PSYCHIATRY AND POLITICAL DISSENT

150

Mental Health PSYCHIATRY AND POLITICAL DISSENT

hardly surprising that this procedure often fails.

W. L. TONGE

Whiteley

Wood

Clinic, Sheffield S10 3TL

This paper

the validity of two Russian political offenders which were included in documents recently published. It is concluded that there are grounds for unease: Soviet forensic psychiatrists seem to have failed to maintain a true professional objectivity in some difficult cases, and there seems to be a lack of adequate safeguards for the rights of compulsorily detained patients in the Soviet Union. assesses

Summary Summary psychiatric reports

on

CONCERN has been expressed over allegations that treatment in mental hospitals is being used in the Soviet Union as a form of social control over political dissenters. U.S. Senate hearings1 have made available documents which purport to be texts of psychiatric reports on these offenders. These reports were smuggled out of Russia, and their authenticity is therefore not beyond dispute. Nevertheless they make possible a cautious appraisal of the clinical judgment of Soviet forensic psychiatrists.

compulsory

SOVIET

SCHIZOPHRENIA

Snezhnevsky2 defines

subgroup of schizophrenia only symptom for most of the time is mildly psychopathic behaviour. The International Pilot Study of Schizophrenia3 noted that because of the subgroups of shift-like " and sluggish " schizophrenia which are not used outside Russia, the diagnosis of schizophrenia was made in Moscow on cases which elsewhere would probably have been given the diagnosis of an affective psychosis. These different conventions of diagnosis complicate the task of evaluating Soviet psychiatric reports. These

(" shift-like")

a

in which the "

first opinion. To do this the court must present " detailed reasons for their disagreement with the experts and substantiate it with concrete arguments ".4 If the defence wishes to present further expert evidence, it must first persuade the court to reject the first expert opinion. It is

"

difficulties become apparent in the case of Natalie GorShe experienced an episode of auditory hallucinations in 1955, and the suspicions she entertained in hospital in 1959 that the other patients were really healthy people made ill by autosuggestion are characteristic

banevskaya.

schizophrenic experiences. On the other hand, the description of her mental state (report no. 28/S) does not contain any clear-cut sign of schizophrenia. The commission noted an abnormal lack of anxiety about the fate of her children and herself, and they noted paralogical and inconsistent thinking, but gave She seems to have lacked some insight no example of it. into her situation at that time. Although this type of behaviour could be consistent with schizophrenia, the absence of florid symptoms would lead most psychiatrists to the opinion that she had a personality disorder with hysterical symptoms. Most psychiatrists would agree that Gorbanevskaya had a psychological disturbance and was in need of help; but was she in need of compulsory treatment? At this point an important difference between English and Soviet law must be made clear. In English law, if expert medical evidence is called by either side, it is open to the other side to call further expert evidence in rebuttal if they wish. In Soviet law the expert is independent, and a second opinion is only sought if the court rejects the

In these cases the accused is in effect on trial on two the offence with which he is charged and his sanity. The tragedy of these cases lies in the sense of helplessness. There is pathetic testimony of this in the letters and statements of Gorbanevskaya.1 counts:

