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The use of psychiatry for political purposes has been a major subject of debate within the world psychiatric community during the second half of the 20th century. The issue became prominent in the 1970s and 1980s due to the systematic political abuse of psychiatry in the Soviet Union, where approximately one-third of the political prisoners were locked up in psychiatric hospitals. The issue caused a major rift within the World Psychiatric Association, from which the Soviets were forced to withdraw in 1983. They returned conditionally in 1989. Political abuse of psychiatry took also place in other socialist countries and on a systematic scale in Romania, and during the first decade of the 21st century, it became clear that systematic political abuse of psychiatry is also happening in the People's Republic of China. The article discusses the historical background to these abuses and concludes that the issue had a major impact on the development of concepts regarding medical ethics and the professional responsibility of physicians.
Time and again, human rights and mental health organizations receive reports on cases of abuse of psychiatry for political purposes. The fact that these reports come from a wide range of countries shows that there is an ongoing tension between politics and psychiatry and that the opportunity to use psychiatry as a means to stifle opponents or solve conflicts is an appealing one, not only to dictatorial regimes but also to well-established democratic societies.
According to a position article of the Global Initiative on Psychiatry (GIP), “political abuse of psychiatry refers to the misuse of psychiatric diagnosis, treatment and detention for the purposes of obstructing the fundamental human rights of certain individuals and groups in a given society. The practice is common to but not exclusive to countries governed by totalitarian regimes. In these regimes abuses of the human rights of those politically opposed to the state are often hidden under the guise of psychiatric treatment. In democratic societies ‘whistle blowers’ on covertly illegal practices by major corporations have been subjected to the political misuse of psychiatry.” (The full text of the position article of GIP can be ordered from GIP.)
Historically seen, using psychiatry as a means of repression has been a particular favorite of Socialist-oriented regimes. An explanation might be found in the fact that Socialist ideology is focused on the establishment of the ideal society, where all are equal and all will be happy, and thus, those who are against must be mad. In fact, this second part seemed to have had the strongest influence because even in the Soviet Union of the 1970s, where many were not happy and society was far from ideal, many psychiatrists still believed that those who turned against the regime must be mad.
The political abuse of psychiatry in the Soviet Union originated from the concept that persons who opposed the Soviet regime were mentally ill because there was no other logical explanation why one would oppose the best sociopolitical system in the world. The diagnosis “sluggish schizophrenia,” an old concept further developed by the Moscow School of Psychiatry and in particular by its leader Prof Andrei Snezhnevsky, provided a very handy framework to explain this behavior. According to the theories of Snezhnevsky and his colleagues, schizophrenia was much more prevalent than previously thought because the illness could be present with relatively mild symptoms and only progress later. As a result, schizophrenia was diagnosed much more frequently in Moscow than in other countries in the World Health Organization Pilot Study on Schizophrenia reported in 1973.1 And, in particular, sluggish schizophrenia broadened the scope because according to Snezhnevsky and his colleagues patients with this diagnosis were able to function almost normally in the social sense. Their symptoms could resemble those of a neurosis or could take on a paranoid quality. The patient with paranoid symptoms retained some insight in his condition but overvalued his own importance and might exhibit grandiose ideas of reforming society. Thus, symptoms of sluggish schizophrenia could be “reform delusions,” “struggle for the truth,” and “perseverance.”2
While most experts agree that the core group of psychiatrists who developed this concept did so on the orders of the party and the Soviet secret service KGB (Komitet Gosudarstvennoi Bezopasnosti) and knew very well what they were doing, for many Soviet psychiatrists this seemed a very logical explanation because they could not explain to themselves otherwise why somebody would be willing to give up his career, family, and happiness for an idea or conviction that was so different from what most people believed or forced themselves to believe. In a way, the concept was also very welcome because it excluded the need to put difficult questions to oneself and one’s own behavior. And difficult questions could lead to difficult conclusions, which in turn could have caused problems with the authorities for the psychiatrist himself.
