyacheslav Igrunov, Iosip Terelya. subsequently shelved at the request of the authors because of direct

Yakov Lazerevich Landau, associate of the Serbski Institute, threats that if the book would be published they, their partners

involved in the cases of, a.o., Pyotr Egides and Gederts Melngaitis. and offspring would lose their jobs and possibility to ever work in

Tamara Pechernikova, associate of the Serbski Institute, involved psychiatry again. However, considering the nature of the study and

in cases such as Natalya Gorbanevskaya, Vyacheslav Igrunov and Ivan the fact that twenty years have passed, the author decided to quote

Yakhimovich. the manuscript, keeping the authors anonymous.

Psychological and legal interventions for domestic violence 49

slowly but surely encompassed more political reasons. For

The post-Soviet period

instance, one of the authors describes receiving a phone call

from the local Party organs, asking him to postpone the dis- In 1991, when the USSR imploded and all ﬁfteen Soviet

charge of a patient for two weeks ‘‘because we don’t want republics gained or regained their independence, the domi-

to run the risk of having a Communist festivity disturbed’’. nance of communism as the only-permitted ideology ended.

For a psychiatrist who did not want to be in trouble and who With it disappeared this monistic view on reality, and thus

was part of a highly hierarchical controlling power structure, one of the main preconditions for the existence of a system

it became virtually impossible not to fulﬁll such a seemingly of political abuse of psychiatry.

innocent request. Indeed, the practice of using psychiatry against political

One should not forget that Soviet psychiatrists had little opponents virtually ceased to exist. Some cases sur-

chance to escape the all-pervasive control by the Communist faced, notably in 1996 in Turkmenistan and in Uzbekistan.

Party and its organs because of their three-fold dependency What came in its place, however, was a very disturb-

on the Soviet state: scientiﬁcally, because their research ing collection of other forms of abuses, including human

work depended on their allegiance to the Soviet authorities; rights abuses due to lack of resources, outdated methods

politically, because they had to organize their professional of treatment, lack of understanding of human individ-

life and interact with authorities so as not to lose their sup- ual rights and a growing lack of tolerance in society

port; and economically, as private practice did not exist and [17].

they were all employees of the State. People in leadership Although on the outside the political climate in the

positions could not just be successful in leadership: ‘‘that former Soviet republics might have changed, in the minds

. .

success depended on other conditions; those who were of the citizens much of the psychological climate remained

able to maintain the necessary interactions with the author- unaltered. As a result, the effect of a monistic worldview

ities had the biggest chance of making a career. For that, continued to dominate societies in most of the former Soviet

they had to fulﬁll a multitude of requirements. Next to spe- republics. Especially in Central Asian republics, the Rus-

ciﬁc personal qualities that were necessary to be able to sian Federation and Belarus, the psychological climate of

maintain contacts with speciﬁc Party ofﬁcials, there were the Soviet period has remained by and large the same,

also other demands, in particular having a character by the and in some, the communist ideology was replaced by

book’’ [15]. In other words, one had to understand that a nationalist or even neo-fascist world view that is as

‘‘Befehl ist Befehl’’ and orders should not be questioned. totalitarian as its predecessor [18]. One should also note

Another factor that helped to impose political abuse of that in these countries the reform movement in mental

psychiatry on the psychiatric community and root out poten- health had only a limited impact. Many of the mental

tial opposition was the fact that for many years, there was health institutions remained inhuman environments, while

an unchangeable, informal and outwardly invisible hierar- the level of psychiatric care was far from acceptable

chy of mental health institutions. This looked more or less and knowledge about modern therapeutic approaches, the

as follows: the highest step on the ladder formed the scien- role of relatives and carers and the self-help capabili-

tiﬁc research institutes, then the psychiatric faculties, then ties of mental health users remained scarce and limited

Moscow and Leningrad psychiatric hospitals, then oblast and [19,20].

city psychiatric hospitals, then oblast and city outpatient Starting this century, the number of individual cases of

clinics and, at the lowest step, came the regional psycho- political abuse of psychiatry has increased, in particular,

neurological outpatient clinics and cabinets. If a doctor who over the past few years in Russia, Belarus and Kazakhstan.

worked in a dispenser would change a diagnosis, it was usu- So far, it does not yet appear to be a systematic repres-

ally considered an ‘‘attack’’ on the institution that was sion of dissidents through the mental health system. In most

higher up on the hierarchical ladder. In other words, a diag- cases, citizens fall victim to regional authorities in localized

nosis established by a ‘‘higher institution’’ was obligatory to disputes, or to private antagonists who have the means to

follow by a ‘‘lower institution’’ and as a result, if the Serb- bribe their way through the courts [2].