POLITICAL

DELUSIONS

One of the central features of this controversy is the extent to which unacceptable political ideas are taken to be signs of mental illness. This point is raised in the case of Pyotr Grigorenko. On Feb. 7, 1970, former Major-General Grigorenko was found guilty by a Tashkent court of lying and making slanderous statements and of agitating against the Soviet State. The court also made an order for his compulsory treatment at the prison psychiatric hospital in Kazan. On Aug. 18, 1969, Grigorenko had been examined on the premises of the K.G.B. by a commission of doctors led by Professor Detengof, and it was concluded that he did not show any symptoms of mental illness: "in what he did he was of sound mind". On Oct. 21, 1969, Grigorenko was admitted to the Serbsky Institute. They found Grigorenko to be suffering from a mental illness " in the form of a pathological [paranoid] development of the personality, with the presence of reformist ideas that have appeared in his personality, and with psychopathic features of the character and the first signs of cerebral He was considered not to be arteriosclerosis". his actions and to be of unsound mind. for responsible It is instructive to compare the two reports. Although their conclusions are contradictory their observations regarding Grigorenko’s mental state are Both reports describe him as making a similar. normal emotional contact but liable to become excited and flushed when his political activities were discussed. Neither report produces evidence of paranoid delusions. Both reports showed that Grigorenko had insight into his current social situation and there were no disturbances in his memory or concentration. There is an interesting difference between the two reports in their attitude to Grigorenko’s political activities. Professor Detengof and his colleagues note

(report

no.

40) :

"... Evaluates critically his criminal activities before 1964, when he produced and distributed leaflets and other documents amongst the population. Considers this method of struggle to be incorrect.... Grigorenko’s activity had a purposeful character, it concerned current events and facts, arose from his personal convictions and in many cases from the same convictions as his fellow thinkers, and it did not contain sick or hysterical symptoms ".

Professor Lunts and his colleagues (report no. 59/S) describe Grigorenko’s abnormal mental state at the time of a previous admission to the Serbsky Institute in 1964 and go on to note: " At the same time he affirms that all he wrote during that period was perfectly correct: he does not, renounce the views which he expressed then ".

even

now,

151

Their report concludes: Confirination of this [paranoid

development of be seen in the psychotic condition present in 1964 which arose during an unfavourable which manifested itself in ideas with strongly affective colouring of reformism, and of persecution. Subsequently, as is evident from the documents of the .::’.::Jll1al case and the data of the present clinical examination. the paranoid condition was not completely overcome. Reformist ideas have taken on an obstinate character and determine the conduct of the patient; in addition, the ensity of these ideas is increased in connection with various external circumstances which have no direct ralation to him, and is accompanied by an uncritical 3t:ltude to his own utterances and acts ".

personality]

can

While Professor Detengof was concerned to show :h3t Grigorenko had gained insight into the illegality of the ways in which he had sought to disseminate his ideas, the staff of the Serbsky Institute were more The issue concerned with the ideas themselves. between the two reports therefore is whether Grigorenko’s political ideas are in themselves symptoms of equal diagnostic significance to the paranoid ideas expressed in 1964. COMPULSORY

TREATMENT

The problem becomes more acute when psychiatrists are asked to give an opinion on the emergency compulsory admission of a patient to hospital (without recourse to the courts) on the grounds that the patient may become socially dangerous. In the Soviet Union this type of admission is governed by the instructions issued in 1961. The relevant paragraphs (the

emphases

are

mine)

are as

follows :4

mentally ill person presents a clear himself, health agencies shall have danger the right to place him in a psychiatric institution without the ccnsent of the patient himself and his relatives or ruardians (in the form of rendering immediate psychiatric "1.When the to

others

or to

2. The principal consideration for compulsory hospitalisation shall be the social danger of the patient, indicated by the following characteristics of his illness: a...

’

Systematised delusional syndromes of a chronic progressive course, if they motivate the socially dangerous conduct of the patient.... The conditions of illness erated above, which contain doubtless social dangers, be accompanied by externally correct behaviour and nulation. In this connection ’&mid ot; exercised in

extreme

caution should

the psychiatric condition of persons so as to, without expanding the criteria for immediate hospitalisation, at the same time, ’ mely confinement, prevent the possibility of the of socially dangerous acts on the part of the ill person ".

