Monday, Jun. 23, 1980

The Children of Pavlov

Pills, pep talks, and outpatient clinics for mental well-being

The old building on Chekhov Street, just off Moscow's Pushkin Square, was the town house of a wealthy man in prerevolutionary times. Now it is Psychoneurological Dispensary No. 14, one of the outpatient psychiatric clinics that deal with the day-to-day problems of the anxious, the alcoholic and the seriously disturbed in the Soviet Union.

More than 200 patients a day silently wander the halls, beneath a sign that reads REMEMBER, CONVERSATIONS AMONG PATIENTS ABOUT YOUR DELIRIUMS ARE FORBIDDEN. In one room 15 elderly women are putting together white ballpoint pens and costume jewelry; such work is regarded as therapy, but the pens and decorative chains are sold to help the center financially. A basement room decorated with film and travel posters is the center's Sobriety Society --the Soviet equivalent of Alcoholics Anonymous. There a young reformed drunk is sanding wood for a remodeling program that will expand the society's facilities to include billiards and Ping Pong.

Like community mental health centers in the U.S., Soviet clinics mostly dispense pills and pep talks. Some patients at Dispensary No. 14 are expected to stay the whole day; they come at 9 a.m., are fed two free meals and released at 4 p.m. Psychiatrists, about 70% of them women, have a good deal of power in dealing with patients. They not only direct treatment, but also help recuperating patients get jobs on the outside, and even track down citizens who fail to show for regular visits.

Most staff psychiatrists at the dispensary spend two hours after work each night making house calls. Particularly in the cities, the dispensaries double as social centers to give lonely and deprived people somewhere to go. Dr. Fira Passer, a short, energetic, middle-aged woman who runs the center, says that most Muscovites who come in are considered to be borderline cases, that is, people in basically good mental health who are temporarily having trouble coping with life. Says she: "They are afflicted with the problem of loneliness and the inability to find a partner or friend--neuroses connected with life in a large city."

Psychotropic drugs, such as chlorpromazine and haloperidol, are the main form of treatment. Because the Soviet pharmaceutical industry is small and cautious, it is slow to put new drugs into production. Soviet hospitals and dispensaries frequently treat schizophrenia with insulin shock therapy. After an insulin injection cuts blood sugar and induces coma, the patient is revived with glucose--a procedure repeated 20 or 30 times.

For less serious ailments, the dispensaries have their own form of talk therapy. At No. 14, these take place in a large room lined with seven couches, beneath portraits of Pavlov and Freud, the contemporary giants of modern psychology. Pointing to Freud, Dr. Passer smiles and says:

"See, we're not so close-minded." However, Freudian analysis, unlike Pavlov's behaviorist ideas, has never taken hold in the Soviet Union, although the Georgian Academy of Sciences recently sponsored a symposium on the concept of the unconscious. In the U.S.S.R., talk therapy or "rational psychotherapy," is mostly a series of admonishing lectures. The doctor listens to the patient, then tells him how he ought to behave. If the complaint is deemed too trivial--anxiety, or mild depression--a patient may be told not to come back at all. Hypnosis is often used by doctors to encourage healthier behavior, like trying to get an alcoholic to stop drinking. Says Dr. Vyacheslav Kotov, chief doctor-psychiatrist for the city of Moscow: "A psychiatrist should understand his patient, but only up to a certain point. He doesn't have to turn his brains inside out in an effort to understand the patient fully."

The U.S.S.R. handles as many cases as it can by outpatient treatment. Nonetheless, statistics gathered in Leningrad and Moscow indicate that 1 1/2% of the population is in mental hospitals at any given time, for an average stay of 60 days. The comparable U.S. figures are .8% and 30 days. Western visitors are generally impressed by the large number of staff members available. Says Dr. Gerald Klerman, the U.S. Alcohol, Drug Abuse and Mental Health administrator: "There are a good many nonprofessionals feeding, walking and checking on patients. They use the hospital system as a way to keep down unemployment, and I think this results in a lot of tender loving care." Patients also are kept busy at such tasks as gardening or cleaning their rooms, an approach that impresses U.S. visitors.

When patients are released, their records go to the local mental health center, which follows up on the case whether the patient cooperates or not. That way, says Yale Psychiatrist Walter Reich, an expert in Soviet therapeutic methods, "no one suffers from neglect, but it is very difficult to get away from the system. If you don't want to be involved with the mental health service, once you are identified as a patient, you get followed nonetheless."

There is a dark side to Soviet psychiatry: its misuse as a political weapon to punish dissidents, in 1970 Biologist Zhores Medvedev, who now lives in London, was committed to a psychiatric hospital on the order of his city commune. He was released 19 days later, after a wave of international protest. Medvedev had struck a deal with hospital authorities that if discharged he would write nothing about his hospitalization or the struggle to get him out; when he learned that he would have to report regularly to mental health centers for follow-up care, he and his brother, Historian Roy Medvedev, published their now classic study on Soviet political psychiatry, A Question of Madness.

The rise of political psychiatry in the Soviet Union has paralleled the rise of Dr. Andrei Snezhnevsky, who since 1962 has been director of the Institute of Psychiatry of the U.S.S.R. Academy of Medical Sciences in Moscow. Snezhnevsky is the virtual czar of Soviet psychiatry. The standard Soviet theory is that schizophrenia is caused by environmental factors. But in the 1960s Snezhnevsky began promoting his idea that the disease is genetic, permanent and diagnosable even in the absence of such classic symptoms as hallucinations and delusions.

One of his most controversial concepts involves what he calls "creeping" or "sluggish" schizophrenia, which is said to show itself early in difficulties with parents and authority figures, and with stubborn "reformist tendencies."

In Snezhnevsky's view, many people experience nervous breakdowns as children or adolescents, and think they recover completely. But their schizophrenia remains latent and can blossom 20 or 30 years later--often in the form of political dissidence. Exiled Writer Vladimir Bukovsky, now at Cambridge University, notes: "This means nobody knows whether he is schizophrenic or not unless Professor Snezhnevsky diagnoses it." That theory has proved convenient to the KGB, particularly since Soviet law allows for compulsory commitment by the courts when the accused has been classified as mentally ill. Indeed, the proceeding may be held without the dissident because he is considered too sick to attend. Thus, as Reich says, "dissenting views are pronounced the sick products of sick minds."

Roughly 1,000 dissidents have been misdiagnosed as latent or active schizophrenics and confined to mental institutions. After the World Psychiatric Association condemned the Soviet Union's psychiatry in 1977 for its political abuses, many Western doctors believed that the Kremlin would find less embarrassing ways of dealing with dissenters. They were apparently wrong. Amnesty International reports that incarceration of political dissenters as mental patients is just as prevalent as ever in the Soviet Union, and may even be increasing.

The politicization of psychiatry has in fact produced a kind of schizophrenia of the profession itself. As Bukovsky points out: "It is not easy for the ordinary person to get admitted for treatment in a psychiatric hospital. For a political case, though, it is very easy. They are taken to a hospital without making any request."

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