Psychiatry in Communist Europe [1st ed.] 9781137490919, 9781137490926

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Mental Health in Historical Perspective Series editors: Matthew Smith, Senior Lecturer, Director of Research (History) and Deputy Head of School of Humanities, University of Strathclyde, UK Catharine Coleborne, Professor of History, School of Social Sciences, Faculty of Arts and Social Sciences, University of Waikato, New Zealand Editorial Board: Dr Allan Beveridge (Consultant Psychiatrist, NHS and University of Edinburgh, book reviews editor History of Psychiatry) Dr Gayle Davis (University of Edinburgh, former book reviews editor of History of Psychiatry) Dr Erika Dyck (University of Saskatchewan) Dr Alison Haggett (University of Exeter) Dr David Herzberg (University of Buffalo) Professor Peregrin Horden (Royal Holloway) Professor Mark Jackson (University of Exeter and Wellcome Trust) Dr Vicky Long (Glasgow Caledonian University) Professor Andreas-Holger Maehle (Durham University) Professor Joanna Moncrieff (University College London) Associate Professor Hans Pols (University of Sydney) Professor John Stewart (Glasgow Caledonian University) Professor Akihito Suzuki (Keio University) Professor David Wright (McGill University) Covering all historical periods and geographical contexts, this series explores how mental illness has been understood, experienced, diagnosed, treated and contested. It publishes works that engage actively with contemporary debates related to mental health and, as such, are of interest not only to historians, but also mental health professionals, service users, and policy makers. With its focus on mental health, rather than just psychiatry, the series endeavours to provide more patient-centred histories. Although this has long been an aim of health historians, it has not been realised, and this series aims to change that. This series emphasises interdisciplinary approaches to the field of study, and encourages titles which stretch the boundaries of academic publishing in new ways. Titles in the series: Mat Savelli and Sarah Marks PSYCHIATRY IN COMMUNIST EUROPE Chris Millard SELF-HARM IN BRITAIN A History of Cutting and Overdosing

Forthcoming titles: Alison Haggett A HISTORY OF MALE PSYCHOLOGICAL DISORDERS IN BRITAN, 1945–1980 Marjory Harper THE PAST AND PRESENT OF MIGRATION AND MENTAL HEALTH

Mental Health in Historical Perspective Series Standing Order ISBN 978–1–137–53471–2 (Hardback) 978–1–137–54775–0 (Paperback) (outside North America only) You can receive future titles in this series as they are published by placing a standing order. Please contact your bookseller or, in case of difficulty, write to us at the address below with your name and address, the title of the series and the ISBN quoted above. Customer Services Department, Macmillan Distribution Ltd, Houndmills, Basingstoke, Hampshire RG21 6XS, England

Psychiatry in Communist Europe Edited by

Mat Savelli Research Fellow, McMaster University, Canada

and

Sarah Marks Research Fellow, Murray Edwards College, University of Cambridge, UK

Selection and editorial matter © Mat Savelli and Sarah Marks 2015 Individual chapters © Respective authors 2015 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The authors have asserted their rights to be identified as the authors of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2015 by PALGRAVE MACMILLAN Palgrave Macmillan in the UK is an imprint of Macmillan Publishers Limited, registered in England, company number 785998, of Houndmills, Basingstoke, Hampshire RG21 6XS. Palgrave Macmillan in the US is a division of St Martin’s Press LLC, 175 Fifth Avenue, New York, NY 10010. Palgrave Macmillan is the global academic imprint of the above companies and has companies and representatives throughout the world. Palgrave® and Macmillan® are registered trademarks in the United States, the United Kingdom, Europe and other countries. ISBN 978-1-137-49091-9

ISBN 978-1-137-49092-6 (eBook)

DOI 10.1007/978-1-137-49092-6 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Psychiatry in communist Europe / edited by Sarah Marks, Teaching Fellow, University College London, UK and Mat Savelli, Research Fellow, McMasters University, Canada. pages cm — (Mental health in historical perspective) 1. Psychiatry—Europe—History—20th century. 2. Mental health—Europe— History. 3. Psychiatric hospitals—Europe—History. I. Marks, Sarah, 1984– II. Savelli, Mat, 1982– RC339.E85P79 2015 616.89—dc23 2015012940

Contents Acknowledgements

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Notes on Contributors

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1 Communist Europe and Transnational Psychiatry Sarah Marks and Mat Savelli 2 The Dialectics of Labour in a Psychiatric Ward: Work Therapy in the Kaschenko Hospital Irina Sirotkina and Marina Kokorina 3 Insulin Coma Therapy and the Construction of Therapeutic Effectiveness in Stalin’s Soviet Union, 1936–1953 Benjamin Zajicek

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4 Soviet Psychiatry and Drug Addiction in Central Asia: The Construction of ‘Narcomania’ Alisher Latypov

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5 Psychiatry and Ideology: The Emergence of ‘Asthenic Neurosis’ in Communist Romania Corina Doboş

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6 The History of the Hungarian Institute of Psychiatry and Neurology between 1945 and 1968 Melinda Kovai

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7 Ecology, Humanism and Mental Health in Communist Czechoslovakia Sarah Marks

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8 Beyond the Therapeutic Revolution: Psychopharmaceuticals Crossing the Berlin Wall Volker Hess Translated from the German by Arthur Eaton 9 Blame George Harrison: Drug Use and Psychiatry in Communist Yugoslavia Mat Savelli

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10 Over the Cuckoo’s Nest: Russian Variations on a Psychiatric Theme Rebecca Reich

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Index

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Acknowledgements Our decision to pursue this book project was born some time ago, during a conference hosted at University College London on the history of psychiatry. We have been fortunate to receive advice, feedback, training, and funding from a variety of excellent sources. Mat Savelli offers sincere gratitude to Sloan Mahone and Richard Caplan, both of whom fundamentally shaped the way I think about psychiatry and Eastern Europe. Meanwhile, Pietro Corsi and Eric Gordy were kindly dedicated to helping support my career through its earliest stages. Carin Berkowitz and others at the Chemical Heritage Foundation in Philadelphia created a tremendous working environment which helped push this and other projects along. While at the University of Pittsburgh, Pat Manning, Urmi Engineer, Katie Jones, and Ljiljana Djuraskovic reminded me of the centrality of transnational connections, helping to shape my frame of mind for the introduction. Meanwhile, James Gillett, Gavin Andrews, David Wright, Lori Ewing, and Kristine Espiritu (all at McMaster University at one time or another) have been supportive of my work. Gessie Stearns provided constant encouragement throughout the latter stages of the writing process. Finally, I owe a special debt to the students, staff, and faculty of the University of Oxford – especially St. Antony’s College and the Wellcome Unit for the History of Medicine – the intellectual climate they created is inextricably connected to this book and, in truth, all other work I will ever undertake. Sarah Marks would particularly like to thank Michael Marks for his assistance with the final editing process of this book. Many colleagues have informed this project through discussions, especially Jon Agar, Brian Balmer, Roger Cooter, Dora Vargha, Robert Priest, Matei Iagher, Arthur Eaton, Chantal Marazia, Fabio de Sio, Corina Dobos, Jelena Martinovic, Richard Rawles, the staff and students at UCL Department of Science and Technology Studies, and the Department of History and Philosophy of Science, University of Cambridge. This book has also drawn significantly from contemporary perspectives in the history of Communism in Eastern Europe and Russia and, as such, I would particularly like to thank Susan Morrissey both for initially sparking this interest through her undergraduate teaching, and for her encouragement and valuable critique of my work. I am also grateful for collaborations and discussions on this topic with Claire Shaw and Paul Vickers. Finally, I am vii

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indebted to Sonu Shamdasani for his advice and support over the past few years, and for establishing an excellent community for research and debate in the form of the UCL Centre for the History of Psychological Disciplines. We are both tremendously grateful to the anonymous readers whose comments helped reshape parts of this book and whose enthusiasm arrived at exactly the right time. The staff at Palgrave Macmillan, meanwhile, provided consistent encouragement and understanding, never failing to offer clear directives on the next steps. Finally, we would also like to thank Jaromír Mašek and Jitka Marišková at the Psychiatric Hospital at Havlíčkův Brod, Czech Republic for permission to reproduce the cover image from the hospital’s archives.

Notes on Contributors Corina Dobos is a researcher at the University of Bucharest and the ´ Institute for the Investigation of Communist Crimes in Romania. She has studied at Central European University in Budapest and University College London. Her current research focuses on the history of medicine and population politics in Romania since 1945. She is the co-author and editor of Pronatalist policies of the Ceausescu Regime (volume 1: 2010; and volume 2: 2011) and is a contributing author to the book Ideological Storms: Intellectuals and the Totalitarian Temptation (2015), edited by Vladimir Tismaneanu. Volker Hess is the Director of the Institute for the History and Ethics of Medicine at Charité Medical School, Berlin and an affiliated Professor at the History Department of Humboldt University. Trained in medicine as well as history and philosophy, he is the author of a number of books and articles in the field. He chairs the German Research Foundation (DFG) research group on “Cultures of Madness” and is Advanced Investigator Grantee of the European Research Council with a project reconstructing the “paper technologies” of medical practice in historical context. Marina Kokorina, is the Director of the Museum for the History of Psychiatry at Alekseevskaya City Hospital, Moscow. She graduated from the Pirogov Medical Research University in Russia in 1998 and has worked as a laboratory researcher, medical doctor, and expert consultant in the history of medicine to Pirogov University Museum. She has published many articles on the history of mental health care in Russia and the Soviet Union. Melinda Kovai received her PhD in Sociology at the Eötvös Loránd University, Budapest and the University of Pécs. Her research focuses on the history and sociology of mental health care from the perspective of patient experience, and the history of everyday life in Kádár-era Communist Hungary. She is Assistant Professor at the Institute of Psychology in Károli Gáspár University, Budapest and is completing a monograph on Hungarian Psychiatry since 1945. Alisher Latypov holds an MA and PhD in the History of Medicine from University College London, and an MHS in Public Health from ix

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Johns Hopkins University. He has published extensively on the politics of drugs, health, and healing in Central Asia and Eastern Europe and is a member of the editorial boards of The International Journal of Drug Policy and Harm Reduction Journal, an Associate at the Central Asia Programme of the Elliott School of International Affairs, George Washington University, and a Research Affiliate at Columbia University, Global Health Research Centre of Central Asia. Latypov is an editor of Health, Drugs and Healing in Central Asia (2014), and works as Senior Technical Advisor for Health in Ukraine, where he leads a project to strengthen the Ukrainian Centre for Disease Control. Sarah Marks is a research fellow in History and Philosophy of Science at Murray Edwards College, University of Cambridge. She completed her PhD on the history of psychiatry in Communist East Germany and Czechoslovakia at UCL Centre for the History of Psychological Disciplines in 2015. She holds masters degrees from University College London in East European Studies and the History of Medicine, and teaches and writes on various topics related to the region, and the history of psychiatry and mental health. Rebecca Reich is University Lecturer in Russian Literature and Culture in the Department of Slavonic Studies at the University of Cambridge. She is the author of “Madness as Balancing Act in Joseph Brodsky’s ‘Gorbunov and Gorchakov’” (2013) and “Inside the Psychiatric Word: Diagnosis and Self-Definition in the Late Soviet Period” (2014). Her current book project is about psychiatric and literary conceptions of insanity in the late Soviet period. Mat Savelli is a postdoctoral fellow in the Department of Health, Aging, and Society at McMaster University, Canada. He was awarded a DPhil from the University of Oxford in 2011, and has held postdoctoral research fellowships at the University of Pittsburgh and the Chemical Heritage Foundation in Philadelphia. His research encompasses work on the history of psychiatry in Yugoslavia, the history and sociology of addiction, and the global advertising of psychopharmaceutical medications. He is completing a manuscript on the social psychiatry movement in Yugoslavia. Irina Sirotkina received her degrees from the Moscow State University (Candidate of Science in Psychology, 1989) and from the University of Manchester (PhD in Sociology, 2002). She is a researcher at the Institute for History of Science and Technology, of the Russian Academy of Sciences (Moscow, Russia). She has published articles on the history of

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psychology and the history of medicine in Russia. Her book, Diagnosing Literary Genius: A Cultural History of Psychiatry in Russia, 1880–1930 (2002), was awarded the MLA Award in Slavic Literature and Languages. She is also the author of Free Movement and Modern Dance Plastique in Russia (2012) and The Sixth Sense of the Avant-garde (2014). Benjamin Zajicek holds a PhD from the University of Chicago. His research focuses on the history of science and medicine in the Soviet Union in the Stalin and post-Stalin eras, particularly the history of psychiatry. He is an assistant professor in the History Department at Towson University, Maryland and is completing a monograph provisionally titled Soviet Psychiatry under Stalin.

1 Communist Europe and Transnational Psychiatry Sarah Marks and Mat Savelli

In a 2002 article published in the Harvard Review of Psychiatry, historian Greg Eghigian posed the question: was there a Communist Psychiatry? Specifically, he was asking if there was “something essentially ‘communist’ about East European psychiatry” and if a distinct and identifiable school or system of mental health practice existed across Eastern Europe.1 Eghigian raised his query against a backdrop of opinion that assumed that psychiatric policy across the Eastern bloc originated in Moscow and spread outwards.2 Imagined hallmarks of Communist Psychiatry might include the misuse of the profession for political ends, the wholesale rejection of Freud, Pavlovization and strict adherence to physiological approaches to mental illness in accordance with ideological materialism, and a stress on work as the primary means of therapy. The extent to which the countries of Eastern Europe underwent shared or unique experiences of Communism is highly debated among historians, but, as of yet, psychiatry and mental illness have rarely figured into this debate.3 Given psychiatry’s prominent role in regulating deviance (and thus helping to create and defend the norms of a society), this development is somewhat surprising. Historians of psychiatry and medicine have also been relatively slow in addressing the topic of mental health care in the former Communist world. When compared against the voluminous material on psychiatry in Western Europe, North America, and the colonial world, this shortfall is especially remarkable. This volume, Psychiatry in Communist Europe, highlights the need for addressing the topic of mental health in the context of Marxist-Leninism. It is not so much an attempt to answer Eghigian’s question (much more work will need to be done before that is possible), but rather it is meant to stir debate and remind readers that it is a question well worth asking. 1

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Although not necessarily profound, interest in how psychiatrists in the Communist world approached mental illness is longstanding. With a few exceptions, Western observers first started reporting regularly on Soviet psychiatry in the post-Second World War period. In a foreshadowing of the later scandals over psychiatric abuse, early commentators were particularly interested in the issue of forensic psychiatry.4 Undoubtedly the most important work during this period was carried out by Joseph Wortis. A psychiatrist himself, Wortis’ monograph Soviet Psychiatry served as the primary source of knowledge for those interested in mental health matters in the USSR for quite some time.5 Amidst the brewing tensions of the Cold War, the book proved sufficiently controversial that the publisher’s president felt it necessary to include a foreword in which he stated that the book should not in any way be viewed as evidence of “any admiration on our part for Soviet science, economy, or ideology.”6 The reason for the controversy stemmed from Wortis’ sympathetic appraisal of Soviet mental health care. Although not visiting the USSR himself, Wortis studied Soviet medical literature and concluded that, ultimately, Soviet psychiatrists might very well better meet the needs of the country’s citizens than their American counterparts. Perhaps naive about the actual conditions in the country (at one point Wortis refers to Trotskyists as “doubting Thomases,” vanquished in their belief that socialism could not be built in the Soviet Union), Wortis did a commendable job in highlighting some major tendencies in Soviet mental health practice in very inhospitable research conditions.7 A more nuanced (but still broadly sympathetic) assessment came from the sociologist Mark Field, who, over a series of trips, researched various aspects of the Soviet psychiatric system. Along with his colleague, the psychiatrist Jason Aronson, Field produced a series of articles that served to educate readers on the key developments and trends in Russian psychiatry.8 Through their reports, they began to sketch a picture of Soviet (and perhaps East European) psychiatry that has, to some extent, persisted to this today; namely a therapeutic outlook that relied heavily on work therapy, an elevation of Pavlov’s beliefs with a simultaneous rejection of Freud, and a devotion to physiological approaches to mental illness. Dismissing the prevailing notion that Soviet authorities cared little for the welfare of their citizens, Field and Aronson praised many elements of the Soviet approach, including the great strides made in community care, the warmth of doctor-patient relations, and the ability of Soviet psychiatry to help reintegrate patients into the working community. In particular, Field was effusive in his praise of community

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care, noting that “[t]he main contribution the Soviets have made lies, probably, in their concepts of not condemning psychotic patients to the idle, demoralizing, de-socializing, untherapeutic and wasteful life of the chronic patient in the large mental hospital.”9 Other reports from this period were similarly impressed with Soviet psychiatric developments, especially in terms of outpatient care.10 The tone of reporting on Soviet and East European psychiatry changed dramatically during the 1970s. While earlier texts concerned themselves with ideological and practical concerns in mental health care, from the early 1970s until the collapse of Communism commentators overwhelmingly concentrated on the misuse of psychiatry for political purposes. Soviet dissidents, Western practitioners, and human rights campaigners combined to highlight terrible abuses occurring in “special hospitals” typically run by the Ministry of the Interior or equivalent. Most frequently, the term “psychiatric abuse” was engaged to describe the practice of using psychiatry to suppress political dissidents, although other groups of persecuted peoples have also been identified as victims of this practice.11 Reports emerged describing forced hospitalization, isolation within the hospital, involuntary drugging, and beatings at the hands of hospital staff. Psychiatrists practicing these types of abuses labelled patients as suffering from problems such as a “split personality” (having interests in two unconnected fields, e.g. scientific work and human rights) and, most famously, “sluggish schizophrenia” – an illness which could sometimes manifest without symptoms.12 Crucially, these definitions were so apparently vague that psychiatrists could twist them to mean virtually anything.13 Although historians are yet to identify the exact moment this misuse of psychiatry began, these practices were evident from at least the mid-1960s and seemed to intensify throughout the 1970s.14 Investigators have posited a multitude of reasons to explain the increase in the employment of psychiatric abuse. Bloch and Reddaway highlighted the authorities’ need to avoid public legal proceedings (and thereby improve the USSR’s human rights image), the fact that no physical evidence was necessary for institutionalization, and the notion that dissident ideas might be discredited by a diagnosis of insanity.15 The Medvedev brothers (of whom Roy himself was a victim of the practice) underlined the institutional defects that permitted psychiatric abuse, such as the fact that no legal recourse could be taken against physicians for sectioning a person without grounds.16 Others, meanwhile, concentrated on the personalities of psychiatrists themselves to explain the origins of abuse, noting that this malpractice served to affirm practitioners’

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personal sense of power.17 Finally, other commentators have employed the familiar language of the antipsychiatry movement to note that the profession, as a global institution, is prone to misuse through its ambiguous diagnostic boundaries and dual loyalty to both the patient and the state.18 When placed within the framework of the Soviet Union’s political authoritarianism, this dichotomy would inevitably be settled on the side of the state.19 Throughout the 1970s and 1980s, psychiatric abuse for political purposes came under increasing scrutiny. Within the USSR, figures such as Semyon Gluzman (himself a psychiatrist) and Vladimir Bukovsky (a victim of psychiatric abuse) proved to be vital sources of information regarding the practice and, while confined in the same labour camp, the two co-wrote a “Manual on Psychiatry for Dissidents” on how to avoid becoming a victim of psychiatric abuse. Outside the Communist world, professional medical bodies and human rights advocates undertook efforts to publicize the practice and increase pressure on their Soviet counterparts to put an end to these tactics. Realizing that they were likely to be expelled at the forthcoming World Congress of Psychiatry in Vienna, Soviet representatives eventually withdrew from the World Psychiatric Association in 1983.20 After Gorbachev launched the glasnost reforms, the Soviet delegates were readmitted to the WPA but, by this point, Communism’s collapse was nigh. As Communism fell across Eastern Europe, historians, medical practitioners, and others began to reassess the issue of psychiatric abuse. Almost immediately, a number of controversies arose to provoke debate in medical and legal journals. Firstly, it has proven difficult to ascertain exactly how widespread these activities were. Robert Van Voren, a human rights campaigner with deep engagement in the issue of psychiatric abuse, has estimated that one in three dissenters in the Soviet Union wound up in psychiatric hospitals, but that these thousands “form only the tip of the iceberg of millions of Soviet citizens who fell victim to totalitarian Soviet psychiatry.”21 Helsinki Watch (the forerunner of Human Rights Watch) concluded that hundreds of dissidents were targeted by this practice, with many more “non-political” persons also falling prey to psychiatric misuse.22 Harvey Fireside, meanwhile, estimated that “thousands” of dissidents had probably suffered this injustice.23 Although Soviet abuses have received, by far, the most publicity, some commentators have asserted that abuse was likely common to all Communist countries.24 Others have, probably correctly, questioned the numbers and extent of this “systematic” malpractice, especially in the non-Soviet context.25 Despite the attention given to

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this topic, the true extent of abuse and the question of whether it was characteristic of all Communist countries remains unresolved. Further complicating the picture is the question of psychiatrists’ intentions and misdiagnosis. While to some critics the matter has been cut and dried, the isolation in which many Communist psychiatrists operated has provoked some reconsideration of whether this abuse was always intentional. In particular, commentators have underlined the differential training of psychiatrists and culturally embedded features of psychopathology in pointing out how it may have been possible for domestically trained psychiatrists to participate in psychiatric abuse without realizing they were doing so.26 As psychiatrist Paul Applebaum asked, “are they deliberately engaging in … hyperdiagnosis – knowing their patients to be mentally healthy – or are they applying politically tinged diagnostic criteria to … dissidents they believe to be ill?”27 For example, Van Voren related the tale of one Ukrainian practitioner who recalled how, upon Mikhail Gorbachev’s elevation to General Secretary of the Communist Party, she grew concerned that the new leader might be suffering from “sluggish schizophrenia.” After all, he had been exhibiting symptoms common to those with that diagnosis: reformist ideas, a struggle for truth, and a bizarre perseverance. It was not until the fall of the USSR and the end of Soviet psychiatry’s isolation that she understood the truth.28 Such examples call into question how many “perpetrators” of psychiatric abuse may have been innocently applying the politically charged education they had received in medical school. At the centre of the debate on psychiatric abuse is the diagnosis of “sluggish schizophrenia.” The term is inextricably linked with Andrei Snezhnevsky, a leading Soviet psychiatrist who was involved in the cases of a number of famous victims of abuse. Those who place sluggish schizophrenia and Snezhnevsky at the centre of the discussion on abuse stress the diagnosis’ elasticity and the fact that it could apparently be applied in the total absence of symptoms. For these critics, the political undertones of symptoms reported in some cases (such as the patient’s failure to adapt to society or the presence of “reformist delusions”) were proof that the concept of sluggish schizophrenia was cooked up on the orders of the Party and KGB.29 Not all commentators have agreed with this assessment. Helen Lavretsky, for example, has argued that the diagnosis of sluggish schizophrenia must be seen within the wider cultural and historical context of Russian psychiatry’s broader conception of mental disorder; it was not merely a fabrication to facilitate psychiatric abuse.30 Others, meanwhile, argue that the origins of abuse are quite separate from “sluggish schizophrenia,” which, in some studies, has

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appeared as a Russian formulation of Western disorders such as latent schizophrenia or manic-depressive psychoses).31 In any case, most scholars calling into question how we frame the issue of psychiatric abuse are not, as Robin Munro has stated, advancing a revisionist theory that psychiatric abuse did not occur, but rather trying to analyse the issue for all its complexities.32 The intensity of debate regarding the issue of psychiatric abuse has, on the whole, deflected attention away from attempts to understand the development of psychiatry in Eastern Europe and the USSR in a wider context. For many, the picture of mental health care under Communism is a caricatured one in which most psychiatrists occupied themselves with attempting to brainwash and punish vast numbers of political dissidents. Recently, however, newer research is beginning to sketch a more complete picture of the psychiatric systems of Communist Europe. By the time of Soviet Union’s collapse in the early 1990s, only a handful of monographs had appeared from Western authors that attempted to analyse broader aspects of Soviet psychiatry. Often taking a comparative perspective, they looked to pinpoint structural, organizational, and theoretical differences between practice in the USSR and in the West.33 Paul Calloway visited the Soviet Union during the glasnost years, and based his study on both English and Russian language sources, as well as observations from research trips. While his account is primarily an analysis of the situation in late 1980s, his attention to prior developments led him to conclude that, “there is no single ‘Soviet’ view of psychiatry and even before the era of glasnost there was a wide heterogeneity of views, some influenced by the West. There are different schools in psychiatry, and, more obviously, wide individual differences in philosophy and practice.”34 Emphasis on the variety of different approaches was echoed by Wolf Lauterbach, a West German psychotherapist who based his report on Soviet psychotherapy on his seven-year stay at the Bekhterev Institute in Moscow in the 1970s and 1980s, aiming to bring Soviet methods to a Western audience with a view to enabling therapeutic innovation. One striking difference, he noted, was the breadth of techniques which were included under the rubric of “psychotherapy” in the USSR: in addition to talking therapies, hypnosis, and suggestion, psychotherapy also included music therapy, education about the causes and treatment of neuroses and “psychogymnastics” (a form of nonverbal group therapy developed in Czechoslovakia, which included expression through mime and relaxation).35 Both Calloway and Lauterbach noted that greater weight was given to the causal effects of the individual’s physical and social environment

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in Soviet aetiological theories of psychiatric illness than in the West, with early childhood experiences also playing a less significant role (perhaps, in part, because this was associated with psychoanalysis). A predominant theme in the Soviet literature was a concern with external physical agents and their effects on neuropsychology, with a great deal of research carried out on possible links between toxins or viral infections on the immune system and mental functioning.36  In terms of the influence of the social environment, one of the most lauded psychiatrists during the post-Stalin period was Vladimir Myasishchev, who held the directorship of the Bekhterev Psychoneurological Institute in Leningrad from the early 1950s until his death in 1973, along with the chair of psychology at Leningrad University. His understanding of personality and its disorders cantered on the concept of otnoshenia, which broadly equates to the attitudes and attachments relating the individual to their social and material environment. The role that traumatic events played in the generation of psychopathology was particularly key to Myasishchev’s approach to diagnosis and treatment and this, in turn, was taken up by many others in the field.37 Regardless of the extent of his professional influence, Myasishchev was marginalized by the official institutions, and was twice denied membership of the Academy of Medical Sciences. This has been attributed to the dominance of the Academy by the Pavlovians who rejected the concept of otnoshenia.38 With Pavlovism so heavily represented in the official Soviet narrative of psychiatry, it is unsurprising that this thread has subsequently also come to be a predominant theme in the historiography of psychiatry in the region, especially in those studies that primarily draw on official documents and Party literature as sources. Official Party support for Pavlov’s theory of higher nervous activity, particularly during the Stalinist period, has attracted substantial attention. Historian Roger Smith has argued that because Pavlovian concepts were adopted as the orthodox interpretation by the Soviet authorities, research across the human sciences was stifled throughout Central and Eastern Europe, as researchers were constrained by political pressure not to make use of alternative models.39 Chapters in this volume demonstrate that this was not the full case for psychiatry in all of the satellite states in the post-1956 period. There was, however, substantial political pressure to elevate Pavlov’s theories above alternative etiologies during the late Stalinist period in the Soviet Union itself. The height of this campaign was the “Pavlov Session” 1951, where neurologists and psychiatrists publicly vowed adherence to the theories of higher nervous activity, with some “repenting” for having deviated from these

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in their previous work, an event documented by the historian George Windholz.40 More recently, Benjamin Zajicek has argued that the theory of higher nervous activity discussed at the Pavlov Session cannot be seen as an absolute dogma in itself, and that this meeting should be read as one moment in a series of events during which the Soviet medical profession attempted to elucidate what Pavlovian psychiatry might consist of, and that this had more fluid implications for practice than has often been assumed.41 Whilst psychiatry in Communist Europe can be no means reduced to a Pavlovian paradigm, there are many cases where concepts drawn from Pavlov’s work did play a constructive role in the genesis of theories and treatments of mental disorder. Zajicek’s further work examines the implications that the campaign for Pavlovian psychiatry had on psychiatric practice in the Soviet Union towards the end of the Stalin years, including the widespread use of Pavlov and Ivanov-Smolenskii’s sleep therapy in the hospital context, a practice which also extended to East Germany in the 1950s.42 Furthermore, Corina Dobos’ contribution to this volume examines the development of Pavlovian psychiatry in Romania as it developed free from the direct influence of parallel developments in the Soviet Union. Pavlov’s own work has recently come to be the object of renewed interest from historians, with George Windholz having published numerous articles on different aspects of Pavlov’s work; and Daniel Todes’ biography, which explores how Pavlov’s experimental work laid the basis for his theory-building, informing his positions on the nature of psychiatric disorder.43 Historians have juxtaposed the success of Pavlov’s theories in many parts of Eastern Europe with the decline and, in some cases, outright eradication of the Freudian school and wider world of psychoanalysis. As Alexander Etkind has noted, psychoanalysis thrived in Tsarist Russia with important contributions made by theorists such as Sabina Spielrein and Moshe Wulff. At this time, many Marxists were themselves deeply interested in psychoanalysis and a number of Bolsheviks saw in psychoanalysis the potential for altering man’s consciousness along socialist lines.44 Yet, as Martin Miller has written, a clash between Freud’s ideas and the Bolshevik interpretation of Marxism was inevitable.45 Although originally finding sympathy among key members of the Party (such as Bukharin and Trotsky), the Stalinization of science and medicine during the late 1920s served as the death knell for psychoanalysis under the Soviets. Whether ideologically repugnant or guilty by association (through Trotsky, and perhaps Jews more broadly speaking), psychoanalysis was driven underground with only a modest revival at the tail

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end of the USSR’s existence. Elsewhere in Eastern Europe, the picture depicted by historians is similar, with a few exceptions. In Yugoslavia, “psychoanalytically-oriented psychotherapy” for individuals and groups rose to prominence after a short initial period immediately after the Second World War, where party members questioned the appropriateness of the theory in a socialist society. Key figures of the psychiatric elite (such as Vladislav Klajn and Stjepan Betlheim) provided opportunities for the implementation of Freudian knowledge, although true psychoanalytic training was rare.46 Christine Leuenberger’s work challenges assumptions that psychoanalysis ceased to be practiced in the GDR as a result of political interference and describes the “underground” ways in which psychoanalysis continued in the 1970s – in part through integration with more ideologically acceptable “group therapies.”47 Hungary followed a broadly similar course, with an initial period of suppression followed by clandestine training and treatment and, eventually, state acceptance. On the whole, however, psychoanalysis in Eastern Europe has attracted far less attention from historians than it has within the Soviet Union. With the exception of the former GDR, few published words on psychiatry under Communism have originated from the historical communities within the countries of the former “Eastern Bloc” themselves. This volume addresses this lacuna by bringing together new contributions in the English language from Hungarian, Romanian, Russian, and Tajik historians of psychiatry. Where such analyses do exist, they tend to be focused upon the institutional histories of asylums, such as Josef Tichý’s short history of the Bohnice Psychiatric Hospital in the northern suburbs of Prague, based on an analysis of the hospital’s annual reports.48 The opening up of asylum archives in some countries has led to the first thorough historical analyses of institutional structures, administration, and clinical practices. Wolfgang Rose’s monograph on the psychiatric clinics of Brandenburg in East Germany, for example, charts the difficulties of initiating treatment reforms due to lack of resources and Party resistance towards “Western” models of care. His research also highlights the strong continuities between inter-war models of mental disorder and those used by psychiatrists in the post-war period, demonstrating that biological etiologies of psychiatric illness were more a consequence of long-standing intellectual traditions in German psychiatry than the imposition of Pavlovian models from the Soviet Union.49 Melinda Kovai’s work on the archives of the now defunct Hungarian Institute of Psychiatry and Neurology at Lipótmező, featured in Chapter 6 of this volume, offers an insight into the relationship between the Party

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and the medical profession, and the shifts and debates that political changes had upon these relationships across the Rákosi and Kádár periods. Kovai’s previous work has also analysed case histories which provide a micro-history of doctor–patient interactions, and which document the retrospective interpretation of the events of the Hungarian Revolution of 1956 in an asylum context.50 That there has been considerably more literature on East German psychiatry than other former Communist countries – mostly produced by historians at German academic institutions – is perhaps a reflection of German society’s continued support for historical research that deals with difficult aspects of the country’s past. The questions of post-war denazification, and East German political abuse of psychiatry in particular, have become part of a broader contemporary political process of Vergangenheitsbewaltigung (“coming to terms with,” or “mastering the past”).51 A wide variety of approaches and thematic foci have been brought to the fore by German historians of psychiatry, which could be profitably drawn upon for histories of other East European countries.52 Comparative questions have been particularly significant, with attempts to chart the variations or similarities in psychiatric theory and practice under the two opposing political systems in East and West Germany. Attention to such contrasts has led to substantial work being carried out on the development of the social psychiatry movement and deinstitutionalization, the impacts of economic and bureaucratic factors on the functioning of asylums, and differences in approach in therapeutic models.53 An important field of research, centred on the work of historians at the Institute for the History of Medicine in Berlin, has been the comparative history of psychopharmaceuticals across both sides of the Berlin Wall.54 Volker Hess’s chapter in this volume examines the introduction of psychoactive agents into East German psychiatry through archival sources from the Institute of Neurology at the Charité Hospital, and the subsequent standardization and production of drugs such as chlorpromazine by the state pharmaceutical manufacturers in association with practicing psychiatrists. Such work is indicative of the fact that research on psychiatry within the GDR is far more developed than elsewhere in Eastern Europe; this volume introduces the work of historians who are beginning to redress that imbalance.

Transnational connections and psychiatry in Communist Europe For very obvious and well-founded reasons, both academic and popular literature has painted the Communist experience as one of isolation.55

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A high degree of state censorship, limited economic means, and closed borders (to name three of the most significant barriers), made it difficult for people and information to travel within and beyond the Communist world. On the subject of mental health care, however, it would be fallacious to overstate this point; East European practitioners engaged in a variety of transnational activities across the Marxist-Leninist world and beyond. Rather than pariahs operating in total darkness, East European psychiatrists participated in scientific and medical processes – sometimes contradictorily, sometimes complementarily, and sometimes cooperatively – with each other and with professional colleagues across the world. This point does not deny the hardships endured by many mental health care workers – infrequent and unpredictable access to Western (or other) medical journals, difficulties obtaining permission to travel abroad, and so on – but rather to highlight that psychiatrists working under Communism were active contributors to the production of mental health knowledge on both sides of the Iron Curtain. One particularly interesting (and certainly under-researched) consideration focuses on the connections between practitioners and professional organizations across Eastern Europe. There is plenty of evidence of regional collaboration in a variety of arenas. For example, Polish, Czechoslovak, and Soviet colleagues met regularly to exchange ideas on best practice diagnostic and treatment modalities. Similarly, the national organizations of psychiatry in Yugoslavia and Czechoslovakia held joint meetings every two years; alternating between venues such as Sibenik (on the Dalmatian coast) and the Bohemian city České Budějovice. At such meetings, for example, Vladimir Hudolin (Yugoslavia) and Jaroslav Skala (Czechoslovakia) could exchange knowledge on alcoholism and the implementation of mutual support groups for treated alcoholics. Such meetings would have been particularly useful for individuals from countries with stricter travel restrictions; even in periods of harsher repression, it was usually easier to obtain travel permission for sites within the Communist world than elsewhere. Scientific and medical publications formed another site of cooperation and information exchange. Archival evidence suggests that it was common practice for large medical libraries and psychiatric research institutes to maintain subscriptions to important journals from elsewhere in Eastern Europe. Many of the region’s languages are sufficiently mutually intelligible (at least with reference to basic medico-scientific writing), especially with the aid of abstracts written in one of the region’s lingua francas – Russian or German. In addition to reading them, East European practitioners sometimes published in each other’s journals.

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East German and Czechoslovak journals carried articles by Hungarian, Soviet, and Bulgarian researchers (and vice versa). The published conference proceedings of meetings held in Yugoslavia, meanwhile, testify to the participation of psychiatric experts from across the region on topics ranging from occupational therapy to psychopharmaceutical interventions. Another common practice was the reviewing of foreign books, providing easy summaries for readers of research developments throughout Eastern Europe. Finally, the most accomplished practitioners were able to keep abreast of developments in neighbouring countries by sitting on editorial boards. Despite the sometimes lukewarm relations between Yugoslavia and the Soviet Union, for example, Andrei Snezhnevsky (among the highest ranking Soviet psychiatrists and also the figure at the centre of debates about sluggish schizophrenia and psychiatric abuse) served on the editorial board of the Yugoslav journal Neuropsihijatrija for many years. Holding these types of administrative roles would have given practitioners direct access to new research as it was being produced. Although these practices (reading foreign journals, accessing book reviews, attending conferences) might seem mundane or inconsequential from the perspective of Western psychiatry, it is worth bearing in mind that these “privileges” could not always be taken for granted. During certain eras, such as the height of Pavlovianism or the early Informbiro years in Yugoslavia, accessing foreign medical knowledge was by no means assured. In the midst of such periods (and indeed, for the duration of Communism in some countries), practitioners had to trade scientific literature “underground,” perhaps bringing back journals and textbooks acquired while at conferences abroad. On that point, an individual’s ability to travel could also be limited with little to no notice, subject to the whims of shifting international relations or petty squabbles between clinic administrators. Finally, neither this volume nor historians more broadly have grappled with the issue of psychiatry in Albania, a country whose leadership ensured deep and prolonged periods of isolation. In any case, despite these formidable and often unpredictable obstacles, psychiatrists across Eastern Europe participated in continuous and productive dialogue, passing and producing knowledge regarding mental illness across regional borders. If cooperation had remained restricted to the region, then perhaps it would be easier to speak of a uniform approach to mental illness, a “Communist Psychiatry.” In truth, however, this was almost never the case; (some) mental health professionals in Eastern Europe engaged their colleagues in the West and with enough regularity that it would be

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inappropriate to describe the situation as true isolation. There are seems to have been relatively little mystery in terms of most types of Western psychiatric knowledge, with many East European practitioners clearly up to speed on key developments (such as psychopharmaceutical development) elsewhere. Thus, “East European psychiatry” was significantly informed by Western practices, including in places that shunned particular approaches (i.e. psychoanalysis) which were deemed to be too Western. Even these “bourgeois” approaches, it should be noted, often found their way into East European practice in one form of another as “forbidden knowledge” circulated in tight-knit, unofficial circles. Over time, regional governments gradually relaxed many of the controls on what type of written information practitioners could access (and cite in their work).56 Importantly, until the building of the wall in 1961, East and West German psychiatrists were still in frequent correspondence with each other, attending the same conferences and publishing research in each other’s journals.57 Although it became logistically more difficult after 1961, cooperation between the medical communities of the “Two Germanys” was never fully prevented, providing a useful conduit for the transmission of Western literature and research eastwards. Direct engagement was also a possibility. Depending on country of origin and era, it was not unusual for particularly promising or accomplished psychiatrists to spend time training at Western institutions. Paris, New York, and London were natural hotspots for these types of activities. In the case of early post-Second World War Yugoslavia, for example, many leading practitioners were able to secure grants through the Rockefeller Foundation or Yugoslav agencies which enabled them to train abroad. The individuals who took these trips (including Dusan Petrovic, Vladimir Hudolin, Vladimir Vujic, Vojin Matic, Jovan Ristic, and Dmitrije Milanovic) established connections with Western institutions and colleagues that would prove doubly significant. On the one hand, these practitioners dominated post-war psychiatry; these men were largely responsible for training future generations of mental health care workers. At the same time, they were able to exploit the links they developed over future years, sending their own students to study under professional luminaries such as Serge Lebovici, René Diatkine, Joshua Bierer, and Maxwell Jones. In light of the connections between practitioners across Eastern Europe, their training also had a knock-on effect, providing an avenue through which knowledge could pass to those individuals elsewhere in the Communist world who were barred from travelling to the West. Yugoslavs were not, of course, the only regional practitioners to go abroad to develop their skills and knowledge base; in

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the 1950s, Czech neurologist and pedagogist Oldřich Starý, for example, conducted research visits across the United Kingdom. Most notably, he spent time at the Burden Neurological Institute in Bristol and the Institute of Psychiatry in London.58 During their time abroad, it was not uncommon for people to submit articles to their domestic journals, recounting the methods and techniques to which they were witness. The Yugoslav Eugenija CividiniStranic, for example, made repeated trips to London over a two-year period to study at the Institute for Group Analysis (under Siegfried Foulkes) and the Tavistock Clinic in London. She described in detail the methods employed by her trainers, which were of particular interest to Yugoslav psychotherapists on account of their affinity for group treatment.59 At times, authors would go into greater detail, offering their readers a glimpse into the “glamourous” life of a foreign trainee. For example, Maja Beck-Dvorzak’s “Letter from Paris” discussed her daily walk to La Salpêtrière, remarking on the statues of Philippe Pinel and the “old feel” of the place. She took care to also mention that the hospital was the site of Freud’s tutelage under Charcot.60 In her second letter, she concentrated on the progress being made in terms of patient rights, noting that those forcibly confined could petition the prefecture if they wanted to leave and that the patients of some psychiatric hospitals had even begun forming unions and publishing newsletters.61 It is also worth noting that, particularly among the more developed nations of the Habsburg lands and their successor states, the medical professions already had a tradition of sending doctors to France, Germany, or Austria to train during their early careers. Ladislav Haškovec, considered one of the founders of Czechoslovak neurology and psychiatry, travelled to Paris to study with Charcot himself at the end of the nineteenth century, recording and disseminating his experiences on his return to Prague to the Czech-speaking medical community.62 Given the small size and hierarchical culture of the medical communities in smaller nations, and the frequent use of historical and commemorative articles within their professional journals celebrating individuals within the field, one cannot underestimate the long-term influence that such intellectual traditions may have had despite the political caesuras of the Second World War and the Communist takeovers. More so than training courses, East European practitioners participated in international congresses and meetings. In all likelihood, such events were more meaningful and significant for those coming from Eastern Bloc countries than their Western colleagues. After all, such events provided an opportunity to discover new scientific ideas, many

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of which might appear only after a delay or in censored form (if at all) once published in international journals. Additionally, however, these meetings offered a chance to access consumer goods that were difficult to come by at home. Although not necessarily numerous, most major international conferences held in the West featured a smattering of individuals from the GDR, Hungary, Bulgaria, and the like. Despite these cases, it is worth bearing in mind that the ability to travel abroad was never a certainty; many practitioners were barred from ever doing so for political or professional reasons. Leaving the country for prolonged periods of time might depend on a number of factors, including having a well-connected supervisor, paying bribes to appropriate officials, and avoiding any sort of politically contentious activity. Moreover, training or attending meetings in the West would have likely produced significant consequences upon return, most notably having one’s communications monitored and being generally of greater interest to the state security apparatus. In most cases, only “trusted” individuals were likely to be granted the necessary permissions and funds to leave; in times of harsher repression or economic downturn, it was very difficult for anyone but the highest profile individuals to leave. When East European psychiatrists headed west, they did not necessarily do so as supplicants. For one, practitioners did not attend conferences as mere spectators. Rather, they presented their own research findings in the hopes of contributing to the broader dialogue on mental illness. Although the biological approach favoured by many East European practitioners seemed laughable or even obsessional during the early Communist era, it is worth pointing out that the medical model has, by and large, become the de facto standard in much of the Western world. Thus, the knowledge they sought to impart to Western colleagues was not mere ideological rambling about the genius of Pavlov, but rather earnest attempts to disseminate their (biologically grounded) research. Take, for example, a decade in the career of Czechoslovak practitioner Cyril Höschl. A graduate of Charles University’s medical program in 1974, Höschl pursued a specialization in psychiatry with a particular focus on neuroendocrinology. He later took a position at the Bohnice Psychiatric Hospital in Prague. During the Communist period, Höschl actively conducted research on a variety of topics, primarily in biological psychiatry. He presented his research findings at major meetings including the 3rd and 4th World Congresses of Biological Psychiatry (Stockholm 1981, Philadelphia 1985), the 16th Collegium Internationale Neuro-Psychopharmacologicum (one of the world’s

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largest psychopharmacological meetings, Munich 1988), the Congress of the European College of Neuropsychopharmacology (Goteborg 1989), and the 8th World Psychiatric Congress (Athens 1989). Throughout 1984 and 1985, meanwhile, he was also invited to lecture at a host of North American institutions including the universities of McMaster, McGill, and Dalhousie (all Canada) and the Manhattan Psychiatric Institute in New York. Outside of a brief period in Suzdal (USSR), all of his training and research occurred within Czechoslovakia. Although certainly not typical, Höschl demonstrates how East European practitioners were not merely learning from Western psychiatry, but also strove to actively contribute to it. Höschl is simply one of a number of individuals whose work drew interest in the West (outside the paradigm of psychiatric abuse); for example, in the 1970s, the Bulgarian psychiatrist and psychotherapist Georgi Lozanov drew substantial academic and popular attention for his research on “suggestopedia” which was subsequently integrated into teaching and therapeutic approaches in the United States and elsewhere.63 As demonstrated elsewhere in this volume, meanwhile, Vladimir Hudolin’s novel approach to alcohol and drug dependence found currency in dozens of countries around the world. Russian thinkers had a particularly profound influence on developments in the United Kingdom. In particular, a number of the behaviouralists conducting research at the Maudsley psychiatric hospital in London, such as Neil O’Connor and Monte Shapiro, were sympathetic to the Soviet cause, becoming members of the British Communist Party and drawing heavily upon Pavlovism for the formulation of their research, which laid the foundations for behaviour therapy.64 The famous Soviet psychologist Alexander Luria was also notably a member of the editorial board of the British Psychological Society’s Journal of Social and Clinical Psychology.65 Beyond his own research (which found a wide audience in translation), Luria was instrumental in bringing Lev Vygotsky’s ideas to English-language audiences.66 In trying to understand the transnational dimensions of East European psychiatry, it would be a mistake to imagine that all traffic flowed westward. Psychiatrists and psychologists from across Western Europe and North America eagerly visited research sites and clinical institutions across Eastern Europe. These visits were inspired by a mixture of intellectual curiosity and, in later years, concern over the treatment of those suspected of being victims of psychiatric abuse. Regardless of the motivation of their visit, Western visitors typically reported discovering a diversity of approaches to mental illness in contradiction to the stereotype of the slavish devotion to Pavlov.67 Not that a firm grounding

