<i> Glasnost </i> in Psychiatry : Soviets Still See Dissidence as an Aberration

It was astonishing when the Soviets invited an official American delegation to investigate their psychiatric practices. Now that the delegation’s report is out, what may be even more astonishing are the implications of its findings. Read closely, they strongly suggest that, in many cases, Soviet psychiatrists have actually believed healthy dissidents to be mentally ill.

The delegation reported that half of the patients it re-examined--people identified by Western human-rights groups as dissidents hospitalized for their views--had no mental illness according to diagnostic criteria widely accepted in the West. Especially striking is the fact that a significant number of these healthy patients were hospitalized in 1987 or 1988, well after Mikhail S. Gorbachev’s “new thinking” on human rights hit its stride, and at a time when Soviet psychiatry was already under vigorous attack in the Soviet press for abuses of many kinds.

Why is this so striking? By 1987-88, any advantages that could be gained by deliberately and cynically misdiagnosing and hospitalizing dissidents were far outweighed by the nasty publicity that each such hospitalization would provoke abroad--publicity of a sort that Gorbachev was doing everything he could to avoid. By then, KGB officials and the psychiatrists who at one time accommodated them could assume that they’d be in serious trouble if they were to hospitalize someone they knew to be mentally well. In fact, it was probably risky even to keep in a hospital a healthy dissident who had been diagnosed before the Gorbachev era. Yet a significant number of patients found by the American psychiatrists to have no mental illness were, in fact, kept in hospitals with the same diagnoses well into 1988 and even in 1989.

Soviet psychiatrists, at least those in charge of diagnosing and hospitalizing dissidents, aren’t known for taking undue risks with their own well-being. How, then, are we to explain their behavior? The most logical explanation, and the most compelling, is that they actually believed that the dissidents they were hospitalizing, or keeping in hospitals, were ill.

This conclusion is supported by the fact that the American delegation was invited in the first place. Soviet psychiatrists must have been asked whether a visit by American colleagues would prove embarrassing. After all, whatever value such an invitation might have as a sign of Soviet sensitivity to Western human-rights concerns would be vitiated by a report revealing ongoing psychiatric abuses. For the Ministry of Foreign Affairs to have pressed ahead with the invitation, it must have been assured that, at least at the time, healthy dissidents were not being sent to or held in hospitals.

This leaves us with the intriguing question of why Soviet psychiatrists see at least some healthy dissidents as truly ill. The answer can be found in the nature of both Soviet psychiatry and Soviet society.

The dominant Soviet system for diagnosing severe mental illness is very broad; it permits the diagnosis of schizophrenia without any evidence of the kinds of psychotic symptoms, notably hallucinations and delusions, that are required to make the diagnosis in the West. One type of schizophrenia unique to Soviet psychiatry, known as the “sluggish” type because it is said to undergo a slow and insidious progression, may be characterized in some cases by “reformism”--the wish to reform society. Despite this suspicious feature, sluggish schizophrenia wasn’t invented merely to make it possible to diagnose healthy dissidents as ill; it was a central part of the Soviet diagnostic system well before it was ever used in dissident cases, and it continues to be used routinely, in nondissident cases, all across the Soviet Union.

Until just a few years ago, it was very dangerous to be a dissident. Punishment for the public expression of unorthodox views was sure and devastating. The rare persons expressing such views, which everyone agreed had no chance of changing society, were occasionally seen as courageous but were also likely to be suspected of being mentally ill. After all, who in his right mind would do anything so hopeless if it was also so dangerous? Ordinary Soviet citizens thought that way. KGB agents thought that way. And Soviet psychiatrists thought that way.

When the KGB had genuine doubts about the mental health of some dissidents and asked for psychiatric evaluation, those psychiatrists also had such doubts. But they had something else, too. They had a diagnostic system perfectly suited to contain those dissidents. They could therefore diagnose them as having, say, sluggish schizophrenia, resolve their doubts and feel assured that they were making a legitimate and accurate diagnosis.

Why should this practice have survived into the Gorbachev era, when speech is incomparably freer and it’s even hard to find an orthodoxy to violate? In the case of at least some dissidents who had been diagnosed before Gorbachev’s rise to power, the existence of those earlier diagnoses tended to make psychiatrists assume that the same illnesses were still present and justified new or continued hospitalization.

But even some healthy dissidents who were never before diagnosed as mentally ill may still be seen as ill by some Soviet psychiatrists. If someone has a particularly unusual political program, or pursues it on his own with unusual force and persistence, he may well be seen as odd and be diagnosed by Soviet psychiatrists as a schizophrenic, sluggish or otherwise. This is happening much less than it once did, but it hasn’t fully stopped.

Will it ever? If Soviet society continues to normalize and become ever more accustomed to dissent of all kinds, then dissent itself increasingly will be seen as normal. And if Soviet psychiatrists manage to rid themselves of their overly broad and unscientific diagnostic system, they will be less likely to diagnose courageous and unusual behavior as mental illness.

But if the current trends in Soviet society reverse themselves--if, in particular, Gorbachev fails and his “new thinking” is undone--then the old thinking will very easily and quickly return, and with it the diagnoses, the hospitalizations and, in full and devastating force, the psychiatric terror.

In 1983, Soviet psychiatrists quit the World Psychiatric Assn. to avoid being expelled. Last week, the American Psychiatric Assn. said it would oppose the Soviets’ request for reentry as full members at next month’s WPA meeting in Athens. The Americans have demanded, as a price of full membership, that the Soviets dissociate themselves from past abuses, take action to prevent their repetition, and discharge from hospitals all persons who are not mentally ill by Western diagnostic standards.

All that should go without saying. It’s a shame, and a tragedy for psychiatry, that we still have to say it.