The misuse of psychiatry in Soviet Russia still finds small echoes in everyday mental health care in the west.
by JP Sutherland
“Doctor, she needs more risperidone.”
“Good morning Mr. Jones, how are you?”
“Three milligrams isn’t enough. I’ve known her for twenty years, so you have to listen to me.”
“I am listening. And we will alter the dose, depending on how her illness progresses. At the moment she appears to be improving as we would expect.”
“But she’s still manic, and she was talking about a divorce.”
I managed to bite my tongue before I pointed out that wanting a divorce wasn’t necessarily a sign of mental illness, but it wasn’t easy. Something about this man brought out the worst in me, and I had taken an immediate dislike to him. He was short, middle-aged and mustachioed, and if I stopped to think about it then I could see that it was his entitled sense of authority that was the cause of my aversion. Fortunately, psychiatrists get trained in recognising and then hiding our occasional (but inevitable) hostility to some of our patients and their families, or what Freud called managing the countertransference. As a result, I knew that I appeared professionally detached, and no worse than that. Or at least I hoped that I did.
Most patients and their families agree to be called by their first names, but Mr. and Mrs. Jones didn’t look comfortable with that in their initial meeting with me, and I instinctively reverted to the polite honorifics. Mrs. Jones was forty-seven, looking sixty, and had been admitted with a recurrence of her bipolar disorder. For a month before hospitalisation, she had been overactive, increasingly talkative, and overspending. Her mood had tended to irritable rather than the more common elation of a manic episode, and when irritable she had been arguing repeatedly with her husband, and demanding a divorce. Her old charts listed a couple of previous admissions with a similar pattern, and now that her previous psychiatrist had retired, I was going to take over her care.
One theory of his that nags away at the corner of my mind is that psychiatrists are used by the state to define those who society wishes to exclude, and then to detain and medicate them.
In 1977 the World Psychiatric Association adopted a resolution condemning the abuse of psychiatry for political purposes, and specifically naming the Soviet Union as a place of concern in this regard. This was the culmination of a struggle over the preceding six years during which Soviet politicians and doctors had managed to prevent such a declaration at previous congresses. There had been increasing suspicion that political dissidents were being detained for ‘mental illness’ reasons since the nineteen-sixties, and this was confirmed when a over a hundred pages of psychiatric reports were leaked to the western press by Vladimir Bukovsky. This showed that opponents of the regime such as he were being detained in mental hospitals, medicated against their will, and often diagnosed with ‘sluggish schizophrenia’. This diagnosis was unique to the Soviet Union, and was made in the absence of any of the usual symptoms such as hallucinations, delusions, or thought disorder. And the premise behind the diagnosis was that anyone who opposed the world’s ‘most advanced social and political state’ must ipso facto be mentally ill.
“Good morning Mrs. Jones, how are you today?” I asked as we entered the interview room together.
“Not bad thank you doctor. But I do feel a little slowed.”
“I was wondering about that from watching the way you walked.”
“I feel a bit stiff in my legs. And my arms too.”
“I’m sorry to hear that – may I examine you?”
I reached over and took her arm in my hands. As I put it through the usual range of movements, slowly at first and then suddenly faster without any warning, I felt the stiffness, and also the jerky stop-go movement at the elbow that I was looking for.
“I’m sorry about this, but you seem to have a side effect of the risperidone. That’s what is slowing you down and making you feel stiff.”
She looked worried.
“Is it serious?”
“Not at all. It’s temporary, and all we have to do is drop the dose for it to go away. Let me just check on your manic symptoms first and then we’ll make a plan.”
A review of her mental state showed none of the previous overactivity or overtalking, and she now denied any of the grandiose ideas and disinhibited spending wishes of the past. She still wore a smile, but the fast-changing alternation of inappropriate cheerfulness and sudden irritability was gone.
“I think you are much improved, Mrs. Jones. How much would you say you are back to normal?”
“Maybe ninety percent. I can see how I was manic again, but I don’t think my concentration is quite right yet.”
“You’ve only been with us for a couple of weeks, so I would call that a fairly speedy recovery. However, your husband doesn’t seem to think you are your normal self.”