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in Pavlovian ideas necessarily put off all researchers; Christian Astrup, a prominent Norwegian practitioner with deep interests in behaviouralism and conditioning, naturally went East for additional training at research institutes in East Berlin and the USSR.68 On the whole, however, Western visitors were largely surprised by what they discovered in Eastern Europe. For instance, the International Council of Psychologists sent a delegation of 30 psychologists and psychiatrists to survey mental health programs in the USSR, Bulgaria, Romania, Hungary, Yugoslavia, Poland, and the GDR in the mid-1960s. To the shock of the visitors, Eastern European countries seemed to offer useful lessons to American mental health care, especially regarding community-based programs.69 Western practitioners also saw Eastern Europe as a novel research landscape and sought out colleagues willing to engage in cooperative research. Paul Lemkau and Guido Crocetti, both based at Johns Hopkins, connected with two Yugoslav colleagues to conduct large-scale research projects on the epidemiology of psychoses across Croatia. Specifically, the research group was interested in Yugoslav psychiatry’s long-held assumption that certain regions of Croatia possessed far greater rates of schizophrenia than elsewhere in the country. Co-sponsored by the Andrija Stampar School of Public Health (Zagreb) and the Department of Mental Hygiene at Johns Hopkins (Baltimore) (among other Yugoslav and American agencies), the studies produced several separate papers which were published in American journals.70 Meanwhile the 1972 Health Agreement signed between the USSR and United States prompted a collaborative research project between the National Institute of Mental Health and Institute of Psychiatry of the Academy of Medical Sciences in Moscow. Jimmie Holland, a psychiatrist based at the Einstein School of Medicine in New York, spent an academic year in Moscow working alongside the Soviet practitioner Irina Shakhmatova. Together, the two attempted to bridge the differences between American and Soviet classifications of schizophrenia by developing a combined classification system.71 Thus far, our discussion of transnational psychiatric links has focused on East–West connections and undoubtedly these were the strongest, at least from the perspective of Eastern Europe. With that in mind, however, it is worth remembering that, whether in Prague, Bucharest, or Moscow, one could still head further east, or south for that matter. A small amount of historical scholarship and contemporaneous sources demonstrate that East–East and East–South connections did influence psychiatric developments in those countries concerned. Most obviously, fellow Communist countries were, at least during some periods, influenced by psychiatric theories and practices originating in Eastern

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Europe, especially the USSR. For instance, although relatively little is known about psychiatry in North Korea, it appears that mental health care in the country was greatly influenced by developments elsewhere in the Communist world.72 From the early 1950s until the Cultural Revolution, Chinese psychiatry also integrated many key elements of dominant Soviet psychiatric notions of the time, including a prohibition on psychoanalysis and the elevation of Pavlovian theory.73 Cuba’s Institute of Neurophysiology and Psychology, led by José Angel Bustamante (who maintained strong links to the transcultural and social psychiatry movements), also operated an exchange program with mental health institutes across Eastern Europe, swapping personnel back and forth. In the case of Yugoslavia, its links with the Non-Aligned Movement ensured that Yugoslav psychiatrists had some bearing on the development of mental health care across what was then called the Third World. The Yugoslav government, for example, sent psychiatrists to countries such as Morocco and Ceylon (modern Sri Lanka) to act as expert advisers. Connections to the Non-Aligned countries also opened up research possibilities; transcultural psychiatrist Vladimir Jakovljevic, to take one example, conducted a comparative investigation of psychopathology in Guinea, Macedonia, and Paris.74 Ideas could also flow in the opposite direction as was the case when Yugoslav theorists began citing the Tunisian physician Sleim Ammar in their discussions of cultural factors in depression.75 These examples merely offer a cursory glance at the connections between psychiatry in Eastern Europe and the non-Western world. Historians of medicine and psychiatry would be doing the field a tremendous service by more deeply exploring the transnational creation and dissemination of psychiatric knowledge outside of the Western context. Such work would make an invaluable contribution to understanding the processes by which psychiatric practices and ideas about abnormality have been globalized since the Second World War. On the subject of the global mental health movement, the impact of East European practitioners is certainly worth considering. Until the furore over the political misuse of psychiatry forced their resignation under threat of expulsion, the Soviet and other East European psychiatric associations had been active members of the World Psychiatric Association, taking part in World Congresses and sending members to serve on the executive committee. Similarly, individual practitioners engaged with the World Federation for Mental Health, a non-governmental association dedicated to mental health promotion with close ties to the World Health Organization (WHO). Indeed, East European psychiatrists and

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psychologists made valuable contributions to the mental health work of the WHO. For example, Yugoslavia’s Stjepan Betlheim was a member of the Alcoholism Subcommittee of the Expert Committee on Mental Health which, crucially, defined the problem of excessive drinking as simultaneously a social and medical problem.76 The overarching Expert Committee on Mental Health, among its five members, also included Czechoslovak psychiatrist Josef Hadlik. As part of the first group to formulate the WHO’s long-term mental health plan, Hadlik was central in promoting the idea that mental health was best tackled from a preventative, public health position.77 Another Yugoslav (and future President of the World Psychiatric Association) Norman Sartorius, served as the director of the WHO’s Division of Mental Health from 1977 until 1993. These are but small samples of the role played by East European practitioners in the twentieth century construction of “global psychiatry.” Studying the transnational links between East European countries, as well as the connections between the region and wider world, provides a novel perspective for understanding not only “Communist Psychiatry” but also the global development of ideas relating to mental health. As this chapter (and indeed this volume) has tried to demonstrate, mental health care within Eastern Europe consisted of a more complex and nuanced picture than that which emerges solely through discussions of psychiatric abuse and the prohibition of psychoanalysis. East European practitioners busied themselves with the construction of new mental health knowledge – at times heavily influenced by Western sources and at times serving as the inspiration for psychiatric practices beyond the Iron Curtain. In short, historians of psychiatry and medicine must begin to integrate Eastern Europe into the wider historiographical debates if we are truly to understand the globalization of psychiatry. The issues dominating debates about “mainstream” (i.e. Western) twentieth century mental health care – the rise of psychopharmaceuticals, antipsychiatry, and the patient rights movement, deinstitutionalization (to name a few) – should no longer exclude the countries of the former Communist world. To do so would not only be a disservice to the historiographies of Eastern Europe but also to the history of psychiatry more broadly. *** Returning to Greg Eghigian’s question, “was there a Communist psychiatry?,” it is evident that there were multiple psychiatries practiced across the period and the region. This book is the first to bring together these

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varied histories and to explicitly address the ways in which Communism did – or did not – shape theory and practice; be it through institutional arrangements, macropolitical and economic factors, the personal political beliefs of practitioners, or even the generation of new forms of mental distress through the experience of Cold War historical events. Psychiatry can also offer an excellent prism through which to explore the different facets of social, political, and intellectual history of Communist Eastern Europe. From the broader perspective of the historiography of the region, few studies to date have explored transnational and comparative themes across borders. This volume, through its comparative concluding chapter, explicitly addresses the ways in which East European psychiatric communities were situated as part of professional networks within the region, and in relation to the wider world beyond the “Iron Curtain.” The Soviet and Cold War political contexts shaped the conceptual content and practice of psychiatry in a variety of complex and sometimes detrimental ways, but it also brought about constructive exchanges and collaborations as a result of socialist fraternity, especially between countries with related Slavic languages such as Czechoslovakia and Yugoslavia. Rather than a top-down model of imposition from the Soviet centre to its distant peripheries, we argue that psychiatry in Communist Europe can be better interpreted in the light of recent work on the history of science and medicine in colonial contexts, which explore the formation of hybrid forms of knowledge that draw upon local traditions as well as those of the “colonizing” power, as described in Alisher Latypov’s chapter on psychiatry in Soviet Tajikistan. In addition, many of the chapters in this volume deconstruct traditional totalitarian models of Communism in the region through close reading of documents relating to professionals and patients. The evidence drawn from such sources foregrounds the breadth of complex ways in which individuals related to the Party, and to the Communist project as a whole. Beyond the boundaries of Eastern Europe, this book also explicitly offers new perspectives on the history of psychiatry in the twentieth century. While there is a substantial body of existing literature on the themes of psychoanalysis in the early part of the century, and deinstitutionalization in the Western world in the second half of the century, large swathes of psychiatric practices and theories remain to be analysed. Narratives are often polarized between triumphalist descriptions of scientific progress, and historical work which has its origins in the critical psychiatry movement, particularly focused on historical critiques of the influence of the pharmaceutical industry on the psychiatric

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profession.78 The approaches taken by authors in this volume offer new explanatory frameworks for understanding and interpreting the history of psychiatry in the twentieth century, drawing on cultural and social history, as well as approaches from science and technology studies, to elucidate the intellectual and political contexts in which psychiatric knowledge and practice were generated, and how these debates played out in the broader social realm. Furthermore, such considerations are crucial for accurately informing current policy debates, as descriptions of the past are frequently appropriated as a means of justifying proposed transformations of contemporary mental health policies.79 With the history of psychiatry under Communism being invoked in such a way for present political purposes, it is imperative that historians engage in research that reconstructs the nuances of psychiatric services, institutions, and practices under the Communist systems of Eastern Europe.

Notes 1. G. Eghigian, “Was There a Communist Psychiatry? Politics and East German Psychiatric Care, 1945–1989,” Harvard Review of Psychiatry 10, no. 6 (2002): 364. 2. R. Smith, The Fontana History of the Human Sciences (London: Fontana, 1997), p. 189. 3. J. Rothschild and N. Wingfield, Return to Diversity: A Political History of East Central Europe since World War II (Oxford: Oxford University Press, 2000); R.J. Crampton, Eastern Europe in the Twentieth Century – and After (London: Routledge, 2005); A. Brown, The Rise and Fall of Communism (London: HarperCollins, 2009); R. Service, Comrades!: A World History of Communism (Cambridge, MA: Harvard University Press, 2007). 4. F.W. Killian and R. Arens, “Use of Psychiatry in Soviet Criminal Proceedings Part I,” Journal of Criminal Law and Criminology (1931–1951) 41, no. 2 (1950); H.J. Berman and D.H. Hunt, “Criminal Law and Psychiatry: The Soviet Solution,” Stanford Law Review 2, no. 4 (1950). 5. J. Wortis, Soviet Psychiatry (Baltimore: Williams and Wilkins, 1950). 6. R.S. Gill, “Foreword,” in Soviet Psychiatry, ed. J. Wortis (Baltimore: Williams and Wilkins Company, 1950), viii. 7. Wortis, Soviet Psychiatry, xv. 8. M. Field, “Approaches to Mental Illness in Soviet Society: Some Comparisons and Conjectures,” Social Problems 7, no. 4 (1960); J. Aronson and M. Field, “Mental Health Programming in the Soviet Union,” American Journal of Orthopsychiatry 34(1964); M. Field, “Soviet Psychiatry and Social Structure, Culture, and Ideology: A Preliminary Assessment,” American Journal of Psychotherapy 21, no. 2 (1967); M. Field, “Psychiatry and Ideology: The Official Soviet View of Western Theories and Practices,” American Journal of Psychotherapy 22, no. 4 (1968); M. Field and J. Aronson, “Soviet Community Mental Health Services and Work Therapy: A Report of Two Visits,” Community Mental Health Journal 1, no. 1 (1965).

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9. Aronson and Field, “Mental Health Programming,” 296. 10. N. Kline, “The Organisation of Psychiatric Care and Psychiatric Research in the Union of Soviet Socialist Republics,” Annals of the New York Academy of Sciences 84, no. 4 (1960); Z. Lebensohn, “The Organization and Character of Soviet Psychiatry,” American Journal of Psychotherapy 16 (1962). 11. In the Soviet Union, where the best-known cases of abuse occurred, religious believers, nationalists, and would-be emigrants also suffered from this practice. One could also add to this list “hippies” and “jazz lovers,” although less work has been done on these “non-political” deviants. See S. Bloch and P. Reddaway, Russia’s Political Hospitals: The Abuse of Psychiatry in the Soviet Union (London: Gollancz, 1977), 278–9. Greg Eghigian, meanwhile, has argued that systematic psychiatric abuse against political dissenters did not occur in Germany so much as psychiatry was used to control the “socially undesirable,” i.e. prostitutes, alcoholics, and delinquents. See G. Eghigian, “Was There a Communist Psychiatry?”: 364. Some authors have cogently argued that psychiatrists themselves were often victims of abuse, being required to do the horrendous or impossible by the regime. For instance, see N. Adler, G.O. Mueller, and M. Ayat, “Psychiatry under Tyranny: A Report on the Political Abuse of Romanian Psychiatry During the Ceausescu Years,” Current Psychology 12, no. 1 (1993): 4–5. 12. R. Medvedev and Z. Medvedev, A Question of Madness (London: MacMillan Ltd, 1971), 46; Bloch and Reddaway, Russia’s Political Hospitals, 247. 13. S. Bloch and P. Reddaway, Soviet Psychiatric Abuse: The Shadow over World Psychiatry (Boulder, Colo: Westview, 1985), 24. 14. S. Bloch, “Psychiatry as Ideology in the USSR,” Journal of Medical Ethics 4, no. 3 (1977). 15. Bloch and Reddaway, Russia’s Political Hospitals, 274–5; Bloch and Reddaway, Soviet Psychiatric Abuse, 19. 16. Medvedev and Medvedev, A Question of Madness, 105. 17. R. Bonnie and S. Polubinskaya, “Unraveling Soviet Psychiatry,” Journal of Contemporary Legal Issues 10 (1999); Adler et al., “Psychiatry under Tyranny.” 18. K.W. Fulford, A.Y.U. Smirnov, and E. Snow, “Concepts of Disease and the Abuse of Psychiatry in the USSR,” British Journal of Psychiatry 162 (1993); Bloch, “Psychiatry as Ideology.” 19. H. Fireside, Soviet Psychoprisons (New York: WW Norton and Company, 1979). 20. For a personal account regarding many of these events, see R. Van Voren, Cold War in Psychiatry: Human Factors, Secret Actors (Amsterdam: Rodopi, 2010). 21. R. Van Voren, “Comparing Soviet and Chinese Political Psychiatry,” Journal of the American Academy of Psychiatry and the Law 30, no. 1 (2002): 134. 22. In her Human Rights Watch report, Catherine Fitzpatrick cited victims of disgruntled bosses or spouses as examples of common people who were illegitimately detained in psychiatric facilities. See C. Fitzpatrick, Psychiatric Abuse in the Soviet Union: A Helsinki Watch Report (New York: Helsinki Watch, 1991). In many ways, the stories of these victims echo those who were unfairly incarcerated during the pre-asylum period of private madhouses and the trade in lunacy. 23. Fireside, Soviet Psychoprisons, xvii. 24. Adler et al., “Psychiatry under Tyranny,” 1–2; Vladimir Bukovsky in the introduction to C. Brown and A. Lagos, The Politics of Psychiatry in Revolutionary Cuba (New York: Freedom House, 1991), xi–xiii.

Communist Europe and Transnational Psychiatry 23 25. J. Neumann, “Psychiatry in Eastern Europe Today: Mental Health Status, Policies, and Practices,” American Journal of Psychiatry 148, no. 10 (1991): 1387; A. Stone, “Psychiatrists on the Side of the Angels: The Falun Gong and Soviet Jewry,” Journal of the American Academy of Psychiatry and the Law 30, no. 1 (2002): 110; S. Lee and A. Kleinman, “Psychiatry in Its Political and Professional Contexts: A Response to Robin Munro,” Journal of the American Academy of Psychiatry and the Law 30, no. 1 (2002): 122–4; J. Füredi, P. Mohr, D. Swingler, I. Bitter, M.D. Gheorghe, L. Hotujac, M. Jarema, M. Kocmur, G.I. Koychev, S.N. Mosolov, J. Pecenak, J. Rybakowski, J. Svestka and N. Sartorius, “Psychiatry in selected countries of Central and Eastern Europe: an overview of the current situation,” Acta Psychiatrica Scandinavica 114, no. 4 (2006): 223–231. 26. R.J. Bonnie, “Political Abuse of Psychiatry in Soviet Union and in China: Complexities and Controversies,” Journal of the American Academy of Psychiatry and the Law 30, no. 1 (2002): 136. 27. P. Appelbaum, “Law & Psychiatry: Abuses of Law and Psychiatry in China,” Psychiatric Services 52, no. 10 (2001): 1298. 28. Van Voren, “Comparing Soviet and Chinese Political Psychiatry”, 132–3. 29. R. Van Voren, “Political Abuse of Psychiatry – an Historical Overview,” Schizophrenia Bulletin 36, no. 1 (2010). 30. H. Lavretsky, “The Russian Concept of Schizophrenia: A Review of the Literature,” Schizophrenia Bulletin 24, no. 4 (1998). 31. Stone, “Psychiatrists on the Side of the Angels,” 110; Fulford et al., “Concepts of Disease and the Abuse of Psychiatry,” 804. 32. R. Munro, “On the Psychiatric Abuse of Falun Gong and Other Dissenters in China: A Reply to Stone, Hickling, Kleinman, and Lee,” Journal of the American Academy of Psychiatry and the Law 30, no. 2 (2002): 266. 33. W. Lauterbach, Soviet Psychotherapy (London: Pergamon Press, 1984); P. Calloway, Soviet and Western Psychiatry: A Comparative Study (London: Moor Press, 1992); D. Cohen, Soviet Psychiatry (London: Paladin, 1989). 34. Calloway, Soviet and Western Psychiatry. 35. Lauterbach, Soviet Psychotherapy, 6; H. Junová, “Psychogymnastics in Group Psychotherapy for In-patients,” Psychiatrie, Neurologie, Und Medizinische Psychologie 31, no. 7 (July 1979): 421–8. 36. Calloway, Soviet and Western Psychiatry, 79–81. 37. Calloway, Soviet and Western Psychiatry. 38. Lauterbach, Soviet Psychotherapy, 95; J.V. Brown, “Heroes and Non-Heroes: Recurring Themes in the Historiography of Russian-Soviet Psychiatry,” in Discovering the History of Psychiatry, ed. Mark Micale and Roy Porter (Oxford, UK: Oxford University Press, 1994), 297–310. 39. R. Smith, The Fontana History, p. 189. 40. G. Windholz, Soviet Psychiatrists Under Stalin Duress: The Design For A “New Soviet Psychiatry” and Its Demise, n.d.; G. Windholz, “The 1950 Joint Scientific Session: Pavlovians as the Accusers and the Accused,” Journal of the History of the Behavioral Sciences 33, no. 1 (1997): 61–81. 41. B. Zajicek, Scientific Psychiatry in Stalin’s Soviet Union: The Politics of Modern Medicine and the Struggle to Define “Pavlovian” Psychiatry, 1939–1953 (University of Chicago, 2009), 370. 42. Zajicek, Scientific Psychiatry in Stalin’s Soviet Union, 370.

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43. G. Windholz, “Pavlov’s Conceptualization of Paranoia Within the Theory of Higher Nervous Activity,” History of Psychiatry 7, no. 25 (1996): 159–66; G. Windholz, “Pavlov’s Conceptualization of the Dynamic Stereotype in the Theory of Higher Nervous Activity,” The American Journal of Psychology 109, no. 2 (1996): 287–95; G. Windholz and L.H. Witherspoon, “Sleep as a Cure for Schizophrenia: A Historical Episode,” History of Psychiatry 4, no. 13 (1993): 83–93; D.L. Grimsley and G.L. Windholz, “The Neurophysiological Aspects of Pavlov’s Theory of Higher Nervous Activity: In Honor of the 150th Anniversary of Pavlov’s Birth,” Journal of the History of the Neurosciences 9, no. 2 (2000): 152–63; D.P. Todes, Pavlov’s Physiology Factory: Experiment, Interpretation, Laboratory Enterprise, 1st ed. (Baltimore: The Johns Hopkins University Press, 2001). 44. A. Etkind, Eros of the Impossible: The History of Psychoanalysis in Russia (Boulder: Westview Press, 1997). 45. M. Miller, Freud and the Bolsheviks: Psychoanalysis in Imperial Russia and the Soviet Union (New Haven: Yale University Press, 1998). 46. M. Savelli, “The Peculiar Prosperity of Yugoslav Psychoanalysis,” Slavonic and East European Review 91, no. 2 (2013): 262–88. 47. C. Leuenberger, “Socialist Psychotherapy and its Dissidents,” Journal of the History of the Behavioural Sciences, 37, no.3 (2001): 261–73. 48. Josef Tichý, Historie bohnické psychiatrie v letech 1903–2005 (Praha: Galén, 2006). 49. W. Rose, Anstaltspsychiatrie in der DDR: die brandenburgischen Kliniken zwischen 1945 und 1990 (Berlin: Be.bra, 2005). 50. M. Kovai, “Láttam Eléggé Közelről, De Csak Ilyen Icipici Ablakokon, Hogy Mi Megy Végbe Itt Magyarországon,” in Tükörszilánkok – Kádár-korszakok a Személyes Emlékezetbe, ed. Éva Kovács (Budapest: MTA Szociológiai Kutatóintézet, 2008), 289–317. 51. See particularly S. Hanrath, Zwischen ‘Euthanasie’ und Psychiatriereform. Anstaltspsychiatrie in Westfalen und Brandenburg (Paderbord: Schöningh, 2002); S. Süss, Politisch Missbraucht?: Psychiatrie Und Staatssicherheit in Der DDR (Berlin: Ch. Links, 1999); K. Behnke and J. Fuchs, Zersetzung der Seele. Psychologie und Psychiatrie im Dienste der Stasi (Hamburg: Europäische Verlagsanstalt, 2010). 52. It is striking that few authors have thus far drawn on oral history interviews with psychiatrists and patients for example, with T. Müller, Psychiatrie in der DDR: Erzählungen von Zeitzeugen. (Leipzig: Mabuse-Verlag, 2006) and M. Savelli, “The Peculiar Prosperity of Yugoslav Psychoanalysis,” Slavonic and East European Review 91, no. 2 (2013): 262–88 offering exceptions. 53. H. Schmiederbach and S. Priebe (2004), “Social Psychiatry in Germany in the Twentieth Century: Ideas and Models,” Medical History 48, no. 4 (2004): 449–72; V. Hess, “The Rodewisch (1963) and Brandenburg (1974) Propositions,” History of Psychiatry 22, no.2 (2011): 232–4; S. Hanrath, Zwischen ‘Euthanasie’ und Psychiatriereform. 54. U. Kloppel and V. Balz, “Psychopharmaka im Sozialismus. Arzneimittelregulierung in der Deutschen Demokratischen Republik in den 1960er Jahren,” Berichte zur Wissenschaftsgeschichte 33, no. 4 (2010): 382–400; V. Balz and M. Hoheisel, “East-Side Story: The Standardisation of Psychotropic Drugs at the Charité Psychiatric Clinic, 1955–1970,” Studies in

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55.

56.

57. 58. 59. 60. 61. 62.

63. 64.

65. 66. 67.

68. 69. 70.

71.

History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 42, no.4 (2011):453–66. As just one example, see Jochen Neumann’s piece written just after the fall of the Berlin Wall and the collapse of Communism. Neumann accurately describes some of the most pressing issues facing East European psychiatrists at the time, but his description likely overstates the isolation in which East European practitioners operated, perhaps reflecting the situation of the late 1980s rather than the entire Communism period. Neumann, “Psychiatry in Eastern Europe Today.” As an example, see Eghighian’s description of how East German party officials eventually relinquished responsibility over monitoring psychiatrists’ access to foreign materials, especially during the détente period. G. Eghighian, “Care and Control in a Communist State: The Place of Politics in East German Psychiatry,” M. Gijswijt-Hofstra, H. Oosterhuis, J. Vijselaar, H. Freeman (eds), Psychiatric Cultures Compared: Psychiatry and Mental Health Care in the Twentieth Century: Comparisons and Approaches (Amsterdam: Amsterdam University Press, 2005). This is evident from the contents of the East German journal Psychiatrie, Neurologie und Medizinische Psychologie. Archives of the Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IIb/1.1 Karton 1, č 60. E. Cividini-Stranic, “Gdje Je Danas Grupna Analiza?” Psihoterapija 6, no. 2 (1976). M. Beck-Dvorzak, “La Salpetriere: Pismo Iz Pariza, ” Neuropsihijatrija 3, no. 3–4 (1955). M. Beck-Dvorzak, “Centar Za Lijecenje I Socijalni Readaptaciju U Dusevnoj Bolnici Ville-Edward: Pismo Iz Pariza,” Neuropsihijatrija 4, no. 2 (1956). Ladislav Haškovec, Johann Martin Charcot unpublished typescript, 1895, National Library of the Czech Republic; Ladislav Haškovec Zápisky z Paříže (Prague: 1895). W.J. Bancroft, “The Lozanov Method and Its American Applications” The Modern Language Journal 62(4) 1978. See S. Marks, “Psychologists as Therapists: Behavioural Traditions,” in John Hall, David Pilgrim, and Graham Turpin (eds), Clinical Psychology in Britain (London: BPS Books, 2015). British Journal of Social and Clinical Psychology, 1 (1962), p. 1. P. Rabbitt, “Introduction,” in P. Rabbitt (ed.), Inside Psychology: A Science over Fifty Years (Oxford University Press, 2009). L. Kalinowsky, “Impressions of Soviet Psychiatry,” Comprehensive Psychiatry 1, no. 1 (1960); L. Salzman, “Psychotherapy in the Soviet Union and Iron Curtain Countries,” Comprehensive Psychiatry 4, no.4 (1963). Some of this work is detailed in C. Astrup, Pavlovian Psychiatry: A New Synthesis (Springfield: Charles C Thomas, 1965). C.S. Moss, “Visitation to Mental Health Programs in Eastern Europe,” American Psychologist 22, no. 6 (1967). G. Crocetti, Z. Kulcar, B. Kesic, and P. Lemkau, “Differential Rates of Psychoses in Croatia, Yugoslavia,” American Journal of Public Health 54, no. 2 (1964). Also see the three papers co-authored by the same four individuals in American Journal of Epidemiology 94(2) 1971. J. Holland, “A Comparative Look at Soviet Psychiatry: Training, Concepts, and Practice,” in S. Corson and E. O’Leary Corson (eds), Psychiatry and Psychology in the USSR (New York: Plenum Press, 1975).

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72. Y.S. Park, S.M. Park, J.Y. Jun, and S.J. Kim, “Psychiatry in Former Socialist Countries: Implications for North Korean Psychiatry,” Psychiatry Investigation 11, no.4 (2014). 73. A. Kleinman, Rethinking Psychiatry: From Cultural Category to Personal Experience (New York: Free Press, 1991), p. 100. 74. V. Jakovljevic, “Socijalno-Patoloska Priroda Mentalnih Poremecaja,” Neuropsihijatrija 14, no. 1 (1966). 75. Dj. Bogicevic, “Kultura I Depresija,” III Kongres Psihoterapeuta Jugoslavije (Belgrade: 1979). 76. World Health Organization Technical Report Series No 42, Expert Committee on Mental Health. Report of the First Session of the Alcoholism Subcommittee. Geneva 11–16 December 1950. 77. World Health Organization Technical Report Series No 9, Expert Committee on Mental Health. Report of the First Session, Geneva 29 August–2 September 1949. 78. On the former, see E. Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. (London: Wiley and Sons, 1997); on the latter see D. Healy, The Antidepressant Era (Cambridge, MA: Harvard University Press, 1999); D. Healy, Let Them Eat Prozac: The Unhealthy Relationship between the Pharmaceutical Industry and Depression (New York: New York University Press, 2004); J. Moncrieff, The Myth of the Chemical Cure (London: Palgrave Macmillan, 2009). For a detailed discussion of the large gaps still existing in the history of psychiatry in the twentieth century see V. Hess and B. Majerus, “Writing the History of Psychiatry in the 20th Century,” History of Psychiatry 23 (2012): 404–18. 79. See, for example, E. Dragomerická, A. Bržinová, E. Pálová, P. Baudiš and P. Šelepová “The History of Mental Health Care in Czechoslovakia,” in R.M. Scheffler and M. Potůček (eds), Mental Health Care Reform in the Czech and Slovak Republics: 1989 to the Present. (Prague: Karolinum, 2008).

2 The Dialectics of Labour in a Psychiatric Ward: Work Therapy in the Kaschenko Hospital Irina Sirotkina and Marina Kokorina

In 1796, the Quaker couple, William Tuke and his wife Esther, opened a “retreat” for the mentally ill in York. By contrast with contemporary madhouses, where violence reigned, in their Retreat inmates were treated in a humane, albeit disciplined, way to push them towards moral improvement and mental health. Above all, the insane were to be taught to work and labour made pleasant and attractive.1 In the “moral treatment” that was practised at the Retreat, work was of primary importance. In itself, work has a power to constrain which was superior to all other forms of physical coercion, as the regularity of hours, the demands it made on attention, and the obligation to achieve a result removed what would have otherwise been a harmful liberty of thought, fixing patients in a system of responsibility.2 To re-phrase Foucault’s comments, work “was both spontaneity and constraint,”3 and to that extent it was the only means of counteracting the aliénation mentale – alienation or estrangement of mind. The term aliénation mentale was introduced by Philippe Pinel in his Traité médico-philosophique sur l’aliénation mentale ou la manie (Paris, An IX), probably on the basis of the Latin alienatio mentis,4 and it gave birth to a whole cluster of derivatives: aliéné, aliénist, asile or maison des aliénés. William’s grandson, Samuel Tuke, preferred the term the aliéné to the English the insane. By contrast with the fatal “madness,” “alienation” had connotations of a passing ailment (“reason hid without ever disappearing”)5 and implied “the abolition of the thinking capacity,” with other capacities intact.6 Bringing together Pinel’s aliénation mentale and Hegelian dialectics, Foucault writes about “the 27

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dialectic of alienation.” Apparently, F. W. H. Hegel also made use of Pinel’s treatise.7 In the German language, though, the verbs entäußern and entfremden are reflexive, and, in Hegel’s rendering, aliénation acquired the meaning “alienation from oneself” – from one’s own essence. According to Hegel, alienation happens when the individual’s striving to realise his or her potential and to reach unity or wholeness is perpetually frustrated. The person experiences “alienation” as a feeling of lack of self-worth and of meaning in life, of the world as “the irrational void of necessity.”8 Karl Marx also discussed Entfremdung in the context of his critique of capitalist society. He understood alienation in a threefold way: the worker is estranged from the means of production, from the product, and from his own essence, the “essential being.” Workers sell their work force, so that the work they do does not respond to their own desires. Under capitalism, work destroys creative capacity rather than developing it: “the worker feels himself only when he is not working, when he is working he does not feel himself. He is at home when he is not working, and not at home when he is working. His labour is therefore not voluntary but forced; it is forced labour.”9 In fact, under capitalism “all classes are considered alienated in the ways and to the degree that their members fall short of the communist ideal.”10 In a communist society, Marx believed, people would overcome alienation and re-unite with their true selves, their human essence, social by nature. In a communist society, work, freed from exploitation, would become the primary condition of human life, a way towards the individual’s “self-actualisation” and a new, “harmonious” person. According to Marx, work is therefore a value in itself; its potential for personal growth might be more important than its material product. In his analysis of madness, Foucault shows that, in their effort to care for the needs of bourgeois society, the alienists equated reason with bourgeois order. Only by submission to this order would the madman “return to his consciousness as a free, responsible subject, thereby regaining reason.”11 Asking the question – which reason, whose reason? – Foucault is as radical as the young Marx. He also analyses moral treatment and its main tool, “therapeutic work:” In the asylum work was stripped of any production value, it was only imposed as a moral rule. It was a limitation of liberty, submission to order, an engagement to responsibility, of which the only goal was the tethering of a spirit that roamed too freely in the excess of a liberty which physical constraints only limited in appearance.12

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Foucault’s first point – that work in the asylum had no “production value” and was done for the sake of its restorative function – reminds us of Marx’s conception of communist labour for the sake of creative development. Yet, Foucault’s second point, about work as moral constraint or interiorised coercion, takes Marx’s analysis of alienation even further. He makes it clear that work, even when freed from exploitation and done for “restorative” purposes, can still be coercive, if by it is intended moral constraint or self-constraint. The mental patient experiences double alienation: first, being admitted to an asylum, she is labelled as alienated from her reason; and second, participating in work therapy she falls under moral constraints and is therefore alienated from her essence – from herself. Unlike Hegel or Marx, Foucault is cautious about essential human nature.13 We could imagine this might in part be because Foucault was aware of the failure of the communist experiment in Russia. After 1917, the Bolsheviks established a real cult of “freed labour” of the working class and proletariat. Work was conceived as both retribution for the idleness of wealthy classes and the promise of salvation, a personal obligation and a reward. In the official mythology it became imbued with magic powers: an ability to improve, reform, and remodel both social life and the individual (Trotsky’s idea of labour camps was not distant from such thought.) Marx’s ideal of creative work, work done out of one’s free will and not of necessity, shone as a beacon for the Soviet adepts. Having taken the place of the old religion, the new secular faith penetrated all areas of Soviet life. Echoing current ideas, the Soviet psychiatrist L. L. Rokhlin wrote: “now, when, in our country, work has become the primary human need, the foundation and stimulus for creative life, one appreciates even better the psychotherapeutic importance of meaningful, purposeful and joyful work.”14 Another influential psychiatrist, V. A. Giliarovskii, especially valued the element of self-coercion in work, which, in his words, makes the patient overcome inner resistance.15 As a result, for a long time – until the era of new pharmaceutical medication – work therapy became the dominant method in Soviet psychiatric hospitals. The American medical doctor Joseph Wortis visited the Soviet Union after the Second World War. After having seen several establishments for the mentally ill (of course, only those he had been shown), Wortis observed that work therapy has exceptional significance, since it gives the patient an opportunity to preserve and strengthen his powers and to preserve

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his ties with the outside world. A work program is also important for the utilisation of the remaining work capacity of chronic cases, or in cases of partial remission with residual defects.16 He thus summarised the main principles of Soviet mental care: “(1) avoidance of hospitalisation wherever possible, (2) utilisation of sheltered workshops, special vocational placement or agricultural work colonies, (3) extensive development of occupational facilities in hospitals.” In other words, psychiatry in the Soviet Union was to be preventive, community-oriented, and based mainly on work as cure.17 When Wortis cautiously enquired about “forced labour camps” that he had vaguely heard of, he was told that “some misinformed discussion in unfriendly circles” might have been caused by the “deep confidence in the whole restorative functions of work” widespread in the country of freed labour.18 Apparently satisfied with the answer, Wortis emphasised the concordance between Soviet psychiatry and dialectical materialism. The idea of work therapy in a psychiatric hospital is based on several models: the patriarchal model, with the physician as head of the extended family; the capitalist model of individual labour for remuneration; and the communist model of creative and transforming work. Ironically, genuinely “freed labour,” in Marx’s sense of the word – that is, work for the sake of its transforming capacity – was limited in the USSR to psychiatric hospitals. The conditions in hospitals were such that sometimes it was more fulfilling for the patient to work rather than not. For this reason, and also because the organisation of workshops and agricultural colonies required from psychiatrists an extra effort, work therapy was a luxury. Paradoxically, it may be argued that in a psychiatric hospital an opportunity to work was better appreciated than elsewhere in the country, where heroic and romantic labour was officially praised yet “freed labour” was commonly understood as “freedom from labour.”

Work therapy in Russia With the beginning of zemstvo medicine in the 1880s, the network of psychiatric hospitals expanded. New facilities were built according to the most progressive Western models, following the type of asylum built in the countryside, such as the York Retreat or the Alt Scherbitz Hospital near Leipzig. The main arguments for constructing hospitals in the country were tranquillity, space, and close contact with nature; physicians emphasised the healing powers of cultivating the soil and

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looking after domestic animals. The idea was to imitate as much as possible patriarchal and communal life; the image of a “colony,” a socialist commune, or a “phalanster” was often evoked. New hospitals were often referred to as “agricultural colonies.”19 By the turn of the century, there were about a dozen hospital-colonies: in Kolmovo, of the Novgorod zemstvo; Burashevo, of the Tver’ zemstvo; Sapogovo, of the Kursk zemstvo; Galenchino, near Riazan’; Kuvshinovo, near Vologda; Karamzino, near Simbirsk; and others.20 One of the main proponents of countryside hospitals was the influential psychiatrist Piotr Kashchenko (1858–1920).21 Before designing his first hospital-colony near Nizhnyi Novgorod, he went on a research trip to England, Scotland, Belgium, France, and Germany. In three months, he visited a dozen facilities and as a result drew up a detailed plan for hospital buildings, including interior design. In 1895, the sponsor, I. M. Rukavishnikov, bought land in the village of Liakhovo, the former estate of the writer P. I. Mel’nikov-Pecherskii. The architect P. P. Malinovskii built the colony acceding to the psychiatrist’s requests. The hospital possessed vast terrain, with ploughed fields, woods, and meadows. There was a separate building of workshops for carpentry, sawing, shoe making, and basket weaving.22 In 1904, Kaschenko was invited to head the Moscow City Hospital (named after the late mayor and benefactor, N.A. Alekseev), which was also built in the nearby countryside, after the model of an agricultural colony. Kaschenko replaced Viktor Romanovich Butske (1845–1904) who also had done a lot to set up a hospital with a curative regime. Butske criticised “the medicine of the old days, which invested all its power in pharmacology,” and he tried the alternative method of creating a therapeutic environment in the hospital. His ideal was to design a hospital where “the walls cure.” “In essence, I am an inventor,” Butske said of himself.23 He introduced in the Alekseevskaya Hospital systematic work both in workshops and outside. During his first year, the inmates planted a thousand trees and bushes, made a plantation of willows for weaving baskets, and cultivated a vegetable garden and a rose garden (part of which can still be seen in the hospital). A year later, the budget for the equipment for “work and entertainment” was larger than that for medication.24 Doctor S. S. Stupin was appointed to oversee the works.25 An inventor, like Butske, he had already suggested a number of initiatives for reforming mental health care, such as the organisation of “people’s sanatoria” for cases of mild psychoses and for convalescent patients.26 Stupin was the first psychiatrist in Russia to raise publicly the issue of work for patients. If originally conceived as purely therapeutic, work in

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practice became product-oriented as it often constituted the hospital’s income. Since hospitals constantly experienced economic and organisational shortages, it was tempting to use patients’ work. Some country hospitals opened large production-oriented workshops. In the early 1900s, the textile factory of the Novoznamenskaya psychiatric hospital produced enough fabric to make dresses for female wardens and inmates and summer costumes for male wardens and inmates, and also to supply the neighbouring hospital of Vsekh Skorbiaschikh.27 In the Vinnizy Regional Hospital, founded in 1897, there was a brick factory, and new hospital pavilions were built with their own brick.28 Stupin warned about the ongoing exploitation of patients: “Currently the situation of a working [mental] patient is worse than that of the inmates in prisons, work houses, and penal establishments.”29 In the latter work is paid, while in psychiatric hospitals “almost everywhere the work by the mentally ill is a relevant part of the income of the city or zemstvo budget, and it pays off the subsistence of the mentally ill which had been already paid by either the community or the patient’s relatives.” Using patients’ work to cover the hospital’s expenses, Stupin argued, is incompatible with the idea of moral treatment. At the same time, in modern capitalist society, patients would not work for the sake of “passing time,” and they would expect to be paid for their work. “The patient, who is locked up against his own will, would not work calmly and willingly, fully conscious that his family had lost in him a worker and that he, for all his works, would earn nothing here.”30 In other words, one should not alienate the patient twice: first, by locking her up in the asylum and second, by exploiting her work. Thus, a hundred years after the foundation of the York Retreat, the idea of moral treatment was put into question. Tuke believed that patients’ work did not have to be productive and that it served other, moral goals. For this reason, Russian psychiatrists refused to give monetary reward to patients even when they used their labour. They complained that the whole business of calculating wages brought into hospitals the “commercial spirit” alien to communal medicine.31 They justified their decision also by the fact that it was complicated to make a calculation for each patient, and that, by receiving unequal wages, patients believed they had been unjustly rewarded, causing conflicts. Finally, not all the patients worked,32 while everybody benefited from the work of those who did. In spite of the difficulties “moral treatment” met in Russia, Stupin wanted to preserve it. For this, he thought, work should not be productoriented: “let the patient spoil on the way some material yet advance in

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his business.”33 Work should be therapy, education, or entertainment. Workshop buildings should be beautiful, well equipped, and luxurious. And, if there were income from work, it should be spent on bonuses for the work instructors and wardens. Instructors should be paid for each person whom they taught, and “the harder it was to teach him, the larger the bonus should be.”34 Stupin’s doubts followed from the dilemma of work therapy in a psychiatric hospital: on the one hand, work is curative and does not require monetary reward; on the other hand, in contemporary society, unless work is paid, it becomes exploitation. The First World War and the Revolution put psychiatric hospitals on the edge of extinction. Many medical doctors went to the front and hospital buildings were given to the wounded soldiers. After the Revolution of 1917, some hospitals stopped functioning due to the lack of funding, and the family fostering35 in villages (when peasant families looked after the mentally ill) was closed down. Patients died of famine, cold, and lack of care.36 Although Kaschenko equated communism with mental illness,37 he agreed to serve in the new government, which promised to stop the collapse of mental health care. In August 1919, at their first meeting after the Revolution, psychiatrists discussed the organisation of psychiatric help in the new republic. Kaschenko argued for rebuilding colonies for the chronically ill, while also developing an “active” or “preventive” model of mental health care, with attention given to treating acute cases rather than looking after the chronically ill. In fact, already before the war, at the XVIII congress of physicians of the Moscow Region (1913), hospital-colonies were criticised. “Not everybody likes these ‘phalansters’ and finds them pleasant” – the psychiatrist T. I. Iudin wrote in retrospect – “many of the mentally ill do not want to be taken away from the families.” Iudin believed that “one’s participation in active life, even with a lessened ability to work, is more desirable than a stay in ‘phalansters’, however comfortable.”38 At the second national meeting of psychiatrists, “active” psychiatry won. Precedents existed: in 1903, Butske created a type of outpatient service, and Moscow was divided by the physicians of the Alekseevskaya hospital and the Probrazhenskaya hospital. At the 1923 meeting, the Moscow psychiatrists Lev Rozenshtein and Piotr Zinoviev suggested “neuropsychiatric dispensaries” which would detect the onset of mental illness and provide outpatient care.39 The first “state neuropsychiatric dispensary” was opened in 1925; among other functions, it had the task of rehabilitating the mentally ill, including finding them employment.40 Other institutions of “active psychiatry” were “day hospitals” (dnevnye statsionary) and “prophylactic work units” (trudovye

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profilaktorii), where patients came for the day and worked and lunched there.41 The Soviet system of mental health care included dispensaries, psychiatric hospitals, wards in general hospitals for acute cases, and sanatoria for the “borderline” and mild cases. Unfortunately, the main problem facing any system of psychiatry remained: what to do with the patients rejected by their milieu and who had lost employment and a place to live? For some of them, the psychiatric hospital was the last resort. By 1931, the Alekseevskaya hospital (in 1922, renamed after Dr Kaschenko) accommodated 1,338 patients, hugely exceeding its capacity.42 The hospital was overcrowded with the chronically ill and cases it was not meant for, including alcoholics, psychopaths, and persons with neurological or organic diseases. In 1929, the first five-year plan pushed for widespread industrial modernisation or “reconstruction,” and psychiatry was also to be affected by the reforms. On October 26, the Russian Federation government issued a decree to inspect all facilities for mental health care. The decree stated that the hospital network was insufficient; hygienic conditions in hospitals were poor and there was a shortage of personnel and facilities for work therapy. The decree also suggested that psychiatric hospitals, instead of being homes for the mentally ill, should become places for active treatment. To get rid of the chronic cases, psychiatrists had to return to the old practice of countryside colonies. In 1931, the Kaschenko hospital set up an “agricultural labour colony.”

