Psychiatry
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From abuse to reform in
Soviet psychiatry
The mental health systems of post-communist countries face
considerable challenges, write Angela Carballedo and Declan Lyons
During the 1970s and 1980s, reports that the security
authorities in the Soviet Union were incarcerating dissidents
in psychiatric institutions caused considerable concern
in the west. By January 1983, a protracted campaign by
professional western psychiatric bodies and international
human rights organisations led to a decision by the Soviet
All-Union Society of Psychiatrists and Neuropathologists to
withdraw from the World Psychiatric Association in order to
avoid almost certain expulsion.1
It was not readmitted to the body until 1989, after several years of Perestroika and the preliminary establishment
of direct access by western psychiatric delegations to Soviet
forensic-psychiatric institutions and their alleged mentally
ill political inmates.2
The aim of this article is to provide an objective view of
the reforms and challenges that post-communist countries
in Europe have been facing in their mental health systems;
from the most authoritarian institutional culture of the
Soviet era to the most westernised model of the present.
Punitive psychiatry in the Soviet Union
Psychiatric services were meant to be grounded on
humanistic principles, universality of access and a core set
of international standards upon which the ethical and legal
practice of psychiatry around the world should be evaluated. However, no historical account of Soviet psychiatry
can ignore the tremendous association with political dissent
and suppression. The origins of Soviet abuse of psychiatry
date back to the non-medical use of psychiatry in Tsarist
Russia, but became common practice after the Bolshevik
Revolution.
Evidence of experimentation with psychiatry for specific
political reasons comes from the late 1940s at the peak
of Stalin’s rule. Previously, psychiatric departments had
been considered a ‘refuge’ against being sent to the Gulag,
the government agency that administered the penal labour
camps of the Soviet Union. More than 18 million people
passed through the Gulag between 1929 and 1953. From
the late 1940s, this policy changed and hospitalisation
and abuses to political dissidents for non-medical issues
became notorious.
It was during this same period that the Soviet psychiatric establishment began to apply, especially in the field
of forensic assessment, the now widely deplored range of
unorthodox clinical theories whereby particular forms of
political and religious dissent were seen as being attributable to certain specific varieties of ‘dangerous’ mental
illness.3
The most frequently used diagnosis of this type was
‘sluggish schizophrenia’, a diagnostic concept that was
first formulated and used briefly by American psychiatrists
during the 1930s, and then later adopted and radically
developed by Andrei Snezhnevsky, a leading figure in Soviet
psychiatry from the 1940s until his death in 1987.
Sluggish schizophrenia was the most frequent diagnosis to be applied to cases of alleged ideological deviance.
According to the notorious Serbski Institute for Forensic
Psychiatry, this ‘diagnosis’ could present with minimal personality change that could pass unnoticed to the ‘untrained
eye’. Psychotic features were not essential. Symptoms
referred to as part of the ‘negative features’ included conflict with authorities, poor social adaptation and pessimism,
and were themselves sufficient for a formal diagnosis of
the illness.
As a consequence of the above, people with non-psychotic
mental disorders or those who were not mentally ill at all
but questioned the ideological values of the state could
very easily be labelled with sluggish schizophrenia and be
treated with a number of heartless forms of restraint, pharmacological and physical treatments like electro-convulsive
therapy or unnecessary lumbar punctures.
Transition post-1989
The downfall of the Berlin Wall revealed more differences between the western and eastern countries than the
fictional assumed similarity proposed at the time. Sociopolitical observers have begun to identify the long-term effects
of dictatorial regimes that, with their constant disregard for
human rights and individual dignity, seem to survive long
after their dictators are formally removed.
In distancing themselves from the imposed image of
‘second world’ nations, eastern European countries took
different routes after the collapse of the Berlin Wall.
Those from central Europe settled into the mould of
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Psychiatry
western democracies, establishing mental healthcare policies with a relatively high degree of structuring of their
services.
In the rest of the eastern bloc, mental health systems
submitted to the excessive control of the previous regimes
to a much larger degree. The more pronounced the role
of traditional values in regulating communal, family and
professional life prior to dictatorial times, the easier it was
for health systems to yield to authoritarian pressure. This
brought about the pervasive idea of an institutional culture
in psychiatry which is still difficult to leave behind, even
to this day.
After 1989, the need for progress was not contested
but innovation was met with prejudice and stigma, which
manifested itself not only in terms of adverse laypersons’
attitudes to mental health but also in terms of legal restrictions in many domains of psychiatric practice.