And with the mention of his name, her face dropped.
“He doesn’t like me manic. Or talkative.” She looked at me hesitantly. “I’m not sure he really likes me much at all.”
“That’s sad to hear. Would you like to talk about it more?”
Hesitantly at first, and guiltily as well, she told me how their marriage was so one-sided, and how she could never seem to please him except by silence and submission. She told me how his first reaction to any show of independence from her, or any argument, was to question whether she had taken her medication, and then make her take the ‘extra’ dose that we allow patients to use at the first sign of their illness returning. Medication such as risperidone can usually be taken without any significant side-effects, but if the dose is raised too high then people become slowed and quiet, as well as stiff in the muscles as we had just discussed. I checked that she wasn’t being physically abused as well as mentally, and then asked her a big question.
“When you were ill, I heard that you said you wanted a divorce. How do you feel about that now?”
“There’s nothing for me in the marriage. But I don’t think that I could manage alone.”
“I know it’s a big step to take, but if a divorce was what you wanted then we could help you tell your husband, and we could arrange some out-patient support for you later.”
There was a lengthy silence, during which she looked at me long and hard, with the saddest eyes I had seen in a long while.
“Let me think about it.”
“Don’t you dare prescribe more drugs to keep her quiet and please her husband.”
Misusing psychiatry as a form of social control was never more blatantly and openly done than in the former Soviet Union, but there have been plenty of other, similar, allegations against my profession. Thomas Szasz was the most vocal critic of psychiatry for my generation, despite being a psychiatrist himself. He made many arguments against his chosen occupation, including his claim that mental illness was unreal and nothing but a myth. Most of us have had no difficulty in seeing through his unproven allegations, and despite achieving considerable fame he accomplished little change. However, one theory of his that nags away at the corner of my mind is that psychiatrists are used by the state to define those who society wishes to exclude, and then to detain and medicate them. And although I don’t consider myself an agent of the state, and I certainly don’t receive any government orders regarding my patients, I nonetheless worry that he did have a point.
I am old enough to have trained in the last remaining Victorian asylums in the UK, which were situated outside city limits, and which hid their work behind a high perimeter wall. ‘Asylum’ means a place where those needing shelter and support can be helped, and I have frequently seen the truth of this, when a hospital admission away from someone’s overwhelming stressors allows them to recuperate and face the world again. However, when the asylums were built, a patient’s journey was often a one-way banishment from their lives and their families into the world behind the wall. With time, long-term patients became institutionalized, which reduced their chances of ever successfully returning to their former lives, and many of the mentally ill patients of a hundred years ago found that they had been rescued from the agonies of their disease, only to remain prisoner-like behind the asylum’s wall.
The old asylums have long been torn down, and hospitalisations are now radically shortened compared to the past, when they gave more credence to Szasz’s claims. Yet even though I have rejected his theories, I still picture him frowning as I sign a certificate to detain another acutely ill patient for a month or two. For me this was his true legacy; to remind us of the potential for abuse that comes with our power as psychiatrists, and to make sure that we carefully weigh the benefits of diagnosis and hospitalisation and medication, against their possible misuse.
Doreen wasn’t the most vocal social worker that I had worked with, but she wasn’t the quietest one either. I like to think that everyone who works in mental health will have some feeling for the injustices of the world, and a wish to help those whose lives have been burdened by adversity, or poverty, or the blind chance of disease. But within our multidisciplinary teams it is undoubtedly the social workers who are the strongest champions of equality and empowerment. Their training deals in detail with the unfairness of society’s hierarchies, and though their daily work in mental health often revolves around the more basic tasks of navigating the benefits system and doing family therapy, their sensitivity to injustice still burns bright. Once I had briefed our team on the details of Mrs. Jones’s situation, and her husband’s advice regarding her treatment, Doreen was the first to speak, leaning across the table and stabbing her finger towards me.
“Don’t you dare prescribe more drugs to keep her quiet and please her husband.”
“Doreen,” I laughed, “of course I won’t. She actually needs a slightly smaller dose to avoid the dystonia. But she is in a terrible situation. What shall we do?”
“Divorce.”
“Marital Therapy.”