appraising

The practical consequences of these instructions -- been far reaching. The case of Zhores Medvedev is well known. The used for the first contact with Medvedev was inquiry about his son whose behaviour had been - . -bed over the previous two or three years. The had been opened by a Government gation initial the inquiries being made by the chairof the city soviet. In the interviews with the

psychiatrist it was soon clear to Medvedev that it was his opinions that were in question.5 A society which exacts ideological conformity from its members must regard dissent as lawbreaking. If the dissenters are honest, hardworking, and responsible men such as Medvedev they are accused of insanity. It is important to note that compulsory admission is arranged primarily to prevent the commission of socially dangerous acts, but the patient. is released with a caution if no overt illness can be found. The conclusion cannot be avoided that compulsory admission to hospital is used to warn off the would-be offender under circumstances in which police action would not be appropriate. It is not surprising that the Medvedev brothers refer to this as " psychiatric blackmail". The material presented shows that Soviet forensic psychiatrists may fail in the task of demonstrating that reformist political ideas are not the same as paranoid delusions. The psychiatrist is struggling against a cultural current which assumes that a taboo activity must stem from a mental disorder. When the psychiatrist abdicates from this responsibility he is allowing himself to be swept away by a tide of irrational prejudice from a position of scientific

objectivity. decision finding a dissenter to be insane must sometimes be convenient for the authorities. It explains away the fact of dissent to a fearful public who might otherwise be disturbed that an important person such as Grigorenko was found to be a traitor to his country. It is also possible that convincing An anxious evidence of guilt might be lacking. Government would prefer the custodial care of a special hospital to the possibility of a verdict of not A

court

guilty. It is also possible that some forensic psychiatric commissions took the view that their responsibility to the State was more important than their responsibility to the patient. These are grave charges for which, it must be admitted, there is no direct evidence. It is difficult, however, to accept as fortuitous that all the available reports of the Serbsky Institute decided that the offender is non-accountable even when they were unable to offer convincing evidence. The provincial commissions tended to produce a conflict of opinions, as might be expected in difficult It is also difficult to explain why the reports cases. from the Serbsky Institute always recommended treatment in a special rather than an ordinary mental hospital. Finally, we must not ignore the possibility that Professor Lunts and his colleagues were themselves subject to pressure in forming their opinions. It may be wondered why so much more attention has been paid to the " illegal " detention of patients in Soviet mental hospitals than in other countries. This must be due to some extent to the publicity efforts of anti-Soviet groups, but Cooperhas shown that compulsory treatment for schizophrenia in Britain is most common in the lower occupational groups. These patients and their families are the least able to make an effective protest if they feel that they are wrongly detained. Unfortunately for the Soviet psychiatrists, some of the most influential and able citizens have found themselves dealt with under the

152 1961 instructions. There are not many patients who write a book about their experiences and arrange for it to be published in a foreign country. It would seem, therefore, that there are grounds for uneasiness regarding the use of the Soviet mental health services in the control of political dissent, yet I will have failed in my purpose if psychiatrists in all countries do not recognise the problems met in preparing an objective forensic opinion and the dangers involved in compulsory admission. It has been suggested that these difficulties could best be overcome by the establishment of some international tribunal to which appeal could be made. This idea does not commend itself to me. In the first place, only intellectually and socially resourceful people would be able to make use of such a procedure. Second, it would be very difficult to offer a valid opinion on a conflict between a patient and a mental-health service if the tribunal belonged to a different society and culture to the appellant. Third, the authority of the tribunal must be accepted by all parties if it is to be effective. As Greenland has shown,’ mentalhealth review tribunals do not always have good relationships with the hospitals they visit. Such difficulties would become insuperable with a foreignbased tribunal. I do not believe that any administrative regulations The difficulties decrease, will solve this problem. surely, with an improvement in the standard of practice of psychiatry. The recasting of mental-health regulations can only be achieved at the insistence of the

Views of General Practice

can

indigenous psychiatrists. Twice in recent years there have been attempts in international psychiatric conferences to raise the question of the wrong use of mental hospitals. In both cases the attempt failed on the grounds that the psychiatrists of the socialist republics might withdraw. Yet we do our colleagues a disservice if we collude with them in avoiding the dangerous problems. The difficulties of forensic psychiatry and compulsory admission require more searching attention. In arranging international conferences on these topics some of the more obvious political hazards might be avoided if we were to pay attention to an interesting feature of Soviet culture: the practice of inviting selfcriticism. The problems are present in different ways in all mental-health services: the dialogues of international psychiatry might merit more respect if we were

invited

to

present

our

failures rather than

our

’

successes.