The Troparevo agricultural labour colony The place where the colony was founded, to the south-east of Moscow and a few miles from the Kaluzhskaya city gates, had a reputation as the “psychiatric region” for four decades. In the early 1890s, the psychiatrist Nikolai Bazhenov had opened a family fostering programme in the village of Semionovskoe. Persons with chronic diseases were placed in peasant families and supplied with bedding, clothes, and food money; the host family was paid a monthly sum. Female patients, who helped the host family around the house and by looking after the children, were especially welcome. In 1897 the Alekseevskaya hospital opened its own family patronage, which gradually expanded to several villages: Troitskoe, Ziuzino, Nikulino, Bogorodskoe, Nikol’skoe, Derevlevo, and Troparevo (all now parts of Moscow). The “Psychiatric Region” was 6–7 kilometres in diameter.43 By 1917 there were 450 persons living with peasant families. In the coming years, the October Revolution, civil war, and collectivisation hit the village hard. The family fostering

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programme gradually shrank, although by the beginning of the Second World War it still had 60 patients.44 The idea of a countryside colony had been raised already in 1911, yet its realisation came 20 years later, helped by chance. Near Troparevo, there was a commune of tolstovtsy – the spiritual children of Lev Nikolaevich Tolstoy. The commune, called “Life and Work” (Zhizn’ i trud) was founded at the end of 1921, when several young people rented the estate of Shestakovka from the Moscow Regional Government.45 The commune leader, Boris Vasilievich Mazurin (1901–1989), followed Tolstoy’s ideas and way of life. The co-founders, Efim Moiseevich Serzhanov and Shvil’pe (unfortunately, his first name is not known), called themselves “pan-anarchists” and “all-inventors” (vseizobretateli). “You, tolstovtsy, strive for the natural – they argued – by contrast, we consider the natural a wild chaos. We believe that everything, everything in human life should be perfected and re-invented.”46 All-inventors wanted, above all, to improve and perfect humankind and to increase longevity. They “tried to make concentrated food, in the form of pills‘pictons’, which would supply a person with all vital elements … and not require energy for digestion.” Regretting that humans slept a third of their lifetime, the all-inventors tried to sleep as little as possible. “From these experiments – Mazurin wrote – one of the future members of the commune, Misha Rogovin, nearly died.”47 Between themselves, Serzhanov and Svil’pe spoke in the language “Ao,” and they had special names, Biaelbi and Biabi – “the inventors of life.”48 In the commune, work started at three in the morning and continued until sunset. Even in religious communes, such enthusiasm was rare; in the theosophy commune, “Dawn in the East,” work began at 9, after breakfast, and ended in late afternoon.49 As Mazurin wrote in retrospect, “our only fault was an overwhelming eagerness to work. Work absorbed all our time, energy and attention.”50 The editor of Tolstoy’s works, Mikhail Gorbunov-Posadov, stayed in “Life and Work” for a month; the commune appeared to him one of the most severe tolstovtsy communes.51 “Work – we have, life – we do not,” the commune members complained.52 In a tragic irony, official communism stopped the genuine communism of the tolstovtsy. In February 1930, a government decree ordered the tolstovtsy to move to Siberia. “Life and Work” sold the estate to the Kaschenko hospital for 17,000 roubles.53 And, in the spring of 1931, the first 126 patients from the hospital and the family fostering programme were moved to the colony. Patients with any diagnosis were accepted: the condition was whether or not they were able to work.

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The Kaschenko physicians reported optimistically: “in our experience, even excitable epileptics, inaccessible schizophrenics, irritable idiots, and unstable psychopaths, working collectively, are susceptible to the collective’s influence and gradually adjust to it.”54 On the walls of the colony, it was even written: “the main method of treatment is work.”55 Immediately after arrival, 85% of the patients were sent to rebuild houses and to fix tools.56 They worked nearly as much as members of the tolstovtsy commune: the day began at 6:45 and continued until 19:00 in summer, and until 17:00 or 18:00 in winter. All patients had to work; one could be exempt only on medical grounds, with the physician’s authorisation. Those who persistently refused to work were transferred to the family fostering programme. In 1934, the colonists ploughed fields, kept cattle, rabbits, and beehives, and planted a cherry orchard.57 There were glass-houses and, thanks to the loving care of the patient Livenstov, a plantation of strawberries. “All agricultural development – it was reported – was due to the active participation and exceptional attention of the patients, who had been previously considered hopeless cases, socially retarded and untreatable.”58 A former patient of the Donskaya hospital, the agronomist G. S. Sergeev, oversaw the works. In May 1931, the colony acquired a resident doctor; the personnel included 12 nurses (medsestry) and 40 female attendants (sanitarki). Every 10 days, a psychiatry professor came to examine patients. In 1937, the facility for electrotherapy was opened, and a year later, there was a dentist’s cabinet. By 1939, the colony had 160 beds (115 in the working ward and 45 in the ward for weak patients). The same year, increasing the number of beds to 300 was envisaged. Patients came from both the Kaschenko and the Soloviev hospitals and the family fostering programme which, in the 1930s, still hosted a hundred women.59 The colony was favourably contrasted with the fostering: in the latter, “the wealthy kulak peasants made the patients work hard,” whereas in the colony “everyone enjoys full rights, is a member of the work collective,” and “everyone feels socially useful and, from this awareness, begins to trust himself and stand firmly on his own feet.”60 Patients in the colony could learn new skills and acquire qualifications and prospects for a normal life. All working patients received wages, which were saved to buy clothes for the day when the patient would be dismissed. Medical reports paint colony life in rose. Allegedly, the colony adopted an “open-door, no-restraint” system, and “discipline was maintained by the collective and not by repression.”61 In 12 years, the number of accidents could be counted on the fingers of one hand and were by far

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outnumbered by the cases of successful treatment. One example was provided by I., a 23-year-old woman with no family, diagnosed schizophrenic, who had spent her childhood in orphanages. In her early youth she was arrested under suspicion of counter-revolution. From the Butyrki prison, she was transferred to the Institute of Psychiatry and from there to the family fostering programme, where she refused to work. In 1932 she arrived in the colony and at first was aggressive and unruly, “always with a cigarette between her teeth.” She was given a job in the vegetable garden, but quit. Yet when she was sent to look after rabbits, she showed interest and intelligence. Finally, she adapted to the “collective life” and even became one of its leaders.62 Before September 1951, the Troparevo colony had independent status; later it became a branch of the Kaschenko hospital.63 According to reports from the early 1950s, life in the colony was cloudless: patients took sun baths, bathed in the lakes, read newspapers, watched films, made theatrical pieces, and listened to medical lectures. The colony had a “club” with table games, a gramophone, and a library of 500 volumes. In 1951, the first TV set appeared and patients had “64 seances of television.”64 We also learn, however, that there were only two work instructors – not enough to supervise 10 “brigades.”65 Medical care was not always available: the colony did not have its own lab, and patients had to be taken to the hospital for medical tests. The colony of 200 patients had no resident psychiatrist.66 The conditions for personnel were also inadequate; yet nurses attended a weekly seminar on the history of the Communist Party (by contrast, the seminar in psychiatry was only once a month).67 Two thirds of the patients stayed long periods (on average, over 10 years), not just due to illness, but because they had neither family nor a place to live.68 Finally, the inevitable happened: Moscow expanded and absorbed the lands of the colony and the family fostering programme. Today, Moscow Medical University stands on the site of the Troparevo colony.

The Kaschenko hospital in the “reconstruction period” In the early 1930s, work became of utmost importance, both in the colony and in the hospital itself. From 1923 on, the annual report included a special section on “work therapy.” Some workshops were moved from the wards into a separate building equipped with machines and supervised by a senior physician.69 There were also workshops inside the wards and even in the dining room and isolation chamber.70 The hospital hired more work instructors and established a special

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educational centre (metodicheskoe buro).71 By the mid-1930s, nearly 90% of the patients for whom work therapy had been prescribed worked. When trying to find for each patient an operation which she could handle and which would produce visible results, physicians could choose from 15 work operations.72 These operations, however, were part of two “production processes:” in the male ward they made a toy car, and in the female one a doll and a toy rabbit. In 1932, these were replaced by making shoes with soft soles. In the acute ward, patients made envelopes and cardboard boxes and sewed bed linen.73 The textile workshop made stockings and other articles for sale, and it was so productive that the administration created a bonus fund with the income. Those patients who worked could have extras, including hot breakfasts and products from the cooperative shop. To help estimate the efficiency of work therapy, the instructor and physician filled out a special form for each patient. In addition, the nurses kept a diary for each patient and there was a separate form for the patients in the textile workshop.74 B., a young woman of 19 years, was diagnosed with catatonic schizophrenia when she first went to the textile factory, arriving looking scared and feeling lost. After two or three days, she worked successfully and came back to the ward more cheerful and “accessible” for contact. After 10 days, she told the instructor that for the entire three months that she had been in the hospital, she believed herself surrounded by enemies who threatened to murder her. Working in the factory with normal people, B. was finally persuaded that her fellow patients wished her well. And, after two months, she was dismissed in good condition and with the qualification of a weaver. The case of O., 40 years of age, was equally successful. Initially she asked to be let out of “the madhouse,” but gradually she began to work. Her condition improved and later she became an instructor in a psychiatric hospital.75 Such cases led psychiatrists to overestimate the efficiency of work therapy.76 They believed that stuffing a toy with sawdust helped the most hopeless patients disinhibit and coordinate their movements.77 As a patient with “ambivalent schizophrenia” confessed, “I hate your rabbits but I make them with pleasure.”78 A bed-ridden patient wanted to work, remarking that she otherwise “outpours with anger.”79 Another patient reported that during work she “feels herself a human being” and “forgets she is in a hospital.”80 The period of industrialisation provided the ideal opportunity to introduce machines into the hospital. The psychiatrist V. P. Bugaiskii argued that patients felt empowered by the machine: they assume “the role of machine manager and feel they can either move or stop it.”81

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Despite the water supply system and canalization remaining unrepaired (since the construction of the hospital) and the fact that even the baths were not working, it was decided to set up mechanised workshops.82 Even the agricultural colony had a rubber workshop. “There is nothing here for the patients to do” – the physician complained – “moreover, the machines make a terrible noise. Where is the quiet therapeutic regime? In the wards there is a warning ‘Silence please’, yet the workshops where patients spend five to six hours a day are terribly noisy.” “No, who needs this ‘factory’” – the reporter went on – “There is a large winding machine which also takes a lot of room; the machine is not used.”83 Imitating contemporary political discourse and practice, psychiatrists tried to form the patients into “production brigades” and “work collectives.” Soviet ideologists often emphasised the advantages of a “socialist collective,” the members of which shared values and objectives. Psychiatrists also claimed that, in the (Soviet) agricultural colony, “the collective is natural, grounded in the production process.” They contrasted the situation with western psychiatric clinics, where “a group of patients is a mechanical formation.”84 The doctors Melekhov and Veis and the instructor Cherenkova themselves formed a “brigade of work therapy.” Their attempt to create “collectives” of the patients failed in the first and second brigades they set up (which included “stupor-like and paranoid forms of schizophrenia, of agitated and heavy depression with inhibition, of pre-senile syndrome and rough organic damage”). By contrast, the third brigade (which included cases of “reactive depression,” “early organic defects,” and “simple and depressive forms of schizophrenia”) worked successfully. It had a “production plan with strict control over the daily product” and represented the results in a weekly chart. The brigade, which was expected to make 120 toys a month, produced 270 pieces.85 Even in the acute ward, almost 80% worked. Patients also held meetings, discussed each other’s work, published a bulletin, and used the “red” board to mark the achievements of good workers and the “black” board to punish the bad ones (the latter, too painful for some patients, was dropped).86 Medical institutions came to share a discourse and practices previously completely alien to them. Psychiatrists talked of “communist education” and “shaping public opinion based on class attitudes,”87 of “personnel training” and “workshop equipment,” of “strengthening the economic basis,” and even of “udarnichestvo” (from udarnik – the most efficient worker) and “socialist competition.”88 They argued that the “liquidation of unemployment [in the country] and the demand for a work force” made it possible to use “workers with diminished

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capacity for work,” namely mental patients.89 To keep patients at work, their remaining work capacity was to be estimated and “small workshops with uncomplicated production” were to be organised.90 Medical schools and the colleges of continuing education for medical doctors were to introduce courses in work therapy and to train work instructors familiar with psychiatry. In the context of industrialisation, the planned “reconstruction of the psychiatric regime” was interpreted as a complete “transfer to the principles of work.”91 Like society in general, the hospital was divided into social classes. In the period of “national reconstruction,” or industrial modernisation, patients were classified according to their social status, and workers were privileged over other classes and rated “Group A.” Group A patients were put into more comfortable and less crowded wards, their food was better, and the personnel were better qualified (they had a work instructor, a gymnastic teacher (fizkul’turnik), and a “cultural entertainer” (kul’turnik)). Group A patients could also use the sanatorium located in a separate building with garden, sun deck, and open-air showers, gymnastic grounds, and “all possible comforts” inside. Patients even enjoyed “rational psychotherapy” (psychotherapy by persuasion) and the assistance of social workers after leaving the hospital.92 Physicians admitted there were excesses in the “reconstruction” of psychiatry, and, in the language of the day, that “the wrong positions had been duly criticised.”93 In the heads of many comrades – Doctor Posvianskii wrote – work therapy acquired significance as the dominant and almost only form of treatment for mental diseases. The point has even been made that the very name, “psychiatric hospital”, should be dropped; instead there should be “establishments for treatment and production” (lechebno-proizvodstvennye kombinaty), and wards should be renamed “workshops.”94 The critics warned that not every patient could be given work therapy, that its results could sometimes be negative,95 and that the physician, not the instructor, should supervise work therapy.96 In spite of the critique, work in hospitals did not stop. Even during the Second World War, in the Kaschenko the patients knitted warm clothes for the army and made cups out of cans in the tin-ware workshop for themselves.97 And, soon after the war, extra buildings for workshops were constructed, with over 600 working places. It was a complicated business to supply the production workshops with raw materials and parts.

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Psychiatrists paid lip service to therapy, regretting that patients had to work according to the needs of the hospital, sometimes at the expense of their health.98 In 1954, the Ministry of Health Care issued the “Regulations on therapeutic-and-production workshops [lechebno-trudovye masterskie] at psychoneurological and psychiatric facilities.”99 In comparison with the early 1930s, the rhetoric had become more cautious. It was recommended that facilities involve the maximum number of the mentally ill in work processes, but that only those for whom work therapy was prescribed be included.100 Contradicting what had been said earlier, Rokhlin wrote in retrospect: “in the Soviet psychiatric hospitals work is used only in the cases when it is beneficial for the mentally ill. For each patient, the physician chooses the kind of work which would neither tire the patient nor harm his health.”101

Work therapy in the age of drugs It is unclear what would have happened to work therapy in the country of freed labour if not for the arrival of new psychiatric drugs. Beginning in 1929, small doses of insulin were given to the patients who refused food, and insulin therapy became common practice from the mid1930s.102 But the real age of drugs began around 1950, with the coming of aminazin.103 Suddenly, from one extreme – work therapy – physicians went into another; in their enthusiasm, they even forgot to explain the causes of illness.104 This provoked a reaction from the proponents of work therapy: they argued for its efficiency even where drugs failed. Thus, B-v, 18 years old, still at school, developed illness and was hospitalised three years later. During his stay in the hospital, he had 32 (!) sessions of insulin treatment and seven of electric shock, with no improvement. He was then occupied by some elementary work (weaving thread bags, gluing boxes), and subsequently given more complex tasks. The boy’s condition improved; he was motivated and, after being discharged from the hospital, he kept coming to the workshop.105 Work therapy gradually gave way to medication, not only in the hospital, but even in the colony. Physicians now argued that work therapy was yet another kind of psychotherapy and, as such, had an auxiliary meaning: it “stabilises the results of drug treatment and increases the efficiency of drugs.”106 Soon it was impossible to think of the patient’s “rehabilitation” without a “long treatment by both drugs and psychotherapy.”107 Even committed supporters of work therapy agreed that the chances of rehabilitation “had significantly increased after the

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introduction of efficient anti-psychotic drugs.”108 Yet work therapy continued to exist until the end of the Soviet Union. Even in the 1970s and 1980s, new agricultural colonies and industrial workshops were being opened (redefined as “centres for rehabilitation”). Just as in the 1930s, nearly all patients were considered fit for work, only with diminished work capacity; in jobs where one healthy person managed, two to four patients were employed. In 1973, in the Kaluzhskaya Regional Hospital, a turbine factory was opened inside the hospital’s walls. Patients were paid proper wages and bonuses and had a system of sick leave. The administration provided them with jobs of various degrees of complexity: from simple cardboard making to assembling electronic radio plates. Patients had the opportunity to join the trade union and to participate in public events.109 With the collapse of the Soviet Union, work therapy in psychiatric hospitals nearly ended. One of the reasons was the new psychiatric law of 1992–1994, which “forgot” to mention the status of workshops. The other reason concerned accusations regarding the exploitation of patients’ labour. According to the “United Nations Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care” (1991), in no circumstances shall a patient be subject to forced labour … the labour of a patient in a mental health facility shall not be exploited. Every such patient shall have the right to receive the same remuneration for any work which he or she does as would, according to domestic law or custom, be paid for such work to a non-patient.110 The Russian Federation Law of Mental Care formulates the principle as follows: “All patients, if their work is productive, have a right equal to other citizens to receive remuneration according to the quantity and quality of work.”111 Yet independent research shows this is not the case in the majority of Russian psychiatric hospitals. Many physicians do not feel the difference between work therapy and the use of patients’ labour.112 The abuse of psychiatry in the USSR – especially in the facilities for criminal offenders (the so-called special psychiatric hospitals, SPH, of the Ministry of Internal Affairs) – also contributed to the decline of work therapy. In his book, Punitive Medicine, the dissident and former SPH inmate Alexander Podrabinek reported that in the 1970s, occupational or work therapy was compulsory in some SPHs, whereas in others it was merely encouraged by the administration. “Many healthy prisoners

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are happy to work, and in that case SPH authorities have yet another means of punishment – banning work.”113 In the facilities where work was compulsory, patients complained that it was hard to work under drugs in the workshops with loud pop-music.114 Others refused to work because the job was too elementary for their qualifications. Wages were paid (into an account), yet they were meagre and did not compensate for the labour which patients widely regarded as forced.115 Even in the ordinary psychiatric hospitals of the Health Care Ministry, some patients perceived occupational therapy as coercion or, at least, inappropriate for their educational and professional level. For this reason, in a number of Western countries, in the course of de-institutionalisation of psychiatry, occupational therapy was replaced by work contracts, which guarantee the patient’s rights and remuneration.116 Those psychiatrists who do not want to abandon the idea of work therapy have completely tried to redefine it: first, it should be “the kind of work which is not elementary, primitive, and monotonous” and has a “creative or playful” element; second, the patient should do it out of his own free will; third, it should be meaningful; and, fourth, it should improve the patient’s condition.117 Yet there is a problem here too: how are we to understand “one’s own free will”? In the case of psychiatric patients whose freedom and rights are almost always violated it is especially hard to tell what she does voluntarily and what is forced. Exploitation is often defined in a negative way: “anything beyond the limits of occupational therapy (every kind of hobby) and of work therapy (involvement in productive work) and for which the person does not receive a just reward” – whether with or without the patient’s consent [nezavisimo ot dobrovol’nosti].118 As a result of this confusion, occupational therapy had been reduced to innocent occupations like watering plants or arranging pictures.119 It would satisfy neither the founders of moral treatment nor Soviet psychiatrists. Yet we do not expect a quick solution. Work was introduced into the psychiatric institution as a means to overcome the “alienation of mind” and to heal the divided soul. But the patient in the hospital can hardly be free, and her work cannot be free either. The dream of “freed, creative, harmonising labour” has remained utopian in the psychiatric hospital as well as for the rest of us. The alienation of labour is still a big puzzle. Marx hoped that alienation would end under communism, but in the Soviet Union it never happened. Bertell Ollman criticised Soviet authors for being simply wrong when they claim that nationalisation of the means of production and the abolition of the capitalist class have done away

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with all forms of alienation. Rather, Marcuse is correct in saying that as long as wealth is measured in terms of labour time, itself a function of the division of labour, alienation will exist.120

Notes 1. Anne Digby, Madness, Morality and Medicine: A Study of the York Retreat, 1796–1914 (Cambridge: Cambridge University Press, 1985). 2. Michel Foucault, History of Madness, trans. Jonathan Murphy and Jean Khalfa (London: Routledge, 2006), 485. 3. Ibid., 482. 4. Linked, in its own turn, to the legal term, alienus – “of another person” (in particular, “another person’s slave”). 5. Foucault, History of Madness, 482. 6. Samuel Tuke, Description of the Retreat (London: Process Press, 1996 [1813]), quoted in Foucault, History of Madness, 473. 7. Ibid., 481; Dora B. Weiner, “Mind and Body in the Clinic: Philippe Pinel, Alexander Crichton, Dominique Esquirol, and the Birth of Psychiatry,” in The Languages of Psyche: Mind and Body in Enlightenment Thought, ed. G. S. Rousseau (Berkeley etc.: University of California Press, 1991), 333; Daniel BertholdBond, Hegel’s Theory of Madness (New York: SUNY Press, 1995), 93–94. 8. Berthold-Bond, Hegel’s Theory of Madness, 93–94. 9. Karl Marx, “Economic and Philosophical Manuscripts (1844),” in Early Writings, trans. Rodney Livingstone and Gregory Benton (London: Penguin Books, 1975), 326, accessed at http://www.marxists.org/archive/marx/ works/1844/manuscripts/preface.htm, December 27, 2013. 10. Bertell Ollman, Alienation: Marx’s Conception of Man in Capitalist Society (Cambridge: Cambridge University Press, 1976), 132. 11. Foucault, History of Madness, 485. 12. Ibid., 486. 13. Foucault’s own project apparently involved “eliminating the subject while keeping the thoughts, trying to construct a history without human nature” (Unpublished text, Collège de France; quoted in Didier Erbibon, Michel Foucault, trans. Betsy Wing (Cambridge, MA: Harvard University Press, 1991), 218. 14. L. L. Rokhlin, Ocherki psikhiatrii (Moscow: Minzdrav RSFSR, 1967), 331. 15. Ia. P. Bugaiskii, Organizatsiia meditsinskogo obsluzhivaniia psikhicheskikh bol’nykh v usloviiakh raionnogo dispansera (opyt raboty psikhonevrologicheskogo dispansera Frunzenskogo raiona g. Moskvy) (Moscow: Medizdat, 1961), 158. 16. Joseph Wortis, Soviet Psychiatry (Baltimore: The Williams & Wilkins Company, 1950), 155. 17. For a contrasting example of how work was connected with the notion of promoting health, see Vicky Long, The Rise and Fall of the Health Factory: The Politics of Industrial Health in Britain, 1914–60 (London: Palgrave Macmillan, 2011). 18. Ibid., 182. Indeed, Leon Trotsky’s idea of labour camps also echoed the belief in the “transforming power” of work. Lenin gave the idea his personal support, and it soon became the reality of the GULAG. 19. L. F. Iakoubovich, Trud dushevnobol’nykh Vinnitskoi okruzhnoi lechebnitsy i ego vospitatel’noe znachenie (Kiev: Kul’zhenko, 1902).

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20. F. A. Naumov, Organizatsiia psikhiatricheskoi pomoschi i psikhoprofilaktika (Leningrad: Prakticheskaya meditsina, 1927), 97. 21. O. V. Limankin and A. G. Chudinovskikh, Piotr Petrovich Kaschenko. Zhizn’ i sud’ba (Saint-Petersburg: Kovcheg, 2009). 22. A. A. Davydova, Istoriia formirovaniia i razvitiia arkhitekturnogo kompleksa kolonii dlia dushevnobol’nykh pri sele Liakhovo (Nezhegorodskaya oblastnaya psikhonevrologicheskaya bol’nitsa № 1), accessed at http://www.opentextnn. ru/space/nn/dom/?id=1708, December 19, 2013. 23. Ibid. 24. A. A. Litvin, “Osnovnye etapy razvitiia trudovi terapii v psikhiarticheskoi bol’nitse imeni P. P. Kaschenko,” in Voprosy kliniki i terapii psikhicheskikh zabolevanii, ed A. L. Andreev (Moscow: Minzdrav RSFSR, 1960), 368–370. 25. Ibid., 372. 26. T. I. Iudin, Ocherki istorii psikhiatrii (Moscow: Medizdat, 1951), 333. 27. Naumov, Organizatsiia, 96. 28. Iakoubovich, Trud dushevnobol’nykh. 29. S. S. Stupin, “K voprosu o pravil’noi organizatsii rabot dushevnobol’nykh v psikhiatricheskikh bol’nitsakh” [1901], Zhurnal nevropatologii i psikhiatrii imeni S. S. Korsakova 2 (2007), 49–52. 30. Ibid. 31. Ibid. 32. Ivan Bykovskii, who had spent “100 days” in the Alekseevskaya hospital and left memoirs, did not mention any work. We can conclude that he was very likely not drawn into work therapy, perhaps because of his noble origins. See: I. K. Bykovskii, Sto dnei v sumasshedshem dome (Vpechatleniia avtora) (Moscow: M. A. Dobryshev, 1903), 117. 33. Stupin, “K voprosu o pravil’noi organizatsii.” 34. Ibid. 35. The Russians adopted the French term patronage familial. 36. Irina Sirotkina, “Toward a Soviet Psychiatry – War and the Organisation of Mental Health Care in Revolutionary Russia,” in Soviet Medicine: Culture, Practice, and Science, ed. F. L. Bernstein, C. Burton, and D. Healy (Dekalb: Northern Illinois University Press, 2010), 27–48. 37. In the words of Olga Zubets, whose grandfather-communist was a friend of P. P. Kaschenko. 38. Iudin, Ocherki istorii psikhiatrii, 333–334. 39. Ibid., 369. 40. Ibid., 376–378. 41. A. I. Kudinov, “O rabote dnevnykh statsionarov,” in Voprosy trudovoi terapii, ed. E. A. Babayan (Moscow: Minzdrav RSFSR, 1958), 259–261. 42. I. N. Koganovich and P. B. Posvianskii, “Osnovnye printsipy lecheniia i organizatsii psikhicheskih bol’nykh v psikhiatricheskom statsionare (Dvukhletnii opyt rekonstruktsii Psikhiatricheskoi bol’nitsy imeni P. P. Kaschenko),” in Psikhiatricheskaya bol’nitsa na putiakh rekonstruktsii. Sbornik rabot Psikhiatricheskoi bol’nitsy imeni P. P. Kaschenko Mosgorzdravotdela, vol. 1, ed. I. N. Koganovich (Moscow: Medgiz, 1934), 6. 43. D. A. Amenitskii, “Rol’ Kanatchikovoi dachi – Bol’nitsy imeni P. P. Kaschenko v istorii dorevoliutsionnogo razvitiia otechestvennoi psikhiatrii,” in Problemy kliniki i terapii zabolevanii. 5-i sbornik nauchnykh rabot psichiatricheskoi bol’nitsy

46

44.

45. 46.

47. 48.

49. 50. 51.

52. 53. 54.

55.

56. 57. 58. 59. 60.

Irina Sirotkina and Marina Kokorina imeni P. P. Kashcenko, ed. V. A. Giliarovskii, M. O. Gurevich, V. A. Vnukov, 294–304. Moscow: Gosudarstvennoe meditsinskoe izdatel’stvo, 1946. N. P. Danaev, “Istoriia razvitiia derevenskogo patronazha i trudkolonii,” in Problemy psikhiatrii voennogo vremeni. 4-i sbornik nauchnykh rabot Psikhiatricheskoi bol’nitsy im. P. P. Kaschenko, ed. V. A. Giliarovskii, M. O. Gurevich, V. A. Vnukov, 61–69. Moscow: Gosudarstvennoe meditsinskoe izdatel’stvo, 1945. M.Iu. Korobko, “Bogorodskoe-Voronino: ischeznuvshaya podmoskovnaia,” Moskovskii zhurnal 7 (1992), 43. B. V. Mazurin, “Rasskaz i razdum’ia ob istorii odnoi tolstovskoi kommuny ‘Zhizn’ i trud’,” in Vospominaniia krest’ian-tolstovtsev, 1910–1930 gody, ed. A. B. Roginskii (Moscow: Kniga, 1989), 93–206. Ibid. S. N. Kuznecov, “Interlingvistiko en ‘kosma dimensio’: vojagˆo inter kosmoglotiko kaj kosmolingvistiko,” accessed at http://www.lingviko.net/ db/10_kuznecov.htm December 22, 2013. The Ao language is an artificial language, a candidate for the universal one, created in an effort to consolidate humanity and provide a means to contact other civilisations. Its authors were brothers, Aba Gordin (1887–1964) and Wolf Gordin (Vladimir) (see: V. L. Gordin, Grammatika logicheskogo iazyka Ao (Moscow, 1924)). This linguistic search echoed the poetic experiments of Velimir Khlebnikov and other authors of zaum’. In 1927, the language Ao was presented at the First World Exhibition of Interplanetary Devices and Mechanisms. See: A. V. Arolovich, “Anarkhizm-universalizm v kontekste russkoi ‘kosmicheskoi paradigm’ nachala XX veka” (Ph.D diss., Moscow State University, 2004). T. V. Petukhova, Kommuny i arteli tolstovtsev v sovetskoi Rossii (1917–1929) (Ulianovsk: Ul’ianovsk State University, 2008), 61. Mazurin, “Rasskaz i razdum’ia.” M. I. Gorbunov-Posadov, “Tri kommuny. Otryvki vospominanii,” in Vospominaniia krest’ian-tolstovtsev, 1910–1930 gody, ed. A. B. Roginskii (Moscow: Kniga, 1989), 441–442. Mazurin, “Rasskaz i razdum’ia.” Ibid. S. S. Vangengeim and R. S. Povitskaya, “Opyt sel’skokhoziaistvennoi trydovoi kolonii pri Bol’nitse imeni Kaschenko,” in Psikhiatricheskaya bol’nitsa na putiakh rekonstruktsii. Sbornik rabot Psikhiatricheskoi bol’nitsy imeni P. P. Kaschenko Mosgorzdravotdela, ed. I. N. Koganovich, vol. 1 (Moscow: Medgiz, 1934), 43–44. “Ob’’iasnitel’naya zapiska k statisticheskomu otchetu filiala bol’nitsy ‘Troparevo’ za 1951 god,” the Archive of the Psychiatric Hospital No.1 named after N. A. Alekseev. Ibid. Danaev, “Istoriia razvitiia,” 61–69. Vangengeim and Povitskaya, “Opyt sel’skokhoziaistvennoi,” 45. Z. M. Ageeva and V. M. Morkovin, Moskovskaya klinicheskaya psikhiatricheskaya bol’nitsa imeni P. P. Kaschenko (Moscow: Meditsina, 1987), 82–83. Vangengeim and Povitskaya, “Opyt sel’skokhoziaistvennoi,” 47.

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61. Ibid. 62. Ibid. 63. “Otchet o rabote filiala bol’nitsy Troparevo za 1952 god,” the Archive of the Psychiatric Hospital No.1 named after N. A. Alekseev. 64. “Ob’’iasnitel’naya zapiska.” 65. Ibid. 66. “Otchet o rabote filiala bol’nitsy Troparevo za 1964 god,” the Archive of the Psychiatric Hospital No.1 named after N. A. Alekseev. 67. Ibid. 68. “Otchet o rabote filiala bol’nitsy Troparevo za 1960 god,” the Archive of the Psychiatric Hospital No. 1, named after N. A. Alekseev. 69. Litvin, “Osnovnye etapy,” 376–378. 70. Koganovich and Posvianskii, “Osnovnye printsipy,” 15–21. 71. By mid-1930s, there were 32 instructors, 13 assistants, and one instructormethodologist (see: Litvin, “Osnovnye etapy”). 72. P. B. Posvianskii, “Osnovnye problemy trudovoi terapii psikhozov (Doklad na I Vseukrainskom s’’ezde nevropatologov i psikhiatrov v iune 1934 г.),” in Problemy kliniki i terapii psikhicheskikh zabolevanii. Sbornik nauchnykh rabot Psikhiatricheskoi bol’nitsy imeni P. P. Kaschenko, eds. V. A. Giliarovskii, M. O. Gurevich, V.A. Vnukov, 115-117. Moscow: Minzdrav RF, 1936. 73. Ibid., 95–96. 74. I. N. Koganovich, D. E. Melekhov, P. B. Posvianskii, “Trudterapiia v psichiatricheskikh bol’nitsakh (Doklad na koferentsii ‘Aktivnaya terapiia shizofrenii’),” Sovetskaya nevropatologiia, 1 (12) (1932), 716–725. 75. D. E. Melekhov, O. V. Veis, F. F. Cherenkova, “K voprosu o trudovoi terapii pri ostrykh psikhicheskikh zabolevaniiakh. Rabota brigady v sostave: Dr D. E. Melekhov, Dr O. V. Veis and Instructor F. F. Cherenkova (Iz opyta organizatsii lechebnogo truda bol’nykh v ostrom pokoinom otdelenii dlia proizvodstvennykh rabochikh v Bol’nitse im. P. P. Kaschenko,” Sbornik rabot Psikhiatricheskoi bol’nitsy imeni P. P. Kaschenko, eds.  V. A. Giliarovskii, M. O. Gurevich, V. A. Vnukov, 99-100. Moscow: Gosudarstvennoe meditsinskoe izdatel’stvo, 1934. 76. Ibid., 106–110. 77. Ibid. 78. Ibid., 98–99. 79. Ibid. 80. Posvianskii, “Osnovnye problemy,” 115. 81. Bugaiskii, Organizatsiia meditsinskogo, 172. 82. Koganovich and Posvianskii, “Osnovnye printsipy,” 25–27. 83. “Otchet o rabote filiala bol’nitsy Troparevo za 1952 god.” 84. Vangengeim and Povitskaya, “Opyt sel’skokhoziaistvennoi,” 51. 85. Melekhov, Veis, and Cherenkova, “K voprosu o trudovoi,” 95–96. 86. Litvin, “Osnovnye etapy,” 380–382. 87. Vangengeim and Povitskaya, “Opyt sel’skokhoziaistvennoi,” 51. 88. S. L. Tsetlin, “Puti razvitia trudoterapii,” in Voprosy sotsial’noi i klinicheskoi psikhonevrologii, ed. I. A. Berger and V. V. Chentsov (Moscow: NKSO, 1934), 46–58. 89. Ibid., 59–60.

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90. V. A. Myznikov, “Trudoterapiia v usloviiakh sovremennykh lechebnykh uchrezhdenii i novye vidy trudovoi pomoschi dushevnobol’nym,” Zhurnal nevropatologii i psikhiatrii 3 (1931), 30–34. 91. Ibid. 92. Koganovich and Posvianskii, “Osnovnye printsipy,” 9–10. 93. Aleksandrovskii, in Sovetskaya nevropatologiia, psikhiatriia i psikhgigiena 4 (1934), 122–128, quoted in Iudin, Ocherki istorii, 391. 94. Posvianskii, “Osnovnye problemy,” 107–109. 95. Litvin, “Osnovnye etapy,” 380–382. 96. M. S. Lebedinskii, “Psikhoterapevticheskoe znachenie lecheniia trudom,” in Voprosy trudovoi terapii, ed. E. A. Babayan (Moscow: Minzdrav RSFSR, 1958), 87–98. 97. Litvin, “Osnovnye etapy,” 382–386. 98. Ibid. 99. E. A. Babayn, “Sovremennye zadachi psikhonevrologicheskikh uchrezhdenii v oblasti trudoterapii,” in Voprosy trudovoi terapii, ed. E. A. Babayan (Moscow: Minzdrav RSFSR, 1958), 5–11. 100. Litvin, “Osnovnye etapy,” 382–386. 101. Rokhlin, Ocherki psikhiatrii, 333. 102. Benjamin Zajicek, “Scientific Psychiatry in Stalin’s Soviet Union: The Politics of Modern Medicine and the Struggle to Define ‘Pavlovian’ Psychiatry, 1939–1953” (Ph.D diss., University of Chicago, 2009); T. I. Iudin, Ocherki istorii, 394. In Troparevo, they injected insulin in small doses; see: “Otchet o rabote filiala bol’nitsy Troparevo za 1956 god,” Archive of the Psychiatric Hospital No.1 named after N. A. Alekseev. 103. “Otchet o rabote filiala bol’nitsy Troparevo za 1960 god.” 104. N. V. Panchenko, R. S. Rubinova, I. I. Slutskaya, “Primenenie trudovoi terapii pri zatiazhnykh formakh shizofrenii,” in Voprosy trudovoi terapii, ed. E. A. Babayan (Moscow: Minzdrav RSFSR, 1958), 149–153. 105. Ibid. 106. Rokhlin, Ocherki psikhiatrii, 333. 107. A. V. Snezhnevskii, ed. Spravochnik po psikhiatrii (Moscow: Meditsina, 1985), 300. 108. Nauchnyi tsentr psikhicheskogo zdorov’ia RAMN. Sotsial’no-trudovaya reabilitatsiia psikhicheski bol’nykh, accessed at http://www.psychiatry.ru/lib/54/ book/28/chapter/109, December 24, 2013. 109. Ibid. 110. United Nations Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care. Principle 13, parts 3 and 4, accessed at http://www.health.govt.nz/system/files/documents/publications/ectappendixone.pdf, December 24, 2013. 111. Quoted in [Anon.] “Monitoring psikhiatricheskikh statsionarov Rossii – materialy k obsuzhdeniiu,” Nezavisimyi psikhiatricheskii zhurnal 3 (2004), accessed at http:// www.npar.ru/journal/2004/3/monitoring.htm, December 24, 2013. 112. Ibid. 113. Alexander Podrabinek, Punitive Medicine, trans. Alexander Ginzburg (Ann Arbor: Kroma Publs, 1980), 28. 114. Quoted in: A. I. Korotenko, N. V. Alikina, Sovetskaya psikhiatriia: zabluzhdeniia i umysel (Kiev: Sfera, 2002), 60, 64.

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115. Podrabinek, Punitive Medicine, 145. 116. G. Del Giudice, Psychiatric Reform in Italy (Trieste: Mental Health Department, 1998), accessed at http://www.triestesalutementale.it/english/ doc/delgiudice_1998_psychiatric-reform-italy.pdf, December 27, 2013. 117. [Anon.] “Monitoring.” 118. Ibid.; the italic is ours. 119. Ibid. 120. Ollman, Alienation, 252.

3 Insulin Coma Therapy and the Construction of Therapeutic Effectiveness in Stalin’s Soviet Union, 1936–1953 Benjamin Zajicek

Nothing was more important to the self-image of Soviet psychiatrists than their ability to deliver effective therapies to psychiatric patients. In a 1940 annual report to Moscow, for instance, a psychiatric hospital director reported that, “We at Polatva Psychiatric Hospital long ago overcame ‘therapeutic nihilism,’ the unhealthy, passive attitude toward patients that developed over the centuries, and replaced it with energetic, vigorous therapeutic activity, with therapeutic enthusiasm.”1 A Ministry of Health report from the mid-1950s made almost identical claims: “What sets Soviet psychiatry apart,” according to the author, is that in contrast with the psychiatric hospitals of the past, Soviet psychoneurological hospitals put in first place the task of treatment, not the task of custody of patients. … In 1954 the following methods of so-called [sic] active therapy were used in hospitals: insulin therapy, sleep therapy, sulfozin therapy, … malaria therapy, and many others.2 These methods of treatment were not unique to the Soviet Union. They had all been developed in Central Europe, and they were in wide use in this same period in the psychiatric hospitals of Europe and America. What is more, all of these methods have since been abandoned, and many of them have been repudiated as ineffective and even dangerous. Why then did Soviet psychiatrists believe that these methods worked? Why were they important to their identity as psychiatric professionals? Work on Soviet psychiatry has tended to focus on the political abuses of psychiatry in the USSR or on the ideologically motivated elimination 50

Stalin’s Soviet Union, 1936–1953 51

of Freudian theory.3 The picture that emerges is one that emphasizes the differences between Soviet psychiatry and psychiatry in the West. This chapter seeks instead to understand how psychiatrists in the Soviet Union used somatic treatments, particularly insulin coma therapy, and how they “constructed” the medical effectiveness of these treatments. Historians have fruitfully approached this kind of question in the study of American psychiatry by attempting to reconstruct the social and institutional context in which these therapies were performed.4 In the words of historian Joel Braslow, the goal is to “… explore the ways in which doctors and, to a lesser extent, patients constructed and reacted to what they judged to be effective remedies.”5 This analysis, however, has not been extended to psychiatry in totalitarian states like the Soviet Union. In this chapter, I attempt to reconstruct how insulin coma therapy came to be seen as an effective, modern, and distinctly Soviet treatment. Insulin coma therapy emerged in the 1940s as the predominant method of treatment in Soviet psychiatric hospitals, and it continued this dominance into the 1950s, despite the “science wars” that took place during Stalin’s last years in power. Why was insulin coma therapy particularly useful to Soviet psychiatrists? How were they able to justify its use after the 1950–1951 “Pavlov Sessions,” even though they had repudiated the therapeutic rationale used to justify it in the 1930s and 40s? *** Insulin coma therapy was first used in Vienna in 1933 by a psychiatrist named Manfred Sakel. Patients with schizophrenia were given injections of insulin, increasing in dosage day by day until the patients began to fall into a hypoglycemic stupor. Sakel then continued to increase the dosage, sending his patients into a hypoglycemic coma which lasted until psychiatrists administered a sugar solution through a tube snaked down the patient’s throat. The insulin coma stage of treatment lasted for weeks, and as the dosage continued to increase, patients began to experience periods of physiological shock, sometimes accompanied by epilepsy-like convulsions. This “shock stage” was understood to be the goal of the treatment, and was allowed to continue for up to an hour before being ended by the administration of glucose. Patients were given dozens of “shocks” before the treatment was ended. Sakel published the results of his work in 1934. He claimed that “of his 50 patients experiencing their first episode of schizophrenia, he obtained a full remission in 70 percent and a ‘social remission’ in a further

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18 percent ….”6 In 1934 schizophrenia was considered an incurable disease. Sakel was claiming to have achieved a revolutionary breakthrough. Sakel’s new “miracle cure” spread quickly. Psychiatrists who observed his method in Vienna set up their own insulin coma therapy clinics in London, New York, and Zurich. It was brought to Moscow by Arthur Kronfeld, a well-regarded German psychiatrist who fled from Germany to the Soviet Union in 1935.7 In Moscow Kronfeld was given a lab at the prestigious Gannushkin Institute, and it was there that he carried out the first major test of insulin coma therapy in the Soviet Union. He reported his results at a national congress of Soviet psychiatrists and neuropathologists in December 1936. Kronfeld reported having tested insulin coma therapy on 120 patients. The method was difficult and potentially dangerous, he cautioned, but the results were very promising: two-thirds of the patients had improved after treatment, and 29% were in complete remission. “These numbers are lower than Sakel’s or Müller’s,” he wrote, “but they still significantly exceed the number of spontaneous remissions even in our most optimistic estimate.”8 Kronfeld’s international prestige and ties to the Kremlin gave these results added weight.9 Insulin coma therapy spread quickly. By 1940 at least 60 of the Soviet Union’s 144 psychiatric hospitals were using it, and the rest were filling their annual reports to Moscow with excuses explaining why they were failing to do so.10 The results from the provinces confirmed Kronfeld’s findings.11 In an analysis of Kronfeld’s case notes, a Moscow psychiatrist concluded that already from the very beginning of treatment, patients become more accessible and contactable and the activity of their “ego” [ia] progressively increases, bringing them closer to the real world and by degrees increasing their contact with reality … A critical attitude toward hallucinations and toward the delusional ideas that accompany them simultaneously appear.12 *** Insulin therapy’s popularity was due in no small part to the fact that by using it, Soviet psychiatrists demonstrated that they had left behind the ideological mistakes of the past and were now actively participating in the construction of socialism. Prior to 1936, Soviet psychiatrists, particularly those who held important positions in the public health system, had prided themselves on focusing on the prevention of mental illness, an approach referred to in Russian as “psikhogigiena.”13 The leaders of

Stalin’s Soviet Union, 1936–1953 53

this movement were explicitly inspired by the American mental hygiene movement begun by Clifford Beers and Adolf Meyer, but their emphasis on social reform and public health also resonated with the values of the early twentieth century Russian intelligentsia. In the 1920s, the RSFSR’s first Commissar of Public Health, Nikolai Semashko, was determined to create a network of public health “dispensaries” intended to foster basic health and hygiene, and he supported the creation of “psychiatric dispensaries.” Their goal was to help people avoid mental illness altogether, either by catching it in its very earliest phases or by eliminating environmental, physical, and social factors that might trigger the disease.14 By 1931, 29 of these psychiatric dispensaries were up and running.15 By 1931, however, the Communist Party had begun to turn its back on many experiments in social change.16 During this period, psikhogigiena came under attack from party leaders, who were offended by claims that the stress of party work was causing nervous exhaustion in young activists.17 In December 1936, the new Commissar of Public Health, G. N. Kaminskii, reproached “certain theorists” of preventive medicine who had predicted that psychiatry would cease to be a hospital-based discipline. “… the central issue,” Kaminskii said, “is that our hospitals should not be isolators, they should be medical treatment institutions.”18 Psychiatrists had neglected what should have been their main focus: curing the sick. In the year that followed, the authorities disbanded the Institute for Neuropsychiatric Prophylaxis, the USSR’s leading psychiatric research institute, dropped the word “psikhogigiena” from the name of the flagship journal, and arrested several psychiatrists (and their families).19 In 1936 and 1937, therefore, Soviet psychiatrists were in need of a new way to prove to Soviet authorities and to themselves that what they were doing was compatible with Party doctrine and useful to the Soviet state. An alternative paradigm was already waiting in the wings. During the 1920s, European psychiatrists had developed new methods of treatment that revived hopes that severe mental illness might actually be curable. The breakthrough began in the 1920s, when a Vienna psychiatrist, Julius Wagner-Jauregg, began to intentionally infect his patients with malaria to cure them of progressive paralysis, a common form of late-stage syphilis. The treatment worked, and Wagner-Jauregg was awarded the Noble prize for his discovery in 1927.20 Psychiatrists were inspired: perhaps other major mental illnesses could be cured in similar ways. By the early 1930s, psychiatrists across Europe were experimenting with “biological treatments,” injecting their patients with anything they could think of that might provoke changes in the bodies of