“Ban him from visiting.”
The suggestions filled the air, and as a team we worked through their details one by one. At the end of the meeting, it was agreed that Doreen would meet Mrs. Jones to discuss a possible divorce, and how we could help her navigate the process, while I would talk to her about approaching both partners jointly to see if we could help the marriage.
“Mrs. Jones, how would you feel about trying some marital therapy sessions with your husband?”
“Call me Norah. I don’t think he would be interested, but if you could get him to agree then I would certainly give it a try.”
“I’ll ask him. And if he agrees then we can see how it goes. If we do proceed with it, then one of the things I will be asking you in the session is for an example of how you would like him to change. And I’ll be asking him the same question about you. Do you know what you would say?”
She thought for a moment.
“There’s so much; but one thing would be for him to hear me when I talk, and not interrupt or walk away or tell me to take another pill.”
“That sounds reasonable. I’ll see if he will agree to meet.”
One of the unexpected benefits of the Soviet Union’s abuse of psychiatry was that the international community addressed the ethical issues of our work more robustly. The Declaration of Hawaii in 1977 was the first of a number of explicit statements aimed at avoiding the misuse of hospitalisation and medication, and says…
The psychiatrist must on no account utilize the tools of his [this was still 1977] profession, once the absence of psychiatric illness has been established. If a patient or some third party demands actions contrary to scientific knowledge or ethical principles the psychiatrist must refuse to cooperate.
Reading it now, it appears to be so intuitive and obvious, and most western-trained physicians will simply take it for granted. Yet it not only stands as a bulwark against state-level coercion, but it is also a reminder to individual practitioners not to misdiagnose or mistreat our patients for the benefit of anyone other than our patient.
“Mr. Jones, could we talk for a few moments?”
“Yes doctor, I’ve been wanting to talk to you too.”
He was visiting Norah, and I couldn’t help but notice that her recently relaxed appearance had disappeared back into a submissive and hesitant posture. We walked to an interview room.
“This is a rather personal subject, but I think it bears discussion. Could we talk about your marriage?”
He stiffened, which suggested how this meeting was going to go, but I ploughed on regardless.
“Mrs. Jones suggests that things haven’t been too easy between you. What does it look like from your point of view?”
“When she’s ill she interrupts me and disagrees and won’t stay quiet. But once she’s better and properly medicated again things are all right.”
“Do the interruptions sometimes go both ways?”
“What do you mean?”
“Does she get interrupted much?”
“Only when she’s overtalkative. She’s bipolar.”
“Suffering from a bipolar illness makes people overtalkative when they are ill, but after recovery they return to their normal level of conversation.”
“That’s what I wanted to talk about. I don’t think she’s been properly medicated for years.”
This was almost certainly wrong. I hadn’t been her psychiatrist before now, but I knew and respected her former doctor and felt sure that he wouldn’t have prescribed inappropriately. Nonetheless, there was a way to double check this.
“How do you find Mrs. Jones at the moment? Would you say she has returned to her baseline?”
“Not at all. She’s still talking too much. I’ve been telling you to increase her dose, but I gather you actually reduced it.”
“Yes – just a fraction. But that was needed to avoid the side effects. Everyone here thinks that she seems well now.”
He stared at me, silently, but I could feel the disagreement and hostility.
“There is another way forward instead of medication increases. If you and she would agree to a few sessions of marital therapy, then we could try and find a way to improve the communication between you so that you might each find the other interrupting less.”
“I’m not doing any marital therapy! There’s nothing wrong with our marriage that risperidone won’t fix if you would only prescribe it properly. And I don’t like what you are insinuating – I think you should get a second opinion.”
Psychiatrists ask our colleagues for second opinions on a minority of our patients, but it is far from rare. The prompt for the request is usually a complicated situation where we either aren’t sure what is happening, or where the first few attempts at treatment have not gone according to plan, and the second opinion helps by suggesting another way forward. And even when my colleague isn’t able to add anything new, that is still helpful in reassuring me that I haven’t missed anything.
