Trends in Soviet and Post-Soviet Psychiatry Lawrence M. Probes, M.D. M.D., Ph.D.,¢ Vadim Molodyi, M.D.§ Soviet psychiatry can now be observed from the vantage point of the post- Soviet era, a period of transition, uncertainty, and new opportunities. With the atmosphere of open discussion that has been permitted since the latter years of glasnost, it is now possible to gather information about Soviet psychiatry and critique it with unprecedented thoroughness. Although improvements in political systems and economic conditions will in the long, run lead to better conditions for psychiatry in countries that were part of the U.S.S.R., there is a tremendous short-term need for international assistance to introduce psychiatrists in the former Soviet republics to current trends and developments in Western psychiatry. Exchange pro- grams are needed to offer these psychiatrists training and clinical experi- ence in other countries. psieq 122.2677) original developments, * Vladimir Kouznetsov, M.D., Ph.D.,7 Vladimir Verbitski, such as fhe 1832 “no re fore the Bolshevik revolution, Russian psychia- {ry had been developing in tandem with Eure aa poon, and especially German, poychiatry [1,2] incorporating new trends and even pioneering a few cost 263¢/992)0200-007905 192 opens 1s Asso: Chaka Piles of Preety. 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Elva bepatiman, roivhagane Resa Conte Measaia Enkei, Masco, Russa Svitlowseyentest formey fim Mocs, LSS, mov wing sensi Colle man“biologism’ in the 1850s, which emphasized phys- {ological brain dysfunction as the cause of psychi- attic disease. Alter a brief period of exploration during the early 1920s, however, Soviet psychiatry and psychology slipped into nationalistic isolation, although the profession did not stegnate. For ex- ample, it developed a major new approach to the classification of schizophrenia. Unfortunately, So- viet psychiatry in the fast two decades became more and more compromised as stete interference led to psychiatric abuse Since glasnast and perestroika, and now the dissolution of the Soviet Union as a palitical entity, psychiatry in the former Soviet re- publics faces major challenges as it struggles to free ital from past abuses and to recover from grave prcblems of economic privation, lack of medications, shortages of peychiatrists and other medical work ers, lack of books and educational materials, and facilities that are overcrowded, outdated, In poor repair, and unsanitary GENERAL FEATURES OF CLINICAL PRACTICE In 1989, there were 37.337 psychiatrisis and 347,000 psychiatric beds in the Soviet Union [31 Almost al psychiaisists worked in hospitals end dispensaries (outpatient medication clinics), al- though, since glasnost, private practice has emerged and grown Psychiatrists in the USS R. were better paid and received longer vacations than their col- leagues in other medical specialties. Psychiatrists dominated the mental health field, Phere were com- paratively few psychologists in the USSR, ebont 5,000, and they played only a minot role in clinical psychiatry ‘The field of sociology was not related to psychiatry, and there were no taining programs in Glinieal social work, The roles typically performed by hospital-based social workers in the US. (con tacs with employers, filling out forms for disability benefits, assistance in finding an apartment, etc.) ‘were performed by psychiatrists and nurses. Pay chiatric nurses worked closely with psychiatrists in both the hospital setting and the dispensaries, which ‘were basically outpatient medication clinics. PSYCHOTHERAPY Psychotherapy has been a constant feature of Soviet psychiatry, consisting primanily of hypnosis, biofeedback, autosuggestion, and group therapy (not a psychodynamic group, but more a class in 68 The PSR Quarterly une 1892, Val 2, No 2 which the “therapist” instructs or educates about some topic). “nother widely used method of psy- chotherapy has been “rational therapy.” developed by the Swiss neuropathalogist, Pau) Dubois, in the carly 1900s [4-6]. Psychodynamic and interpersonal psychotherapies based on psychoanalytic theory and its vasiants have been absent. Behavior trest- ment based on the work of BF, Skinner, as well as other Forms of cognitive-behavioral therapy, which are widely applied in the US., have not been gen exelly utilized in the USSR. Principles of condi Koning, reinforcement, extinction, flooding, and de- sensitization have not been sysiematically applied in the clinieal setting. THE DOCTOR-PATIENT RELATIONSHIP ‘There has been a tendency for the Soviet medical ectucation systern to reinforce an authoritarian and paternalistic approach to the doctor-patient relation- ship in which the doctor knows whet is best for the Patient and considers t unnecessary to educate the Patient about treatment, Discussions with patients generally consist of advice, insinactions on how to take medications, and exhortations to follow such actvice and instructions, [t has been a long tradition of Sovict and Russian medicine not to explain to the atient dofails about his or her illness, and the contemporary U.S. concept of informed consent to treatment has never been recognized. An exception is made when the patient is a physicien [7] SOCIAL AND MILIEU THERAPIES Hospital patients are generally referred for “ cupational therapy” (trudavaia teravia, alternately toanslated cs labor therapy or work therapy), which typically involves games, physical