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the mentally ill. Much of this early research was fruitless. As one of the USSR’s leading researchers complained, psychiatrists in most locales relied on purely anecdotal evidence and very small sample sizes. He called for research to be restricted to designated university clinics and research institutes and for psychiatrists to systematically use control groups.21 Between 1933 and 1935, however, several promising new methods were discovered. Insulin coma therapy was one. The other two were “prolonged sleep therapy” (drug-induced sleep lasting 10 hours or more) and shock therapy (seizures caused by intravenous injections of either camphor oil or a drug called Cardiozol, also known as Metrazol).22 Early testing on these methods began in the USSR in 1936.23 (Lobotomy and electroshock were first used in Europe slightly later, in 1936 and 1938 respectively.)24 When psikhogigiena came under fire in the Soviet Union, medically oriented psychiatrists were ready. They promoted the use of the new “active biological treatments” in restructured psychiatric hospitals as an alternative to the preventative, decentralized, dispensary-based psychiatry advocated by the now-discredited advocates of psikhogigiena. They presented themselves as the vanguard of a new, modern psychiatry, “men of action” who were willing to aggressively treat the body even at the risk of harming their patients. They contrasted this approach with “therapeutic nihilism the fatalistic view that prevention was the only hope, a view that they attributed to the previous generation of psychiatrists. “The physician-psychiatrist in the reconstructed hospital has become a clinician-biologist,” one psychiatrist wrote, “… In the treatment of mental diseases, we should be rid of therapeutic nihilism once and for all.”25 This view was now associated by proxy with capitalism and with the Tsarist past. Under socialism, psychiatrists were not simply agents of the bourgeoisie who accepted the job of keeping undesirables under lock and key. Instead they were dedicated servants of socialist society who saw it as their job to treat the mentally ill and return them to the workplace. *** Testing these new methods of treatment at elite research institutes in Moscow was one thing; putting them into regular use in ordinary Soviet psychiatric hospitals was something else entirely. Most hospital buildings in the USSR had been constructed in the 1880s or 1890s and had been poorly maintained. Many were located far from major cities, and some still lacked electricity. Almost without exception they were overcrowded

Stalin’s Soviet Union, 1936–1953 55

and lacking in medical personnel. Insulin was often in short supply, as were the drugs needed to put patients to sleep or induce seizures.26 Psychiatric hospitals received far less funding per patient for medication than other medical institutions in the USSR, and they had little hope of receiving more in an era when all resources were being diverted to rapid industrialization. Wrote one psychiatric administrator in 1940: “… when no treatment was done, 15.2 kopeks per patient was a lot, but now it simply cannot satisfy us. So too the question of personnel. When treatment wasn’t done the staffing level was low, but now it is catastrophically low.”27 Making the new “active treatments” available to patients required a major shift in how psychiatric hospitals were organized and funded. All these methods of treatment were not only labour- and resourceintensive, they were also dangerous. The drug cocktail used for prolonged sleep therapy (“Cloetta’s mixture”) was known for its “high toxicity, serious complications, technical difficulty, expense, and, finally, significant mortality.”28 “Shock therapy” was also problematic. The camphor used to induce seizures proved very difficult to use because there was no way to predict when seizures would begin. Cardiozol was more predictable, but the intensity of the seizures sometimes resulted in broken bones.29 Insulin coma therapy could also be quite dangerous, and thus required constant monitoring. A typical course of insulin treatment lasted 8–10 hours per day, six days a week, for at least a month, usually more, and each patient had to be carefully observed throughout the process. Nurses were instructed to watch for signs of irregular heartbeat and dangerously low body temperature. During the hypoglycemic shock stage, patients were susceptible to breathing problems, rapidly falling blood pressure, and dangerous epilepsy-like seizures. When these occurred, doctors were supposed to immediately inject the patient with adrenaline or caffeine and to administer the sweet tea solution used to end the hypoglycemia.30 Insulin coma therapy’s difficulty and danger led even some of its earliest proponents to doubt whether it could ever become anything more than a niche specialty treatment in the USSR.31 For the people in Moscow in charge of the psychiatric system, this need for fundamental restructuring was actually part of active therapy’s attraction. If these treatments really were the most modern methods of treatment, and if failing to give them was politically unacceptable, then administrators could justify asking for higher funding, new equipment, and more staff. When administrators submitted reports to Moscow, they meticulously documented the number of “active treatments” that had been given in their hospital each year, presenting the number of insulin

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treatments as evidence of quality. Public health officials in Moscow then used these reports to chart the progress of Soviet psychiatric hospitals away from the pre-medical past and toward the medicalized future.32 For psychiatric hospitals to actually do active therapy, special rooms had to be set aside and equipped. This was particularly important for insulin coma therapy, which required an array of medical supplies and laboratory tests. New routines developed around these insulin wards. Each day nurses systematically checked supplies, examined patients before treatment, and consulted with physicians. Psychiatrists tracked the progress of patients, increased insulin dosages, and studied reams of laboratory results.33 As a result, insulin coma therapy became more than just a new tool method of treatment or a passing fad: it became an organizing principle that shaped the way that doctors, nurses, and patients experienced the psychiatric hospital. Such work was particularly precious to psychiatrists who worked in provincial hospitals because it demonstrably connected them to the world of laboratory research and clinical medicine. At the same time, they were able to demonstrate to themselves and to their superiors that they had overcome the “therapeutic nihilism” of the past. Active therapy thus became a signifier of Stalinist modernity, a way for psychiatrists and administrators to demonstrate to themselves and others that they had overcome the worldview of the Tsarist past and the ideological errors of the 1920s, and that they were doing meaningful scientific and medical work in the present. These changes to the way that psychiatric hospitals were organized were formalized in a new set of official regulations that were written in 1940, when psychiatrists at the Gannushkin Institute in Moscow re-wrote the legal rules and regulations that governed psychiatric hospitals. (These regulations were set to go into effect in 1941, but they were shelved until 1946 because of the outbreak of war.34) Under the new regulations, hospital life was officially organized around the practice of “active treatment.” Larger hospitals were to have a whole complex of small laboratories, including laboratories for biochemistry, serology, bacteriology, electrophysiology, psychology, radiology, and anatomy. Even small psychiatric hospitals were required to have their own “clinical laboratory,” and to establish agreements with nearby hospitals so that they would have access to all the full range of laboratory facilities. All psychiatric hospitals were required to provide their patients with “all the modern methods of treatment.”35 For the duration of the Second World War insulin coma therapy was all but abandoned as Soviet psychiatric hospitals struggled simply to provide

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minimal food and clothing for their patients. After the war ended the Ministry of Health finally implemented the reorganization of psychiatric hospitals around the principles of “active treatment,” but it took years before there was enough insulin and other medications to enable psychiatrists to treat as many patients as had been treated in 1940. In 1949, hospitals in the RSFSR reported that only 14.6% of their patients were receiving some form of “active biological treatment.” Of those who did get treatment, 53.6% received insulin treatment. Sleep therapy and Cardiozol shock accounted for only 6.9% and 2.9% respectively.36 Summarizing the situation for the USSR Ministry of Health, the psychiatrist in charge of the Ministry’s hospital directorate reported that, The large majority of our hospitals which are located in our [urban] centres are carrying out therapy on the level of modern understanding. But when it comes to those hospitals that are far from our centres, then those hospitals are not doing sufficient treatment, especially those hospitals of a colony type and oblast’ hospitals, where there are no universities or medical institutes.37 *** How did insulin coma therapy work? In their more circumspect moments, Soviet psychiatrists admitted that they simply did not know. Writing in 1939, a group of Ukrainian researchers said that “one gets the impression that for some patients insulin hypoglycemia fits like a key in a lock, opening it easily and smoothly ….”38 But what was that “lock”? Researchers were hopeful that by studying the mechanism of the cure they might learn something important about the underlying biological causes of schizophrenia.39 Manfred Sakel, the inventor of insulin coma therapy, had offered only the haziest guess about what might be happening; he speculated that insulin somehow helped to burn off excess energy in the brain.40 In the USSR, Professor Sereiskii suggested that the “lock” was biochemical: “insulin,” he wrote, “causes anoxia in the brain, depressing the central metabolism (lowering utilization of oxygen and processing of proteins). This depression of cerebral metabolism leads to a metabolic-parasympathetic restructuring with subsequent reactive onset hypoxia of the brain ….”41 Variations of this explanation were offered by other psychiatrists in the USSR through the 1940s.42 For the practical purposes of working psychiatrists, however, no clear method existed that could be used to objectively measure whether or not insulin coma therapy was working. This meant that in practice,

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for all their talk of psychiatry standing on its “biological legs,” Soviet psychiatrists had to rely on the traditional art of psychiatric medicine: clinical observation of how the patient moved, talked, thought, emoted, and interacted with other people. In practice, this behaviour was observed in a very specific social setting: the overcrowded wards of the psychiatric hospital. On the wards of psychiatric hospitals patients were expected to follow a routine established by the hospital staff, to be helpful and compliant, to accept as benign the goals and needs of the staff, and to observe basic norms of decorum. A patient with disturbed behaviour could seriously undermine the functioning of a ward, and patients who were consistently “agitated” were transferred to specific wards where they could be more closely monitored and controlled, as were patients who were catatonic or “inaccessible” to staff. Patients who could be reasoned with, who were helpful and “accessible,” were placed in wards for “mild” cases. From the perspective of the medical and administrative staff, such a system was necessary to ensure the safety of patients and staff and to make sure that both “calm” and “agitated” patients got the specific kinds of attention they needed. In this milieu it made sense to treat behaviour as a proxy for disease. The patients were not bad people, they were sick. It was illness that was causing patients to act out. Soviet hospitals prided themselves on not using “restraints” like straitjackets to punish or control patients. Such measures were associated with the carceral approach to psychiatry used by the Old Regime, and symbolically linked to Tsarist despotism. Sedative drugs, on the other hand, were accepted and commonly used on the grounds that they helped to fight “agitation,” which was itself conceptualized as a manifestation of the disease process. At a 1948 staff conference for one of Moscow’s main municipal psychiatric hospitals, the head psychiatrist explained that, “Agitation is an indication of the intensiveness of the [disease] process. It follows that by reducing agitation, therapy reduces the intensiveness of the process, gives improvement ….”43 This same logic can be found in the way that psychiatrists evaluated and conceptualized “active therapies” like insulin shock. After a course of insulin coma therapy patients were found to be calmer, more accessible to reason, and more amenable to hospital discipline. They could be transferred from a ward for agitated patients to a ward for calm patients. They might even be able to live at home and be taken care of by family members. If the behaviour was caused by the disease process, doctors reasoned, then changes in behaviour must reflect changes in the disease process. This meant that a wide range of behaviours could signify disease in need of shock therapy. At one extreme was violent and threatening

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behaviour. A young woman referred to as U., for instance, paced about the ward spitting on people, laughing, and accusing the hospital staff of poisoning her.44 At another extreme was 18-year-old factory worker D., who would not respond to questions from his doctor, would not chew food that nurses put in his mouth, and paid no attention to his family when they visited.45 Between the violent and the inert were patients like 21-year-old Sh. who simply exhibited “lack of initiative, lack of interest in treatment, lack of interest in talking with the physician …. Shows diminished critical awareness of her condition.”46 In all these examples, patients did not participate in the communal life of the hospital. They did not independently follow the routines established by the staff, did not socialize with other patients, and did not take an active interest in their surroundings or in their illness. Perhaps most importantly, in the eyes of their physicians, these patients did not show “critical awareness” of their sickness. All of these were taken to be outward evidence of disease. The psychiatrists saw their job as detecting, controlling, and (when possible) curing diseased bodies. They judged the success of their efforts by their patients’ ability to interact productively on the ward. After 20 insulin shocks, Sh. “became a bit more energetic, stopped shunning the company of other patients. Headaches vanished, as did shouting … Former lethargy and indifference remain.” D., the catatonic 18-year-old factory worker, improved even more quickly: after only eight treatments with insulin his stupor was gone, he showed “correct, orderly behaviour,” and he was able to talk critically with the doctor about his illness. “He was glad to recognize that his psychotic experience was over. His behaviour became entirely correct.”47 Patient S., a 38-year-old woman who was plagued by voices in her head, was given 30 insulin shocks: “Voices disappeared, critical attitude toward delusional experiences appeared, patient was checked out in a state of good remission.”48 This practice of evaluating therapeutic effectiveness according to how a patient behaved in the context of the psychiatric hospital was formalized by the Gannushkin Institute in 1940. The institute proposed five categories to classify the “quality of remission” of a patient undergoing insulin coma therapy. Patients in the first group (“A”) were those who had entirely recovered, “where psychotic symptoms are objectively and subjectively entirely eliminated” and where “one observes a return of the patient’s particular former capacity or (incapacity) to do work.” Group “B” were patients who continued to show some symptoms of illness, but not to the degree that their illness “affected the social-labour capacity of the patient,” while patients in the third and fourth group

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had symptoms that did affect their “social-labour capacity.” (The fifth group, “Group O,” were patients whose symptoms were unaffected by the treatment.)49 In the closed world of the psychiatric wards, the “quality of remission” was judged by how capable an individual was of functioning in a social context. Soviet psychiatric hospitals used these criteria in their administrative reports, in their research, and on the wards. These criteria remained in use at least into the 1960s.50 To patients and observers, insulin coma therapy often seems to have appeared frightening and dangerous. In her published lectures, for instance, Dr Grunia Sukhareva recounts the experience of a 14-year-old girl named V. who had been hospitalized after experiencing extreme paranoia. V. believed that people were plotting to kill her and refused to leave her room. In the hospital, she reportedly hallucinated angels and demons and accused her nurse of writing a denunciation against her. V. began insulin coma therapy in early March, 1937, beginning with small doses and building slowly to 24 units. At just six units, Sukhareva wrote, she “tries to escape the ward, cries, screams …. Complained of feeling bad.” At eight units she cried out “I’m dying.” At 12 units, she “sings songs, cries; pulse arrhythmic ….” At 20 units she finally began to fall into a coma and experience seizures. This treatment continued until the end of May. She experienced 17 “shock” episodes, each lasting half an hour on average. After the treatment, Sukhareva reported, V. regained her “zest for life” and was able to return home. A year later her parents reported that she seemed to have completely recovered.51 Based on other published and unpublished accounts, V.’s experience seems fairly typical. Other patients too reported a terrifying experience. In an archival file that includes a fragment of a patient’s daily chart, for instance, a psychiatrist recorded that on the second day of insulin injections the patient “felt bad around the heart, experienced stormy emotion, crying, fear of death.”52 Records of asylum inspections show that non-psychiatrists could not immediately understand how psychiatrists could subject their patients to this kind of treatment. In one 1939 case, for instance, a psychiatric hospital director wrote to his superiors in Moscow warning that local government officials had “gotten an extremely unpleasant impression of active methods of therapy.” He asked that Moscow be ready to support him if they continued to question whether or not these methods were approved.53 Psychiatrists themselves recognized that insulin coma therapy was dangerous, and that this raised ethnical questions about its use in psychiatric practice. As early as 1937, Sereiskii acknowledged to a meeting

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of psychiatrists that in using insulin coma therapy they would have to “bear in mind the fundamental medical rule that we have no right to risk the life of a patient.” He went on to conclude, however, that “standing before a disease like schizophrenia, we may not refuse this method of treatment.”54 The next year a committee assigned to study the problem concluded that “[insulin coma therapy’s] safety norms … are so developed, and [the treatment] helps so radically, that the method can be considered entirely permissible.”55 Schizophrenia, in other words, was such a terrible disease that if there was a chance they might help the patient, then methods like insulin coma therapy were justified, even if there was a significant chance that the patient might be harmed. This “last resort” logic remained the justification for using such a dangerous method for the next decade. Speaking at a conference in 1947, the director of one of Moscow’s foremost psychiatric research institutes admitted that “All these methods of treatment are somewhat crude and dangerous for the patient … But with further improvement of the method this danger becomes lower and lower, in comparison with the terrible illness that we use it to treat. Therefore the very brutality of the method does not frighten us.”56 Seeing patients transformed by treatment could even be personally meaningful for psychiatrists. When other psychiatrists questioned the efficacy of insulin coma therapy, these personal experiences of seeing a cure happen were invoked as evidence that it did in fact work. The same phenomenon has been described in American hospitals. In her analysis of insulin coma therapy in New York, Deborah Doroshow has written that insulin coma therapy “was able to secure its foothold in psychiatry by making indelible impressions on the minds of practitioners who had seen amazing recoveries for themselves.” These personal experiences convinced doctors that insulin coma therapy worked, even in the face of contradictory statistical evidence.57 In the Soviet case, this is illustrated particularly well by an interaction between two psychiatrists in a 1949 staff conference at Moscow’s 1st municipal psychiatric hospital. At the conference Dr Tikhon Iudin used statistics to challenge the effectiveness of insulin coma therapy. Iudin had trained in Moscow before the revolution and had been one of the USSR’s most vocal proponents of eugenics. When he spoke about research and evidence, he spoke with great authority. At the conference, Iudin attacked the younger generation for making claims for insulin coma therapy on the basis of their successes in treating patients who were freshly ill. Such patients were likely to recover anyway, Iudin said. Anecdotal evidence like this was

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worthless. He focused particularly on the results of a young psychiatrist, Dr Dikovitskii. “Regarding the results of active therapy,” Iudin said, our results are inconsistent. Dikovitskii gets 20% A and B, 32% C and 20% D – that is Gaussian curve, that is, chance. … No claim of results or usefulness can be claimed on the basis of this curve. … This is a sign of accidental benefit. … One can’t make conclusions on the basis only of fresh cases. What we need to do is take a large number of patients who fell ill at a particular age (from 15 to 20) and compare them to the natural curve, a not to individual random patients. In reply, Dikovitskii admitted that he “wasn’t so good with these Gaussian curves,” but chance or no chance, he was certain that his patients benefited from treatment. “I can only say what I have experienced, the experience of a practicing physician, who spends all day at the patient’s bedside,” he said. “That experience, my experience, says that active therapy gives colossal results and that therapeutic intervention deepens and quickens [the patient’s] exit from the disease state.” He described how he had recently checked out one of his patients, a woman diagnosed with catatonic schizophrenia, who “had already been written off as dead.” “Major specialists” had thought that nothing more could be done for her, but after 45 [insulin] shocks and nine seizures she was now “in a wonderful condition” and living at home. “… I personally saw it,” he said. “… Therefore, on the basis of my personal experience, I consider that combined therapy [insulin combined with camphor] cannot be refused.”58 For psychiatrists like Dikovitskii, the experience of seeing patients improve was extremely powerful. Like most of his colleagues, Dikovitskii carefully selected his patients from among those that he thought would benefit from the treatment the most – those who were freshly ill and who were housed on the ward for agitated patients. Giving treatment involved days of structured, highly medicalized work that brought together the psychiatrist and his team of nurses. The group experience was gruelling, but also served to affirm for the people involved that they were actively performing their duty as healers and researchers, not simply acting as custodians of the insane. The political context mattered as well: in performing insulin coma therapy, psychiatrists like Dikovitskii were signifying their fluency with contemporary Soviet ideology by rejecting “therapeutic nihilism,” demonstrating their willingness to act in ways that would meaningfully change the mental condition of their patients.

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Was Iudin right? Was insulin coma therapy really no more effective than chance? Certainly Soviet psychiatrists were not operating under anything approaching double-blind conditions. The patients given insulin coma therapy were also the patients who were most likely to experience spontaneous remission. By the early 1950s some western researchers were actively questioning the effectiveness of insulin coma therapy; Soviet researchers knew of and disputed these results, as did some Western psychiatrists.59 In his history of “bodily cures” in American psychiatry, Joel Braslow usefully distinguishes between “efficacy” and “effectiveness.” Efficacy refers to a treatment’s performance under controlled laboratory conditions, while “effectiveness” refers to its performance in the uncontrolled, real-world conditions of a psychiatric hospital. In the laboratory, results are strictly defined according to specific variables that are carefully controlled for. In the hospital, however, psychiatrists often have to gauge the results of a treatment indirectly, especially for diseases like schizophrenia for which they have no easy diagnostic test. In the conditions of a psychiatric hospital, however, how else was a psychiatrist to evaluate the impact of a treatment other than to observe the behaviour of a patient? If a patient who had been incoherent and disruptive before the treatment became capable of functioning with others, this was success. Judged in these terms, insulin coma therapy, sleep therapy, and Cardiozol shock were all “effective” methods of treatment. It makes sense to think of these not only as medical treatments but, to use a phrase suggested by Braslow, as “social technologies.”60 The “brutality” of the treatment could even be seen as a positive good. In a 1941 analysis, another leading psychiatrist found that the effects of insulin treatment could not be caused solely by the biochemical changes caused by introducing insulin into the body. The therapeutic value of the treatment, he concluded, must be in the “cerebral effects” caused by seizures. The physical violence of the procedure was itself the essence of the therapeutic process. In order to heal, the psychiatrist needed to inflict a violent and frightening “cerebral shock.”61 When alternative methods of treatment were proposed, psychiatrists in positions to approve them expressed scepticism. When a new method was proposed that used mild, electricity-induced sleep, the psychiatrist in charge of the committee evaluating new treatments said that, “Unfortunately, all our attempts to make our methods of treatment milder and more humane [bolee gumannoi] lead to diminished effectiveness. I think that all psychiatrists will agree with this.”62 The harsh brutality of insulin coma therapy had become a signifier of their effectiveness. Something was

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being done to the body, and the more violent and more harsh the body’s reaction, the more likely it was to have greater effectiveness. Speaking at the All-Union Congress in 1948, Sereiskii summed up this position: “Soviet humanism in medicine,” he said, “does not consist of … sitting idly and observing the destruction of the organism under the influence of the further development of the pathological process, but rather in capably giving treatment today using all available methods, not waiting for tomorrow’s discoveries.”63 Not all Soviet psychiatrists were comfortable with the “brutality” of the new biological therapies, and their discomfort grew in the post-war years when two new methods of treatment, lobotomy and electroshock therapy, came into use. Electroshock was first used in the Soviet Union in the late 1930s. After the war, when insulin and other pharmaceuticals were scarce, electroshock was quickly incorporated into the “therapeutic arsenal” of psychiatric hospitals as a cheap and easy alternative.64 By 1949 it accounted for 33% of all “active treatments” administered. Electroshock was easier and cheaper to use than insulin coma therapy and it seemed to have a great effect on patients.65 Lobotomy was treated with much greater caution. Experiments with lobotomy began in Moscow in 1944, and the procedure was tentatively endorsed by the All-Union Society of Neuropathologists and Psychiatrists in 1949. Lobotomy, however, remained restricted to university clinics and research institutes, and it was never approved for general use in normal Soviet psychiatric hospitals.66 Such unease about the new methods of treatment was displayed by prominent participants at the 1948 Congress of the All-Union Society of Neuropathologists and Psychiatrists, the first such national meeting since 1936. Professor Giliarovskii expressed deep unease about electroshock, which he believed caused bleeding in the brain which was responsible for memory loss. “I believe that a treatment that causes diminished memory is not acceptable,” he declared, “and cannot be broadly recommended. … One should not forget that the birthplace of this method is America. [sic] … In capitalist countries where there are millions of unemployed, it does not matter if a patient leaves the hospital with some defect.”67 The implication of Giliarovskii’s outburst was that treatments that worked through brutalizing the brain somehow ran counter to the values of Soviet medicine. In the late 1940s and early 1950s, these divisions within Soviet psychiatry became highly politicized. During these years, Stalin launched a series of ideological campaigns intended to reestablish control over the cultural and scientific elite. Psychiatrists, like all members of the

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intelligentsia, were obligated to hold meetings in their workplaces and in their professional associations to denounce problems such as “cosmopolitanism,” “kowtowing before the West,” and “clannishness.” Just what any of these slogans meant in concrete terms was unclear. Members of each organization, each discipline, were expected to scrutinize their own behaviour and the behaviour of their colleagues and to critically expose mistakes.68 Psychiatrists took this opportunity to denounce their rivals, re-describing scientific or ethical differences as examples of the most heinous cosmopolitanism. What followed was a direct intervention in psychiatry by the Communist Party and the imposition of an official dogma: Ivan Pavlov’s “theory of higher nervous activity.” Ivan Pavlov had won a Nobel Prize in physiology in 1905 for his work on the digestive system. His work on conditional reflexes in dogs had made him a household name worldwide. In the decades after his Nobel Prize, Pavlov had used conditional reflex experiments to develop an elaborate theory that purported to describe the physical correlates of consciousness. “Higher nervous activity,” according to this theory, could be understood as the interaction between two basic physiological processes: “excitation” and “inhibition.”69 Before his death in 1936, Pavlov had regularly visited St Petersburg psychiatric hospitals, observing patients and speculatively describing their symptoms in terms of the patterns of excitation and inhibition that he saw in his experimental dogs. Schizophrenia had particularly interested him, and psychiatrists inspired by Pavlov adopted a theory which claimed that the basic cause of schizophrenia was “a toxic substance circulating in the blood of the schizophrenic and poisoning the cortical cells.”70 To prevent permanent damage to these cells, the brain placed these cells into “a chronic hypnotic state,” referred to as “protective inhibition.” This state of protective inhibition intensified and spread throughout the cortex of the brain, causing the clinical symptoms of schizophrenia, particularly the apparent “splitting” of psychological faculties.71 For Pavlovian psychiatrists, the essential point for clinicians was that schizophrenia was a potentially reversible condition. The patient’s brain was not injured; total recovery was possible. To use a treatment like lobotomy or electroshock was to damage what could be saved.72 Pavlov’s theory was elevated to official dogma at a joint meeting of the Academy of Sciences and the Academy of Medical Sciences that was held in 1950. At this “Pavlov Session,” medical researchers, and physiologists and psychiatrists in particular, were castigated for failing to adhere to Pavlov’s doctrine. The second speaker at the Congress was Anatolii Ivanov-Smolenskii, a psychiatrist who had worked closely

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with Pavlov.73 In his speech, Ivanov-Smolenskii severely criticized psychiatrists for ignoring Pavlov’s discoveries. He condemned most work on “active therapy” as “empiricism:” experimenting blindly, injecting and cutting their patients in the hopes of producing a result. Such “empiricism,” Ivanov-Smolenskii argued, was utterly un-Soviet and anti-Pavlovian. What they should have been doing, he said, was starting from Pavlov’s basic principles and using these to develop targeted, truly “rational” methods of treatment.74 In a closed-door discussion of lobotomy, a member of the Ministry of Health summarized this position: “in socialist society we should have theoretical basis for our methods of treatment. That is the essence of Pavlovian doctrine. If we don’t follow this rule then we end up taking the capitalist position, that is eclectic, not scientific, medicine.”75 In one important respect Ivanov-Smolenskii correctly identified the basic incoherence of Soviet psychiatric doctrine: psychiatrists were using methods of treatment without understanding why or how they might work, while at the same time insisting that all treatments should be based on a scientific understanding of the material causes of mental illness. The claims made for “Pavlov’s doctrine” were powerful precisely because they provided a unifying theory of body and mind, complete with arcane terminology and a massive corpus of empirical research data. This point was stressed by Andrei Snezhnevskii, the psychiatrist who delivered the keynote speech at the psychiatrists’ own “Pavlov Session,” which was held a year later, in 1951. Pavlov’s doctrine, he said, enabled psychiatrists to “consciously and intentionally use the organism’s own mechanisms of fighting disease, mechanisms that have evolved to be the foundation of the organism’s self-defense and self-healing.”76 Lobotomy was banned outright in 1950, and the psychiatrists most associated with it were vilified in official speeches, removed from positions of influence, and transferred to insignificant posts in provincial hospitals.77 Electroshock was also criticized. It was characterized as antiPavlovian and potentially damaging to patients. A study published in 1951 found that electroshock essentially erased conditional reflexes in dogs, and concluded that “when electroshock is used by psychiatrists it is necessary with all seriousness to take into account these negative aspects of electroshock’s impact on brain activity.”78 While it was not banned outright, its use was severely curtailed, and it remained uncommon in Soviet psychiatric practice for the rest of the twentieth century.79 Prolonged sleep therapy was the most obviously “Pavlovian” method, since Pavlov himself had praised it as a means of treating schizophrenia by putting patients into a state of “protective inhibition.”80

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What did these developments mean for insulin coma therapy? In the 1950s, insulin coma therapy actually became more prevalent in Soviet psychiatric hospitals than it had been before. Its nearest rivals, electroshock and Cardiozol shock, had become almost-taboo “last resort” treatments. For all Ivanov-Smolenskii’s claims about Pavlovian science, “conditional reflex therapy” simply did not prove to be of much use, particularly for patients suffering from major mental illness. Sleep therapy was constantly praised, but it continued to be used less than insulin shock. A 1956 report described it as “the most widespread and effective method of treatment of the mentally ill,” used on 60–70 percent of patients who entered with a schizophrenia diagnosis.81 Insulin coma therapy had always been an ambiguous method of treatment. Like sleep therapy, it put patients into a long-lasting slumber. Like Cardiozol shock (and later electroshock), it caused patients to experience seizures. And like treatments for metabolic disorders, insulin coma therapy introduced a potent hormone into the body. Pavlov’s theory of inhibition and excitation held that psychosis developed because of “a disruption of the normal relationship of excitation, inhibition, their irradiation, positive and negative induction and other complicated processes.”82 If a patient’s symptoms lifted, this was taken to mean that they were experiencing a more normal pattern of excitation and inhibition. Pavlovian psychiatry was supposed to provide a rigorous physiological framework for psychiatry, one that enabled them to understand and treat the underlying physiological causes of mental illness. In practice, however, psychiatrists attempting to measure states of inhibition and excitation in their patients relied on the same traditional methods of clinical observation. The biggest change was a shift in emphasis from “brutality” to “protection.” Prior to 1950, psychiatrists had singled out the “brutality” of their treatments as important signifiers of effectiveness. A treatment that caused a crisis of the body was expected to have an impact on the disease process itself, a result measured indirectly through the post-treatment behaviour of the patient. In the new discourse of Pavlovianism, however, treatments were evaluated according to their ability to induce calm. The more dangerous and “brutal” the treatment, the less “Pavlovian.” Psychiatrists now adopted a therapeutic rationale that emphasized the “protective rest” of sleep, not the brutal shock of seizures. “Treatment of mental illness … should be based on the principle of complex treatment, should act on the cause of the illness (toxin, microbe, metabolic disorder, intense neuro-psychic influence), and also should enable the mobilization of the body’s defensive mechanisms.”83

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Psychiatric hospitals used the needs of Pavlovian treatment to justify expanding the number of specialized laboratories and wards. By statute, psychiatric hospital directors were required to demonstrate that they were actively treating their patients, and in order to secure funding they had to demonstrate a need for the expensive equipment and medicine that was required for treatment. Hospital directors added Pavlovian language to their reports and to their therapeutic justifications. More importantly, they used the need for Pavlov-inspired diagnostic tests to ask their superiors for more funding. Using Pavlov as a justification, the medicalized rituals that had developed around insulin coma therapy expanded, blossomed, and became more entrenched in the symbolic enactment of Sovietness. Insulin coma therapy remained the predominant method of treatment for schizophrenia in the USSR until the early 1960s. New antipsychotic medicines developed in the West (Chlorpromazine, Reserpine, and others) were imported to the USSR in 1953 and 1954, and were in regular use by 1957. Soviet psychiatrists reported that the new drugs had roughly the same effectiveness as insulin coma therapy.84 The new drugs were often in short supply, but when they were available they were much safer and easier to use than insulin coma therapy.85 As a result, the use of insulin coma therapy began a long decline.86 In 1963, for instance, 54% were treated with neuroleptics or antidepressants, while only 7% were treated with insulin coma therapy.87 It was still a major part of psychiatric practice in the 1970s, but by the 1980s and 1990s it had become a rarity, consigned largely to the annals of the history of Soviet psychiatry.88

Notes 1. Gosudarstvennyi arkhiv Rossiiskoi Federatsii [State Archive of the Russian Federation], hereafter referred to as ‘GARF’, fond [f.] r-8009, opis’ [op.] 5, delo [d.] 190, list’ [l.] 9ob. 2. “Spravka o sostoianii psikhonevrologicheskoi pomoshchi v SSSR za 1954 god” [1955]. GARF f. r-8009, op. 33, d. 656, ll. 12–13. 3. The best accounts of Soviet psychiatry can be found in David Joravsky, Russian Psychology: A Critical History (Oxford: Basil Blackwell, 1989); Alexander Etkind, Eros of the Impossible: The History of Psychoanalysis in Russia, trans. Noah and Maria Rubins (Boulder, CO: Westview Press, 1997); Martin A. Miller, Freud and the Bolsheviks: Psychoanalysis in Imperial Russia and the Soviet Union (New Haven: Yale University Press, 1998); and Irina Sirotkina, Diagnosing Literary Genius: A Cultural History of Psychiatry in Russia, 1880–1930 (Baltimore and London: Johns Hopkins University Press, 2002). On the use of psychiatry as a weapon against political dissidents, see Sidney Bloch and Peter Reddaway, Psychiatric Terror: How Soviet Psychiatry is Used to Suppress Dissent (New York: Basic Books, 1977); Theresa C. Smith and Thomas A. Oleszczuk, No Asylum: State Psychiatric Repression in the Former USSR (New York: New York University

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4.

5. 6. 7.

8.

9. 10. 11.

12. 13.

14.

15. 16.

17.

18.

Press, 1996); and Vladimir Bukovskii, Moskovskii protsess (Paris and Moscow: Russkaia mysl’, 1996), 144–161. Andrew Scull, “Somatic Treatments and the Historiography of Psychiatry,” History of Psychiatry 5, no. 1 (1994): 1–12 and Madhouse: A Tragic Tale of Megalomania and Modern Medicine (New Haven: Yale University Press, 2005); Joel Braslow, Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century (Berkeley: University of California Press, 1997); Jack D. Pressman, Last Resort: Psychosurgery and the Limits of Medicine (Cambridge: Cambridge University Press, 1998). See also Hugh Freeman, ed., A Century of Psychiatry (London: Harcourt, 1999); and Edward Shorter and David Healy, Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness (New Brunswick, New Jersey, and London: Rutgers University Press, 2007). Braslow, Mental Ills and Bodily Cures, 4. Shorter, A History of Psychiatry, 209–210. Iu. S. Savenko, “120-Letie Artura Kronfel’da (1886–1941). Tragediia zhizni i tvorchestva Artura Kronfel’da – klassika i vse eshche sovremennika,” Nezavisimyi psikhiatricheskii zhurnal (NPZh), no. 1 (2007). Available at http:// www.npar.ru/journal/2007/1/kronfeld.htm (last accessed (12 October, 2007). A. S. Kronfel’d and E. Ia. Shternberg, “Lechenie shizofrenii insulinovym shokom,” in Trudy 2-go vsesoiuznogo s”ezda nevropatologov i psikhiatrov, ed. M. B. Krol’ and A. O. Edel’shtein (Moscow: Izdanie org. komiteta s”ezda, 1937), 604. Aleksander Etkind, “Trotsky’s offspring: Revolutionaries, Psychoanalysts and the Birth of ‘Freudo-Marxism’,” The Times Literary Supplement, August 9, 2013, 14–15. GARF f. r-8009, op. 1, d. 35, l. 127; Rossiskoi Gosudarstvennyi Arkhiv Ekonomiki (RGAE) f. 1562, op. 18, d. 203. “Lechenie nervnykh i psikhicheskikh zabolevanii: Preniia,” in Trudy tret’ego vsesoiuznogo s”ezda nevropatologov i psikhiatrov, ed. V. A. Giliarovskii (Moscow: Medgiz, 1950), 435; L. L. Rokhlin, Soviet Medicine in the Fight Against Mental Diseases, trans. David Myshine (Moscow: Foreign Languages Publishing House, 1958), 114. A. E. Blankfel’d, “Izmeneniia galliutsinatsii u shizofrenikov pri lechenii insulinom,” Sovetskaia psikhonevrologiia 14, no. 5 (1938): 41–48. L. M. Rozenshtein, “Psikhogigienicheskoe dvizhenie v SSSR i ego zadachi v sviazi s rekonstruktsiei,” Sovetskaia nevropatologiia, psikhiatriia i psikhogigiena 1, no. 3–4 (1931): 36. Irina Sirotkina, Diagnosing Literary Genius: A Cultural History of Psychiatry in Russia, 1880–1930 (Baltimore and London: Johns Hopkins University Press, 2002), 146–161; Susan Gross Solomon, “David and Goliath in Soviet Public Health: The Rivalry of Social Hygienists and Psychiatrists for Authority over the Bytovoi Alcoholic,” Soviet Studies 41, no. 2 (April 1989): 254–275. L. A. Prozorov, “Nevro-psikhiatricheskie dispansery i nevro-psikhiatricheskie otdeleniia dispansernykh ob’edenenii v 1929, 1930 g.,” ZhNiP, no. 4 (1931): 76. Sheila Fitzpatrick, “Cultural Revolution as Class War,” in Cultural Revolution in Russia, 1928–1931, ed. Sheila Fitzpatrick (Bloomington: Indiana University Press, 1978), 8–40. David Joravsky, “The Construction of the Stalinist Psyche,” in Cultural Revolution in Russia, 1928–1931, ed. Sheila Fitzpatrick (Bloomington: Indiana University Press, 1978), 115. GARF f. r-8009, op. 1, d. 47, l. 15; “Iz poslednei pochty: Po lozhnomu puti,” Pravda (December 26, 1936).

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19. GARF f. a-482, op. 24, d. 975, ll. 4–6; GARF f. a-482, op. 24, d. 985, l. 101; Iu. S. Savenko, “‘1937’ 70-letie bol’shogo terrora i psikhiatriia,” NPZh, no. 3 (2007); Iu. S. Savenko, “120-letie L’va Markovicha Rozenshteina (1884–1934),” NPZh, no. 3 (2004). 20. Shorter, History of Psychiatry, 192–196. 21. M. Ia. Sereiskii, “Sovremennye problemy lecheniia shizofrenii,” in Trudy 2-go vsesoiuznogo s”ezda nevropatologov i psikhiatrov, ed. M. B. Krol’ and A. O. Edel’shtein (Moscow: Izdanie org. komiteta s”ezda, 1937), 570–572. 22. Shorter, History of Psychiatry, 200–217. 23. GARF f. r-8009, op. 5, d. 209, l. 67 24. Shorter, History of Psychiatry, 218–227. 25. L. A. Prozorov, “Tekhnicheskoe osnashchenie psikhiatricheskikh bol’nits i aktivnaia terapiia,” Nevropatologiia, psikhiatriia, i psikhogigiena (NPiP) 4, no. 12 (1935): 23–28. 26. GARF f. r-8009, op. 5, d. 209, l. 67 27. GARF f. r-8009, op. 5, d. 209, l. 41. The problem of unequal funding persisted. In 1949, psychiatric hospitals were getting 52 kopeks per bed per day, while somatic hospitals were getting two roubles per bed per day. GARF f. r-8009, op. 1, d. 757, l. 106. 28. V. A. Giliarovskii and P. B. Posvianskii, eds., Metodika i tekhnika aktivnoi terapii psikhicheskikh zabolevanii (Moscow: NKZ RSFSR, 1939), 19. 29. Ibid., 40–43. 30. Ibid., 8–13. 31. “V. Moskovskom obshchestve nevropatologov i psikhiatrov: Zasedanie November 10, 1937,” Nevropatologiia i psikhiatriia (NiP) 7, no. 3 (1938): 160; Sereiskii, “Sudorozhnaia terapiia shizofrenii,” NiP 7 no 12 (1938): 4. 32. GARF f. r-8009, op. 5, d. 164, ll. 209–285. 33. M. A. Belitsina, “Rol’ meditsinskoi sestry v aktivnoi terapii psikhozov,” Meditsinskaia sestra, no. 10 (1950): 17–22. 34. Osnovnye polozheniia po organizatsii i rabote psikhiatricheskikh boln’its (Moscow: 1947), points 28–29, 57. 35. GARF, f. r-8009, op. 5, d. 212a, ll. 8–18, esp. l. 13; GARF, f. r-8009, op. 5, d. 212a, ll. 1–7. 36. V. M. Banshchikov and A. M. Rapoport, “Terapiia v psikhiatricheskikh bol’nitsakh SSSR v 1949 g,” NiP 20, no. 1 (1951): 33–34. 37. GARF f. r-8009, op. 1, d. 757, l. 99. 38. Quoted in M. M. Zak, “Katamnez shizofrenikov, lechennykh razlichnymi metodami,” NiP 19, no. 4 (July–August 1950): 55. 39. “V. Moskovskom obshchestve nevropatologov i psikhiatrov,” NiP 7, no. 3 (1938): 150–164; Zalmanzon, “O mekhanizme terapevticheskogo effekta,” 254. 40. Braslow, Mental Ills and Bodily Cures, 97. 41. M. O. Gurevich and M. Ia. Sereiskii, Uchebnik psikhiatrii, 5th ed. (Moscow: Medgiz, 1946), 347. 42. Giliarovskii included a version of this explanation in his published clinical lectures. Giliarovksii, Psikhiatria: Klinicheskie lektsii (1942), 353; Zalmanzon, “O psikhopatologicheskoi dinamike pri insulinoterapii,” 229–253. 43. Tsentral’nyi arkhiv goroda Moskvy (TsAGM), f. 1126, op. 1, d. 56, l. 47. 44. M. O. Gurevich, Psikhiatriia: Uchebnik dlia meditsinskikh institutov (Moscow: Medgiz, 1949), 417. 45. Gurevich and Sereiskii, Uchebnik psikhiatrii, 357.

Stalin’s Soviet Union, 1936–1953 71 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57.

58. 59.

60. 61. 62. 63.

64.

65. 66. 67.

68.

69.

Gurevich, Psikhiatriia, 416. Gurevich and Sereiskii, Uchebnik psikhiatrii, 357. Ibid., 358. GARF, f. r-8009, op. 5, d. 164, ll. 147–147ob. Gurevich and Sereiskii, Uchebnik psikhiatrii, 355. See, for instance, GARF f. a-482, op. 50, d. 5188, l. 55. G. E. Sukhareva, Klinicheskie lektsii po psikhiatrii detskogo vozrasta, vol. 1 (Moscow: Medgiz, 1940), 145–147. GARF f. r-9592, op. 1, d. 174, l. 29. GARF f. r-8009, op. 1, d. 35, l. 45ob. GARF f. r-8009, op. 2, d. 6, ll. 14–15. “V Moskovskom obshchestve nevropatologov i psikhiatrov: Zasedanie November 25, 1937,” NiP 7, no. 3 (1938): 163. GARF f. r-8009, op. 2, d. 1048, l. 28. Deborah Blythe Doroshow, “Performing a Cure for Schizophrenia: Insulin Coma Therapy on the Wards,” Journal of the History of Medicine and Allied Sciences 62, no. 2 (April 1, 2007 2007): 241. TsAGM, f. 1126, op. 1, d. 61, ll. 42–43. A. E. Lichko, Novoe v insulinoshokovom lechenii psikhozov (Leningrad: Meditsina, 1970), 5–10. William Sargant and Eliot Slater, An Introduction to Physical Methods of Treatment in Psychiatry, 5th ed. (Edinburgh & London: Churchill Livingstone, 1972), 253–255. Braslow, Mental Ills and Bodily Cures, 104–109. M. O. Gurevich, “K teorii aktivnoi terapii shizofrenii,” NiP 10, no. 1 (1941): 20. GARF f. r-8009, op. 2, d. 1048, l. 28. “Lechenie nervnykh i psikhicheskikh zabolevanii: Preniia,” in Trudy tret’ego vsesoiuznogo s”ezda nevropatologov i psikhiatrov, ed. V. A. Giliarovskii (Moscow: Medgiz, 1950), 435. GARF f. 8009, op. 5, d. 212a, l. 21.; Ia. P. Frumkin, I. M. Slivko, and I. A. Mizrukhin, “Dlitel’no-preryvistyi son (elektrokomatoznaia terapiia, elektro-narkoshok) v lechenii i izuchenii shizofrenii i tak nazyvaemoi funktsional’noi psikhicheskoi patologii,” in Trudy tret’ego vsesoiuznogo s”ezda nevropatologov i psikhiatrov, ed. V. A. Giliarovskii (Moscow: Medgiz, 1950), 362–366; “Lechenie nervnykh i psikhicheskikh zabolevanii: Preniia,” in Trudy tret’ego vsesoiuznogo s”ezda nevropatologov i psikhiatrov, ed. V. A. Giliarovskii (Moscow: Medgiz, 1950), 437. V. M. Banshchikov and A. M. Rapoport, “Terapiia v psikhiatricheskikh bol’nitsakh SSSR v 1949 g,” NiP 20, no. 1 (1951): 33–34. S. V. Kurashev, “Nauchnye zasedaniia: II plenum Vsesiouznogo obshchestva nevropatologov i psikhiatrov,” NiP 18, no. 3 (1949): 72–73. “Lechenie nervnykh i psikhicheskikh zabolevanii: Preniia,” in Trudy tret’ego vsesoiuznogo s”ezda nevropatologov i psikhiatrov, ed. V. A. Giliarovskii (Moscow: Medgiz, 1950), 437. Nikolai Krementsov, Stalinist Science (Princeton: Princeton University Press, 1997); Kiril Tomoff, “Uzbek Music’s Separate Path: Interpreting ‘Anticosmopolitanism’ in Stalinist Central Asia, 1949–1952,” Russian Review 63 (April 2004): 212–240; Ethan M. Pollock, Stalin and the Soviet Science Wars (Princeton: Princeton University Press, 2006). Joravsky, Russian Psychology, 77–82, 271–307, 379–414; Roger Smith, Inhibition: History and Meaning in the Sciences of Mind and Brain (Berkeley: University of

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72. 73.