However, we also ask each other for second opinions when our patient, or their family, is dissatisfied with our treatment plan. And then we are hoping that our colleague will agree with us, so as to help convince a patient of the right way to proceed. For this reason I readily agreed with Mr. Jones’s request. He then promptly left the room, looking like he had scored a victory over his wife’s incompetent doctor, and I went off to organize the consultation.
The political abuse of psychiatry reduced massively after the collapse of the Soviet Union, but it never wholly died out, and more recently there have been worries that Russia may be using it again, as first reported by the Dutch human rights advocate Robert van Voren. And whatever youthful optimism I had about the 1977 Hawaii declaration, and how it would end the misuse of mental illness for social control, has been replaced by a sadder and more mature understanding. Now I know that the risk of mistreatment will be ever-present in human society, and my colleagues and I will always need to be alert for the possibility, and vigilant in opposing it.
“Dr. Wong has given her second opinion,” I told the multidisciplinary team at our next meeting, “and she agrees with our treatment, and that Norah doesn’t need a bigger dose of medication.”
“Maybe that will help with Mr. Jones, but I wouldn’t be too sure,” said Clara, who was Norah’s prime nurse. “However, I’ve also chatted with Norah’s sister who has been visiting. She says that Norah is fully recovered from her mania, but more importantly she hasn’t sunk into the overmedicated state that the sister has seen over the last few years. The way she is now is what her sister would call baseline.”
“Thanks Clara, that’s very helpful. Doreen – how did your discussions about divorce go?”
“She won’t do it. It’s mostly because she’s too frightened to live on her own, and she also fears losing the kids. I’ve explained what she might expect to get in terms of a financial settlement, but she’s really not willing to leave. I heard that her husband declined marital therapy, so I think we are unable to help them much.”
“Well, she’s agreed to stay in follow up with me, and I can keep the door open for therapy or separation in case she changes her mind, or in case he agrees to joint counselling in the future.”
Only as they approached the exit to the ward did she turn and give one last forlorn look at her asylum.
I knew that our final meeting before discharge might be awkward. Norah had been looking cheerful and well around the ward for the last few days, but her husband once again had the effect of a straight-jacket on suppressing her speech and mood. She was largely silent throughout the session, but Mr. Jones was not.
“I hear that you’ve been advising my wife to leave me,” he started angrily.
“Not at all.” I replied. “Any decision like that remains wholly with the individual concerned.”
“But you have talked about divorce. I should have your licence removed.”
“If there are difficulties in any of my patients’ marriages then I will always ask if marital therapy might be useful, and I also ask if they have thought about a possible separation. That’s very different from advising someone to divorce.”
I knew that I had been professionally neutral on this subject and had nothing to fear from any complaint to my licensing body. However, I did hope that Doreen had also managed to stay away from nudging Norah towards divorce, and I made a mental note to chat with her later. My answer seemed to have satisfied Mr. Jones, and he moved onto his next grievance.
“I’ve looked at your discharge prescription, and there is no extra dose of medication to take in case it’s needed.”
“That’s right. If either of you think there is a problem then please call, and I’ll speak with Norah by phone or arrange a meeting quickly to assess the need for extra medication.”
“It was always left in my hands before.”
“Yes. I think this is the better way.”
“Well, I don’t. If you won’t do what we want, then I demand you transfer her care to the doctor who gave the second opinion.”
“Dr Wong thought that my plan was appropriate, and we did discuss a possible transfer of care, but she declined. Besides, although you are unhappy with what I’m doing, I don’t think that Norah is asking for a change.”
Norah looked up at me nervously during that last sentence and I realized I should have kept my mouth shut, instead of perhaps handing her husband another reason to berate her. But before I could say more, he was standing and telling us both that they were leaving. I wondered about trying another explanation, but decided to wait until I saw them in my office in a few weeks. I wished them well, and said that I looked forward to seeing her for follow-up.
“Come on Norah, we’re going home,” he said as he headed for the door of the interview room. I tried to catch her eye, but she meekly followed him, with her head bowed. Only as they approached the exit to the ward did she turn and give one last forlorn look at her asylum. Then he grabbed her arm and bundled her through the door, and she was gone.
All names and other identifying details have been changed to protect patient confidentiality.
JP Sutherland 