ski Institute in Moscow declared a dissident to be mentally The resumption of individual cases of political abuse

ill, no lower-placed psychiatrist would dare to go against it. in these countries is, in my view, closely linked to the

Finally, one should not forget that the Soviet Union was, deteriorating human rights situation, and the fact that

to a very high degree, a closed society, a society that was lower-level authorities feel much more freedom to clamp

cut off from the rest of the world. In the world of today, down on undesired elements than previously. Again, an air of

with Internet, social media and a multitude of possibilities untouchability has returned, and the rule of law has increas-

to bypass bans and restrictions with false IP addresses and ingly become subject to political machinations. In particular

the like, it is very hard to imagine that such isolation was in the Russian Federation, much of the structure is still in

possible, but in Soviet times, keeping a country isolated was place that allowed the political abuse of psychiatry to hap-

much easier, and the Soviet authorities were masters of this. pen. The ﬁrst cases of renewed political abuse of psychiatry

In the ﬁeld of psychiatry, this meant that world psychiatric started to emerge in the beginning of the twenty-ﬁrst cen-

literature was unavailable, except to the politically correct tury, after Vladimir Putin resumed the Presidency and the

psychiatric elite [16]. Western psychiatric literature became downward spiral towards increased repression commenced

rare: the number of periodicals that came was limited and a [2]. At this moment we are looking at a country that has

large part wound up in the ‘‘special holdings’’ of the Lenin a growing number of political prisoners (52 in December

library in Moscow and were impossible to access without 2013; 92 in June 2014, 114 in October 2014 and 181 at

special permission, which was given only to a handful of the beginning of March 2015) [21] and where over the past

mainly Moscow-based psychiatrists. years, some two dozen new laws have been introduced that

50 R. van Voren

seriously restrict liberties and freedom of expression in Rus- Internet and the use of social media. Most of these attempts

sian society [22]. are futile and easily bypassed by technical means.

Equally worrying is the fact that in many of the former Mental health professionals are now, at least in the-

Soviet republics, the nature of psychiatric practice has not ory, able to have access to and be active members of the

fundamentally changed. It is not only that psychiatric ser- global mental health community, and thus by instituting

vices remain highly institutional and biologically oriented, a boycott, the result might be the opposite of what one

with few, if any, components that are community-based intends to achieve. However, by stimulating communica-

or community- and user-oriented. At least as disturbing tion and access, by providing training in issues of medical

is the fact that in only a few countries, psychiatric edu- ethics and human rights, and by translating key documents

cation has undergone a signiﬁcant change, and in most, and manuals into the local languages, it becomes impossible

the old generation of Soviet psychiatrists, their peers, stu- for both authorities and authoritarian psychiatric leaders to

dents and offspring remain in charge, thereby passing on keep their constituency uninformed.

the same faulty concepts to future generations. Particularly In the case of the Russian Federation, a key element

difﬁcult is the situation in forensic psychiatry and prison in the continued dominance of the Moscow School lies in

mental health, where repression dominates everything and the fact that probably more than 90% of the rank and ﬁle

the creation of a therapeutic environment within the limi- Russian psychiatrists do not know any other language than

tations of a prison environment remains in most cases a fata Russian. Therefore, when books, articles and documents are

morgana. not available in a language accessible to them, it remains

possible for the psychiatric leaders (many of whom still

stem from Soviet times) to pretend that the diagnosis used

for Soviet dissidents — ‘‘sluggish schizophrenia’’ — is quite

accepted in the world and even part of the International

How should world psychiatry respond?

Classiﬁcation of Diseases ICD-10. The only way to end

Looking back, the issue of Soviet political abuse of psychiatry this ‘‘misunderstanding’’ and the continued perversion of

had a lasting impact on world psychiatry. The most positive medical science is through the creation of open access to

aspect is probably that the issue triggered the discussions on information, the maximal use of modern technology, and a

medical ethics and the professional responsibilities of physi- language that is easily accessible. Knowledge is power, and

cians (including psychiatrists), resulting in the Declaration of that has been given a new meaning in the age of hi-tech

Hawaii of the WPA and subsequent updated versions. Also communication.

many national psychiatric associations adopted such codes,

even though adherence was often merely a formality and

sanctions for violating the code remained absent. In that

sense, the debates surrounding Soviet psychiatric abuse had Disclosure of interest

a very important corrective effect on world psychiatry, but

it did not stop authorities — and psychiatrists — altogether The author declares that he has no conﬂicts of interest con-

from using psychiatry as a means of political repression. cerning this article.

In the 1970s and 1980s, the main drive of the opposi-

tion to Soviet psychiatric abuse was focused on expulsion

of the Soviet society from the world psychiatric commu-

nity, notably the WPA. In that case, the expulsion worked, References

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