74.

75. 76.

77.

78. 79.

80.

81. 82. 83. 84. 85. 86.

87. 88.

Benjamin Zajicek California Press, 1992), 190–204; Daniel P. Todes, “Pavlov and the Bolsheviks,” History and Philosophy of the Life Sciences 17, no. 3 (1995): 379–418. GARF f. r-8009, op. 2, d. 6, ll. 17–22. I. P. Pavlov, “Probnaia ekskursiia fiziologa v oblasti psikhiatrii,” in Isbrannye proizvedeniia, ed. K. M. Bykov, S. I. Vavilov, L. A. Orbeli, and E. A. Asratian (Mosocw: Akademii nauk SSSR, 1949), 440–444; GARF f. r-8009, op. 2, d. 1498, l. 53. A. G. Ivanov-Smolenskii, Ocherki patofiziologii vysshei nervnoi deiatel’nosti (Po dannym I. P. Pavlova i ego shkoly) (Moscow: Medgiz, 1949), 224–233. Ivanov-Smolenskii had himself experimented with insulin coma therapy in the mid-1930s. “Anatolii Georgievich Ivanov-Smolenskii (K 50-letiiu nauchnoi deiatel’nosti),” ZhNiP 67, no. 12 (1967): 1880–1881. Nauchnaia sessiia posviashchennaia problemam fiziologicheskogo ucheniia akademika I. P. Pavlova, 28 iiunia – 4 iiulia 1950 g.: Stenograficheskii otchet (Moscow: Izd. Akademii Nauk SSSR, 1950), 49–51. GARF f. r-8009, op. 2, d. 1498, l. 88. A. V. Snezhnevskii, et al, “Sostoianie psikhiatrii i ee zadachi v svete ucheniia I. P. Pavlova,” in Fiziologicheskoe uchenie akademika I. P. Pavlova v psikhiatrii i nevropatologii (Moscow: Medgiz, 1952), 37. The ban on lobotomy officially went into effect on December 9, 1950. “Prikaz MZ SSSR No. 1053,” ZhNiP 52, no. 1 (1952): 17–18; B. L. Lichterman, “On the History of Psychosurgery in Russia,” Acta Neurochirurgica 125 (1993): 3. I. M. Apter, “Vliianie elektrosudorozhnogo vozdeistviia na vysshuiu nervnuiu deiatel’nost’ sobak,” NiP 19, no. 4 (July–August 1951): 37. “Ot redaktsii,” ZhNiP 52, no. 3. (1952): 15; “O primenenii elektroshoka dlia lecheniia psikhicheskikh zabolevanii,” ZhNiP 52, no. 8 (1952): 71–73; Paul Calloway, Russian/Soviet and Western Psychiatry: A Contemporary Comparative Study (New York: John Wiley, 1993), 89–90. George Windholz, “Pavlov’s Concept of Schizophrenia as Related to the Theory of Higher Nervous Activity,” History of Psychiatry 4, no. 16 (December 1993): 511–526. GARF f. a-482, op. 50, d. 1131, l. 310. V. A. Giliarovskii, “Uchenie I. P. Pavlov – osnova psikhiatrii,” Meditsinskii rabotnik 37 (1950), in GARF f. r-8009, op. 2, d. 1498, l. 7. Snezhnevskii, et al, “Sostoianie psikhiatrii i ee zadachi v svete ucheniia I. P. Pavlova,” 37. See, for instance, TsAGM, f. r-389, op. 1, d. 94, ll. 73–74. TsAGM, f. r-389, op. 1, d. 94, ll. 11–12; Joseph Wortis, “A Psychiatric Study Tour of the U. S. S. R,” Journal of Mental Science 107 (January 1961): 125, 133, 147. Not all psychiatrists were happy about the declining use of insulin coma therapy. A 1960 report, for instance, objected to the widespread use of Aminazine, claiming that insulin gave longer and more substantial remission. GARF f. a-482, op. 50, d. 5188, l. 51. TsAGM, f. 533, op. 1, d. 81, l. 12. A. E. Lichko, Novoe v insulinoshokovom lechenii psikhozov (Leningrad: Meditsina, 1970); Paul Calloway, Russian/Soviet and Western Psychiatry: A Contemporary Comparative Study (New York: John Wiley, 1993), 90–91.

4 Soviet Psychiatry and Drug Addiction in Central Asia: The Construction of ‘Narcomania’ Alisher Latypov

Until recently, the majority of historical studies on the history of medicine in the Soviet Union have been focused on the Russian heartland and its metropolitan centres. In the words of Bernstein, Burton and Healey, these works aimed to explore the ‘internal colonization’ of ‘Slavic peoples’ by the highly interventionist Soviet regime and its drive to transform society. But the USSR encompassed a far larger area than that occupied by majority ethnic Russians, including territories in Central Asia which had a predominantly Islamic population with substantially different intellectual and medical traditions from that of the Russian Soviet elite. For revolutionary Soviet doctors, the Central Asian periphery manifested itself as a host of ‘backwardness’ and ‘primitive’ cultures and traditions. They made a primary contribution to the spread of diseases and blocked the way to a ‘bright’ and ‘healthy’ future. From the early years of Bolshevik rule, eradication of this entire ‘uncivilized’ way of life was seen as the most appropriate remedy. This chapter shows how this relationship between the Soviet ‘centre’ and the Asian ‘periphery’ played out in terms of psychiatric discourses on addiction and opium use, with the construction of the disease category of ‘narcomania’ – a synonym for drug addiction – as a regional problem, which in turn operated as a cypher for the broader cultural Sovietization project in the region. The place of a specialty for drug addiction treatment, or ‘narcology’ as it was specifically termed in Soviet medicine, was itself the object of a disciplinary turf war in the post-revolutionary period. Approaches from traditional psychiatry, which argued for the treatment of ‘narcomania’ in institutional settings, were increasingly challenged by social hygienists, who disputed the very category altogether. To the hygienists, such as Aleksandr Sholomovich, the editor of the journal Issues in Narcology, 73

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the focus should have been on social and economic reform to remove the non-biological causes of drug addiction and treatment in outpatient ‘narcodispensary’ facilities. He argued against psychiatrists’ use of the category of ‘narcomania’, preferring to use the term ‘narcotism’, suggesting that the notion of ‘mania’ invoked concepts of serious, endogenous psychotic illness that, he claimed, the majority of moderate drug users in the population did not experience. While the social hygiene campaign came to an abrupt halt in 1930, with clinical psychiatrists again coming to dominate the treatment of drug addiction, ‘narcomania’ also became the dominant term for drug addiction.1 Having won the battle for professional dominance in the Russian heartland, Soviet psychiatrists were keen to continue cooperating with the regime’s campaign against native Islamic medical practices in the Central Asian region as a means of further securing the position of their profession. To examine the perceived ‘backwardness’ of indigenous medical practitioners and the myth of tabib-induced narcomania, I will discuss the conceptualization of Islamic medicine and religious-spiritual healing, also showing that Central Asian indigenous practitioners were not necessarily unfamiliar with ‘western’ biomedicine. While their therapeutic approaches to habitual opiate use were often based on the same principles as those adopted in the ‘heartland’ by Soviet doctors, the latter also viewed Islamic medical practitioners as their chief competitors and called for their prohibition. Rare attempts by Soviet physicians to distance themselves from purely political rhetoric and to seriously examine the practice and sources of appeal of indigenous practitioners were discouraged and censured. As in contemporary post-Soviet Central Asia, factors such as access to material resources, rates of economic development and geographical location were at the heart of centre–periphery relationships in the early Soviet period. As Pauline Jones Luong and Alisher Ilkhamov demonstrate, the Soviet authorities constructed a triangular hierarchy with two centres and two peripheries. At the top of this structure was Moscow, whereas the capitals of individual union republics were both subordinate to the centre, and presided over the local regional (oblast) and district-level governments.2 Yet even in those regimes, where power was highly centralized, the ‘core’ did not seem to be in a position to completely subjugate the ‘periphery’, with regional peripheral elites engaging in complex, overt and covert negotiations over the shifting of power relationships.3 Whatever the balance of power, the core and the periphery have been mutually imbricated in an intricate fashion and should not be seen as isolated ‘bits’ but as ‘bundles of relationships’.4

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Furthermore, the differences between ‘internal’, lower level centres and peripheries within the region and individual republics often prove to be even more striking and illuminating in terms of our understanding of the nature of drug use and the diversity of responses. In the early decades of Soviet rule, Tashkent and Ashkhabad were the only two ‘focal points’ for the treatment of drug addiction in specialized psychiatric and narcological facilities, while remaining areas often lacked any capacities to address the issue. This lack of material and human resources urged Soviet doctors to make uneasy compromises and adopt alternative therapeutic strategies, which at times were more ‘culturally appropriate’, but were hardly ever effective. Some of these peripheries, like the Gorno-Badakhshan region of Tajikistan and the border districts of Turkmenistan and Kyrgyzstan, were considerably more disadvantaged due to their remote location, geographical isolation and proximity to the major sources of either domestically produced or imported opiates.

Twinned ‘evils’: Central Asian tabibs and ‘opium’ In the ‘Brief Historical Overview of Drug Addictions’, published in 1950 by the Central Asian Professor of Psychiatry A. K. Streliukhin, the author went as far as to assert that before the October revolution ‘the [Central Asian] population had to seek medical care from healers [whom Streliukhin collectively described by the Russian term “znakhari”], and healers treated all diseases with opium’.5 This statement was profoundly misleading, as neither did ‘healers’ become extinct after 1917, nor did the local population cease to resort to healers’ services. Contrary to the implication of Streliukhin’s statement, understandings of health and illness, as well as appropriate interventions, did not conform to a uniform ‘model’ in Central Asia. The twinning of opiates and ‘tabibism’ was an articulated strategy in the Bolshevik struggle to eliminate backward elements in Central Asian societies and it was mobilized in legal measures introduced to curb indigenous medical providers. ‘Tabibs and attors, native medical practitioners and apothecaries, were often guided by numerous Islamic medical texts that were available in many parts of the region’, with the city of Bukhara alone having about 26 bookshops throughout the second half of the nineteenth century.6 In line with medieval knowledge, medical literature circulating in Central Asia during the nineteenth and twentieth centuries distinguished the four humours (savdā – black bile, safrā – yellow bile, balgham – phlegm and khun – blood) in a similar vein to Galenic formulations. From this perspective, a person’s health depended on its state of equilibrium with

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relation to its environment, ‘with one dominant humour determining mizaj or mijaz, the temperament. Illness was thought to result from some excess or deficiency of humours in the body’.7 The extent to which this theoretical construct was brought into daily practice would require critical examination, although the principle of vitiation, deficiency and the centrality of purging in therapeutics can be judged from the fact that Central Asian people often resorted to tabib-performed bloodletting when they believed that they had ‘too much or bad blood which must be tapped off’, including bloodletting performed on the head when a patient would ‘feel in any way oppressed’.8 Tabibs and other local medical practitioners also used a wide range of minerals, plant, and animal materia medica to treat their patients, with some European authors mentioning over 200 items in the tabib’s repertoire.9 Although a substantial quantity of locally available ingredients were imported from Persia, India and Afghanistan, medical practitioners from Chinese Turkestan with knowledge of Chinese medical texts also seemed to have gained great trust and popularity among the native population. Equally, a religious-spiritual model for explaining human suffering, deeply rooted in Islamic and pre-Islamic beliefs, was widespread among both sedentary and nomadic populations of Central Asia. According to this model, diseases were caused by evil spirits and the so-called ‘evil eye’. Evil spirits were known by different terms including jinn, ajina, dev, shayton, pari and albasty.10 ‘Sufferings and misfortunes attributed to the harmful powers of spirits included disturbances of mind, which were widely documented as possessions by jinns’. Local people ‘also used the derivatives of the term jinn to designate madness (junun) and one who has gone mad (jinni)’. ‘Expelling jinns was a task performed by religious healers called ishans (Sufi guides), mullahs, as well as many other ethnospiritual practitioners common across Central Asia, including baqsys or bakhshis (shamans), and folbins (fortune-tellers)’.11 Fortune telling, reciting prayers to counter the influence of the evil eye and to expel the malevolent spirits and the treatment of human and animal diseases were naturally considered the best occupations for coming across many people and collecting intelligence. It is hardly surprising, therefore, that both the Russian and British empires were often willing to recruit local Asian people possessing the above skills to spy upon each other and gather data in

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territories affected by the ‘Great Game’ conflicts for imperial dominance in Central Asia.12 The absence of the ‘dichotomy between “mind” and “body”, along with the widespread presence of both Islamic medical and religiousspiritual illness explanations’, implied ‘that tabibs, ishans, folbins and other practitioners were complementary to each other’.13 By the beginning of the twentieth century, ‘Russian imperial physicians actively sought to outlaw their competitors’, portraying them as ‘backward’, ‘irrational’, ‘uncleanly’, ‘deceitful’ and ‘harmful’.14 Yet, as Dr Shvarts wrote in his ‘letter from abroad’ sent to the prominent weekly newspaper Russkii Vrach and published in 1909, ‘despite nearly half a century of efforts by colonial physicians, the “natives” still preferred tabibs’ and other healers. He further concluded that ‘in terms of “domains regained by the science”, the achievements of colonial medicine were negligible compared to what remained to be done’.15 Throughout much of the first decade of Bolshevik rule in Central Asia indigenous medical practitioners were able to practice without serious interference from the local health authorities. Although senior public health officials of Soviet Turkestan had already begun to call for ‘the most decisive steps to counter the tabibs’ in 1921, a large number of indigenous healers openly approached the state with requests to recognize their legitimacy.16 The Uzbek SSR’s Commissariat for Public Health (Narkomzdrav) also received applications from Afghan, Chinese and Indian practitioners to affirm their status as officially certified doctors.17 In 1926, the Council of People’s Commissars (Sovnarkom) passed a new resolution banning the provision of medical treatment by any unlicensed individual and effectively outlawing indigenous practitioners without biomedical training. One year later, this move was intensified by the Uzbek Narkomzdrav’s initiative to deploy ‘anti-tabib measures’ in the country (which at that time also included the Tajik Autonomous SSR as one of its constituent parts).18 In 1928, the Kazakh Regional Committee of the Communist Party followed suit and instructed the Kazakh Narkomzdrav to develop, ‘massive agitation and propaganda, and generally [to] strengthen[ing] the struggle against the influence of mullahs, tabibs, and baqsys…’.19 The fact that the Soviet public health organs had not approved any of their earlier applications for certification did not prevent many tabibs from adapting to the new bureaucratic challenges and continuing to approach the State as supplicants requesting official recognition. In 1928, the Uzbek SSR Narkomzdrav admitted that it had received ‘a whole pile of statements from tabibs requesting official permission to practice

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medicine’.20 The unwillingness of the State to license tabibs certainly did not deter local people from seeking the ministration of tabibs and other indigenous healers, who remained widespread in both villages and urban settings. In Tajikistan, where the Soviet biomedical project only got off the ground by the mid-1920s due to the persistent military resistance of the Basmachi, indigenous healers often functioned as the only providers of medical care in many parts of the country. In the 1920s, Central Asian tabibs were still able to receive supplies of materia medica from Persia, India and Afghanistan. A very small number of plants were also delivered from China and Turkey. While many diseases were treated by these ‘traditional’ imports and medicines, tabibs and attors also made use of medical products sold by the Soviet state [bio]medical trade organization, Gosmedtorg. They readily utilized quinine manufactured by British companies, as well as aspirin, phenacetin, salol (phenyl salicylate), salvarsan and laxatives from France and Germany.21 Many of these ‘western’ products seem to have reached Soviet Central Asia through India and Persia and were accommodated into ‘traditional’ medicine of the ‘natives’ as such. Yet, as formulated by Attewell, the encounter of tabibs with Western medicine was not just about the ‘accommodation’ of certain medical practices and pharmacopoeia, and in many instances could have included a more complex process of the ‘reworking of knowledge’.22 As the struggle of Soviet authorities against what was then called ‘tabibism’ intensified, the 1926 Criminal Code of the Uzbek SSR was amended in April 1929 to include a new article 2551, penalizing individuals who practiced medicine (vrachevanie) as a profession without receiving appropriately certified [bio]medical education, by up to one year of compulsory labour or a fine of up to 1000 roubles. Uzbek legislation also covered Tajikistan until 1935, when the Criminal Code of the Tajik SSR was introduced. Article 230 of the Tajik Criminal Code specifically referred to ‘tabib’ to give a clear message on the intended meaning of the above formulation in the Uzbek Criminal Code, subjecting tabibs to up to one year of ‘correctional-labour works’ or a fine of up to 500 roubles.23 As Cavanaugh has shown, analysis of the Uzbek state press suggests that calls for the arrest of tabibs and other indigenous healers became more frequent after 1929, although ‘available sources do not reveal whether or not many tabibs were in fact arrested during this period’ in the Uzbek SSR.24 Nonetheless, there were instances when their children were discriminated against on the grounds of their social origin.25 In Tajikistan, when by late 1929 the time was ripe to ensure the ‘purity’ of the Communist Party, engaging in tabibism served as a filter

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to purge some of the members from its ranks.26 It is clear, though, that tabibs and other healers continued to treat their patients throughout the Soviet era, with local newspapers in Tajikistan occasionally publishing stories exposing non-biomedical practitioners as ‘parasites’, greedy and venal ‘exploiters’, ‘charlatans’ and, ultimately, ‘murderers’.27 As many contemporary authors have noted, it was common for Central Asian tabibs and attors to possess opium and other potent substances. Such substances were often wrapped in paper or fabric, placed in jars or other special containers, and stored in their stalls, on the shelves and inside the boxes at their houses, or directly on top or underneath the blankets on which they sat and greeted their clients. This was normal practice for indigenous healers and they did not need any special regulations on the sale and storage of narcotic drugs. In the 1920s, the Soviet state made these above practices illegal.28 The ‘marriage’ of the two outlaws, the tabibs and the mishandled ‘opium’, arranged by the Bolsheviks, was thus one of the instances of the ultimate demonization of indigenous medical practitioners, who could then be given any label and blamed for virtually everything, with ‘narcomania’ being a very natural choice.29 However, this does not mean at all that biomedicine had not been implicated in the rise of opiate addiction in early Soviet territories. Despite all the warnings about the addictive nature of opiates and repeated calls for very strict control of the use of narcotic substances in medical practice, heroin was still prescribed on a long term-basis for cases of pulmonary tuberculosis, and the so-called ‘Inozemtsevy Kapli’ (drops containing opium and ether) were freely available in Soviet pharmacies to anyone who wished to purchase them as late as 1936.30 As described in detail by Shebalin and Bakhtiiarov, therapeutic use of opium by Soviet physicians was very broad, often far outstripping the below-cited examples of administration of opiates by the tabibs, and at least as common as was warranted by some Islamic medical treatises.31 Moreover, as several archival reports from Tajikistan show, it was not uncommon for the Tajik Narkomzdrav inspectors to discover that in some newly established Soviet medical facilities narcotic drugs were stored together with all other medicines, whereas the amounts of narcotics dispensed to patients were measured by eye (‘na glazok’).32 Thus, in 1943 and between 1954 and 1956, N. N. Ershov was involved in ethnographic research in Karategin and Darvaz, where he had a chance to meet Ishoni Maleh-tabib, who died in 1958 and whose fame reached far beyond his native village of Askalon in Garm district. Ishoni Maleh-tabib was both a religious-spiritual leader and a healer, who

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received his education in the madrasahs of Bukhara. Among the subjects taught at some of these madrasahs was the science of tibb (ilmi tibb). Ishoni Maleh-tabib practiced tibb and used a wide range of locally available plants to heal his patients. He believed that any medicine could act as a poison if administered without its appropriate corrector (‘har doru be muslihash zahr ast’) and paid particular attention to patients’ diet as part of the course of treatment.33 Like many other tabibs, in addition to a great number of other plants and animal products, Ishoni Maleh-tabib also used opiates. However, opiates were administered for a very limited array of conditions and only when this was not otherwise contraindicated.34 In Karategin, Ishoni Maleh-tabib and other healers used the roots of field poppy (Papaver rhoeas L.) to prepare a decoction which was taken orally by patients with gastro-intestinal complaints. It was also prescribed to children suffering from measles. A syrup made from dried poppy capsules, sugar and water was known as sharbati kuknor and was used as a cough suppressant and for the treatment of diarrhoea and running colds.35 Other available sources on tabibs, their medical practice and materia medica in pre-Soviet Central Asia similarly suggest that opiates were used primarily to treat measles, as an antidote against the poison of venomous snakes and insects, as the best cure for diarrhoea and as a very effective painkiller and cough suppressant.36 Despite Streliukhin’s far-reaching claim (and similar unsubstantiated statements by prerevolutionary authors), there is little evidence in support of the adoption of a ‘one cure fits all diseases’ approach by the tabibs in Russian Central Asia, with ‘opium’ playing the role of such a panacea in tabibs’ medical practice. On the contrary, available sources point to a moderate and even (in cases such as Badakhshan-based Sho-Zoda Muhammadtabib’s and Ishoni Maleh’s) very minor use of opiates by indigenous healers, many of whom seem to have been well aware of opiates’ actions on the human body. However, it is the question of whether and how the tabibs treated the opiate addiction that is probably one of the most intriguing ones. This is especially so because of the numerous statements made by the Central Asian narcologists about Ibn Sina (Avicenna), the author of al-Qanun fi al-Tibb and perhaps the most esteemed Islamic scholar of tibb, and his knowledge of and success in dealing with this issue already at the turn of the tenth and eleventh centuries AD. According to these accounts, Ibn Sina was able to recognize opiate withdrawal symptoms and to rid the unwitting Emir of Bukhara of his addiction by gradually lowering the dose of ‘opium’. This method of treatment was surely

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widely known in Central Asia in the early twentieth century, not only among the tabibs, but also among the common people. According to Kushelevsky, anyone who was willing to give up the consumption of kuknar could do that only by lowering, day by day, the amount of kuknar.37 Although local tabibs from Fergana believed that the success rate of such treatment was very low, one of the ‘folk’ methods of drug dependence treatment in Turkmenistan was based on the same principle.38 The implications of the widespread knowledge of this method among the local population of Central Asia would be rather clear. There was no need for the tabib’s involvement in it and this was very likely one of the main reasons behind the extremely limited number of available sources that provide the details of treatment of opiate addiction by the tabibs in early Soviet Central Asia. By the same token, qurut (dried and salted sour milk cheese balls) was recommended by both tabibs and ordinary people for alleviation of intoxication with narcotic drugs.39 There was even a ‘folk’ way to fill the gap in what one Russian doctor termed an ‘insufficient willpower to quit drugs on their own’, which implied visiting sacred places and wearing amulets.40 However, there were many other ways of treating addiction or alleviating its health consequences that were known to indigenous healers. In pre-Soviet Central Asia, it was quite common for tabibs to travel to different places to establish themselves as medical practitioners and to learn from each other. There is a record of one such travelling hakim from Kashgar gaining reputation in Bukhara in the first half of the nineteenth century for ‘curing opium eating’ in three days. This process was witnessed and documented by another traveller and well-known European homoeopath John Martin Honigberger. As he believed, on the first day of treatment this hakim from Chinese Turkestan administered only China Root (smilax china), which he mixed with water; on the second day, he gave cortex radicis daturae stramonii with sugar; on the last day of treatment a strong purgative based on semen crotonis tiglii was prescribed and followed by a decoction of liquorice root. The course was expected to remove the cravings and produce an aversion to opium.41 By the early twentieth century, when another European traveller to Central Asia, Ole Olufsen, wrote that the native medical practitioners and apothecaries had as much morphine ‘as one likes’ at their market stalls, the tabibs’ views on both the mechanisms of actions of opiates and the administration of opiates in the course of drug treatment might have undergone substantial transformation.42 The other important source of tabibs’ knowledge was the locus classicus, Risālah-i afyun or Afyuniyah, a Persian manuscript on opium

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evidently widely circulated among literate elites. It was written by the famous Persian physician ‘Imād al-Din Shirāzi in the sixteenth century and described different methods for treating opiate addiction.43 In his treatise, consisting of 14 chapters, Shirāzi argued that ‘because it took a long time to become addicted … it stands to reason that it should also take time to wean oneself off opium’.44 According to Matthee and Elgood, among the methods which Shirāzi had proposed on the basis of this principle were the following: One could either postpone taking opium by an hour each time until one had not taken it for a period of four days without feeling nervous. Because acute sickness tends to last four days, this was a sign of being cured of the addiction. A second way of ending the addiction was by lowering the amount of opium. One could do this by taking the same amount while making sure the opium was moist, thus containing a great deal of harmless weight. Or one could lower the weight. If the result would be that one didn’t feel well, however, it would be advisable not to lower it any further, until one got used to the new amount, after which lowering it further would be in order … Another way of achieving the same result was to replace opium gradually by the husk of the poppy.45 … ‘Imād-al Din’s third method was to replace the opium by another less harmful drug, such as China Root. This brings him to the question of whether alcohol can be used as a substitute. Although he admits that in some cases it may be efficacious, on the whole he does not approve of such a trial.46 In spite of the evidently limited use of opium by tabibs, this did not prevent the mythology of tabib-induced ‘narcomania’ becoming firmly entrenched. Although some of its roots can be traced back to the preSoviet era of tsarist colonization, early, late and post-Soviet authors usually deployed this myth in two ways: to emphasize how ‘ignorant’ indigenous medicine was before the Bolshevik revolution, and to explain the continued misuse of opium in Soviet times.47 However, early Soviet medical literature on drug treatment in Central Asia points to entirely different connections between seeking biomedical treatment for ‘narcomania’, patients’ motives for initiating opiate use and the groups of populations among whom drug addiction had been ‘spreading’.

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Before the late 1920s, there were only a few articles on narcotic drugs written by physicians from Central Asia. As more publications began to come out following the establishment of specialized drug treatment facilities in the Uzbek and Turkmen SSRs, some of them contained information on the native patients and occasionally provided their case histories. While the number of these case histories was very small, receiving treatment from a tabib had hardly been given as an explanation for the onset of opium consumption. Indeed, according to these papers, many natives first used opium in order to suppress coughs, for diarrhoea, migraine, malarial and other fevers, and as an analgesic, but in all cited cases one did not seem to need a tabib to tell him or her about medicinal use of raw opium, with no additional ingredients. Such usage of opium was commonly known in pre-Soviet and Soviet Central Asia, with some people self-treating, and others relying on the advice and assistance of their families and acquaintances.48

Opiate addiction and the biomedical connection Self-treatment and the presence of a ‘medical connection’ were indeed among the key explanatory factors behind opiate use in the early years of the Soviet Union. Yet the connection that emerges from available sources is a ‘biomedical’ one, to which indigenous healers did not make any direct contribution. In 1930, when the first description of 162 opium addicts attending an out-patient neuro-psychiatric dispensary in Tashkent between July 1927 and January 1929 was published in Vrachebnaia Gazeta, 10 of them were classified as biomedical workers. A much larger group of 34 (21.1 per cent) patients reported that their ‘narcotization’ was a result of having undergone a surgical operation or that it occurred ‘after an illness’ or after using opiates ‘as a method of treatment as advised by acquaintances’, with the author of this study criticizing biomedical doctors for their inconsiderate prescription of morphia.49 One year later Kondratchenko and Ioffer published another report which dealt with a group of 134 opium addicts receiving in-patient narcological care in Tashkent between May 18, 1929 and January 1, 1931. In this sample, none of the 34 Uzbek patients had a job in the medical profession, whereas 15 of the 93 ‘Europeans’ were described as biomedical workers.50 Unlike in Tashkent, publications on drug addiction in Soviet Russia became available much earlier. Here too, the majority of papers emphasized the significant role of biomedical professionals in ‘spreading narcomania’ in various ways. In one of the earliest works, written in 1921,

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its author, doctor M. P. Kutanin, estimated that as much as 20 per cent of his drug-addicted patients were medical workers, with many of the rest ‘commencing’ their ‘intoxications’ following injudicious advice from physicians and nurses.51 In the late 1920s, several Leningrad-based authors looked into the professional activities and drug experiences of their patients. The patterns that they were able to identify from available medical records were comparable to the situation in Moscow, reported in 1925 by Mark Sereisky. In 1928, V. A. Gorovoi-Shaltan analyzed data on 42 ‘morphinists’ treated in a clinic for mental illnesses (klinika dushevnykh boleznei) of the Military Medical Academy between 1919 and 1922 and concluded that ‘victims of morphinism’ originated primarily from the medical and military circles.52 One study that originated from Samara in 1931 painted a similar picture. Following the opening of a neuro-psychiatric dispensary in the city in May 1929 and until October 1, 1930, the staff of the dispensary were in contact with 75 ‘narcomans’, of whom 61 were addicted to opiates. Here, 12 of the 75 ‘narcomans’ were medical workers, whereas 27 people reported receiving their first ever injection of narcotic drugs in hospitals and with the assistance of medical workers.53 In another group of 29 patients with opiate addiction, who were treated in Sverdlovsk between 1929 and 1932, 41.4 percent were medical workers and 31 percent became ‘morphinists’ after incautious prescriptions by physicians.54 Finally, in addition to these studies, which elucidated the nexus between biomedicine and opiate addiction in the 1920s and 1930s on the basis of samples of in- and out-patients, many other papers contained some statistical data on opiate addiction and isolated medical case histories with references to the ‘biomedical connection’.55 Against the backdrop of these contexts and realities, one may even suggest that overemphasizing the significance of the supposedly tabib-induced drug addiction also served the purpose of disguising the role of early Soviet biomedicine in turning some patients into opiate addicts.

Gathering data on opiate use in Soviet dominions The number of specialized drug treatment institutions was extremely limited in the early Soviet Union. In Central Asia, as mentioned above, only Uzbekistan and Turkmenistan had dedicated narcological facilities in their capitals, while Tajikistan’s first psychiatric hospital became operational only in 1941. In some cases, doctors also travelled to non-medical settings to assess the levels of drug addiction in societal

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contexts. Psychiatrists from the psychoneurological dispensary went to the Tashkent-based shoe factory named after Faizulla Khodzhaev to examine 300 workers, and found that only three of them were opium eaters.56 Yet none of the workers of this industrial institution seemed to have a need to visit a psychiatrist or narcologist to discontinue their drug use. Others had been able to relinquish drugs without any medical assistance from either tabibs or psychiatrists. As one medical history from the shoe factory showed, a worker with a three-year history of smoking marijuana and opium succeeded in giving up drug use after having befriended a Komsomol member, ‘thanks to whom he became an active worker’ and instead got ‘high’ on the Party and public life (‘uvleksia partiinoi i obschestvennoi zhizn’iu’). This and other similar accounts led the authors to conclude that the influence of the ‘collective body’ (‘kollektiv’) alone was sufficient in enabling workers to ‘forget’ marijuana and opium.57 Since publications on drug treatment came only from Tashkent and Ashkhabad, they did not provide any insight into drug use and users in other republics. Their value was limited also in terms of drawing the patterns of drug consumption within Uzbekistan and Turkmenistan, as they primarily dealt with the residents of these two capital cities and surrounding areas. Yet Kyrgyzstan was a site for major opium production, consumption and regional and cross-border trade, whereas the population of at least one region in Tajikistan had been most severely affected by opiate use in the 1920s and 1930s. Anzor Gabiani uses the term ‘ochagi’ (which is best translated into English as ‘hot spots’ or, in this particular case, as ‘the seats of narcotism’) for such ‘localized’ areas of ‘narcotism’ in Central Asia and the Caucasus in the 1920s–1960s, although without identifying them and, importantly, without describing the response of the Soviet authorities.58 Medical literature that originated from Tashkent and Ashkhabad is similarly silent on the latter issue, despite some of the hot spots, which in fact were far from ‘localized’, being located in Uzbekistan and Turkmenistan as well. In 1930, for example, Kondratchenko called Tashkent ‘a major ochag of narcotism’, but this conclusion at the same time exposed the limitations of his data, as it was reached exclusively on the basis of statistics showing that two thirds of all outpatients began to use opiates in Tashkent. Tashkent was the city where Kondratchenko’s neuropsychiatric dispensary was situated, and it is hard to imagine drug users visiting this facility on an out-patient basis and yet not living (and, in many cases, initiating drug use) in Tashkent.59 In Tajikistan, Soviet authorities tried different ‘administrative’ means of struggling against narcomania,

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but as these measures to ‘suppress’ the fire of drug addiction in a ‘hot spot’ failed, drug users were repressed and incarcerated in prisons and the Gulag camps.60 However, in the absence of relevant information in published medical literature of the 1920s and 1930s, the subject of opiate use in the Soviet Central Asian ‘hot spots’ other than Tashkent and Ashkhabad has until now remained almost entirely uncovered. The situation in Russia and other republics during the early Soviet decades was similar to that in Central Asia. According to L. A. Prozorov’s review paper on the availability and activities of neuropsychiatric facilities in 1929 and 1930, Ukraine had three neuropsychiatric dispensaries in Khar’kov, Dnepropetrovsk and Zhitomir, whereas Belorussia had only one, in the capital city of Minsk. Russia had the largest number with 23 psycho-neurological dispensaries, and nearly all of them were established in the late 1920s and located in large urban areas. With as few as 27 narcological dispensaries and ‘narco-points’ (‘narcopunkt’) operational by 1931, half of these narco-establishments were located in the Moskovskaia Industrial Oblast.61 At the same time, the majority of medical publications on opiate use in the 1920s and 1930s were centred on Moscow and Leningrad and several other big cities, offering readers very little, if any, information on what might have been happening in other areas all over Russia. For instance, one of the other major ‘hot spots’ of opiate consumption was located in the Russian Far East. Yet, as a result of the apparent lack of both specialized drug treatment institutions and medical literature on opiate use in that area, things looked misleadingly calm and quiet there until recent historical studies offered an alternative perspective, showing how drug addicts were forcibly transferred to the concentration colony on Russian Island in 1924 and abandoned one year later, when all available public funding ran out. Finally, given that opium was also known for its powerful hungersuppressing properties, the presence of the connection between opiates and famine in Central Asia and other Soviet regions in the 1920s and 1930s would seem almost inevitable. Yet, against the backdrop of numerous documents on the extent and dramatic consequences of famine, such references are almost completely lacking in medical literature on opiate use in the early Soviet Union. In the 1920s, in Turkmenistan, opiates ‘were used by shepherds who stayed at remote pastures in the mountains and by crop-collectors working in the cotton fields’ in order to adjust to the ‘difficult psychological situation’ and to increase their capabilities of sustaining hard work.62 In the early 1930s, when millions of people across Central Asia and other parts of the Soviet Union were starving to death, the role of opiates as a ‘comfort’ for both hunger and

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misery might have increased dramatically. One can argue that some of these people, who were fortunate to survive famine, would one day be seen as addicted patients in the office of the Soviet psychiatrist. By that time, however, official rhetoric would leave no place in Soviet society for either tabibs or drug addiction – both would soon be ostensibly ‘liquidated’ and then only occasionally referred to as ‘surviving traces’ of the ‘backward’ and ‘ignorant’ past.

Notes 1. For further discussion of the establishment of Soviet narcology see Alisher Latypov, ‘The Soviet Doctor and the Treatment of Drug Addiction: “A Difficult and Most Ungracious Task”’, Harm Reduction Journal 8 (2011): 32. doi:10.1186/1477-7517-8-32. 2. Pauline Jones Luong, ‘Introduction: Politics in the Periphery: Competing Views of Central Asian States and Societies’ and Alisher Ilkhamov, ‘The Limits of Centralization: Regional Challenges in Uzbekistan’ in The Transformation of Central Asia: States and Societies from Soviet Rule to Independence, ed. Pauline Jones Luong (Ithaca and London: Cornell University Press, 2004), 1–26, 159–181. 3. Ilkhamov, ‘The Limits of Centralization: Regional Challenges in Uzbekistan’, 159–181. 4. Georg Iggers and Q. Edward Wang with contributions from Supriya Mukherjee, A Global History of Modern Historiography (Harlow and New York: Pearson Longman, 2008), 284. 5. A. K. Streliukhin, ‘Kratkii Istoricheskii Obzor Narkomanii’, in Sbornik Trudov Stalinabadskogo Gosudarstvennogo Meditsinskogo Instituta, vol. V, ed. A. K. Streliukhin, S. L. Barkagan, S. F. Shirokov, and Z. S. Barkagan (Stalinabad: Stalinabad State Medical Institute, 1950), 327. 6. Alisher Latypov, ‘Healers and Psychiatrists: The Transformation of Mental Health Care in Tajikistan’, Transcultural Psychiatry 47, no. 3 (2010): 420. Kh. Khikmatullaev and S. Karimova, ed., Sobranie Vostochnykh Rukopisei Akademii Nauk Respubliki Uzbekistan: Meditsina (Tashkent: Izdatel’stvo Narodnogo Naslediia Imeni Abully Kadyri, 2000); Ol’ga Sukhareva, Bukhara, XIX-nachalo XX v: Pozdnefeodalnyi Gorod i Ego Naselenie (Moscow: Izdatel’stvo ‘Nauka’, 1966), 48. For a recent survey of Central Asian Islamic medical literature based on the Russian-language manuscript catalogues, see Devin DeWeese, ‘Muslim Medical Culture in Modern Central Asia: A Brief Note on Manuscript Sources from the Sixteenth to Twentieth Centuries’, Central Asian Survey 32, no. 1 (2013): 3–18. 7. Latypov, ‘Healers and Psychiatrists: The Transformation of Mental Health Care in Tajikistan’, 420. 8. Ole Olufsen, The Emir of Bokhara and His Country: Journeys and Studies in Bokhara (London: William Heinemann, 1911), 448. 9. V. I. Kushelevsky, Materialy dlia Meditsinskoi Geografii i Sanitarnogo Opisaniia Ferganskoi Oblasti, Vol. III (Novyi Margelan: Izdanie Ferganskogo Oblastnogo Statisticheskago Komiteta, 1891), 245–259; G. A. Kolosov, ‘O Narodnom

88

10. 11. 12.

13. 14.

15.

16. 17.

Alisher Latypov Vrachevanii u Sartov i Kirgizov Turkestana’, Trudy Antropologicheskogo Obschestva pri Imperatorskoi Voenno-Meditsinskoi Akademii 6 (1903): 67–77; E. Tashmukhamedov, ‘Nekotorye Svedeniia o Sostoianii Lekarstvennoi Pomoschi na Territorii Nyneshnei Uzbekskoi SSR do Velikoi Oktiabr’skoi Sotsialisticheskoi Revoliutsii’, Aptechnoe Delo 7, no. 4 (1958): 69–72. In the brief overview of plant, animal and mineral materia medica used by indigenous medical practitioners in Turkestan, A. F. Gammerman mentions the total number of 373 non-identical samples in the collections of the Museum of the Chief Botanical Garden of Leningrad. Overall, these collections consist of 800 items gathered and received on eight individual occasions between 1881 and 1926. See A. F. Gammerman, ‘Kratkii Ocherk Lekarstvennogo Syr’ia, Upotrebliaemogo v Turkestanskoi Narodnoi Meditsine’, in Trudy Vserossiiskogo Farmatsevticheskogo Soveschaniia, 25.IX–1.X 1926, ed. I. Levinshtein and M. Khaimovich (Moscow: Izdatel’stvo Narkomzdrava RSFSR, 1927), 210–211. Latypov, ‘Healers and Psychiatrists: The Transformation of Mental Health Care in Tajikistan’, 420. For a more detailed discussion of healing and psychiatry in Russian Central Asia and Tajikistan see Ibid., 419–451. Dmitrii Arapov, ‘“Vy Posylaetes’ v Strany, Kotoruiu My Malo Znaem”: Razvedyvatel’naia “Programma” Russkogo Konsula v Kashgare N. F. Petrovskogo’, Istochnik 6 (2002): 52–56; L. I. Sumarokov, ‘Kontrabanda Narkotikov na Iugo-Vostochnykh Granitsakh Rossiiskoi Imperii v Kontse XIX – Nachale XX vv.’, in Afganistan i Bezopasnost’ Tsentral’noi Azii, vol. III, ed. A. A. Kniazev (Bishkek and Dushanbe: Obschestvennyi Fond Aleksandra Kniazeva, 2006), 301. For a detailed discussion of a similar function of recruiting local medical practitioners in British India see Christopher Bayly, Empire and Information: Intelligence Gathering and Social Communication in India, 1780– 1870 (Cambridge: Cambridge University Press, 1996). Latypov, ‘Healers and Psychiatrists: The Transformation of Mental Health Care in Tajikistan’, 423. Ibid., 425. For a detailed discussion of the position of Russian medical professionals towards indigenous healers in pre-Soviet, Russian Central Asia, see Cassandra Marie Cavanaugh, ‘Backwardness and Biology: Medicine and Power in Russian and Soviet Central Asia, 1868–1934’ (PhD dissertation, Columbia University, 2001), 67–79. A. Shvarts, ‘Meditsinskaia Pomosch’ Tuzemnomy Naseleniiu gor. Tashkenta’, Russkii Vrach 8, no. 27 (1909): 923–928. Latypov, ‘Healers and Psychiatrists: The Transformation of Mental Health Care in Tajikistan’, 425. Cavanaugh, ‘Backwardness and Biology: Medicine and Power in Russian and Soviet Central Asia, 1868–1934’, 130. A. A. Kadyrov provides interesting details on one Afghan tabib named Atoullo, who moved to Samarqand from Afghanistan in the end of the nineteenth century and remained in Uzbekistan until his death. Atoullo tabib spoke many languages, including Arabic, Persian, Uzbek and Russian, and was familiar with both western biomedicine and a wide range of nonbiomedical treatment and diagnostic methods. See A. A. Kadyrov, Istoriia

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18. 19. 20. 21.

22. 23.

24. 25. 26. 27.

28.

29.

Meditsiny Uzbekistana (Tashkent: Izdatel’sko-Poligraficheskoe Ob’edinenie Imeni Ibn Siny, 1994), 137. Cavanaugh, ‘Backwardness and Biology: Medicine and Power in Russian and Soviet Central Asia, 1868–1934’, 234–237. Paula Michaels, Curative Powers: Medicine and Empire in Stalin’s Central Asia (Pittsburgh, PA: University of Pittsburgh Press, 2003), 53. Cavanaugh, ‘Backwardness and Biology: Medicine and Power in Russian and Soviet Central Asia, 1868–1934’, 235–236. Gammerman, ‘Kratkii Ocherk Lekarstvennogo Syr’ia, Upotrebliaemogo v Turkestanskoi Narodnoi Meditsine’, 216–217; N. I. Vavilov and D. D. Bukinich, Zemledel’cheskii Afganistan (Leningrad: Izdanie Vsesoiuznogo Instituta Prikladnoi Botaniki i Novykh Kul’tur pri SNK SSSR i Gosudarstvennogo Instituta Opytnoi Agronomii NKZ RSFSR, 1929), 473–477; I. K. Seiful’muliukov, ‘K Voprosy o Tabibizme v Uzbekistane’, Meditsinskaia Mysl’ Uzbekistana 9–10 (1928): 70. Guy Attewell, Refiguring Unani Tibb: Plural Healing in Late Colonial India (New Delhi: Oriental Longman Private Limited, 2007), 28. D. S. Karev, ed., Ugolovnoe Zakonodatel’stvo SSSR i Soiuznykh Respublic. Sbornik (Osnovnye Zakonodatel’nye Akty) (Moscow: Gosudarstvennoe Izdatel’stvo Iuridicheskoi Literatury, 1957), 214, 346. Cavanaugh, ‘Backwardness and Biology: Medicine and Power in Russian and Soviet Central Asia, 1868–1934’, 363. Ibid. The Russian State Archive of Social and Political History [RGASPI], f. 62, op. 2, ch. II, d. 2308, ll. 48, 51, 52. A. Rasi-zade and M. Pesterev, ‘Sharlatany i Ikh Zhertvy’, Kommunist Tadzhikistana, October 19, 1958; I. Mirzokulov, ‘“Slugi Allaha” i Ikh Dela’, Leninabadskaia Pravda, July 5, 1959; O. Mukhiddinova, ‘Im Verit’ Nel’zia’, Leninabadskaia Pravda, February 21, 1960; M. Okhremets, ‘Konets Tainoi Kreposti’, Komsomolets Tadzhikistana, September 8, 1963. These newspaper articles were surely not the only sources that discussed the issue of indigenous healers in Soviet Central Asia between the 1950s and mid-1980s. After that, during the glasnost’ period, a great number of articles appeared not only in the local but also in the central press, revealing the significant role that these practitioners had been playing in the region as well as the great demand for their services, with patients coming from all over the union republics. See Alisher Latypov, ‘Central Asian Tabibs in Post-Soviet Archives: Healing, Spying, Struggling, and “Exploiting”’, Wellcome History 43 (2010): 8–9. See, for example, I. E. Nekliudov, ‘Doklad Organizatsionnogo Komiteta Obschestva Bor’by s Alkogolizmom i Opiokureniem v TSSR’, in Trudy Pervogo Vseturkmenskogo S’ezda Zdravotdelov i Raionnykh Vrachei, 8–18 Noiabria 1928 g., ed. I. V. Ventsenostsev, S. M. Geoklenov, V. A. Kolokolov, P. G. Kopytko, M. A. Miuller, A. S. Raevsky, S. P. Reikhel’, E. M. Samarina, and V. M. Iushtin (Ashkhabad: Izdanie Narodnogo Komissariata Zdravookhraneniia TSSR, 1929), 212–219. It is worth noting that in the pre-Soviet period, some Russian Imperial officials used the same tactics against the tabibs by avoiding references to the benefits of medicinal use of ‘opium’ and presenting it exclusively as a

90

30.