Information on the history of political abuse in psychiatry
in the former Soviet Union is drawn from work documented
by the Global Initiative on Psychiatry. This non-governmental foundation has been linked extensively with the reformist
movement since 1989.
Reformist psychiatrists faced formidable obstacles, such
as the abstention of regular citizens from involvement in
public matters; the criticism of moving away from universal
access and tax-funded health systems to those with greater
reliance on private insurance; and the increased inequality
of access to healthcare.
Legal reform, although crucial to the evolution of psychiatric practice, is only the first step. It is one that must
be supported by a profession concerned with advancing
patients’ interests and by a society supportive of individual
liberty. The majority of eastern European countries have
ratified the International Bill of Human Rights and/or the
Council of Europe Convention for the Protection of Human
Rights and Fundamental Freedoms. These instruments
create a set of obligations on governments to respect and
protect human rights, and they acknowledge a number of
internationally agreed standards related to mental health
and its users.
Numerous centres throughout the former eastern bloc,
some of which are now EU countries (where reform is
mandatory), have been visited by the Council of Europe’s
Committee for the Prevention of Torture and Inhuman or
Degrading Treatment or Punishment (CPT), which ensure
the implementation of human rights and related ethics for
health services users. Changes in the criminal and civil law
and in health legislation have led to the production of a new
ethical code for Russian and other eastern European psychiatrists that is consistent with an internationally accepted
perspective. Hopefully, it will let us see the abuse of psychiatry as a tragic aberration of the past.
Psychosocial aspects of the change
The term ‘perestroika’, equated in the west as the restructuring of political and social aspects of life in communist
countries, in reality revealed a frustration towards authority
and a passivity regarding involvement with issues of change
when applied to many eastern bloc states.
It is important to acknowledge the role of psychological and social defences in times of rapid change. These
have manifested themselves many times in history and
are currently seen in the psychiatric systems of eastern
bloc countries. It has been a trend to refuse acceptance
of change at face value, have a selective perception of
only its negative consequences, and jump to pessimistic
conclusions.
The process of deinstitutionalisation in psychiatry is a
particular challenge, with staff re-allocation and retraining
being especially crucial. Railing against this is a common
perception that the main task of mental health services is
to ‘protect regular citizens’ from those who are mentally ill.
Growing awareness of violence, homelessness, crime and
addictions has taken the Soviet countries by surprise, and
communities have responded with disbelief and frustration
towards authority. Diseases once thought eradicated, such
as tuberculosis and dysentery, combined with the more
modern scourges of HIV, malnutrition and drug addiction, have resurged in a prison population. Nine of the 10
countries with the highest suicide rates in the world are in
the former eastern bloc. The high levels of mortality and
morbidity in the area are related to helplessness-associated
conditions, including suicide, violence and self-destructive
behaviours.
Compounding the lack of a strategic vision for reorganisation of psychiatric services are restricted health budgets
and a problem of wealth redistribution and corruption.
Conclusion
Fifty years of totalitarian disregard for human dignity and
mental wellbeing have left eastern European society almost
completely indifferent to entering public debate in matters
related to mental health and the implementation of legislative reform. The lack of political will and the profound crisis
of leadership and governance have disappointed citizens
when taking part in the active process of socioeconomic
transition.
While the World Health Organization and EU have provided recommendations for reform in mental health, the
real challenges eastern European countries are facing are
retraining staff with less repressive psychosocial rehabilitation skills, avoiding the use of restraints if possible, and
promoting voluntary treatment. Two major areas of need
stand out. These are the vocational, residential and psychosocial rehabilitation of people with severe mental illness
and dementia, and of people in prison settings where the
problems of infectious diseases, drug abuse and suicide are
increasing. Establishing mental health education is another
area that has not been fully developed in the region, where
previously mental illness was thought to affect a minority
and to be only a state matter.
The question of readiness to implement changes in these
countries has not been answered yet, mostly because of
the unequal redistribution of wealth and corruption in the
newly emerged ruling class. This has contributed to the
deterioration of an already fragile economy that is partially
dependant on international budgeting. Despite the presence of new political masters, it appears that psychiatry
could be destined to remain a Cinderella speciality in eastern Europe.
Angela Carballedo is a registrar and Declan Lyons is a
consultant psychiatrist at St Patrick’s Hospital, Dublin
References on request
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