I thank many

colleagues for help in the preparation of this especially Prof. F. A. Jenner, Dr H. Merskey, and Dr C. P. Seager. paper,

REFERENCES 1. U.S. Senate, Subcommittee of the Committee on the Judiciary. Abuse of Psychiatry for Political Repression in the Soviet Union. New York, 1973. See Lancet, 1974, i, 419. 2. Snezhnevsky, A. V. in Modem Perspectives in World Psychiatry (edited by J. G. Howells); p. 433. Edinburgh, 1968. 3. The International Pilot Study of Schizophrenia. World Health Organisation, Geneva, 1973. 4. Morozov, G. V., Kalashnik, I. M. (editors) Forensic Psychiatry (translated by M. Vale). New York, 1970. 5. Medvedev, Z. A., Medvedev, R. A. A Question of Madness (translated by Ellen de Kadt). London, 1971. 6. Cooper, B. Br. J. prev. soc. Med. 1961, 15, 17. 7. Greenland, C. Mental Illness and Civil Liberties: Occasional Papers on Social Administration no. 38. London, 1970.

THE GENERAL-PRACTICE DILEMMA MICHAEL

J. F. COURTENAY

IT has been said that the greatest single contribution in reducing the number of attempted suicides could be made by a change in doctors’ attitudes-if they would listen more and prescribe less.! That is easily said, and- every G.P. must have felt the need to prescribe in order to get rid of a patient in a busy surgery; but what are the implications of giving more time? In a major survey of 46 London general practicesit was found that, of every 1000 patients on a doctor’s list, 140 were diagnosed by him as psychologically disturbed in one year-this without a screening questionary, and with no especial interest in psychiatry. From this Kessel3 concluded that if the doctor tried to see each such patient for only 10 minutes each month, and if he had an average list of 2500, his 350 interviews a month would take him 58 hours (or 14 hours a week). Clearly he must either selectively neglect some of his other patients or decide not to see his psychoneurotic patients so regularly. If he chooses the latter, is there any point in detect-

ing psychological disorder? This brings me to the hidden part of the iceberg4 of undiagnosed illness. Alcoholism and the G.P. S states that most family doctors fail to detect alcoholism in their patients. Yet if G.P.S currently diagnose only 10% of the alcoholics on their lists, where the resources to treat 10 times the present number? A survey by the Patients’ Association6 reports complaints that, because it might take days to get an appointment with the doctor, some people no longer bothered with him and treated themselves instead, possibly with a chemist’s assistance. It also" reported criticisms of receptionists and isolated the officious

are

as a particular menace. But the time for general practitioners to stop sheltering behind our receptionists’ aprons and to take responsibility for anything that is amiss with our appointment systems. Consider another simple calculation. A survey revealed that on average every patient on the list made 5 contacts per year, and a quarter of them were urgent demands on a given day.’ These attendance figures fall within the normal curve of the published range 8 With a population of 2500 patients per doctor this means 10,000 face-to-face consultations a year, or 200 a week. At 9 patients per hour tlds means 22 hours per week, which (allowing for a proportion of visits) equates pretty well with the usual 10 2-hour surgeries per doctor per week. Even a modest increase to 10 minutes per patient would increase this to 33 hours a week, and, if only one in 10 of such conditions as alcoholism are now being diagnosed, where will the results of this expertise lead? And where then is the urgent casual attender to be fitted in by that supposed termagant, the receptionist ? The obvious answers are either to keep a quarter

receptionist " has

come