31.

32. 33.

34. 35. 36.

37.

38. 39.

40.

41.

Alisher Latypov ‘poisonous narcotic drug sold by the native medical practitioners at every corner and to any person’. On the late Soviet physicians’ unsuccessful attempt to exploit the ‘tabib-opium’ nexus in Tajikistan, see Sharif Khamdamov, ‘Pochemy by ne pouchit’sia u starogo lekaria?’ Literaturnaia Gazeta, October 26, 1988. N. V. Kantorovich, ‘Dispansernye Nabliudeniia nad Morfinistami’, Sovetskaia Psikhonevrologiia 12, no. 3 (1936): 71. If we are to trust I. V. Strel’chuk’s book on the treatment of narcomania, then ‘Inozemtsevy Kapli’, Dover’s powder and laudanum were all available to opiate users at least until 1956, when the third edition of his book was published. P. I. Shebalin, Opii. Ego Obrabotka i Dobyvanie v Dzhetysu (v Semirech’i) i v Kirgizstane (Rzhev: Izdanie Dzhetysuiskogo Gubplankoma i Dzhetysuiskogo Otdela Gosudarstvennogo Geograficheskogo Obschestva, 1927), 21; V. A. Bakhtiiarov, ‘K Voprosu o Narkomanii’, in Trudy Nauchno-Issledovatel’skikh Institutov Sverdlovskogo Oblzdravotdela, vol. VII, ed. K. A. Konovalov (Sverdlovsk: Sverdlovskoe Oblastnoe Gosudarstvennoe Izdatel’stvo, 1936), 201–202. The Central State Archive of the Republic of Tajikistan [TsGA RT], f. 172, op. 1, d. 57, l. 37; TsGA RT, f. 172, op. 1, d. 35, ll. 151–159. N. N. Ershov, ‘Narodnaia Meditsina Tadzhikov Karategina i Darvaza’, in Istoriia, Arkheologiia i Etnografiia Srednei Azii, ed. A. V. Vinogradov, M. G. Vorob’eva, T. A. Zhdanko, M. A. Itina, L. M. Levina, and Iu. A. Rapoport (Moscow: Nauka, 1968), 349–357; N. N. Ershov, ‘Narodnaia Meditsina’, in Tadzhiki Karategina i Darvaza, vol. II, ed. N. A. Kisliakova and A. K. Pisarchik (Dushanbe: Izdatel’stvo ‘Donish’, 1970), 258–272. N. N. Ershov and N. N. Kampantsev, ‘O Tabibskoi Meditsine na Pamire’, Biulleten’ Uzbekskogo Instituta Eksperimental’noi Meditsiny 14 (1939): 40–48. Ershov, ‘Narodnaia Meditsina’, 264–266. Kolosov, ‘O Narodnom Vrachevanii u Sartov i Kirgizov Turkestana’, 71, 77; Kushelevsky, Materialy dlia Meditsinskoi Geografii i Sanitarnogo Opisaniia Ferganskoi Oblasti, Vol. III, 248, 250. V. I. Kushelevsky, Materialy dlia Meditsinskoi Geografii i Sanitarnogo Opisaniia Ferganskoi Oblasti, Vol. II (Novyi Margelan: Izdanie Ferganskogo Oblastnogo Statisticheskago Komiteta, 1891), 445. N. Kerimi, ‘Opium Use in Turkmenistan: A Historical Perspective’, Addiction 95, no. 9 (2000): 1323. Ershov, ‘Narodnaia Meditsina’, 266; Sadriddin Aini, Vospominaniia, trans. Anna Rozenfel’d (Moscow and Leningrad: Izdatel’stvo Akademii Nauk SSSR, 1960), 227; Abdurrauf Fitrat, Den’ Strashnogo Suda. Rasskaz-Satira (Moscow: Izdatel’stvo Politicheskoi Literatury, 1965), 7. P. Ortenberg, ‘O Kuknaristakh Andizhanskogo Uezda’, Russkii Vrach 6, no. 25 (1907): 865; Kerimi, ‘Opium Use in Turkmenistan: A Historical Perspective’, 1323. John Martin Honigberger, Thirty-five Years in the East: Adventures, Discoveries, Experiments, and Historical Sketches, Relating to the Punjab and Cashmere; in Connection with Medicine, Botany, Pharmacy, etc., Together with an Original Materia Medica; and a Medical Vocabulary, in Four European and Five Eastern Languages, Vol. I (London: H. Baillière; Calcutta: R. C. Lepage & Co, 1852), 158–159. See also N. A. Khalfin, Zapiski o Bukharskom Khanstve (Otchety

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42. 43.

44. 45. 46.

47.

48.

49. 50. 51. 52.

53.

P. I. Demezona i I. V. Vitkevicha) (Moscow: Glavnaia Redaktsiia Vostochnoi Literatury Izdatel’stva ‘Nauka’, 1983), 23, where Peter Demezon reports that doctor Honigberger had arrived in Bukhara in January 1834. Olufsen, The Emir of Bokhara and His Country: Journeys and Studies in Bokhara, 521. Cyril Elgood, Safavid Medical Practice or The Practice of Medicine, Surgery and Gynaecology in Persia between 1500 A.D. and 1750 A.D. (London: Luzac and Company Limited, 1970), 45. Rudi Matthee, The Pursuit of Pleasure: Drugs and Stimulants in Iranian History, 1500–1900 (Princeton and Oxford: Princeton University Press, 2005), 112. Matthee, The Pursuit of Pleasure: Drugs and Stimulants in Iranian History, 1500–1900, 112. Elgood, Safavid Medical Practice or The Practice of Medicine, Surgery and Gynaecology in Persia between 1500 A.D. and 1750 A.D., 46. For a detailed list of ‘Imad al-Din Shirāzi’s extant works see C. A. Storey, Persian Literature: A Bio-Bibliographical Survey, Vol. II, Part II, E. Medicine (London: Luzac and Company, Ltd., 1971), 241–244. I. E. Nekliudov, ‘Doklad Organizatsionnogo Komiteta Obschestva Bor’by s Alkogolizmom i Opiokureniem v TSSR’, 214; E. V. Maslov, ‘Problema Narkomanii v Turkmenskoi SSR’, Sovetskoe Zdravookhranenie Turkmenii 2–3 (1939): 122; Anna Shikhmuradov, Rasprostrannenost’, Klinika, Lechenie i Profilaktika Narkomanii. Dlia Sluzhebnogo Pol’zovaniia (Ashkhabad, 1977), 33; M. G. Ikramova, Ugolovno-Pravovaia Bor’ba s Narkomaniei. Dlia Sluzhebnogo Pol’zovaniia (Tashkent: Izdatel’stvo ‘FAN’, 1982), 19; Iurii Kurbanov, Narkomaniia: Degradatsiia Lichnosti i Prestupnost’ (Voprosy Profilaktiki) (Dushanbe: ‘Irfon’, 1992), 9. A. E. Blankfel’d and N. I. Egorova, ‘Slozhnye Toksikomanii u Uzbekov’, Za Sotsialisticheskoe Zdravookhranenie Uzbekistana 5 (1932): 24–26; A. K. Streliukhin, ‘Osobennosti Techeniia Opiomanii u Beremennykh’, Sovetskoe Zdravookhranenie Turkmenii 1 (1939): 145–155; B. L. Smirnov, ‘K Probleme Terapii Reaktsii Abstinentsii u Opiomanov’, in Trudy Turkmenskogo Gosudarstvennogo Nauchno-Issledovatel’skogo Instituta Nevrologii i Fiziatrii, vol. I, ed. R. Ia. Malykin (Ashkhabad and Baku: Turkmengosizdat, 1936), 143–144; A. N. Kondratchenko, ‘Obsledovanie Gruppy Opiomanov’, Vrachebnaia Gazeta, no. 17–18, September 15–30, 1339–1346; A. N. Kondratchenko and Kh. Ioffe, ‘Opyt 1 ½ – Godichnoi Raboty Narkostatsionara Tashkentskogo Nevro-Psikhiatricheskogo Dispansera’, Zhurnal Nevropatologii i Psikhiatrii 6 (1931): 83–89. Kondratchenko, ‘Obsledovanie Gruppy Opiomanov’, 1341–1342. Kondratchenko and Ioffe, ‘Opyt 1 ½ – Godichnoi Raboty Narkostatsionara Tashkentskogo Nevro-Psikhiatricheskogo Dispansera’, 84–86. M. P. Kutanin, ‘Narkomaniia’, Saratovskii Vestnik Zdravookhraneniia 2, no. 5–8 (1921): 37–38. V. A. Gorovoi-Shaltan, ‘Morfinizm, Ego Rasprostranenie i Profilaktika’, Voprosy Narkologii, vol. II (Moscow: Izdanie Moszdravotdela, 1928), 47. See also Kantorovich, ‘Dispansernye Nabliudeniia nad Morfinistami’, 69–70. A. L. Kamaev, ‘Na Putiakh Bor’by s Narkomaniiami’, in Puti Sovetskoi Psikho-Nevrologii (Materialy 1-go Kraevogo S’ezda Psikhiatrov i Nevropatologov Srednevolzhskogo Kraia 5–11 Noiabria 1930g.), ed. A. L. Kamaev (Samara: Srednevolzhskii Kraizdrav, 1931), 80–81.

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54. Bakhtiiarov, ‘K Voprosu o Narkomanii’, 200–202. 55. A. S. Sholomovich, ‘Otchet o Dispansernoi Bor’be s Narkotizmom v Moskve’, in Voprosy Narkologii, vol. I, ed. A. S. Sholomovich (Moscow: Izdanie Moszdravotdela, 1926), 75–77; A. E. Blankfel’d, ‘K Voprosu o Lekarstvennoi Narkomanii’, Za Sotsialisticheskoe Zdravookhranenie Uzbekistana 4–5 (1933): 137–139; I. V. Strel’chuk, ‘K Voprosu o Lechenii Morfiinoi Abstinentsii’, in Problemy Narkologii, ed. A. M. Rapoport (Moscow and Leningrad: Gosudarstvennoe Meditsinskoe Izdatel’stvo, 1934), 57; see also Kamaev, ‘Na Putiakh Bor’by s Narkomaniiami’, 72–79 (reports from selected narcological facilities submitted in response to Kamaev’s request) and Mary Schaeffer Conroy, ‘Abuse of Drugs other than Alcohol and Tobacco in the Soviet Union’, Soviet Studies 42, no. 3 (1990): 454 (case studies provided by G. N. Udal’tsov in 1926). 56. Kh. Ia. Ioffe and N. S. Diveeva, ‘Opyt Psikhogigienichiskoi Raboty na Obuvnoi Fabrike im. Faizully Khodzhaeva – g. Tashkent’, Za Sotsialisticheskoe Zdravookhranenie Uzbekistana 1–2 (1934): 117–122. 57. Ioffe and Diveeva, ‘Opyt Psikhogigienichiskoi Raboty na Obuvnoi Fabrike im. Faizully Khodzhaeva – g. Tashkent’, 120. 58. A. A. Gabiani, Na Kraiu Propasti: Narkomaniia i Narkomany (Moscow: Mysl’, 1990), 7. 59. Kondratchenko, ‘Obsledovanie Gruppy Opiomanov’, 1341. 60. For a detailed account of the Soviet ‘opium war’ in Tajikistan, see Alisher Latypov, ‘The Opium War at the “Roof of the World”: The Elimination of Addiction in Soviet Badakhshan’, Central Asian Survey 32, no. 1 (2013): 19–36. 61. L. A. Prozorov, ‘Nevro-Psikhiatricheskie Dispansery i Nevro-Psikhiatricheskie Otdeleniia Dispansernykh Ob’edinenii v 1929/1930g.’, Zhurnal Nevropatologii i Psikhiatrii 6 (1931): 73–83. 62. Kerimi, ‘Opium Use in Turkmenistan: A Historical Perspective’, 1323.

5 Psychiatry and Ideology: The Emergence of ‘Asthenic Neurosis’ in Communist Romania Corina Doboş

Some 30 years later after he left Romania, the psychiatrist Ion Vianu recalled that during his practice there he dealt with numerous patients suffering of ‘neurasthenia’ or ‘asthenic neurosis’. They were ‘exhausted, suffering of sleep disturbances, severe headaches, pains in the limbs and digestive disorders, complaining of a “pellicle on the brain”, or a “mist in the brain”’.1 Vianu remembers that neurasthenia was rather a regional disease affecting the populations of Eastern Europe,2 relatively unknown to his colleagues from Western Europe. As soon as a country entered the Soviet sphere of influence, its population was suddenly and largely affected by neurasthenia, he continued metaphorically.3 ‘Neurasthenia perfectly described the experience of individuals living under state socialism, […] Eastern Europe being transformed in a huge hospice of neurasthenic patients.’4 Vianu is a Romanian psychiatrist and political dissident, who emigrated to Switzerland in 1977 and brought to public attention the abuses of political psychiatry in Communist Romania.5 Vianu’s recollections reflect his critical perspective of the Communist regime in Romania in the 1970s, but ‘neurasthenia’ proved to be more than simple metaphor. An epidemiological study carried out in Bucharest in 1974 shows that ‘neuroses’ represent the most frequent mental disease (between 35 per cent and 38 per cent of those who suffer of a classifiable mental disease or syndrome, in accordance with the ICD-8 system).6 Another study published the same year concludes that ‘neurasthenia’ is the most frequent type (75 per cent of the cases) of mental disease, but that the ‘major mental diseases are relatively rare’.7 In 1967, a physician working in a military hospital in Bucharest acknowledged that ‘lately, asthenic neurosis has become more and more frequent, being treated both in ambulatory and in-hospital’.8 93

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Neurasthenia had a special destiny in postwar Communist societies, being ‘such a popular diagnostic label in “former countries”: the Soviet Union, Yugoslavia, Czechoslovakia’,9 used both by specialists and the larger public.10 In Communist China, the success of neurasthenia was determined by its integration ‘into the epistemological theory of disease causation in the traditional Chinese medical system’.11 Relabelled, reinterpreted, re-systematized, re-organized; neurasthenia became in the postwar years a disease of the Communist world. This chapter deals with the emergence of the ‘asthenic neurosis’ (the local version of neurasthenia) as a major preoccupation of psychiatrists and neurologists in Communist Romania. They undertook significant research, and advanced original explanations of disease aetiology, symptomatology and features. My study reveals how the ideological constraints of the day were innovatively reconfigured into psychiatric knowledge, able to comply not only with political requests but also with the growing needs of a rapidly modernizing society.12 This study also reflects upon main features of the psychiatric discipline in Communist Romania, and ‘asthenic neurosis’ proved to be a useful topic, both methodologically and stylistically, for obtaining some historical perspective on the subject. The historiographical accounts produced before 1989 generally offer triumphal descriptions of the discipline’s progress, consistent with the general ideological ethos of the epoch. These studies were usually written in a whiggish perspective by physicians who assumed the task of writing the history of medicine, and focus on personalities and institutional developments, using a powerfully ideologized language.13 Most studies on psychiatry in Communist Romania written after 1989 deal with the instrumental use of psychiatry for political purposes, and tend to give the impression that the entire psychiatric discipline in Romania existed just for, and because of, its punitive function.14 In recent years, more nuanced accounts of the psychotherapeutic practice in Communist Romania have been given.15 My research contributes to this line of inquiry, showing how the political and ideological conditions of medical knowledge production were used by medical professionals for the expansion of their profession in Communist Romania. The primary sources of my study have been limited to articles and clinical studies mainly produced in two of most important centres for psychiatric research of the country: the Institute of Neurology of the Academy of the Romanian People’s Republic, and the country’s largest facility for mental and nervous diseases, the unified Hospital no. 9, Bucharest: two centres which offered significant research facilities and

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opportunities of professional advancement. Their selection was made because of the volume of scientific research dedicated to asthenic neurosis produced in these centres, and because of their institutional proximity to the circles of political decision and ideological control.

Setting the scene: the ‘Pavlovian Turn’ in Romanian psychiatry My research focuses mainly on the period 1955–1961, as the most active phase in the emergence of this nosological entity in Communist Romania. Years before the introduction of neurasthenia in ICD-8 (1965), ‘asthenic neurosis’ was discussed at length at the first postwar national conference of psychiatry (1955), and consecrated as an autonomous nosological entity in 1961, at the National Conference on Neurosis.16 The monograph Nevroza astenică [Asthenic Neurosis] by the neurologist Arthur Kreindler was published in 1961.17 It was a time of intense research in Romanian psychiatry. National scientific meetings were systematically organized and new periodicals, conference proceedings, collective volumes and textbooks of psychiatry were published, while major Soviet works and textbooks of psychiatry were translated.18 It was also a time of important institutional changes for medical research and practice in Romania. In an accelerated process of centralization and Sovietization, knowledge production was gradually centralized and put under strict ideological control. In 1948, the Romanian Academy (founded in 1879) was banished, and replaced by the Academy of the Romanian People’s Republic (ARPR), an institution reorganized according to the Soviet model.19 The Communist regime invested significant resources in medical research facilities, creating new opportunities of institutional and professional advancement. Even though the Academy of Medical Sciences, founded in 1935, was dissolved and integrated in 1948 in the RPR Academy, several institutes of medical research were created in the new structure, being endowed with significant research facilities.20 Where psychiatry is concerned, top research was concentrated at the ARPR’s Institute of endocrinology (established 1946, director C. I. Parhon) and at the ARPR’s Institute of Neurology ‘I. P. Pavlov’ (established 1948, director A. Kreindler).21 In an accelerated process of Sovietization, Romanian medicine and medical research proved to be, beginning in 1950, very receptive to the latest developments in Soviet medicine.22 Regulated academic exchanges with the Soviet Union took place under the auspices of

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the Romanian Association for Strengthening the Relationship with the USSR (RASRU). Major Soviet medical treatises were translated into Romanian, and numerous study visits to the Soviet Union were organized for the Romanian physicians.23 A yearly event, called Zilele medicale Româno-Sovietice, ‘The Romanian-Soviet medical days’, celebrated this close relationship. These investments in medical research were paralleled by massive political interference and keen ideological control. However, the new political regime created significant opportunities for research and professional advancement in the field of medicine. Romanian physicians and life-scientists, organized in highly centralized institutions put under political control, were ready to adopt Pavlovism, the medical and political dogma built around Pavlov and his work during High Stalinism (1950–1953).24 Leading Romanian medical professionals and scientists openly adhered to Pavlovism as the only acceptable scientific paradigm to inform their own research, and their acknowledgement was made public not only in a series of scientific publications, but also in public meetings. A special session dedicated to ‘Pavlovian teachings’ was organized by the Medical Section of the newly founded Academy of the Romanian People’s Republic in collaboration with the Ministry of Health in December 1952.25 The session, which was supposed to mark the ideological conformity of Romanian medicine, was organized on the initiative of the Central Committee of the Romanian Communist Party (RCP) and had to ‘analyse the theoretical and practical activities in medical sciences, to fight against idealism in medical sciences and to lay medical sciences in accordance with to Pavlovian teachings’.26 The meeting concluded with participants’ commitment to do whatever necessary to ensure the final victory of Pavlov’s teachings in all domains of medical research and practice in Romania and to unveil the unscientific character of the imperialist theories and conceptions from a materialist perspective.27 Pavlovism proved resilient in Romanian psychiatry during the 1950s and 1960s.28 Praised as ‘a new phase of development in the history of Romanian psychiatry’,29 it marked a vast process of reinterpretation of mental disease categories, aetiologies, symptomatology, treatments and cure with the help of Pavlovian tools and principles. Ideologically acceptable nosological entities were gradually developed and reified in daily medical practice. During the process, Romanian psychiatrists proved ready to openly redefine the scope of their discipline, embracing

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new explanations for the pathological mechanisms of mental diseases and new therapeutic methods to address them. Constantin I. Parhon (1874–1969) tried to redefine the domain of psychiatry in accordance with Pavlov. A top medical researcher (member of the Romanian Academy, of the Academy of Medical Sciences and of the Academy of Romanian People’s Republic, and founding director of the Institute of Endocrinology), Parhon was a fellow-traveller of the Romanian Communist Party. After 1944, he had a fulminant political career, acting between 1948 and 1952 as head of state of the newly established People’s Republic of Romania. In an undated manuscript (most probably issued in the first half of the 1950s), called ‘The physiopathology of the organism in the light of Pavlov’s teaching’, he claimed All Pavlovian teaching shows us that the psychology is just a branch a physiology, an expression of the processes of excitation and inhibition and of their interactions that take place in the cells of our brain. The entire Pavlovian teaching is naturally based on the dialectical method. Excitation and inhibition are two contraries and the relationship between them represents a struggle of the contraries, characteristic to the materialist dialectics.30 The Pavlovian transformation of psychiatry further materialized in new textbooks of psychiatry. The 1951 edition of the Textbook of Psychiatry of the Faculty of Medicine in Bucharest explained in a separate chapter the main principles of Pavlovian psychiatry and their profoundly innovative character.31 The 1956 edition aggressively developed these ideas, celebrating Soviet psychiatry, which succeeded to unveil the unscientific character of bourgeois psychiatry, namely of the psychoanalytic, psycho-morphological and psychosomatic concepts […] Romanian psychiatry has to creatively develop the firm materialist orientations of Soviet psychiatry, by closely observing the Soviet model, in both content and organization, on the footsteps of Pavlovian psychiatry.32 Public recognition of Pavlovian psychiatry came in 1955 on the occasion of the first postwar national conference of psychiatry, a showcase of the past and future achievements of Romanian psychiatry and neurology inspired by Pavlovism. The volume Probleme de psihiatrie [Problems of psychiatry], published in 1957 under the editorship of

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C. I. Parhon, confirmed the Pavlovist transformation of psychiatry in Romania during the first postwar decades.33

‘Neurosis’ – the wonder child of Pavlovism Neurosis, a province of pathology where Pavlov conducted major experimental research with significant results, emerged as one of the most successful stories of Pavlovism.34 Neurosis gained popularity in Russia and China, as ‘it fitted well with Pavlov’s concepts of mental functioning and its derangements’.35 The experimental neurosis produced in animals by Pavlov and his disciples offered a good starting point for further investigations of human neurosis, an issue still debated by Pavlovist practitioners, given that ‘the whole sphere of human neurosis remains one of the most litigious domain of psychiatry’.36 Gradually, ‘neurosis’ became interchangeable with Pavlovian (neuro) psychiatry, being thoroughly researched and explored in clinical practice during the 1950s and 1960s. Conveniently constructed at the intersection of neurology and psychiatry, human neurosis appeared as the ideal nosological area where Romanian specialists could openly affirm their Pavlovian orthodoxy, having at the same time enough space for original research.

Creating ‘asthenic neurosis’ The third and most consistent synthetic report presented at the 1955 conference was entirely dedicated to the ‘issue of neurosis’.37 At the 1955 national conference, neurasthenia got a new name, ‘asthenic neurosis’, being described as ‘a human neurosis, characterized by different signs of exhaustion’.38 The problems successively addressed by this report and by the other seven presentations dedicated to asthenic neurosis at the 1955 meeting set up the main lines of its discursive development as a ‘nosological entity’ for the next decades: the Pavlovian-inspired definition of asthenic neurosis, its aetiology, physiopathology and symptomatology, its treatment and its social implications. By skilfully using some Pavlovian concepts and experimental results and acknowledging ‘the importance of Pavlov’s research on neurosis, which put an end to the endless speculations promoted by Freud and psychosomatic medicine’,39 Romanian psychiatrists and neurologists succeeded in redefining the domain of neurasthenia. They managed to create a credible and easily recognizable identity for the (new) disease,

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to find a (new) name for it (‘asthenic neurosis’) and to reify it in clinical practice and theoretical studies:40 The old conception of neurasthenia cannot be considered still valid, neither from a clinical perspective, nor from an aetio-pathogenic perspective. Within this vast and vague concept of neurasthenia we have managed to isolate a better-defined clinical picture and to name it asthenic neurosis.41 The physiological explanations of neurosis offered by the Pavlovian school give neurologists and psychiatrists the opportunity to systematize and (re)organize a vague domain of mental disturbances, situated at the border between the normal and the pathological:42 [In the recent past] neuroses were easily abandoned by physicians, who, with a feeling of relief, let psychologists to take care of them. This happened because neuroses represent a very complex area of medicine, requiring extensive medical knowledge from several domains: neurology, psychiatry, internal medicine, neuro-physiology, psychology, psychopathology, and even of sociology.43 The discursive reorganization of neurasthenia took place along the lines of a ‘nosological scenario’: aetiology, symptomatology and therapeutics.44 Romanian psychiatrists’ choice of a nosological system of disease classification can be better understood in a broader ideological context, illustrative of the general conditions of knowledge production during Communism.45 The nosological organization of mental disease, fiercely supported by Soviet psychiatrists and by (most of) their Romanian colleagues, was opposed to the syndrome-orientated, symptomatological conception, identified as typical for the whole Western psychiatry.46 The option for a nosological organization of a disease was grounded in the ‘dialectical materialism’ promoted by Soviet psychiatry, constituting a ‘strong wall against which all the idealist, agnostic, pragmatic, positivist, and existentialist conceptions are simply shaken off […]’.47 In the nosological perspective, any mental disease had a main cause, and its clinical manifestations and variations represented the interaction between the internal and the external causes which contributed to ‘unleashing the disease’.48 The symptoms of a disease were significant as long as they represented the ‘manifestations of a given nosological entity’.49

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In this ideologically loaded ‘nosological context’, most of the original studies published in the 1950s and 1960s deal with the question of the aetiology and physiopathology of the disease. In bitter opposition to Western authors, who they claimed denied any ‘nosological autonomy’ to neurasthenia, considering it to be only a sign of the beginning of other diseases, Romanian authors insisted upon the autonomous character of the newly defined nosological entity, in comparison with other neuroses or somatic affections.50 Asthenic neurosis was defined as a brain disease, caused by a psychogenic factor, that reflects a cortical disorder and whose clinical expressions are both somatic (asthenia, headache, visceral-vegetative symptoms) and psychic (psychic asthenia, depression, anxiety). Its main cause is of a psychic nature and this is what characterizes aesthetic neurosis in relationship with psychasthenia and hysteria, on one hand and with the vast and vague domain of neurasthenic and fatigue symptoms – which are not determined by a psychogenic factor.51 (The author’s own underlining.) Steadily, the psychogenetic causation had become the paradigmatic etiological explanation of asthenic neurosis. In Pavlovian-inspired psychiatry, psychogenetic causation was always related to a cortical disorder, affecting either the first or second signal system or the relationship between them.52 In the case of asthenic neurosis, the disturbance was related either to the domination of the cortical inhibition over-excitation or to the weakening of the cortical inhibition processes.53 These disturbances were always functional and not morphological, caused by a deterioration of the cortical neurons’ optimal capacity of inhibition or excitation.54 The second defining feature of the disease was its functional character. The fundamental clinical signs (headaches, sleep troubles, physical and mental fatigue) were considered significant symptoms of asthenic neurosis only if they could be associated with a functional disorder of psychogenic causation of the highest nervous activity.55 Romanian authors concluded that minor somatic events could trigger the disease.56 Asthenic neurosis could manifest in conjunction with, but not because of, different ‘somatic events’, such as surgical interventions, mechanical traumatisms, toxins, infections, hormonal disturbances, hepatitis, chronic infections or organic diseases of the nervous system.57 At the 1961 national meeting on neurosis, final conclusions on the aetiology and pathology of asthenic neurosis were drawn: asthenic

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neurosis was determined by the interaction of a determining factor (cause) which was always of psychogenic nature, with other factors that could be either psychogenic or somatic.58 Along these nosological lines, Romanian psychiatrists were able to differentiate between asthenic neurosis and asthenic syndrome. While they both shared the same symptoms, asthenic neurosis was considered to have an underlying psychogenic causation that could not be identified in cases of asthenic syndrome. Neurasthenic syndrome was not caused by a psychic conflict, being usually either the effect or the anticipation of a somatic disease.59 The nosological scenario of asthenic neurosis performed a semantic reorganization, a rebranding in Pavlovian terms of former descriptions, explanations and symptoms of neurasthenia, turning them into more ideologically acceptable statements. The primarily psychogenic causation of (asthenic) neurosis was not something new. On the contrary, it followed a well-known line of explanation with which Romanian authors were familiar. They openly acknowledged the Western psychiatrists (Krapelin, Bleuler, Bumke, Binder, Laughlin, Strecker, Ebaugh, Ewaldt and Kanner) who had promoted it.60 Neither did the symptoms described by the Romanian authors differ much from those already advanced by their Western colleagues.61 However, the physiological explanations of the (asthenic) neurosis’s pathological mechanisms advanced by the Soviet and Romanian authors (in the footsteps of Pavlov’s original insights) were wholly innovative. By using the neurological perspective promoted by Pavlovian psychiatry, Romanian authors believed they were escaping the somatic (materialist) vs. psychological (idealist) dichotomy, opposing both the idealist and the materialist-reductionist orientations of Western psychiatry.62 They gave physiological description of mental processes, relating psychogenic disturbances to abnormal interactions between the first and the second signalling systems. Their research on the physiopathological mechanisms of mental processes led them to develop an original system for organizing patients’ medical history, along the dynamic physiological structures created by the functional mechanisms established during the ontogenesis between the sub-cortical level of the unconditional reflex (the first signal system) and the level of the second signal system, each structure being related to one of the unconditional fundamental reflexes: the alimentary reflex, the orientation reflex, the self-defense reflex, and the reproduction reflex.63

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‘The social structure’ gathered data on patients’ childhood, schooling years, adaptation to educational standards, favourite subjects, professional trajectory and behaviour at the workplace. ‘The self-defense structure’ grouped information on patients’ performance in the military, during war and during air raids, as well as their reactions to natural catastrophes, mental traumas or diseases. ‘The reproductive structure’ drew together facts concerning patients’ sexual activities before and during marriage, sexual perversions and their attitudes towards children: conception, birth and rearing. ‘The alimentary structure’ gathered information regarding patients’ dietary habits. With the data organized in this fashion, the physician was able to determine for each of these structures the relation between excitation and inhibition in order to assess their equilibrium or the predominance of one process over the other. The evaluation of each physiological structure gave the specialist the possibility of evaluating patients’ cortical mobility: successful adaptation to change suggested good cortical mobility, while resistance to change and the unsuccessful adaptation of different life and professional situations implied a diminished cortical mobility. This original organization of the patient’s history, published for the first time in 1955, was reasserted by Kreindler six years later, in his monograph dedicated to asthenic neurosis.64 This system proved practical for the prevention of the disease, as one of Kreindler’s subsequent studies showed.65 The transition from normal to pathological was expressed by the modification of higher nervous activity in connection with a present problem and it represented ‘the first link in the pathological chain’,66 its early exposure being helpful in preventing (pathological) neurosis, confirmed a later study.67 ‘Psychic conflict’ (conflictul psihic) was thematized as one of the paramount mechanisms of psychogenic causation.68 The ‘psychic conflict’ motive was quickly accommodated within the neurological perspective supported by Kreindler, as patients’ personal history, organized around the four narrative lines (social, defence, reproduction and nutrition) could reveal the formation and development of a conflict in one of these four areas. A study conducted on 123 patients with asthenic neurosis concluded that one of the most frequent psychogenic causes of asthenic neurosis was represented by different types of professional conflicts in the workplace.69 It was not easy to harmonize the idea of ‘psychic conflict’ with the image of postwar happiness that Communist propaganda strove to create. In a monograph dedicated to asthenic neurosis, Kreindler discussed the question of ‘psychic conflict’ from a political perspective, offering

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important insights into its possible ideological implications. Kreindler began his examination cautiously, stating that the New Man – created by socialist society – does not and cannot have the psychic conflicts experienced by the capitalist man, the product of the decaying capitalist society.70 However, he continued, during the epoch of transition to communist society many ‘residues’ of the bourgeois ideology still existed and it was reasonable to assume that certain individuals, who could not keep up with the demands of these changing times, were affected by a certain degree of psychic conflict that could generate neuroses. But he was full of hope: the New Man is taking over throughout the world and men are better prepared to overcome the conflict generating factors, and to deal with these conflicts. […] In [contemporary] Romania, in particular, neurosis is not to be analyzed within the context of a backward, decaying society, but in a society in full progress, where an entirely new way of living is being constructed. […] in the new society there are many new, advanced methods of conflict resolution and prevention, leading to the gradual disappearance of neuroses. I am fully convinced that in the [future] communist society, neuroses will simply belong to the past.71 Several studies subsequently developed the ‘conflict theme’ in connection with problems of work, profession and working environment.72 A medical investigation made at the beginning of the 1960s on 121 workers in a confectionery factory (who were suffering from asthenic neurosis) showed that the disorder was provoked by professional conflicts (72 cases) and by domestic conflicts (59 cases).73 Another study, undertaken on 125 in-patients suffering from asthenic neurosis from the Sanatorium for Neurosis from Săvârsin, showed ´ that their neurosis was determined by psychic conflict: in 80 cases it was of a professional nature, whereas 45 cases were of a domestic nature.74 A third study, focusing on 130 individuals suffering from asthenic neurosis, concluded that the frequency of professional conflicts was significantly higher than social or domestic conflicts in causing asthenic neurosis.75 Most of the female patients suffering from asthenic neurosis seemed to be affected by a domestic conflict rather than by a professional one.76

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Asthenic neurosis in practice Following Pavlov’s principle of the fundamental unity between the organism and its environment, the conflict theme was also expressed in terms of a conflict between the (social) environment and the individual.77 Given that ‘work capacity is primarily linked to the socialprofessional physiological structure identified by Kreindler’,78 the asthenic patient’s diminished capacity of adaptation to social expectations primarily affected his/her work relations. Thus, the relationship between asthenic neurosis and work became highly significant, and constituted another recurrent theme of the nosological discourse. It was not easy to discuss the possible negative consequences of work in a country where its social value was continuously trumpeted, but studies that addressed this issue managed to turn their findings into ideologically acceptable statements. In his monograph, Kreindler concluded that a state of fatigue and over-exertion could at best trigger the manifestation of a neurosis, but it could never determine it, as only psychic conflict could constitute the true cause of asthenic neurosis. Thousands of people, he claimed, were over-exhausted, but only some of them had asthenic neurosis. Most of them were simply tired, and they would get well after a period of rest. It was not work in itself, but the situations created at the workplace, like professional conflicts and maladjustments, that made possible the emergence of the asthenic neurosis.79 These conclusions were confirmed by other studies. Given that most cases of asthenic neurosis were registered in individuals aged between 30 and 50 years, the period of maximal professional activity, other authors presumed that there was a connection between asthenic neurosis and professional activity. They decided to carry out an investigation of the professional readjustment of 130 individuals suffering from asthenic neurosis, during a period of six months following their discharge from hospital.80 Two criteria were used in order to analyse their evolution after being released from the hospital: the persistence of neurotic symptoms and work productivity. Following these criteria, only 27 per cent of the subjects could be considered completely cured. Taking into consideration that the complete disappearance of the neurotic symptoms usually took more than six months, the authors believed that it was more practical to use only work productivity as an objective indicator of the degree of clinical remission. In accordance with this criterion; 53 per cent of subjects presented satisfactory occupational productivity and a high degree of social reinsertion. These results confirmed the

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findings of a previous study, which evaluated the professional productivity of 86 neurotic patients at 3–4 years after their hospital release, and concluded that 78 per cent of the subjects had satisfactory, or even good, working productivity.81 While work in itself did not seem to favour the emergence of ‘asthenic neurosis’, certain professions seemed to encourage it.82 Several studies showed that ‘white collar’ workers seemed more likely to be affected by asthenic neurosis.83 After studying 100 female patients admitted to the Central Hospital with a diagnosis of asthenic neurosis, C. Parhon-Ştefănescu found correlations between profession and the main cause of asthenic neurosis. Asthenic neurosis was provoked by a psychic trauma triggered by various factors: physical over-exhaustion (in the case of 22 manual workers) and intellectual over-exhaustion (38 cases: bureaucrats, teachers, students).84 The neurasthenia of the capitalist world differed from the asthenic neurosis of the Communist societies not only in its discursive organization, but also because of the objective relations of production reflected by (social) consciousness. While in the capitalist world neurasthenia could be associated with workers’ cruel exploitation and the existential despair provoked by an individualist and profit-oriented industrial society, the relationship between asthenic neurosis and work in the Communist societies was entirely different.85 Even if ‘mental fatigue is a major symptom of the disease’,86 Romanian authors were well aware that Soviet experience rendered obsolete the prevailing opinion that overly intense intellectual work leads to asthenic neurosis, revealing that well planned and organized work actually stimulates the nervous system, and that a total lack of intellectual effort actually has a negative impact.87 They concluded that it was not intellectual work in itself, but rather hectic and unplanned activities that led to asthenic neurosis, while bad working conditions (noise pollution, working with the public or a crowded working space) and inappropriate qualifications seemed to be relevant for the development of asthenic neurosis.88 The positive role that work played for those suffering of asthenic neurosis was confirmed by patients’ attitude towards work: only 17.1 per cent of them had negative feelings, while 59 per cent of them really enjoyed working and, for 26 per cent of them, work per se did not represent a negative factor.89 In the case of 28 housewives suffering from asthenic neurosis, their conditions were described as being caused by a ‘feeling of inferiority provoked by boredom and hypoactivity’.90 Subjects mentioned that they quit their jobs after getting married and that they missed their workplace, thus suggesting that their disease was

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triggered by the lack of professional activity. Taken together, all these data reinforced the conclusions of the ‘Soviet studies which showed that work has a positive impact on the neurotic patient’s remission’.91 The abusive use of the psychogenic causation in asthenic neurosis could often lead to a continuous disregard of the role played by somatic elements and symptoms in asthenic neurosis.92 Premature discharge of the endocrinological factors might have a negative impact on patients’ general evolution, and some voices warned about the disastrous sideeffects that treatment with inappropriately prescribed neuroleptics might have for a patient with serious endocrine disorders.93 By overlooking important somatic ailments, many physicians chose to defer their professional responsibility to neurologists and psychiatrists, an attitude which revealed the general lack of knowledge about Pavlovian teachings on neuroses, which could also cause damage to patients.94 Other specialists emphasized the need to put an end to the abusive use of the ‘asthenic neurosis’ diagnosis by both physicians and employees.95 The diagnosis of ‘asthenic neurosis’ was often accompanied by paid sick leave, reduced working schedule or rest cures.96 Employees proved ready to use the new opportunities offered by the public health system. In 1955, a psychiatrist disapproved of ‘the popularity asthenic neurosis enjoys with the wider public’.97 Given that the findings of some enquiries made by the Institute for assessment of work capacity have shown in too many cases the early retirements and sick leaves of asthenic neurosis were too easily granted,98 This popularity could have significant consequences for the social insurance system, medical profession, and patients. Thus, the diagnosis of neuroses, and especially the one of asthenic neuroses has lately become a very convenient one. The physicians assign this diagnostic just too easy, and many symptoms and affections are just expediently considered to indicate a neurosis and to be treated as such. Many malingerers simply take advantage of this situation, as they have no trouble to give a list of symptoms that would fit with the diagnosis of asthenic neurosis.99 Beyond employees, university students, with the assistance of benevolent physicians, were also eager to use the ‘asthenic neurosis’ diagnosis in order to justify their truancy.100 This abusive use ‘harms the reputation of Pavlovian teachings’,101 so that objective criteria of the diagnosis had

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to be quickly defined.102 The existence of an underlying psychogenic factor was the difference between asthenic neurosis and asthenic syndrome, and proved important in reaching a correct diagnosis. Research carried out on 4,000 students from Iasi and Bucharest revealed that very ´ few of them were actually suffering from asthenic neurosis; rather, they presented with neurasthenic syndrome caused by intellectual fatigue and fitful work. An improved schedule of working and learning represented the best treatment.103 The high frequency of the disease in Communist Romania can be related to the abuse of this diagnostic category. At the same time, its success could be also explained by reference to its specific social context.104 The rapid processes of industrialization, urbanization, secularization and modernization which were triggered by the Communist regime in postwar Romania were accompanied by a specific mental pathology.105 The structural transformations that Romanian society underwent in the first postwar decades created the social context for the expansion of a disease whose core feature was a persistent feeling of uprootedness, usually experienced by individuals living in rapidly transforming societies.106 The successful emergence of asthenic neurosis as a ‘nosological entity’ also involved the development of an ‘aetiologically oriented treatment’,107 entirely consistent with the nosological plot.108 The therapeutic optimism surrounding this ‘reversible disease’109 contributed to the medicalization of this ‘grey province’ of marginal mental conditions, expanding the medical profession’s prestige, authority and expertise.110 With ‘psychic conflict’ becoming the paramount explanation for asthenic neurosis, ‘conflict resolution’ was seen as a key element of the cure: ‘the best treatment of neurosis is to solve the conflict that has caused it’,111 Kreindler put it plainly. The neurological perspective on mental activity could accommodate a whole range of conflict resolution means, directed to act not only upon the patient, but upon his social environment. The physician turned into a wise mediator, a ‘peace maker’ who was able to solve not only ‘psychic conflicts’, but also professional, social or domestic disagreements.112

Patient-oriented therapies: ‘Rational Psychotherapy’, physical therapies, drug therapy Even though psychotherapy was mentioned as mandatory in most of the studies dealing with asthenic neurosis treatment, it seems to have actually had a marginal role in daily medical practice.113 The few articles

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that discussed psychotherapy in greater detail recommended ‘rational therapy’, which addressed both the causes of disease and the patient’s social reinsertion.114 First of all, the physician had to gain the patient’s trust by displaying ‘a firm, self-confident but welcoming attitude, and much patience. Thus, the physician would not be regarded just as someone who prescribes sick-leave, but as one who heals’.115 The physician was supposed to explain to the patient the physiological mechanisms of his disease, and to assure him that it was a totally reversible medical condition. Afterwards, patient and physician would work together to identify the causes of the psychic conflict(s): the physician has to know how to listen and to lead the patient to talk about the conflict’s possible causes, by addressing him with short questions.[…] Guided by physician’s questions, the patient will be able to get to know the truth by himself.116 This was in total accordance with Pavlovian principles, Kreindler assured, as it was not about getting these conflicts from the realm of the unconscious into the sphere of consciousness, but about a superior degree of consciousness, directly linked to a higher activity of the 2nd signalling system.117 Together, patient and physician would find possible solutions to the psychic conflict(s) and, where this was not possible, the physician would help the patient to better adapt to existing circumstances.118 The physician should also help the patient to reorganize his daily schedule and activities, to alternate working hours with pauses, to have a fixed schedule of working, sleeping and eating, and to have more leisure activities and ‘little hobbies’: music, reading, sports, fishing, artistic activities and community work.119 Although they alluded politely to psychotherapy, most of the studies instead provided substantial reports on the successful results obtained through somatic treatments like sleep therapy and insulin shock therapy.120 The goal of these physical therapies was to equilibrate the processes of inhibition and excitation and the disturbed exchanges between the two signal systems in order to act upon the psychic conflict. The two therapies seem to have had the best therapeutic results because they did not act only upon symptoms (as the drugs did) but upon their root causes. For this reason, insulin shock therapy and sleep

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therapy continued to be preferred as some of the most efficient methods of treatment for asthenic neurosis throughout the1960s.121 While electroshock therapy and psychosurgery were totally unadvised as therapeutic options for asthenic neurosis, other physical therapies were usually recommended in severe cases, and implied a patient’s admission to hospital.122 They could be practiced alongside psychotherapy, occupational therapy and neuroleptic treatment.123 Taking into consideration the necessities of treatment (in- or out-patient facilities), the physician could also prescribe a reduced working schedule or sick leave, depending on the severity of asthenic neurosis. For out-patients, the most commonly recommended therapies were drug therapy and psychotherapy, to take place in ambulatory conditions, policlinics and local health centres.124

Environment-orientated therapies: new working conditions and lifestyles Commentators stressed that particular attention should be given to professional conflict prevention, and several effective measures were recommended: appointment to a position in accordance with one’s professional qualifications and working power, the avoidance of fitful work or of frequent change of employment and the alternation of intellectual and physical activities.125 Professional orientation and adequate professional qualifications were considered important for the prevention of asthenic neurosis.126 Special measures to act upon the ‘unsatisfactory domestic relationships’ were needed, together with educative measures to improve workers’ lifestyles. Equally important was the need to create better conditions in the workplace: reduction of occupational noise pollution, regulation of the work schedule, and regular alternation of work and leisure activities.127 Plant physicians, plant management and different medical institutions were encouraged to work together in order to assure health, hygiene and safety at work, through adequate measures and policies.128 At the same time, even if domestic and social conflicts were less frequent in causing asthenic neurosis, they should not be neglected, and a social worker should intervene to solve them.129 *** The emergence and endurance of ‘asthenic neurosis’ reflects the medicalization of ideological constraints and societal experiences in Communist

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Romania. Under the ideological imperatives brought by the ‘Pavlovian turn’ in Romanian psychiatry, medical professionals transformed fatigue, boredom, apathy, stress and professional and personal conflicts into ‘asthenic neurosis’, a discursive continuum ordered by ‘nosological principles’, reified in medical research and practice. They created a new province of expertise and intervention. The therapeutic success of this ‘reversible condition’ was dependent not only on the success of ‘proper’ medical solutions, like physical and drug therapies, but also on the effective hypostatization of the physician as conflict mediator, acting in an institutional net that extended beyond the walls of the hospital. Against a turbulent ideological context, many Romanian neurologists and psychiatrists undertook significant research on neurasthenia in Communist Romania, advancing original formulations of and explanations for the disease. The resilience of ‘asthenic neurosis’ in Communist Romania shows that, at least in this case, the ‘Pavlovian turn’ of Romanian psychiatry, brought about by the troubled political context of the early 1950s, was reified and developed in medical practice well into the 1970s, long after the ideological circumstances that originally created it had dissipated. The success of asthenic neurosis is also related to its larger social context. For most of the Romanian specialists involved, asthenic neurosis represented the expression of a monotonous life structured by an overloaded work schedule, typical for industrial societies. For Vianu, the dissident psychiatrist, neurasthenia was related to the political regime, being the expression of a general feeling of alienation and frustration that individuals were experiencing in state-socialist societies. Whatever the situation, the creative translation of these realities into medical language and daily practice illustrate Romanian psychiatrists’ ability to recognize, name and deal with the needs of the society they were living in, contributing to a more nuanced perspective of the intricate relationship between science, politics and society in Communist Romania.