exercise, various forms of entertainment, and the assembly of small stems such as ctaf's of spare parts [8|. Resources are limited, and, although this intervention may be of reasonable quality in e few institutions, it is often dull and monotonous. In some cases of involuntary commitment, this intervention amoun's to a form of forced labor, Attempts have been made to imple- ‘ment procedures of milieu therapy at the Bekhterey Institutein Leningrad (now S¢, Petersburg) and other major psychiatric centers, but the concepts of US. authors such 2s A H, Stanton, M.S, Schwartz, and M. Jones are not widely applied, Must patients re- ‘main passive recipients of medications, meals, and Soviet and Post Soviet Payctianyvisits by the doctor or family members. The First author (L.M.P.) visited psychiatric hospitals im Rigz, Moscow, and Irkutsk between (988 and 1991, He observed thai patients inside the hospitals wore pajamas or hospital gowns, nurses wore white uni- forms, and psychiatrists wore white coats, which was the usual custom ia the U.S, until the 1960s, These practices were eventuelly discontinued in the US. on the realization that they reinforced a number of negative characteristics, including 2 pationt’s sense of being “sick” Some hospitals, such as the Riga Neuropsychiatric Hospital, maintain special unlocked units for “bor- derline’ patients where ordinary street clothes are allowed. These units are also used at times for certain “lite” or “VIP* pationts, ever those with psychotic decompensations, At such units, 2 greater variety of psychotropic medications may be avail= able, and length of slay can be more flexible, HOSPITAL FACILITIES With some exceptions, Soviet psychiatric hospitals have been and remain overcrowded, undersia‘fed, and in poor repair. Sanitary conditions are often deplorable [9] One author describes a provincial psychiatric unit: “There was no sewerage sysiem or indoor plumbing, and gerontological patients of Doth sexes lay pell-mell on the flocr in a fecal stench” {personal written communication, Vadim Molod MD., observations in 1975 at Kolomenski Peyci attic Hospital No, 10, about 70 km from Moscow! However, itis important to consider this in light of the overall housing situation in the fomer Soviet Union, in which there are severe shortages and in which multiple families, including divorced couples, must sometimes share 2 single kitchenette or bath- room. There are almost no private or seriprivate rooms in Soviet and post-Soviet psychiatric hespi= tals, Patient beds are located in chambers ox wards of 30 or moze beds in one room, to which a nase 38 assigned for the purpose of monitoring, Psychiatric hospitals are of either the “orcinary” type or the “special” type, the latter constructed and staffed more like a penal facility than a hospital and intended for the treatment of mentally ill criminals. The number of these special psychiatric hospita’s ‘grew from 11 in 1977 to 16 in 1988 [10}, Political dissidents who were given psychiatric diagnoses and hospitalized involuntarily were usually referred to Soviet and Post Soviet Pryehiairy the ‘apecial” psychiatric hospitals (SPHs). Even o- inary psychiatnc hospitals are surrounded by walls with a guard station and checkpoint at the main enivance, This contributes to the etmosphere in raost poychiairic hospitals of high eecurity and control, similar to special forensic psychiatric facilities or ‘older state hospitals in the U.S. “Special” psychiatric ospitals were operated by the Ministry of Internal Aflairs (MVD) until January 1988, when they were transferred to the Ministry of Public Health The MVD performed many pelice, military, intelligence gathering, and internal security functions, and its methods and aims were often harsh and repressive, similar to those of the KGB. The transfer of jusisdic- Gon of SPHs to the Ministry of Public Health was a positive step, but it did not nezessarily lead io @ rapid, major improvementin the conditions at SPHs [11,22}. Many such hospitals stil! have no warm. sunning water, and the conditions inside these in- stitutions are often grossly unsanitary and deha- manizing, FREUDIANISM AND PSYCHOANALYSIS The Russian Paychoanalytical Society swas estab- liched in 1910, but, although many of S. Freud’s works were translated info Russian after 1912, there ‘was professional resistance 10 his ideas. A series entitled ‘Psychological and Psychoanalyticel Li- rary” was isoued until the late 1920s by Professor Ivan Ermakov. Criticism of Freud in the 1920s cc- curred in the context of general debates going on at that time in the Soviet Union about how to create 2 genuinely Marxist psychology. During the early 1920s, academic opposition 10 Freud criticized hie emphasis on sewality, but even his most strident critics in the academic realm accepted his basic concept: the primacy of the unconscious, In the second half of the 1920s, however, Freud’s teachings were exposed to systematic criticism from all quar ters, especially philosophy. His concepts of uncon scious psychic archaisms (such as the Oedipus com- plex), the priority of the unconscious in mental processes, and the sexual nature of all poychic phe: nomena ware determined to be inconsistent with islectical materialism [13], Freud was only one of many victims of Comumu- nist Party politics as well as the politicization of sciences in general and social sciences in particular. His works were eventually banned, and they were Probes etal 69