On basis of the available data, one can confidently conclude that thousands of dissenters were hospitalized for political reasons. The archives of the International Association on the Political Use of Psychiatry (IAPUP) contained over a 1000 names of victims of whom we had multiple data (name, date of birth, type of offense, and place of hospitalization), all information that had reached the West via the dissident movement. However, this number excluded the vast “gray zone,” people who were hospitalized usually for shorter periods of time because of a complaint to lower officials, conflicts with local authorities, or unorthodox behavior. It is estimated that this group was much larger. Their names were, however, not known to the dissident movement and thus not recorded in the west. A biographical dictionary published by IAPUP in 1990 listed 340 victims of political abuse of psychiatry as well as more than 250 psychiatrists involved in these practices.3 An investigative commission of Moscow psychiatrists, who researched the records of 5 prison psychiatric hospitals in Russia from 1994 to 1995, found approximately 2000 cases in these hospitals alone.4
As indicated before, many of these psychiatrists were probably unaware that they engaged in unethical behavior and that they were part of a governmental repressive machinery. For example, Ukrainian psychiatrist Ada Korotenko found out only in the mid-1990s that former colleagues of her had been involved in the political abuse of psychiatry when she participated in a Ukrainian study into the origins of political abuse of psychiatry and in the course of that study examined 60 former victims. Under the original Soviet diagnoses, she found the names not only of former colleagues but also even of some of her friends. While interviewing the former victims and comparing their state of mind with the original diagnoses, she realized not only that they had been hospitalized for nonmedical reasons but also that she could have authored the original diagnoses herself. (See Korotenko and Alkina4 and private conversations of the author with Dr Korotenko. Other former Soviet psychiatrists confirmed this dilemma—see van Voren.5)
The Soviet Union is certainly not the only country where these abuses took place. Over the past decades, we have seen a lot of documentation on other countries. (The author was one of the founding members of the IAPUP. This organization was later renamed in Geneva Initiative on Psychiatry, and since 2005, it is called GIP. See van Voren5) One of the countries where systematic political abuse of psychiatry seemed to have taken place was Romania; in 1997, IAPUP organized an investigative committee to research what actually happened and came to the conclusion that several hundred people had been victims of systematic abuse.6 Like in the Soviet Union, on the eve of Communist festivities, potential “troublemakers” were delivered to psychiatric hospitals by busloads and released when the festivities had passed.
In the 1980s, we also received information on cases in Czechoslovakia, Hungary, and Bulgaria, but all these cases were individual, and there was no evidence that a system of abuse was in place. Information on political abuse of psychiatry in Yugoslavia, received in the 1980s, was inconclusive. (The Review Committee of the World Psychiatric Association came to the same conclusion. See travel report of Prof J. Neumann on the WPA Executive Committee meeting in Sydney, May 1987: p3. The private document is in the author’s possession.) An extensive research on the situation in Eastern Germany concluded that there had not been any political abuse of psychiatry, although in this Socialist country politics and psychiatry appeared to be very closely intermingled.7 Later, information appeared on the political abuse of psychiatry in Cuba, which was, however, short lived.8 In the 1990s, the successor organization to IAPUP, the GIP, was involved in a case of political abuse of psychiatry in The Netherlands, in the course of which the Ministry of Defense tried to silence a social worker by falsifying several psychiatric diagnoses. The case took many years to be resolved, and although the victim was compensated and even knighted by the Dutch Queen, it is still not fully resolved as the Ministry refuses to discard his medical files and keeps him on regard as a mental patient. (For the case of Fred Spijkers, see Nijeboer.9)
And, finally, since the beginning of this century, the issue of political abuse of psychiatry in the People’s Republic of China is again high on the agenda and has caused repeated debates within the international psychiatric community. The abuses there seem to be even more extensive than in the Soviet Union in the 1970s and 1980s and involve the incarceration of followers of the Falun Gong movement, trade union activists, human rights workers and “petitioners”, and people complaining against injustices by local authorities.10,11
During the years of our existence, we were regularly approached with requests to deal with abusive situations in psychiatry in countries such as South Africa, Chile, and Argentine. However, on basis of research, we concluded that in these cases one could not speak of political abuse of psychiatry. In the case of South Africa, severe abuses were the result of the policy of apartheid, which resulted in very different conditions in mental health services for the white ruling class and the black majority of the population. Claims that psychiatry was abused as a means of political or religious repression were never confirmed. In South America, the abuse concerned psychiatrists themselves, not psychiatry as such: Psychiatrists were used to determine which forms of torture were the most effective, and although these abuses clearly constituted a serious violation of the Hippocratic Oath, they could not be classified as political abuse of psychiatry.
Admittedly, those involved in the struggle against political abuse of psychiatry never reached full consensus on what the exact boundaries were between political abuse of psychiatry and more general misuse of psychiatric practice. The definition of political abuse of psychiatry as worded in the GIP position article is the closest we got to a consensus. In the course of the years, many individual cases were discussed extensively, determining whether it should be considered as one of political abuse of psychiatry or not. The issue continues to be discussed, in particular, because recent cases are often more complex and involve a less overt government involvement.
The question remains whether political abuse of psychiatry is on the wane or still used as extensively as before. On one hand, it seems that the number of countries that have a system of political abuse of psychiatry has significantly decreased since the collapse of communism in Eastern Europe. The only country that seems to abuse psychiatry for political purposes in a systematic manner is the People’s Republic of China, and in spite of international criticism, this appears to be continuing. On the other hand, reports on individual cases continue to reach us, including reports from Russia where the deteriorating political climate seems to create an atmosphere in which local authorities feel that they can again use psychiatry as a means of intimidation.
Looking back, the issue of Soviet political abuse of psychiatry had a lasting impact on world psychiatry as well as on the World Psychiatric Association. The most positive conclusion is that the issue triggered the discussions on medical ethics and the professional responsibilities of physicians (including psychiatrists), resulting in the Declaration of Hawaii and subsequent updated versions. Also many national psychiatric associations adopted such codes, even though adherence was often merely a formality, and sanctions for violating the code remained absent.