Acknowledgement This work was supported by a grant of the Ministry of National Education, CNCS – UEFISCDI, project number PN-II-RU-TE-2012-3-44.

Notes 1. Ion Vianu, Exercit, iu de sinceritate (Iasi: Polirom, 2009), 26–27. ´ 2. Ibid., 27.

Psychiatry and Ideology 111 3. Ibid. 4. Ibid. 5. Ion Vianu, Interviewed by Raluca Alexandrescu, ‘Pentru o dimensiune morală a psihiatriei’, Observatorul Cultural, May 23, 2000, accessed March 23, 2014, http://www.observatorcultural.ro/Pentru-o-dimensiune-morala-a-psihiatriei.Interviu-cu-Ion-VIANU*articleID_6429-articles_details.html. 6. Vasile Predescu et al., ‘Metodologia depistării active a bolilor psihice în populat, ia urbană’, Igiena 23 (1974): 364, 366. 7. A. Moga, Th. Ilea, D. Enăchescu and S. Luculescu, ‘Studiul prevalent, ei principalelor boli cronice în România’, Igiena 23 (1974): 345. 8. M. Andon, ‘Despre nevroza astenică la militari’, Revista Militară Sanitară no.5 (1967): 787. 9. Vladan Starcevic, ‘Neurasthenia in European Psychiatric Literature’, Transcultural Psychiatry 31 (1994): 133. 10. Ibid., Vladan Starcevic, K. Kelin and M. Munjiza, ‘A Culture- sensitive Screen for Neurasthenia’, European Psychiatry 12 (1997): 164, Norma C. Ware and Mitchell G. Weiss, ‘Neurasthenia and the Social Construction of Psychiatric Knowledge’, Transcultural Psychiatry 31 (1994): 105–106, Sing Lee, ‘The Vicissitudes of Neurasthenia in Chinese Societies: Where Will It Go From the ICD-10?’, Transcultural Psychiatry 31 (1994): 153–172, Norman Sartorius, ‘Diagnosis and Classification of Neurasthenia’, in Basic and Clinical Science of Mental and Addictive Disorders, ed. L. L. Judd, B. Saletu, and V. Filip (Basel: Karger, 1997), 1. 11. Lee, ‘The Vicissitudes of Neurasthenia in Chinese Societies’, 153. 12. E. A. Rees, ‘Introduction. The Sovietization of Eastern Europe’, in The Sovietization of Eastern Europe: New Perspectives on the Postwar Period, ed. Balázs Apor, Péter Apor and E. A. Rees (Washington, DC: New Academia Publishing, 2008), 9–10. 13. A. Dosies, Constant, a Parhon-Ştefănescu, Vasile Predescu, ‘Some Aspects of Rumanian Psychiatry’, in Psychiatry in the Communist World, ed. Ari Kiev (New York: Science House, 1968), 195–219, Vasile Predescu, ‘Scurt istoric al dezvoltării psihiatriei românes ti’, in Psihiatrie, ed. Vasile Predescu (Bucuresti: ´ ´ Editura Medicală, 1976), 37–41. 14. Nanci Adler and Gerard O. W. Mueller, ‘Psychiatry Under Tyranny: A Report on the Political Abuse of Romanian Psychiatry During the Ceausescu Years’, Current Psychology: Research & Reviews 12 (1993): 3–17, Ioan C. Cucu and Toma Cucu, Psihiatria sub dictatură. O carte albă a psihiatriei comuniste românesti ´ (Piatra Neamt, , 2005), accessed December 10, 2013, http://bibliotecaonline2. files.wordpress.com/2010/04/psihiatria-sub-dictatura-comunista.pdf. 15. Cătălina Tudose and Florin Tudose, ‘History of psychotherapy in Rumania during the socialist dictatorship of Nicolae Ceauşescu’, European Journal of Mental Health 7 (2012): 221–235, Paradoxurile psihanalizei în România: convorbiri cu sase ´ psihanalisti: Ion Vianu, Eugen Papadima, Radu Clit, Alfred Dumitrescu, Vera sandor, ´ ´ Irena Talaban, ed., Ioana Scorus (Pites ti: Paralela 45, 2007). ´ 16. ***, ‘Concluziile consfătuirii ´ privind nevrozele (Bucures ti, December 4–5, ´ 331–333. 1961)’, Neurologia, Psihiatria, Neurochirurgia 7, no.4 (1962): 17. Arthur Kreindler, Nevroza astenică (Bucures ti: Editura Academiei RPR, 1961.) ´ 18. Constant, a Parhon-Ştefănescu, ‘Activitatea s tiint, ifică psihiatrică în t, ara ´ noastră, 1955–1960’, Neurologia, Psihiatria, Neurochirurgia 6, no.6 (1961): 553, Predescu, ‘Scurt istoric al dezvoltării psihiatriei românes ti’, 37–38. ´

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19. Petre Popescu-Gogan and Carmen Ilie-Voiculescu, ‘Desfiint, area Academiei Române s i înfiint, area Academiei R. P. R.’, Analele Sighet 6 (1998): 487–506; ´ Nadia-Ruxandra Mezincescu, ‘Anul 1948 s i Academia Română’, Analele ´ Sighet 6 (1998): 507–519, Nicoleta Ionescu-Gură, Stalinizarea României; Republica Populară Română, 1948–1950: Transformări institut, ionale (Bucures ti: ´ Editura All, 2005): 455–464, Rees, ‘Introduction. The Sovietization of Eastern Europe’, 23–24. 20. ***, ‘Stenograma audient, ei prof. Danielopolu la Tov. Pres ed.Prezid. dr. Groza. ´ Septembrie 1953’, Arhivele Nat, ionale Istorice Centrale (ANIC), Fond CC al PCR- Sect, ia Propagandă s i Agitat, ie, file no.67/1953, f.1. ´ 21. Ippolit Gh. Derevici, ‘Asupra unor probleme de profilaxie s i organizare a ´ asistent, ei psihiatrice în R. P. R.’, in Lucrările Sesiunii s tiint, ifice ‘Acad.C. I. ´ Parhon’: cu ocazia a 50 -a aniversare a Spitalului Socola, Ias i, 1955, ed. L. Ballif, ´ S. Blumenfeld and M. Moskovici (Ias i: Intreprinderea Poligrafică, 1957), 291. ´ 22. Paul Pruteanu, Spitalul unificat (Bucures ti: Ed. de Stat pentru Literatură ´ s tiint, ifică, 1954). ´ 23. ***, Învăt, ătura lui I. P. Pavlov. Baza înflorii s tiint, elor medicale. Conferint, e ´ ale membrilor delegat, iei medicale care au vizitat URSS (Bucures ti: Editura ´ Academiei R. P. R., 1952). 24. George Windholz, ‘Soviet Psychiatrists Under Stalinist Duress: The Design for a “new Soviet psychiatry” and its Demise’, History of Psychiatry 10, no. 39 (1999), 329–347; Benjamin Zajicek, ‘Scientific Psychiatry in Stalin’s Soviet Union’, (PhD Diss, University of Chicago, 2009), Ethan Pollock, Stalin and the Soviet Science Wars (Princeton: Princeton University Press, 2006), 136–167. 25. ***, Lucrările Sesiunii lărgite a secţiunii de ştiinţe medicale, 18–20 decembrie 1952 (Bucureşti: Editura Academiei RPR, 1953). 26. ***, ‘Decizie privind organizarea unei sesiuni extraordinare a Sect, iei de s tiint, e ´ ă si Medicale a Academiei RPR’, ANIC, Fond CC al PCR- Sect, ia Propagand ´ Agitat, ie, file nr.82/1952, f.16. 27. Lucrările Sesiunii lărgite a secţiunii de ştiinţe medicale, 407. 28. C. I. Parhon, Cuvânt înainte to Probleme de psihiatrie, ed. C. I. Parhon (Bucureşti: Editura Medicală, 1957), 5, 10. 29. A. Kreindler and O. Sager, ‘Perspective deschise neurologiei, psihiatriei s i neurochirurgiei în t, ara noastră de învăt, ătura lui I. P. Pavlov’, in ´ A 18-a conferinţă de Neurologie, Psihiatrie şi Neurochirurgie (Bucures ti: Editura ´ Medicală, 1955), 7. 30. C. I. Parhon, ‘Fiziopatologia organismului luminată de concepţia lui Pavlov’ [manuscript], ANIC, Fondul personal C. I. Parhon, III.43, f.4. 31. I. Iancu, ‘Concept, ia lui I. P. Pavlov în psihiatrie’, in Psihiatrie. Curs provizoriu întocmit de colectivul clinicei de psihiatrie (Bucures ti: Institutul Medico´ Farmaceutic, 1951): 365–392. 32. ***, Curs de psihiatrie (Bucures ti: Institutul de Medicină s i Farmacie, 1956), ´ ´ 9–10. 33. Probleme de psihiatrie, ed. C. I. Parhon (Bucureşti: Editura Medicală, 1957). 34. Ware and Weiss, ‘Neurasthenia and the Social Construction’, 106. 35. Sartorius, ‘Diagnosis and Classification of Neurasthenia’, 1. 36. C. Belciugăt, eanu, ‘Probleme actuale în clasificarea nevrozelor’, Neurologia, Psihiatria, Neurochirurgia 6, no.6 (1961): 420.

Psychiatry and Ideology 113 37. Arthur Kreindler et al., ‘Problema nevrozelor’, in A 18-a Conferinţă de Neurologie, Psihiatrie şi Neurochirurgie, 35. 38. Ibid., 38. 39. Ibid., 35, A. Kreindler, Nevroza astenică (Bucures ti: Editura Academiei RPR, ´ 1961), 7. 40. Kreindler, Nevroza astenică, 15. 41. Ibid., 7. 42. Belciugăt, eanu, ‘Probleme actuale în clasificarea nevrozelor’, 420. 43. Kreindler, Nevroza astenică, 7. 44. Ibid., 23, Belciugăt, eanu, ‘Probleme actuale în clasificarea nevrozelor’, 422–423. 45. Vasile Predescu, ‘Psihiatria azi-orientare, metodologie s i sarcinile ei ca ´ ramură a s tiint, elor medicale’, in Psihiatrie, 80–82. ´ 46. Vasile Predescu, ‘Bazele materialiste ale psihiatriei ruse s i sovietice II’, ´ Neurologia, Psihiatria, Neurochirurgia 6, no.3 (1961): 244–245. 47. Ibid., 245. 48. Ibid., 243. 49. Ibid., 245. 50. Kreindler, Nevroza astenică, 18. 51. Ibid., 23. 52. M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul Nevrozei astenice’, Neurologia, Psihiatria, Neurochirurgia 7, no.4 (1962): 303, Belciugăt, eanu, ‘Probleme actuale în clasificarea nevrozelor’, 422. 53. Kreindler et al., ‘Problema nevrozelor’, 38. 54. Ibid., 41. 55. A. Kreindler et al., ‘Cercetări asupra etiologiei nevrozei astenice’, in Lucrările Sesiunii stiint, ifice ‘Acad.C. I. Parhon’: cu ocazia a 50 -a aniversare a Spitalului ´ i, 1955, ed. L. Ballif, S., Blumenfeld and M. Moskovici, 80–81, Socola, Ias Kreindler,´ Nevroza astenică, 15, 23, I. Voinescu and E. Bicescu-Lazăr, ‘Evolut, ia nevrozei astenice la 3–4 ani de la ies irea bolnavului din spital’, Studii s i ´ ´ cercetări de Neurologie 3, no.2 (1958): 227. 56. Constant, a Parhon-Ştefănescu et al., ‘Studii asupra reinternărilor bolnavilor cu nevroză astenică’, Neurologia, Psihiatria, Neurochirurgia 11, no.2 (1966): 101, L. Baliff et al., ‘Contribut, ii la studiul clinic al nevrozei astenice la femei’, in Probleme de psihiatrie, 297. 57. C. Belciugăt, eanu et al., ‘Aspecte de constelat, ie etiologică în nevroza astenică’, Neurologia, Psihiatria, Neurochirurgia 13, no.3 (1968): 258. 58. ‘Concluziile consfătuirii’, 331. 59. Kreindler, Nevroza astenică, 277–278, 320; G. Meiu and A. Solomonovici, ‘Organizarea profilaxiei s i asistent, ei nevrozelor’, Neurologia, Psihiatria, ´ Neurochirurgia 7, no.4 (1962): 316–317, A. Solomovici, Gh. Meiu, A. Sturza, E. Chiticeanu and A. Pascal, ‘Cercetări etiologice, clinice s i evolutive în nevroza astenică tratată în condit, ii sanatoriale. Asistent, ă´ s i profilaxie,’ ´ Neurologia, Psihiatria, Neurochirurgia 7, no.4 (1962): 323. 60. Belciugăt, eanu, ‘Probleme actuale în clasificarea nevrozelor’, 419. 61. Sartorius, ‘Diagnosis and Classification of Neurasthenia’, table 1, 3. 62. Ibid. 63. Kreindler et al., ‘Cercetări asupra etiologiei’, 79. 64. Kreindler, Nevroza astenică, 130–132.

114 65. 66. 67. 68. 69. 70. 71. 72.

73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90.

91. 92. 93. 94.

95. 96.

Corina Doboş Meiu and Solomonovici, ‘Organizarea profilaxiei’, 318. Ibid. Ibid. Kreindler, Nevroza astenică, 11. Solomonovici et al., ‘Cercetări etiologice’, 326, 329. Kreindler, Nevroza astenică, 93–94. Ibid. Meiu and Solomonovici, ‘Organizarea profilaxiei’, 317, Gh. Meiu, A. Solomovici, P. Cortez, A. Sturza and A. Rosenblum, ‘Considerat, ii asupra încadrării în muncă a bolnavilor suferind de nevroză astenică’, Neurologia, 11, no.5 (1966): 434–435, M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul nevrozei astenice’, 310. Meiu and Solomonovici, ‘Organizarea profilaxiei’, 317. Ibid. Meiu et al., ‘Considerat, ii asupra încadrării în muncă’, 435. Ibid., 434. Belciugăt, eanu, ‘Probleme actuale în clasificarea nevrozelor’, 420–421, Andon, ‘Despre nevroza astenică la militari’, 791. Meiu and Solomonovici, ‘Organizarea profilaxiei’, 319. Kreindler, Nevroza astenică, 277–278, 320; Meiu and Solomonovici, ‘Organizarea profilaxiei’, 317. Meiu et al., ‘Considerat, ii asupra încadrării în muncă’, 434–435. I. Voinescu and E. Lazăr-Bicescu, ‘Catamneses of asthenic neuroses’, Psychiatrie, Neurologie, und medizinische Psychologie 10, no.2 (1958): 42–45. Kreindler, Nevroza astenică, 273, Solomonovici et al., ‘Cercetări etiologice’, Table 3, 326. Meiu et al., ‘Considerat, ii asupra încadrării în muncă’, 433–434, Solomonovici et al., ‘Cercetări etiologice’, 326. Parhon-Ştefănescu et al., ‘Studii asupra reinternărilor’, 98. Kreindler, Nevroza astenică, 92–94. V. Voiculescu and Zahariade St., ‘Studiul oboselii intelectuale în nevroza astenică’, Studii s i cercetări de neurologie 3, no.4 (1958):403. ´ Meiu and Solomonovici, ‘Organizarea profilaxiei’, 316. Ibid., 317. Meiu et al., ‘Considerat, ii asupra încadrării în muncă’, 435. Constant, a Parhon-Ştefănescu, Z. Bodin and T. Procopiu-Constantinescu, ‘Aspecte anamnesice la bolnavii cu diagnosticul de nevroză astenică’, Neurologia, Psihiatria, Neurochirurgia 11, no.3 (1966): 242–243. Meiu et al., ‘Considerat, ii asupra încadrării în muncă’. N. Vasilescu, ‘Asupra interpretării gres ite a not, iunii de nevroză în practica ´ medicală’, in A 18-a conferinţă de Neurologie, Psihiatrie şi Neurochirurgie, 83. Constant, a Parhon-Ştefănescu, ‘Considerat, ii asupra cadrului s i dignosticului ´ nevrozei astenice’, Neurologia 7, no.4 (1962): 296, 300. Vasilescu, ‘Asupra interpretării gres ite’, 83, Constant, a Parhon-Ştefănescu, ´ terapeutica bolilor psihice’, Neurologia, ‘Pentru o orientare etio-patogenică în Psihiatria, Neurochirurgia 6, no.4 (1961): 294. Parhon-Ştefănescu, ‘Considerat, ii asupra cadrului s i dignosticului’, 300. ´ Meiu et al., ‘Considerat, ii asupra încadrării în munc ă’, 435–436; M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul nevrozei astenice’, 311.

Psychiatry and Ideology 115 97. 98. 99. 100.

101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112.

113. 114. 115. 116. 117. 118. 119. 120.

121. 122. 123. 124.

Vasilescu, ‘Asupra interpretării gres ite’, 83. ´ Ibid. Ibid. Sorin Stănescu, ‘Astenicii se pregătesc de sesiune (I)’, Viat, a student, ească, 19, no. 20, May 15, 1974: 7, Sorin Stănescu, ‘Astenicii se pregătesc de sesiune (II)’, Viat, a student, ească, 19, no. 21, May 22, 1974: 7. Vasilescu, ‘Asupra interpretării gres ite’, 84. ´ Parhon- Ştefănescu, ‘Considerat, ii asupra cadrului s i dignosticului’, 300. ´ Ibid. Vladan Starcevic, ‘Neurasthenia: A paradigm of social-psychopathology in a transitional society’, American Journal of Psychotherapy 45 (1991): 544–553. Predescu, ‘Scurt istoric al dezvoltării psihiatriei românes ti’, 39. ´ David M. Berger, ‘The return of neurasthenia’, Comprehensive Psychiatry 14, no. 6 (1973), 562. ‘Concluziile consfătuirii’, 332. Parhon-Ştefănescu, ‘Pentru o orientare etio-patogenică’, 289–290. Kreindler et al., ‘Problema nevrozelor’, 37, 42–43. C. Lichter and V. Pîrvan, ‘Asupra stărilor marginale în psihiatrie’, Neurologia, Psihiatria, Neurochirurgia 12, no.4 (1962): 318. Kreindler, Nevroza astenică, 320. Meiu and Solomonovici, ‘Organizarea profilaxiei’, 319–320, M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul nevrozei astenice’, 309–311. A. Ramler, ‘Contribut, ie la terapia nevrozelor’, in A 18-a conferinţă de Neurologie, Psihiatrie şi Neurochirurgie, 71. Lichter and Pîrvan, ‘Asupra stărilor marginale’, 315. M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul nevrozei astenice’, 309. Ibid. Kreindler, Nevroza astenică, 322. Ibid., 320, M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul nevrozei astenice’, 310. Kreindler, Nevroza astenică, 321, M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul nevrozei astenice’, 309. Kreindler et al., ‘Problema nevrozelor’, 40–45, N. Ionescu-Sises ti et al., ´ A 18-a ‘Câteva contribut, ii la insulino-terapia nevrozelor astenice’, in conferinţă de Neurologie, Psihiatrie şi Neurochirurgie, 69–70; E. Façon, O. Müller, G. Frühling, G. Meiu, M. Gheorghe, C. Sonnenreich, D. Volanschi, A. Vrejean, ‘Contribut,ii la problema metodei si tehnicii somnoterapiei. Experient,ă realizată la centrul de somnoterapie de´la Spitalul nr. 9, Bucuresti’, ´ in A 18-a conferinţă de Neurologie, Psihiatrie şi Neurochirurgie, 74–75. M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul nevrozei astenice’, 308–309. ‘Concluziile consfătuirii’, 332, Parhon-Ştefănescu, ‘Pentru o orientare etio-patogenică’, 292–293. M. Saragea, Gh. Constantinescu and I. Voinescu, ‘Tratamentul nevrozei astenice’, 310–311, Meiu and Solomonovici, ‘Organizarea profilaxiei’, 320–321. Meiu and Solomonovici, ‘Organizarea profilaxiei’, 321, Solomonovici et al., ‘Cercetări etiologice’, 324–325.

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125. Kreindler et al., ‘Cercetări asupra etiologiei’, 88–89, Meiu and Solomonovici, ‘Organizarea profilaxiei’, 321–322, Meiu et al., ‘Considerat, ii asupra încadrării în muncă’, 437–438. 126. Kreindler, Nevroza astenică, 277–278. 127. Meiu and Solomonovici, ‘Organizarea profilaxiei’, 320–321, Solomonovici et al., ‘Cercetări etiologice’, 324–325. 128. ‘Concluziile consfătuirii’, 332. 129. Meiu et al., ‘Considerat, ii asupra încadrării în muncă’, 437–438.

6 The History of the Hungarian Institute of Psychiatry and Neurology between 1945 and 1968 Melinda Kovai

The Hungarian Institute of Psychiatry and Neurology (known as Lipótmező) was established in 1868 in Budapest as one of the first major psychiatric institutions in the country. Until its closure in 2007, Lipótmező functioned as an iconic symbol of the lunatic asylum in Hungary. This chapter analyses the history of Lipótmező from 1945 to 1968. This period covers the development of Hungarian state-socialism and the transition between its two distinctive eras. The Stalinist period, hallmarked by the party leader, Mátyás Rákosi, started after the Communist takeover in 1948 and ended with the revolution in 1956. The second period, labelled after the new party leader, János Kádár, started with the retaliation of 1956 and lasted until 1989. By the mid-1960s, the Kádár regime had been consolidated and the ideological basis and power practices of the system had partly changed. The Party leadership provided a relatively high living standard and, in exchange for the apolitical behaviour of citizens, only mildly supervised the private sphere and professional environments. This chapter examines Lipótmező as a case study representative of psychiatry’s key developments in Communist Hungary. While the history of the whole field would require a monograph, and although Lipótmező was an institute specifically focused on biological methods, the hospital’s central position and rather eclectic pool of professionals meant that the hospital functioned as a sort of microcosm of many of the most important debates and developments in Hungarian psychiatry at this time. This chapter concentrates on the professional biographies of psychiatrists, and the formal–informal professional circles in which they operated. Ultimately, Lipótmező provides insight into the ways in which politics influenced professional development within the Communist 117

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context. Lipótmező’s story cautions against any simplistic reading of the Pavlovization or Stalinization of science. Of course, politics did substantially influence the development of psychiatry across much of the Communist world, but the case of Lipótmező demonstrates the complexity of this process. Orders did not simply originate in Moscow to be taken up by the satellites. Rather, political constraints and power were formed, navigated and challenged at the local level. Individuals were subject to (and active participants in) the ebbs and flows of political winds, but, as the fate of Lipótmező demonstrates, they found ways to mitigate the effects of these winds – personal networks, informal educational groups and selective support for state-sponsored policies (among other techniques). This chapter begins by delving into the history of the psychiatric profession in the interwar period, analyses the key developments during the early years of postwar reconstruction, demonstrates the effects of the failed 1956 revolution and concludes by examining how psychiatry settled into relative autonomy from the 1960s onwards. By tracing this history through the doors of Lipótmező, it will become evident that political power informed psychiatric development without necessarily determining it.

Health care and the medical profession before World War Two The great health care institutions like Lipótmező were products of the public health care boom of the era following the 1867 AustroHungarian Compromise. Large state-sponsored national health care institutions were established in this period, with Lipótmező Royal National Lunatic Asylum founded in 1868 and other large lunatic asylums opening in Angyalföld (1884) and in Nagykálló (1896). However, after a few decades, the typical crisis symptoms of large European lunatic asylums emerged in Lipótmező as well: the institution became overcrowded and it succumbed to wider social problems, offering care to those who were perceived as hopeless cases (the homeless, alcoholics, patients suffering syphilis, tuberculosis and incurable neurological diseases). As is well known, this period was characterized by “therapeutic nihilism,” eventually giving birth to neuro-pathological and histological research. Hungarian psychiatry followed (with a few decades’ delay) West European trends, especially German developments. Most notably, the university department of psychiatry, having a clinic and laboratory, soon appeared as a rival to the large lunatic asylum.1

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After the turn of the century, psychiatry became more diverse in terms of scientific views and practices than it had been when the asylums were being built. Various theoretical and therapeutic schools and interdisciplinary fields arose; one of the most important fields was experimental psychology. Pál Ranschburg’s institution for the education of disabled children attracted many young psychologists (his student and successor, Lipót Szondi, would go on to play a vital role in the history of Hungarian psychiatry after 1945). Beyond experimental psychology, the Hungarian psychoanalytic movement flourished in the early twentieth century. It is worth bearing in mind that these fields of expertise developed separately and were only loosely connected to institutionalized psychiatry. For example, psychoanalysts had their own organization and training curriculum in Hungary from 1913, and psychoanalysis was a well-known intellectual and therapeutic movement by the 1920s. The special cultural embeddedness of psychoanalysis and the attachment of some of its representatives to leftist reform movements fundamentally determined its position after 1945, especially in the way Hungarian psychotherapy was reorganized in the first part of the 1960s. With the Trianon peace treaty of 1920, the social structure of Hungary changed radically, as the country’s territory was reduced by two-thirds and its population halved. These broad social changes occurred during a period of micro-level transformation within the professions. Changes in occupational structure and the expansion of tertiary education had resulted in a vast increase of educated professionals. Consequently the post-Trianon arrival of refugees from the dismembered territories considerably increased the unemployment rate of educated professionals. As a result, between 1920 and 1930 the number of medical doctors almost doubled (from 4,653 to 8,285).2 The health care system, partly because of the uneven distribution of medical service in the countryside, could not employ a significant portion of physicians. One characteristic trait of nineteenth-century modernization was that the Hungarian nobility avoided occupations considered “modern.” Participation in the market of health services was not accepted by the traditional elite before the last third of the nineteenth century. Consequently, more than half of health care professionals came from non-Hungarian ethnic origin, mostly German and Jewish. Thus, the tug of war within the professions had an ethnic character from the beginning.3 The National Association of Hungarian Doctors (MONE) played a significant role in this process. MONE was established in 1919 and rapidly

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grew to be one of the strongest, most aggressive extreme right-wing organizations of the country during the interwar period. Only certified, “pure Christian Hungarian” doctors were allowed to join the organization. Almost half of practising medical doctors enrolled in its membership; its leadership incorporated the non-Jewish elite of the profession, and the deans of medical faculties were among the members of the presidency. The anti-Jewish laws in 1938 and 1939 set limits on the proportion of Jews in the so-called intellectual free professions. Each professional community, however, had some leeway in whether they received the laws enthusiastically or with aversion. The physicians (as opposed to the lawyers) were at the forefront of those who rigorously enforced the law.4 It was compulsory for the doctors of Lipótmező to join the MONE – an “official duty” required by the director chief physician, Rudolf Fabinyi in 1925.5 István Zsakó, director chief physician, dismissed Jewish colleagues immediately after the regulation came into force. However, under the German occupation, several chief doctors hid Jewish “patients” on their wards, with the later director of the hospital, Sándor Stief, among those engaged in this activity. Despite these efforts, many more perished: “at the end of the war, the estimated number of Jewish doctors to have fallen victim to … roundups was 2500, over half of the Jewish doctors in wartime Hungary.”6

The years of transition (1945–1948) After the war, psychology and psychiatry recreated their diverse professional and intellectual milieus characteristic of the pre-war period. Medical and psychological university training was restarted, research institutes were re-established, and new (and old) journals began publishing. Sources are very limited with regard to how the medical profession faced its criminal activities during the war, but MONE and the Medical Chamber were among the first associations to be banned in 1945. The properties and archives of the latter were taken over by the Free Trade Union of Hungarian Physicians (MOSZSZ), which, during the years of transition and later – as much as was possible under the dictatorship – provided effective protection of the interests of medical employees. Its leaders were mostly committed leftist, communist or social-democrat doctors, many of them Jewish. The evaluation of MONE’s membership divided the medical profession after the war for many decades: the older generation of the former Christian middle class mostly managed to preserve its positions, but its habitus was fundamentally different from that of the new younger communist elite or of those who were

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discriminated and excluded from academic and clinic positions before the war. Many older, conservative professors felt a reasonable fear of being stigmatized as “reactionary” or “Anglophile.”7 The inner division of the medical profession did not manifest in public statements or rival scientific schools, but it was decisive in shaping informal connections, relationships and friendships; all of which were significant in job nominations or lobbying for resources. After 1945, the leaders of Lipótmező were almost without exception committed leftist professionals, many of them (formerly illegal) communists and resistance fighters. In 1946, a new director was appointed, with the former director, István Zsakó, convicted by a political screening committee and disqualified without pension. According to the verdict, Zsakó’s carelessness had caused the food reserves and supply deficit; moreover, he had failed to perform his duties as a physician by declining to treat wounded Soviet soldiers during the war. To make matters worse, his son (István Zsakó Jr) had been a leader of both MONE and an association of young Nazi sympathizers. After Zsakó’s departure, Sándor Stief was officially nominated to fill the position, but he too, according to witnesses, was a weak leader.8 In fact, during the early years of the Communist takeover, his deputies led the hospital. From 1948, the deputy director was István Tariska. Tariska would go on to become one of the most significant actors at Lipótmező and a key driver of psychiatry-related health policies for decades. In the 1930s, as a medical student, he had been a member of the leftist, antifascist Márciusi Front, and during the war he joined the resistance as a member of the illegal Communist Party in Debrecen. From 1947, he served as a health care policy expert. As head of the health protection department of the Ministry of Health, he organized and led the Mental Health Inspectorate, which became the most important government body concerning psychiatry. Tariska’s nomination was intertwined with the government’s plans for Lipótmező – the political influence of the deputy director was much stronger than that of the senior professors of the university clinics.

The years of Stalinism (1948–1956) In the last year of the transition, psychiatry began to feel the results of the Communist Party’s ideological takeover. The political battles of Soviet science that were carried out in the fields of psychology, pedagogy and psychiatry were replayed in Hungary too. Scientific schools which were categorized as “bourgeois,” “reactionary” and “idealist”

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were simply eliminated. One of the most spectacular developments was a press campaign against psychoanalysis. Lipótmező’s new deputy director, István Tariska, contributed to the anti-psychoanalysis campaign with threatening articles published in Fórum, a journal aimed at intellectual readers.9 The Hungarian Psychoanalytical Association, to avoid the official prohibition and persecution of its members, declared its own dissolution at its general meeting in February 1949, following the suggestion of Imre Hermann and Lili Hajdu. In 1948, an attack was initiated against “reactionary propaganda” in public education and consequently the National Institute for Pedagogy (operated by Szondi followers) was dissolved. The Institute’s leader, the communist Ferenc Mérei, was excluded from the Party, and eventually the whole institutional system of psychology (except for psycho-physiology) was eliminated in psychotherapeutic institutions and in university departments. The ideological basis of the critiques was the adoption of “Pavlovism,” an argumentation schema based on I. P. Pavlov’s reflex theory. According to this viewpoint, social relations were external stimuli that caused conditional reflexes in people, thus affecting the “higher nerve-functions” influencing behaviour. From this view, Western psychotherapy was deemed an “imperialist psychology” due to the fact that it supposedly individualized social problems, thereby concealing and sustaining their real causes, namely economic inequality and the exploitation-based social class-structure.10 The “Pavlovization” of sciences in the Soviet Union started 15 years after Pavlov’s death.11 Pavlov’s theory was suitable for the fundamental aims of Stalin’s science-politics, namely to ideologically unify sciences. Pavlovism was assigned to take an integrative role in the theory of physiology, medical science, biology, psychiatry, psychology and pedagogy.12 Although the Marxist-Leninist criticism of (Western) psychotherapy attributed the final causes of mental illness to social relations, there was no trace of social psychiatry or attention to patients’ life circumstances in Hungarian psychiatric practice. According to official ideology, in a society built on collective property and the power of the working class, the relations that caused mental illnesses would be eliminated. On the basis of the medical files and the official psychiatric textbooks of the time, therapeutic processes and diagnoses were not based on Pavlov’s reflex theory but rather traditional biological approaches; the nervesystem’s presumed or perceived abnormalities were treated by globally applied methods, such as drugs, durable anaesthesia, ECT and insulin coma treatments.13 Beyond the ideological rhetoric braying in the public forums of medical science, applied Pavlovism in reality meant the

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harassment of certain persons and schools or their exclusion from the scientific field. However, the fact that the lecturers of the annual conferences organized by the Pavlov Mental Health Expert Committee of MOSZSZ discussed concrete scientific medical problems after repeating the obligatory political rhetoric provides evidence for the relative autonomy of the profession. It seems that the trade union did not take the political cleansing particular seriously either. The B-listing of the doctors’ political reliability kept track of whether the given physician was a member of the Party and in what sort of position he could be employed. Among the 123 neurologist-psychiatrists of Budapest, only six names were marked as “unsuitable,” and among the cadres who were “suitable for leading a big ward,” the pre-war era’s conservative professional authorities were present almost without exception, as were several psychoanalysts.14 Under these circumstances, those engaged in political lobbying for health care funding needed to develop a special strategy: publicly, they followed the ideological rhetoric by refuting the need for development, but, in the background, they smartly utilized political connections in order to acquire resources for development. The national mental hospital Among several substantial changes that concerned psychiatry from the 1950s onwards, one of the most important was the complete transformation of the health care system and its financing. After the nationalization of hospitals and medical treatment centres, health insurance companies were also nationalized. Consequently, the scope of people with health insurance increased to include most of the population. Due to the nationalization of workplaces and the collectivization of agriculture, people who had never seen a doctor before suddenly gained access to medical treatment. Health care became a growing profession (the oversupply of medical professionals had disappeared) and the number of hospital beds no longer satisfied the increased demand of the population. From this point forward, the lack of medical doctors became a permanent problem.15 The former status of Lipótmező (as the biggest mental health institute of the country but one without significant medical scientific prestige) was partly maintained and partly modified through the 1950s and 1960s. In accordance with plans of the Ministry of Health, Lipótmező gained in prestige when it was named a national institute in 1952. The hospital, which had employed only 13 doctors previously, now became a

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complex research and healing institute, serviced by nine chief physicians and 35 junior doctors.16 However, the ministerial position which had prepared the rise of the institute was abolished in 1951. In February of that year, István Tariska was taken away from Lipótmező in one of the large black cars synonymous with state security services. It is worth noting, however, that Tariska became a victim of a show trial as a former activist of the Márciusi Front and not as a psychiatrist. Ultimately, Tariska was sentenced to 12 years of imprisonment. Although Tariska would later be rehabilitated – the fact that he was imprisoned with János Kádár (later Secretary General of the Party) and György Aczél (later the head of cultural policy) would help him later in his career – Mrs Gimes Lili Hajdu, his enemy, was nominated to the position of deputy director of Lipótmező. Lili Hajdu had been the last president of the dissolved psychoanalytical association and was chief physician of the second male ward of the hospital at that time. Subsequent developments at Lipótmező would go on to reflect her particular form of stewardship. The “Great Lady” Mrs Gimes Lili Hajdu’s was born in Miskolc into a lower middle class, strongly assimilated Jewish merchant family. Her parents looked after the education of their children; Lili Hajdu followed her elder sister and started her studies at the medical faculty. During her university years, she became involved with the Galilei Circle, one of the most important progressive intellectual groups of the early twentieth century. There she met her later husband, Miklós Gimes, a fellow medical student. In 1914 she started working at the university clinic as a resident doctor and as the assistant professor of Ernő Moravcsik. In 1918, together with her husband, she led a private institute for disabled children. In the 1920s she started her training analysis with Vilma Kovács, and by the middle of the decade she had established her own private psychoanalytical practice, providing her with a permanent source of income by the 1930s. Her therapeutic and theoretical interest was psychosis; she published studies on the aetiology and therapy of schizophrenia. After the anti-Jewish laws, her workplace (the polyclinic in Mészáros Street) was abolished. With her psychoanalyst colleagues, Imre Hermann and István Schönberger, she took a social-psychological course for doctors, where the questions of mass-psychology, anti-Semitism and democracy were discussed. Shortly after, her husband was deported and died of typhus at the concentration camp of Leitmeritz. After the war, similar to several traumatized survivors who were committed to social reforms,

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Lili Hajdu also joined the Communist Party, although she was more sceptical of the regime than her children.17 I remember how she marched into Lipótmező. We were startled by her robust shape and masculine strength. We welcomed her with distant antipathy […] But I came to like her soon. I was glad when she was trusted with leading the hospital. Maybe this military woman, whom everybody fears a little, and whose opponents respect her too, could pacify this Augias-stable. […] And I haven’t been disappointed with the Great Lady.18 This extract is from the first edition (1957) of István Benedek’s famous book, Aranyketrec [Golden Cage].19 From the later editions those parts that were about the “Great Lady,” that is, Mrs Gimes Lili Hajdu, were erased for political reasons. From 1954 (after Sándor Stief’s retirement) Mrs Gimes was officially director of the institution. The exact motivation for her nomination to this position is unclear (due to a lack of sources), but the fact that her son Miklós Gimes Jr was a communist journalist who strictly followed the party line might help explain her ascent. After the years of transition, Lipótmező continued to face the same problems as it had prior to the war. “Therapeutic nihilism” was moderated by the invention of penicillin, thus combating the chronic and incurable neurological symptoms of syphilis. The miracle drug could not, however, solve the problem of overcrowding. The treatment of patients fundamentally changed in the early 1950s with the use of tranquilizers for psychosis. In Lipótmező, similar to other mental hospitals of the world, chlorpromazine represented a tremendous hope for changing the landscape. Under the management of Lili Hajdu, the national institute continued to quietly treat patients, host research and coordinate mental health developments. At the same time, it continued to mirror the minor and major political intrigues of the day. Although Pavlovism remained in force, at least publicly, colleagues informally learned the prohibited, “bourgeois” methods (e.g. projective tests), and they lent Western psychiatric literature to one another.

Revolution and retaliation In the “thaw” of 1956, after the rehabilitation of political prisoners, the professional discourse carefully restarted around psychological theories which

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had formerly been declared “reactionary.” In journals, unusual review essays appeared which described psychoanalysis and western psychotherapeutic schools objectively, some of which even criticized Pavlovism. By the autumn of 1956, discontent with health policies and the dysfunctional and politicized operation of medical science became noisier. Young doctors István Pataky and Dezső Prágai, leading members of the Petőfi Circle, spent weeks organizing a debate entitled “The young doctor and society.”20 The aim of the initiative was the same as previous debates: to reveal and discuss the situation of a given professional (in this case doctors and pharmacists), to raise questions and problems that dealt with doctors, and to encourage new thinking on health policy. The venue and the date were known weeks before the event: Gólyavár (University of Budapest), 23 October, half past 5 p.m. No one guessed that this would be the last debate of the Petőfi Circle. That date would mark the beginning of the 1956 revolution. According to reports, the discussion was very intense with many comments coming from the crowd, sometimes via shouting. It was both surreal and elevating all at once; at times, someone came in from the street and reported about the outside situation as it was unfolding. For example, there was shooting outside a radio station and tear gas was thrown into the crowd. At another point, at the suggestion of the moderator (István Pataki), the participants sang the national anthem in reference to happenings in the streets. Eventually, the discussion continued.21 The topics, apart from some words on the street fights, were strictly professional from beginning until end. Regarding psychiatry, two comments were particularly interesting. One of them related to István Bálint, citing his position as official psychiatrist of the State Security Authority and identifying him as responsible for the mental and physical torture of the victims of the security services; in many cases he apparently denied medical treatment to wounded individuals. This point was received with great applause and shouting by the audience. Secondly, István Tariska, the deputy director of Lipótmező who had been arrested and put on show trial, reported on the misuses of political power in health care and science management. He also expanded his criticisms to include the deficiencies of neurology textbooks. He spoke passionately about the decreasing number of hospital beds in psychiatry, the inefficient placing of mental patients into state farms, and more violently about mistakes of the party leadership.22 Details of the revolution in Lipótmező are hard to come by. The later director, Béla Mária, dedicated only two sentences to the revolution and its retaliation in his chapter for the centenary almanac of

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the National Mental Hospital published in 1968: “The events of the counter-revolution in 1956 caused only provisional difficulties. The so-called revolutionary committee removed Mrs Gimes from the director chief doctor position, but she automatically got her position back after the fall of the counter-revolution.”23 From the almanac published on the 125th anniversary of the establishment, we know that the president of the revolutionary committee was István Tariska and the “provisional difficulties” were caused by the absence of the dissident doctors.24 Lili Hajdu’s son, Miklós Gimes Jr, was a member of Imre Nagy’s inner circle; he was one of the intellectual leaders of the 1956 revolution. He was arrested on 5 December and would eventually be executed. Lili Hajdu, after her son’s arrest, offered her resignation as director but requested to stay on at Lipótmező in the chief doctor position. It was not permitted: in July 1957, when the charges against her son were delineated, she was retired at “her own request.”25 On 17 June 1958 she heard from Radio Vienna about the execution of her son. She attempted to emigrate to Switzerland to stay with her son’s escaped family, writing letters and using her professional connections. After her passport application was rejected for the third time, with a hint that further attempts would be useless, she committed suicide on 27 May 1960. The funeral was held several months after her death. At the tomb, her former colleague, the psychoanalyst Imre Hermann, gave a speech. According to her friend Pál Avar, when Imre Hermann finished his speech, Imre Csécsy [philosopher, political scientist, sociologist and old friend from the Galilei times] unexpectedly stood up as if he was just speaking to himself. Half a monologue, half a prayer were the words that he said. We knew this, though we did not understand anything about it. It was not obvious that we could entomb her in public. Mainly the regime’s enemies were standing at her grave.26 In many ways, the mourning and memorial symbolically touched on the executed and unburied martyrs of the failed 1956 revolution.

The 1960s – years of consolidation As with most of Hungarian society, the medical profession became frightened in the aftermath of the revolution’s defeat. On the whole, they escaped to passivity and apathy in order to survive the period of retaliation. Beginning in 1963 with the amnesty of political prisoners,

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the social-political system of the next decades was formed, deemed by some as “the most cheerful barrack” of the Communist world. The permanent ideological monitoring of the sciences stopped. In exchange for the political passivity of citizens, private life and professional communities received freedom for relative autonomy. At Lipótmező, Lili Hajdu’s place as director was taken by Béla Mária in 1957. Béla Mária was a “veteran of the party”; he had taken part in the labour movement from 1920s and, together with the later deputy minister István Simonovits, he organized the communist doctor group during the war, deserting in 1944 to join the Yugoslav partisans.27 According to János Füredi, one of the young doctors of Lipótmező at that time, “as a director of a national institute he was an influential person, but he didn’t have any scientific publications. He didn’t have real authority, but people knew that he was the chief.”28 The case of Béla Mária reveals how the inner life of Lipótmező was heavily influenced by single chief doctors who had very strong informal prestige and good political connections. The 1960s at Lipótmező were a decade of political consolidation and economic boom. The financial support of the government provided for significant developments: in 1966 the number of patients was 1,678 with 76 doctors and 369 psychiatric nurses working for the institute.29 Although it took its share from the periodic training for physicians, “Lipót” was still disconnected from broader university education, never becoming a university clinic. Due to its speciality, a great variety of psychiatric schools which were abolished in the “external world” went to Lipótmező. Among the physicians and psychologists of the forbidden disciplines were Szondi-followers, psychoanalysts and representatives of traditional biological psychiatry as well. Lipótmező, due to its independence from university education, would be able to provide work places for experts who were politically suspicious or “rehabilitated.” In the 1960s, the previously prohibited fields of psychology and psychotherapy were reorganized through local initiatives. Psychology [and] psychoanalysis were still swear words, but the specialty of Hungarian development was that it would be possible to create and work in some local, small, relatively autonomous professional groups, usually under the control of some single person who was politically loyal, reliable enough or with reliably high political relationships. Generally it meant György Aczél.30 Such “autonomous professional groups” included the child psychotherapy ambulatory clinic in Faludi Street, led by Júlia György,31 the

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Budapest Psychotherapeutic Methodology Centre, led by Ernő Szinetár,32 and Intaháza, led by Dénes Goldschmidt (from 1958). The chief doctor of Lipótmező, Miklós Kun, had been a loyal friend of both psychotherapy and György Aczél since his youth.33 On his initiative, in 1964 the psychological laboratory of Lipótmező was reorganized under the leadership of Ferenc Mérei, who was freshly released from prison.34 Mérei, just like István Pataky – the moderator of the doctor debate of the Petőfi Circle – was placed in Lipótmező because the political authorities did not want to give him a university position, but they also lacked any strong desire (partly due to his patron) to really discriminate against him. Thus Lipótmező was a compromise solution. Mérei’s psychological laboratory was a typical creature of the so-called “second public” of the Kádár era. The “Professor” and his circle of followers formed a very strong informal group and a peculiar professional environment. In closed, informal meetings (on “Mérei Thursdays”), the participants engaged in professional education, discussing foreign literature and sometimes conducting research. Such an organization was characteristic of the contemporary psychotherapeutic education. The work of these little workshops continued silently and isolated. Psychotherapeutic training occurred through informal frameworks, in private apartments, partly illegally, and without hope for official recognition of their education. Informally, however, everybody knew who was an educated expert and who was not.35 This “tolerated” opposition, especially among young people, increased the prestige of psychotherapy. And due to its personal, informal character, these groups created a strong, emotionally involved vocation and solidarity. By the beginning of the 1970s, the institution of psychology was officially reorganized – university education was restarted and clinical psychology became an officially recognized vocation.

Conclusion The range of possibilities for psychiatry and the constraints imposed upon it were very similar to the ones with which other professional communities had to cope: in the 1950s, political attacks against professional autonomy and resistance against it; later, a relatively peaceful cohabitation with political exigencies. Indeed, the “adaptive” strategies utilized by psychiatry were also similarly employed in the different communities: subservience, forced compromises, solidarity, organized protests and the instrumentalization of political connections. Lipótmező’s history demonstrates how politics penetrated the personal fates of the leaders and doctors, and the inner world of the

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hospital. At the same time, however, it is also clear that different schools of Hungarian psychiatry somehow persisted and preserved elements of autonomy. Lipótmező played an important role in these strategies of resistance. On the one hand, it was a national institution with a wide range of activities, employing various types of professionals; on the other hand, it was not directly linked to university education. This situation, which might be deemed “central periphery,” meant both a professional environment and isolation, both of which insulated it against direct ideological influence. The professional autonomy of psychiatry and neurology was also protected by the traditionally closed and hierarchical medical community. The fields (psychoanalysis, psychology and psychotherapy in general) which were not within the medical hierarchy were much more defenceless. On the whole, the case of Lipótmező reveals how political and power relationships sometimes transformed professional boundaries, but at other times only perpetuated them. Doctors often employed existing power relationships internal or external to the medical field as a profit-maximizing strategy. The leaders and influential doctors of Lipótmező came from very different milieus, which strongly informed their personal and professional values, relationships and behaviour. The private and public, and the personal and professional, could obviously never be totally independent from one another, but, as one could see in the 1950s and 1960s, they characteristically dissolved. Personal connections gave shelter against political attacks on professionalism, and informal groups took over certain functions of the scientific public as personal and/or political relationships worked in the scientific public sphere as “private” resources. Professional workshops created in the “second public” were special phenomena of the Kádár-era as “one person institutions.” They were built around a single charismatic leader whose political connections made possible the institutionalization between partly legal and partly informal frameworks. Paradoxically, the various schools of Hungarian psychiatry existed simultaneously in both a “privatized” and excessively politicalized environment. Therefore, Lipótmező was an exclusive world, with strong professional solidarity, an inner hierarchy tainted with patriarchalism, and a very heterogeneous milieu, both institutionally and professionally.

Notes 1. Emese Lafferton, A History of Hungarian Psychiatry, 1850–1908. PhD dissertation (Budapest: Central European University, 2003).

History of Hungarian Institute of Psychiatry and Neurology 131 2. Mária Kovács, Liberal Professions and Illiberal Politics. Hungary from the Habsburgs to the Holocaust (Oxford: Oxford University Press, 1994). 3. For solving the problem of overcrowding in the educated profession the numerus clausus law (Law XXV of 1920) restricted access to universities and established a quota system on the basis of “races and nationalities” living in the country. The peace treaty had cut Hungary off from most territories with mixed ethnic population, so the quota clearly referred to the Jews. 4. Kovács, 1994. 5. Budapest City Archive (BCA) XVII. 1709. 17. Lipótmező Mental Hospital, Political Screening Commission. 6. Kovács, 1994: 131. 7. Tibor Huszár, A politikai gépezet 1951 nyarán Magyarországon. Sántha Kálmán ügye (Budapest: Corvina, 1998). 8. Béla Horányi, Stief Sándor, a neuropathológus, Ideggyógyászati Szemle 1955. évi melléklete, 255–256;Gábor Paneth, “Pszichoanalízis in tempore belli,” BUKSZ, 3 (1994): 260–268. 9. István Tariska, “… és ami a Freudi illúzióból következik,” Fórum, 11 (1948a): 899–903; István Tariska, “A freudizmus mint az imperializmus házi pszichológiája. A harmadik londoni mental-hygiénés kongresszus,” Fórum 10 (1948b): 799–805;István Tariska, “Reakció az ősök várócsarnokában. Benedek István sorsanalitikus könyvéről,” Fórum 12 (1948c): 987–993. 10. Tariska, 1948b. 11. Alex Kozulin, Psychology in Utopia. Toward a Social History of Soviet Psychology. (Cambridge, MA: MIT Press, 1984); David Joravsky, Russian Psychology: A Critical History. (Oxford: Blackwell, 1989); George Windholz, “Soviet Psychiatrists Under Stalinist Duress: The Design for a ‘new Soviet psychiatry’ and its Demise,” History of Psychiatry 10 (1999): 329–347. 12. Joravsky (1989); Alexei Kojevnikov, Games of Stalinist Democracy. Ideological Discussions in Soviet Sciences 1947–1952, in Stalinism. New Directions, ed. Sheila Fitzpatrick (London: Routledge, 2000), 142–177. 13. Gyula Nyírő, Psychiatria. Egyetemi tankönyv (Budapest: Medicina, 1959). 14. Central Archive of Trade Unions 42. 373, List of Psychiatrists and Neurologists of Budapest (1951). 15. György Ádám, Az orvosi hálapénz Magyarországon (Budapest: Magvető, 1986). 16. Central Archive of Trade Unions 42. 807, Report on Psychiatric Wards of the State Hospitals. 17. Révész Sándor (1997). Mellékhalál…, Beszélő, 2: 89–90; Révész Sándor (1999). Egyetlen élet. Gimes Miklós története. Budapest: 1956–os Intézet – Sík Kiadó; Anna Borgos, Mechanisms of Defense. Encounters of Psychoanalysis and Politics in Lilly Hajdu’s Life Course (Vienna: Rosa Mayreder College, 2009), 7 November 2009. (Guest lecture) 18. István Benedek, Aranyketrec. Egy elmeosztály élete (Budapest: Bibliotheca, 1957), 142. 19. István Benedek (1915–1996) writer, psychiatrist. From 1948 he was chief doctor in Lipótmező, and head of the psychological laboratory. In 1951, for political reasons, the laboratory was abolished and he was dismissed. In 1952 he was nominated to act as chief of a work therapy colony in Intaháza. His experiences were recounted in his book Aranyketrec. Egy elmeosztály élete

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20. 21. 22. 23.

24. 25. 26. 27. 28. 29. 30.

31.

32.

33.

34.

Melinda Kovai (1957) (Golden Cage. Life in a Mental Ward), which made both the topic and the author very popular. An intellectual circle established in March 1955; its members were young reformist communists who criticized Stalinism. B. Hegedűs, András and Ember Mária, eds., 1994, A Petőfi Kör vitái VII. Iparművészvita, Orvosvita. Budapest: 1956–os Intézet. Hegedűs and Ember (1994). Béla Mária 1968. Intézetünk története 1945-től napjainkig. In: Az Országos Ideg- és Elmegyógyintézet 100 éve, Böszörményi, Zoltán (ed.) (Budapest: OIE) 117. Elemér Kuncz “Intézetünk az alapítástól a centenáriumig,” In: Az Országos Pszichiátriai és Neurológiai Intézet 125 éves (Budapest: OPNI, 1993). Révész (1999); Borgos (2009). Cited by Borgos (2009), 14. György Pollner (1975). Mária Béla, Orvosi Hetilap 39, 28 September. Author’s interview with János Füredi, February 2011. Maria (1968). János Harmatta, “A Pszichoterápiás Hétvégek (1974–1986) története és hatása,” Pszichoterápia 16 (2006): 86. György Aczél (1917–1991) from 1957 was Deputy Minister of Culture. However, he had far more influence than his official power, due to his personal relationships, especially his friendship with the first secretary of the Party, János Kádár. Aczél was a quasi-omnipotent leader of cultural politics throughout the whole period. “Júlia György could open a child psychotherapy policlinic in Faludi Street. Aczél came from a chaotic family, he lived in the street in his puberty, and then he went to Júlia György’s ambulatory clinic. And he was grateful to her until the end of his life. Actually Júlia György helped him back to society, and helped each other their whole lives […] Aczél gave an institute through the Budapest City Council to Júlia György.” Interview with Lívia Nemes (psychoanalyst), The Institute for the History of 1956, Oral History Archive No 768. Made by Júlia Lévai, March 2003, 69. Ernő Szinetár (1902–1996) doctor, psychoanalyst. Before the war he was a member of Wilhelm Stekel’s circle of so called “active analysts.” From 1946 he was one of the official physicians of the State Security Authority and psychiatrist counsellor for several communist politicians. Due to his political relationships, from 1952 he led an autonomous psychotherapy division of János Hospital, called informally “Szinetárium.” From the 1960s the Szinetárium had great informal prestige among young doctors who were interested in psychotherapy as they could find regular seminars of psychoanalysts (without official association), and the application of “western” group therapy methods. “Júlia György asked me to look after one of her patients who was brought up in the Jewish orphanage. He was György Aczél. He was a worker on a construction site at that time.” Kun (2004), 64. Ferenc Mérei (1909–1986) was one of the most significant figures of Hungarian psychology, pedagogy and psychotherapy after 1945. He was born in Budapest into a lower middle-class Jewish family. After graduating from high school, he studied at the Sorbonne. As a student of the Marxist psychologist Henri Wallon he specialized in child psychology and vocational guidance.

History of Hungarian Institute of Psychiatry and Neurology 133 He joined the French Communist Party in 1930. Returning home in 1934 he worked as a psychologist without pay at the Budapest Institute of Psychology under Lipót Szondi’s guidance. He was expelled from the laboratory after the passing of the anti-Jewish laws. From 1940 he worked at the out-patient department of the Jewish Patronage Association led by Júlia György, until he was sent away to do labour service. In 1944 he escaped and joined the Soviet army, where he attained the rank of captain. From 1945 until 1948 he was the head of the Budapest Institute of Psychology, a professor at the Pedagogical College, and the leader of the central seminar of NÉKOSZ (People’s National Association of Colleges). He was appointed head of the National Institute of Educational Psychology in 1946. In 1949 the Institute was liquidated; Mérei was discharged from his position and he became a translator for a living. He was rehabilitated in 1956, becoming a key scientific scholar at the Hungarian Academy of Sciences Institute for Psychology. He was arrested in October 1958 and charged with seditious organization and was sentenced to 10 years imprisonment. He received an amnesty in March 1963. From February 1964 he worked at Lipótmező where he founded and became the leader of the clinical psychology laboratory. From 1976 he led the Hungarian Psychological Society and the training of psycho-dramatists. Beyond his formal career, he was a central figure of some strong informal groups, e.g. the “Tribe” (artists and intellectual friends from the French emigration), the “A-Group” (informal training group for studying group dynamics) and the “M-Group” (informal psycho-drama training group). These groups still exist with the old members – most of them well-known psychotherapists. 35. Harmatta (2006), 86.

7 Ecology, Humanism and Mental Health in Communist Czechoslovakia Sarah Marks

In the 2008 volume History of Psychiatry and Medical Psychology, John Gach characterises trends in psychiatry in the second half of the twentieth century thus: In summary, post-war American psychiatry was dominated by an environmental/psychoanalytic orientation with some attempts at biomedical integration, while the biomedical model dominated in European psychiatry.1 Gach’s simplification is symptomatic of the paucity of comparative historical research on psychiatry after the Second World War, not only in the East European region, but on the international scale. It overlooks the sheer variety of different explanatory frameworks that existed in European psychiatry, which, if one includes the countries to the East of the Iron Curtain – or indeed Britain from the 1950s onwards – included those strongly influenced by environmentalist models as much as they were by biological ones.2 This chapter examines the take-up of environmentalist, and later explicitly ecological, aetiologies of mental health and illness in Czechoslovakia from the late 1950s to the 1970s. Furthermore, it examines the appropriation of psychiatric knowledge outside of the medical community. In a planned economy, the state took responsibility not only for health care and the distribution of resources, but also detailed aspects of everyday life, down to the planning of factory work schedules and the spatial arrangement of urban landscapes. If such environmental factors were considered to have a causal relationship with mental disorder – as was consistent with the Marxist worldview – this had subsequent policy implications. As a consequence, psychiatric concepts came to be bound up in networks 134

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of disciplinary and professional interests outside of medicine, and could be put to use in arguments for particular political and academic programmes, both at home and internationally. As the possibility of prevention was implied by certain aetiological theories, psychiatrists and neurologists made efforts towards prophylaxis and mental health education, encouraging citizens to take responsibility for the welfare of themselves and their families for their own sake, and for that of the collective. Czechoslovakia in the 1950s is often characterised as one of the most politically repressive of the regimes of the region. Yet, as medicine was afforded more autonomy than many other fields of intellectual endeavour, a remarkable level of plurality was able to flourish in spite of this even as early as 1957, when the Communist elites were still strongly resisting the tide of destalinisation which was occurring in the Soviet Union and other countries of the Warsaw Pact. This was, in part, due to the relative failure to ‘sovietise’ the field earlier in the decade. The limits of the ‘sovietisation process’ are brought into sharp relief with the case of psychiatry. In the summer of 1950, following a direct order from Stalin, the Joint Scientific Session or ‘Pavlovian Session’ between psychologists and physiologists from the Soviet Academy of Sciences, and neurologists and psychiatrists from the Soviet Academy of Medical Sciences attempted to institutionalise Pavlov’s theory of higher nervous activity as the official Soviet approach to psychopathology.3 Members of the profession who had ‘deviated’ from this line confessed their mistakes to their assembled colleagues, and those assembled passed resolutions to develop a new form of psychiatry based upon the experimental verification of Pavlov’s theories.4 Czechoslovak psychiatrists and neurologists were expected to follow suit, although it took four years before a similar resolution was passed by the Czechoslovak medical association, the Purkyně Society, in 1955.5 Following the resolution, the Society’s journal, Neurologie a psychiatrie Československá, contained a number of articles on neurology, reflex theory and pieces that advocated Pavlovian sleep therapy.6 In addition, refutations of ideologically suspicious material that had been previously published in the journal began to appear, such as Zdeněk Macek’s critique of an article entitled ‘Psychiatry and Neurosis’ by Ferdinand Knobloch in the previous year’s issue, insisting that the author was misguided, and that neurosis is best understood through Pavlovian neurology.7 This late attempt to reform the mental health sciences was short-lived, however, as Khrushchev’s ‘Secret Speech’ in 1956 provided a legitimation for critical re-examination of the ideologies of the Stalinist period. This led to a

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dramatic shift in the profession’s confidence in terms of critiquing Party directives on the content of their research. On 6 June 1956 the Purkyně Society convened a meeting in the wake of the 20th Congress of the Communist Party of the Soviet Union. They criticised the ideological phraseology that had permeated the introductions of so many books, papers and congresses in recent years that, they argued: usually advocate some undefined ‘materialistic’ standpoint in the face of some usually unknown bourgeois ideology, and ideological differences are – without specific explanation – indiscriminately applied to all practical problems in psychiatry. Such caricatures of ideological struggle suppress independent thinking in psychiatry, ridicule Marxist philosophy, and lead to the opinion that the study of foreign scientific literature is pointless. The second most serious ideological shortcoming has been the schematic and dogmatic application of the teachings of Pavlov, which has manifested itself particularly in experimental work in recent papers. For the most part these are based on predetermined formulae, drawn from weak material which is modified so as to make it appear that the results ‘came out’ of it, and are in fact not based on any clinical analysis … We recognise that there is, as yet, no method that unambiguously and conclusively reveals changes in the higher nervous activity of humans, in the way that Pavlov’s conditioned reflexes do in animals.8 In conclusion, the meeting resolved that ‘Pavlov’s teachings on physiology remain the basis of higher nervous activity, but his name should not be used to defend totally speculative and unproven interpretations’.9 A careful balance was struck between lambasting Stalinist research practices and maintaining an allegiance to Pavlov’s teachings and Marxist philosophy as a general framework for guiding psychiatric science in future. Although the Society’s statement was politically cautious, acceptable topics for publication in the field were significantly broadened following 1956. Within a year it was even possible to publish research papers in Československá psychiatrie [Czechoslovak Psychiatry] which interpreted female sexual frigidity entirely through psychoanalytical concepts, provided a disclaimer was included at the end denying that the editors shared the ‘inaccurate and incorrect’ opinions of the author.10 Through the 1960s, and in some cases even beyond the Soviet invasion of 1968, psychiatric research in Czechoslovakia was remarkably eclectic. Yet despite the slackening of coercion towards the use of Pavlovian models, some researchers nevertheless continued to

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draw inspiration from this tradition. What is more, attention to the understanding of conditioned reflexes and the interaction of man and the environment – whether referencing Pavlov explicitly or merely implicitly – was a common trope in British and American research in the human sciences during the same period. While there was nothing essentially ‘Communist’ about the use of these models, it is notable that the majority of the key figures in environmental psychiatry and neurology in Czechoslovakia were indeed loyal and active members of the Party, unlike many of their colleagues within the profession, who were overtly ‘politically inactive’. At the Second International Neurology Conference in London, August 1935, Pavlov delivered a lecture on ‘Conditioned Reflexes and Psychiatry’, in which he made reference to a number of conditions that fell under the category of neurosis: My own clinical experience has been very limited, although I have visited regularly the neurological and psychiatric clinics for the last three or four years, and hence I offer the following remarks presumptively. Constitutional neurasthenia is a form of general weakness, occurring in the middle human type. Hysteria is the result of general weakness in the artistic type; psychasthenia (Pierre Janet), a product of weakness in the thinking type.11 Pavlov continued to argue that his colleague M. K. Petrova had successfully managed to induce such neurosis in dogs in the laboratory: The inhibitory process … may be weakened either through strain or through collision with the excitatory process. Its weakening results in an abnormal predominance of delay and other normal phenomena of which inhibition is a part, expressed also in the general behaviour of the animal, struggling, impatience, unruliness, and finally as pathological phenomena, e.g., neurasthenic irritability.12 These lectures were published in Czech, Slovak and German translations, along with numerous books and articles popularising the concepts by the mid-1950s.13 Soviet researchers continued to use Pavlov’s categories of neuroses: neurasthenia and hysteria in particular, in laboratory settings on both human and animal subjects, particularly in terms of the induction of neuroses through conditioned reflexes.14 The neuroses, because of their predominantly exogenous aetiology, became an important priority for prophylaxis and treatment. The

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category had existed in both nations in the pre-war period, partly as a result of the influence of French and German psychiatry, but also because Czechoslovakia was one of the earliest Central European nations to industrialise in the late nineteenth and early twentieth centuries. In Czechoslovakia under Communism, prevention of neurosis was one of the four designated research priorities for the Bohnice psychiatric research institute as set by the Ministry of Health in the 1960s.15 One of the most prolific writers on neurasthenia was the Czechoslovak neurologist Eliška Klimková-Deutschová, who later became head of the Research Group on Environmental Neurology of the World Federation of Neurology.16 In 1956 she co-authored a book with the neurologist Zdeněk Macek, Neurasthenia and Pseudo-Neurasnthenia: A Clinical Study, which was published by the State Health Publishers in Prague in 1956, and three years later in German translation by the GDR publishing house Volk und Gesundheit, became the key textbook on the topic in both countries.17 Macek, a senior neurologist at the Prague Neurological Clinic and the head of the neurological department of the Institute for the Training of Doctors (Ústavu pro doškolování lékařů), was favoured by the regime, and became the editor-in-chief of the State Health Publishing House in 1953.18 He was also a long-term evangelist of Pavlovian approaches to psychiatry and neurology, publicly calling out colleagues who claimed otherwise.19 Basing their study on a cohort of 500 patients, and referring to the Pavlov School, Klimková-Deutschová and Macek identified the key symptoms of neurasthenia to include problems with disturbed sleep, headaches, emotional liability, anxiety and depressed moods, inability to concentrate, shaking of the limbs, muscular tension and problems with reflexes, reduced libido and impotence in men, or ‘frigidity’ in women. They designated three subcategories of neurasthenia on aetiological grounds. The first, based on the symptomatology of George Miller Beard (1839–1883), were classified as those whose illness was aetiologically predominantly psychogenic.20 Secondly, came the pseudoneurasthenias, a group of illnesses that were symptomologically similar to neurasthenia, but caused by factors such as toxins, work conditions, haematological disorders or brain tumours, i.e. exogenous physical factors. Patients whose illness appeared to be caused by a combination of the factors in the first two groups were assigned to the third group, such as the following case study provided as a representative example by the authors. J. F., a 38-year-old technical employee. For seven years he had been overloaded in the workplace. For five-and-a-half years he had

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frequent conflicts with senior colleagues. Nevertheless, the patient felt himself always to be healthy, and was highly productive. Four months (prior to admission) he became feverish, contemporaneously with a flu-like illness. Even within one week, he felt fully recovered. However, when he returned to work, he realised that he was no longer able to cope with tasks that he had earlier mastered. He became moderately irritable, impulsive, disquieted, anxious, and could no longer concentrate on his work. Any controversy with his superiors led him to a severe depression. His sleep, which up until then had been very good, became superficial and disturbed; he could only sleep with difficulty, and woke up again shortly after. In short, he developed a typical neurasthenic syndrome.21 This case example raised issues about the long-term consequences of both physical workload, and the psychological problems associated with worker relations. Because neurasthenia and pseudoneurasthenia had exogenous causes that were often associated with the workplace, they were illnesses of particular significance for advanced industrial society. It was one of the obligations of a socialist nation to educate and prevent them through centralised management of production where possible, and attention to workplace practices that might reduce some of these problems.22 In turn, as a syndrome considered to have its origins in problems of the higher nervous system, neurasthenia could be treated by Pavlovian-influenced psychotherapeutics such as sleep therapy, or the autogenic therapies. Concern about neurasthenia as a category of psycho-neurological illness that was essentially caused by industrialisation – a process fundamental for the development of socialism – opened up a space for therapeutic innovation. Psychiatrists and neurologists in Czechoslovakia were thus able to make a strong case for their necessary role in mitigating the side-effects of the project of building socialism and the Five Year Plan. In some ways, the basic assumption that ‘higher nervous activity’ was based upon the interrelationship between a material substrate within the body and the outside environment opened up a broad range of interpretations for psychiatry and neurology. One key individual in the field, who was particularly focused on campaigning against reductionist tendencies, was the neurologist and Communist Party activist Oldřich Starý, who was also responsible for the teaching of Pavlov and dialectical materialism in the curriculum for Charles University Medical School.23 Son of the modernist architect of the same name, Starý reaped the benefits of his Communist Party membership for the development

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of his career in the 1950s, being sent on research trips to the Soviet Union, China and Great Britain.24 He was, in turn, able to use the Party’s trust in him, and his stable position within the university, as a means to promote his own policy perspectives within medicine. Following the 12th Congress of the Communist Party of Czechoslovakia in 1962, Starý published his ‘Humanist Manifesto’ in the journal Československá neurologie.25 Drawing from the resolutions of the congresses, he argued that one of the key tasks of the medical profession in the building of socialism from this point on was the prevention of illness. Of particular concern were the consequences of industrial progress. The development of radio technology, according to Starý, may increase the risk of harm to the nervous system as a result of generators producing electromagnetic waves of different frequencies, as could the widening use of atomic energy and radioactive fallout. The human nervous system was also at risk from ‘increased load’ caused by the mechanisation and automatisation of work processes.26 In response, modern medicine under Communism needed to ensure that all doctors were well trained in biology, chemistry and cybernetics in order to best develop prophylactic and diagnostic measures. Nevertheless, although these disciplines were crucial, he believed that they might not necessarily on their own be able to address the issue of the causes of illness. The question of the pathogenesis and prevention of nervous and mental illnesses is arguably one of the most complex, because it involves the most complex organ in the whole of the human body, the organ which reflects both external and internal conditions, and which currently acts as the ‘integrator’ of all the reactions of the organism. In order to address the question of aetiology and pathogenesis of nervous and mental illness is it necessary to make use of the most broadly based physical, chemical and physiological research – but also, currently, to apply methods from sociological research – until the results of all of the different methods lead to synthesis and interpretation. The application of only certain sub-methods leads to incorrect synthesis, and results in a certain reductionism, whether it be physical, chemical, biological or sociological … The programme for the building of Communism … allows us to find the way towards the maximal physical and psychic health of man; towards an ever increasing, revolutionary increase in life expectancy; as well as towards the raising of his physical and mental abilities.27 Starý’s reference to ‘humanism’ in the title of the article is illustrative of a humanist trend in Czechoslovak Marxism in the 1960s, one which

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ultimately reached its apex with the Prague Spring reform movement, of which he became an active supporter. It was also consistent with a longer-standing trope in Czech philosophy linked with the interwar president and national hero Tomáš Garrigue Masaryk. One of Masaryk’s most famous works from 1903 (which was indeed reissued in 1968 during the Prague Spring) was The Humanist Ideal, in which he critiqued major political worldviews of the late nineteenth century – including Marxism – on the basis of humanistic ethics. The use of ‘humanism’ in the title of Starý’s article would have been understood as an implied reference to this philosophical tradition.28 It is important at this stage to state that such political allegiances in the 1960s did not prevent Starý from being a genuinely active and loyal member of the Communist Party. Indeed, by 1966 he was made Rector of Charles University in Prague, the country’s most prestigious educational institution, and a position which afforded him significant political and cultural influence, particularly in terms of building relationships with scientific institutions abroad. Yet, despite his administrative duties, he continued his campaign for a more enlightened approach to mental health, which took into account the relationship between the individual and their environment. Like Macek and Klimková-Deutschová, Starý was also concerned by the neuroses, leading him to raise awareness of the problems and its causes in an article in the glossy women’s magazine Vlasta, nestled between photographs of the latest fashions and readers’ poems in praise of President Alexander Dubček. Starý was asked by the magazine’s reporter whether neurosis was more common ‘in our country’ compared to abroad.29 He argued that its prevalence was similar to other similarly industrially developed nations, such as Britain and Sweden – between 12 per cent and 18 per cent – but that in the most developed capitalist countries, such as the USA, the proportion of the population suffering from neurotic symptoms was thought to be as high as 30 per cent. The difference in rates between the former and the latter, he claimed, was due to the availability of national health insurance programmes that provided free health care in the former, whereas access to health care in the United States was not provided by the state (an argument which safely situated the narrative in socialist terms, whilst according validity to some of the more ‘social democratic’ countries of the West). In terms of the origins of neurosis, Starý identifies the workplace as the primary site of the origins of neurosis, particularly difficulties in relationships with other workers or managers, or internal emotional conflicts, such as when there is ‘a considerable discrepancy between the worker’s ambitions and his actual abilities’ or,

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conversely, the stifling of a worker’s great talents in a role that does not allow for their cultivation.30 Women, for whom the home was the most important immediate environment, were particularly vulnerable to conflicts within the family, or within their sexual relationships.31 The focus on the responsibility for the state and its citizens to actively improve human relationships, the workplace, the family, and allow opportunity for the maximisation of human potential was congruent with other key texts of the reformist period. In particular, the Academy of Science’s 1966 report Civilization at the Crossroads, which became a bestselling paperback and was translated into a number of different languages, pointed out the double-edged nature of the Scientific-Technological Revolution.32 On the one hand, the rapid development of new technologies in factories and cities allowed for great opportunities for progress and the liberation of humans to fulfil their creative potential, but unless their effects were properly understood, they could also cause significant damage to health and social relations. As such, better understanding of the impact of these changes was needed, which foregrounded the important role of scientific and medical expertise for the socialist state. In addition, as human subjectivity was formed through interaction with the environment, it was necessary to turn to the sciences of the environment, particularly ecology, cybernetics and systems theory, to enable effective planning for the future.33 With such concerns in mind, in January 1968, Oldřich Starý wrote to Harry B. Friedgood, based at the Mental Research Institute in Palo Alto (California), a centre particularly associated with the development of family and systemic approaches to psychotherapy. The need for an integral synthesizing approach to the burning individual and societal problems of contemporary man on a wide international platform is generally recognised in scientific circles. This was brought home to me once again at a recent conference, ‘The University and the Quest for Peace’ held in Rome which had the support of 420 universities, predominantly American. I had the honour of being elected vice president … and many American universities offered us close co-operation in the field of social, psychological and biological phenomena that are closely related to international understanding.34 The letter provides insight into the processes that senior academics – even those who held influence within the Communist Party – engaged

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in on the international stage in order to initiate collaborative work within the political constraints of the Cold War. Starý continues: In our country this concept has met with full understanding. Academician Šorm has entrusted me with preparing the programme [for an International Convocation of Human Ecology]. Together with colleagues from the research project ‘The fundamentals of nervous and mental health’ we decided to widen the project to give more space to the problems of human ecology … Our work has the support of the Academy of Sciences and Charles University. I am convinced that both sides will succeed in gaining the sympathies of the politicians for the Human Ecology program. For the present it is difficult to assess the development in the near future and the attitude of the relevant authorities, and therefore I do not dare suggest the date for the convocation. As soon as you will know the concrete attitude on your side I shall do the necessary on our side.35 Friedgood passed a copy of the letter on to the Office of the President of the Ford Foundation in the hope of securing financial support for the Czechoslovak venture.36 The Ford Foundation was an American philanthropic organisation founded by the industrialists Henry and Edsel Ford in 1936 to promote human welfare through international project funding. Friedgood reported that the Foundation were indeed very interested in supporting the venture, but that international relations prevented them from being able to initiate a conference in the Communist region, suggesting that Starý arrange to meet the American Ambassador to Czechoslovakia, ‘under informal and unofficial circumstances’, although it was thought the chances of such a collaboration being encouraged at a governmental level were slim.37 I am saddened by world conditions which stand in the way of good human relations and international understanding. Because human ecology is non-political, it can serve as a vehicle for bringing about a meeting of the minds of scientists and educators from all over the world to talk about the condition of man, and how one can improve this condition through education; and I see nothing on the horizon other than the project to which you are giving leadership, which is in a position to bring this about. I attach great significance to the complex project38 at Charles University.39

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Starý likewise was disheartened by the obstacles that faced their collaborative research, but was nevertheless hopeful that the culture of reform in Czechoslovakia might improve the situation. Fortunately Charles University stands in the first line of our process of renaissance, of which you are probably aware, and this fact assures us more than ever before that eventually we shall solve these problems scientifically as well as organisationally.40 Starý was referring here to the Prague Spring reforms, and the mood of optimism within the country at the time as a consequence of this. He himself became a signatory of the ‘Two Thousand Words Manifesto’, published on the front page of the intellectual weekly Literární listy on 6 June 1968 by Ludvík Vaculík, calling for more openness in the Party, democratic election of officials and more freedom of the press.41 The Soviet invasion of Czechoslovakia in August of the same year led to significant repression of the reforms, and a significant purge of the cultural sphere in particular. Yet Starý, perhaps because he was somewhat protected by his position as a scientist, remained Rector of the university until he resigned in January 1969 after organising and giving the address at the funeral of Jan Palach. Palach died by self-immolation in protest at the crushing of the Prague Spring reforms and the subsequent demoralisation of Czechoslovak society. His funeral acted to galvanise protest against the regime, and Starý’s involvement in it made his position untenable, although his resignation letter to Gustav Husák made no explicit mention of these circumstances, citing instead a desire to devote more time to his scientific research.42 In spite of the consequences of the Soviet Invasion of Czechoslovakia, the Integrative Human Ecology conference mentioned in the letters between Starý and Friedgood was nevertheless organised for October 1969. It included international cooperation and participation in the organising committee from Denis Leigh of the World Psychiatric Association and Lawrence E. Hinkle, Director of the Division of Human Ecology at Cornell University.43 Held in English, with attendance from delegates of UNESCO and the WHO, the aim of the conference was To be concerned with partial but for practical life very important problems of human ecology. (a) The influence of city environment, urbanisation, industrialisation and the scientific and technological revolution on the

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health (especially mental health) of man, his psychology and his individual and social behaviour. (b) The demands and challenge arising from the aforementioned facts for the design of the living environment, the building of residential districts and towns and regional planning. The Integrative Human Ecology conference was an example of interdisciplinary work supported by the Czechoslovak Academy of Sciences, intended to address large-scale societal problems, engaging with international literature on the subject, especially from the West. This conference featured participation from a wealth of prestigious academics from Western Europe and America, including psychiatrists David Hamburg of Stanford University and E. H. Hare of the Maudsley Hospital in London; as well as epidemiologists such as John Cassell of the University of North Carolina, sociologists, bio-climatologists, architects and urban planners. David Hamburg, E. H. Hare and John Cassell in particular exemplified a growing tendency towards the use of population statistics to analyse the determinants of mental health and illness. Hare, who had published work on the topic of ‘human ecology’ and used this term on the recommendation of his tutors at Cambridge in the early 1950s, later stated that it was more accurately described as ‘psychiatric epidemiology’.44 Whilst still methodologically quite varied, the amount of resources and funding given towards epidemiological studies of the socio-economic and environmental factors associated with mental disorder had increased in the post-war period. The Midtown Manhattan Study started by Thomas Rennie in 1950, for example, surveyed a population sample of a particular area of New York, and concluded that mental health was linked to socioeconomic status.45 By 1967, human ecology approaches had become a mainstream approach to aetiological theory-building, with the American Psychiatric Association’s publication of General Systems Theory and Psychiatry following a meeting at which the founder of GST (General Systems Theory), Ludwig von Bertalanffy, was made an Honorary Fellow of the APA and presented a paper which some of the psychiatrists present saw as a discipline-changing event: It warns us that our time as effective human beings and behavioural scientists is limited, as is the time of the world as an effectively human ecology, unless we seriously and creatively face the thesis of this book, that the theory of all the behavioural sciences has been and continues to be mechanistic, and therefore capable only of

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producing more excellent or efficient robots. The urgent challenge is that of changing our world view from one of mechanism to one of organized complexity and employing models that are open, organismic, and humanistic.46 Among the conclusions and recommendations of the conference was a commitment of all parties to ‘continue to support with greater vigour the basic scientific disciplines concerned with the study of man-environment relationship’, as well as an ultimate goal of the ‘gradual building of a fundamental theory of an optimal human environment’ through interdisciplinary cooperation.47 More broadly, they hoped that UNESCO would institute conferences and comparative studies of ‘environmental factors influencing the behaviour and interests of man, from the micro- to the macro-environment’.48 The Integrated Human Ecology conference was reflective of a genuine attempt by Czechoslovak researchers to engage not only with colleagues from abroad, but specifically with international non-governmental organisations as a means of exchanging knowledge and promoting their own national research agenda on the world stage.49 This was in keeping with broader outward-looking policies in terms of so-called ‘soft power’: Czechoslovakia had particular involvement in international health, technical and educational development projects in Africa during the 1950s and 1960s, for example.50 The prestige of such international collaborations also served to further secure their research agendas at home. Concerns around mental illness in particular were being appropriated here for the purposes of furthering the professional interests of other groups. As well as psychiatrists and neurologists, among the Czechoslovak representatives at the conference was Zdeněk Lakomý, founder of the Academy’s Department for Architecture Theory and the Living Environment. A prominent architect, Communist Party member and promoter of Marxist theories of human-environment relations, Lakomý was particularly concerned with collaborative work with psychologists and sociologists to understand and improve environmental factors in the health and behaviour of ‘socialist man’.51 He had been one of the younger generation of architects to explicitly engage with Soviet architectural theory and break away from what he described as ‘worn-out functionalist traditions’ which had dominated Czechoslovak architecture since the First World War, leaning instead towards interdisciplinary theories of urbanism which saw the built environment as a systemic totality in the service of human social development.52 Having attended the

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Integrated Human Ecology conference, along with both Czechoslovak government, USSR and UN-affiliated meetings on the problems of environment, and drawing on UN and Soviet reports on the management of the natural world and the ecological crisis, Lakomý published an article in the Czechoslovak Sociological Review on ‘the problem of the relationship between socio-economic planning and the care of the living environment’. He took up the argument shared across these different sources, that man’s health and development were ultimately dependent upon his ability to rely on the resources of the natural environment, and thus the future of society necessitated a more carefully managed approach to the effects of industrialisation and care of nature in the long term, beginning at the micro-scale of immediate surroundings in settlements in expanding circles of scale up to the entire biosphere, with all of these levels being ecologically integrated. If this was not managed rationally, then the environment’s habitability by man was at risk. Local planning and the built environment thus became bound up with grand narratives of ecological crisis and its prevention, which had become significant motifs in both East and West by the start of the 1970s. Furthermore, as man’s place in the world was so dependent upon his material conditions, it was important to understand the history of this relationship and the ways in which interaction with the environment had led to the evolution of man at particular moments in his history (a view linked closely with early Marxist writings such as Theses on Feuerbach). Furthermore, Lakomý emphasised the ‘human need’ for aesthetic qualities in the surrounding environment, both natural and man-made, and this required careful planning and information gathering in terms of producing the most ideal conditions for human flourishing in future.53 In his monograph, written in the same year but published three years later, Man within the World: Civilisation, Culture, and Living Environment (Člověk mění svět: civilizace, kultura a životní prostředí), Lakomý justified the need for an integrated approach to urban planning and environmental management as outlined above, by dedicating a chapter to the topic of ‘The Influence of the Environment on the Health of Man’.54 Within this, the question of how to prevent and minimise ‘civilisational illness’ (civilizační choroba) is raised through pragmatic architectural theory. Concepts of mental disorder which focussed on the interaction between environment and the human psyche thus provided an imperative for re-shaping and managing the environment, an argument which could be mobilised as a rationale for practice in architecture and urban planning, and ultimately as a foundation for policy-making.

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Psychiatric knowledge, particularly with regard to aetiology, had come to have significant currency and reach outside the clinical setting, becoming bound up with discourses of environmentalism and rationalistic planning, and often undergirding arguments drawn from both socialist and humanist principles. What is more, the authors involved in promoting these concepts, while committed to the Marxist project and with a sincere respect for Pavlovian concepts and their utility in psychiatry, neurology and beyond, were by no means dogmatic ideologues. They accorded respect to Western contacts and scientific literature, engaged seriously with both traditional ‘Soviet’ science as well as with research output from countries on the other side of the Cold War, and ultimately saw the international scientific community as a resource which could offer innovations that they could in turn adapt for the task of building socialism, both before and after the Prague Spring.

Notes 1. John Gach, ‘Biological Psychiatry in the Nineteenth and Twentieth Centuries’, in History of Psychiatry and Medical Psychology, ed. Edwin R. Wallace and John Gach (New York: Springer, 2008), 399. 2. Britain became the centre for research into behaviourist psychiatry in the 1950s, particularly based on classical conditioning, including behavioural therapies at the Maudsley Hospital in London, and cybernetic modelling at the Burden Neurological Institute in Bristol. See Andrew Pickering, The Cybernetic Brain: Sketches of Another Future (Chicago: University of Chicago Press, 2010), 92; Roderick D. Buchanan, Playing with Fire: The Controversial Career of Hans J. Eysenck (Oxford: Oxford University Press), 211. 3. George Windholz, ‘The 1950 Joint Scientific Session: Pavlovians as the Accusers and the Accused’, Journal of the History of the Behavioural Sciences 33, no. 1 (1997): 61–81. 4. George Windholz, ‘Soviet Psychiatrists Under Stalinist Duress: The Design for a “New Soviet Psychiatry” and its Demise’, History of Psychiatry 10 (1999): 329–347. 5. ‘Resoluce psychiatrické sekce Čs. Lékařské společnosti J. E. Purkyně’, Neurologie a psychiatrie československá 18, no. 3 (1955): 161. 6. J. Koluch, R. Hříbal, ‘Pokus o hodnocení účinků spánkové léčby methodikou zaměřených slovních reakcí podle L. B. Gakkelové’, Neurologie a psychiatrie Československá 18, no. 3 (1955): 202–206. 7. Zdeněk Macek, ‘Neurologie a Neurosy’, Neurologie a psychiatrie Československá 18, no. 3 (1955): 225–229. 8. Dušan Bilý, ‘XX. Sjezd KSSS a současná situace v naši psychiatrii’, Českoslovenksá Psychiatrie (1956): 242. 9. Ibid. 10. Editorial note accompanying L. Haas, ‘Frigidita a premenstrualní syndrom’, Československá psychiatrie 53, no. 4 (1957). 11. I. P. Pavlov, Lectures on Conditioned Reflexes, Volume II (London: Lawrence and Wishart, 1941).

Ecology, Humanism and Mental Health 149 12. Ibid. 13. S. N. Davidenkov, Učení I. P. Pavlova o neurosách a jejich léčení, knižnice sovětské biologie a zdravotnictví, sv. 15, 1. vyd (Praha: SZdN, 1953); Vladimir Nikitic Vinogradov, Učení I. P. Pavlova a klinické lékarství (Praha: SZdN, 1953); Ivan Petrovič Pavlov, Učenie I. P. Pavlova a jeho vzt’ah k prírodovede a lekárstvu (Bratislava: Výskumný ústav zdravotníckej osvety, 1953). 14. See, for example, L. B. Gakkel, ‘K voprosu o roli iavlenii induktsii vo vzaimodeistvii signal’nykh sistem’, Zhurnal vyssheĭ nervnoĭ deiatelnosti imeni I. P. Pavlova 5 (1955): 801–806; A. F. Dimitriyeva and L. G. Pervov, ‘Relationships Between the Signal Systems in Neuroses’, Pavlov Journal of Higher Nervous Activity 11 (1961): 1028–1033. Similar experiments were carried out at the Physiological Institute at the Czechoslovak Academy of Sciences on dogs and rats. See V. Novakova, ‘On Experimental Neuroses in Animals’, Pavlov Journal of Higher Nervous Activity 11 (1961): 157–163. Ivanov-Smolensky’s summative work on the Pavlov School’s work on experimental neurosis and its relevance for human psychiatry was translated and published by the Slovak Academy of Sciences in 1952, A. G. Ivanov-Smolenskiĭ, Náčrty patofyziologie vyššej nervovej činnosti (Bratislava: Nakladatel’stvo Slovenskej akadémie vied a umení, 1952). 15. Josef Prokůpek, Jaroslav Stuchlík and Stanislav Grof, ‘Czechoslovak Psychiatry’, in Psychiatry in the Communist World, ed. Ari Kiev (New York: Science House, 1968), 139. It is important to stress that similar parallel developments were happening in other countries of the region, as can be seen in Corina Dobos’s chapter in this volume for the Romanian case. Similarly, a Hungarian article was published in the main East German psychiatric journal, in which all of the neuroses were categorised as ‘diseases of civilisation’ (Zivilizationshkrankheiten), and were thus potentially reversible through treatment and the correct management of the social or environmental conditions which initially produced them: F. A. Völgyesi, ‘Zivilizationskrankheiten und zeitgemäße Psychotherapie: Der Mensch als homeodynamische Einheit’, Psychiatrie, Neurologie und medizinische Psychologie 11, no. 8 (1959): 226–239. 16. Johan A. Aarli, The History of the World Federation of Neurology: The First 50 Years of the WFN (Oxford University Press, 2014), 129. 17. Eliška Klimková-Deutschová and Zdeněk Macek, Neurasthenie a pseudoneurasthenie; klinická studie (Praha: Státní zdravotnické nakladatelství, 1956). 18. ‘Osobnosti České medicíny vážně i nevážně’, Zdravotnictví a medicína 11 (2012) Accessed at http://zdravi.e15.cz/clanek/mlada-fronta-zdravotnickenoviny-zdn/osobnosti-ceske-mediciny-vazne-i-nevazne-465041, July 1, 2014. 19. See Zdeněk Macek, ‘Neurologie a neurosy’, Neurologie a psychiatrie Československá 18 (1955): 225–229. 20. Eliška Klimková-Deutschová and Zdeněk Macek, Neurasthenie und Pseudoneurasthenie; Eine klinische Studie, 39. 21. Ibid., 39. 22. Ibid., 60–65. 23. Archives of the Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IIb/1.1 Karton 1, č 60. 24. Archives of the Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, biografická informace.

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25. Oldřich Starý, ‘Manifest humanismu’, Československá neurologie 25 (1962): 77–79. 26. Ibid., 78. 27. Ibid., 79. 28. Tomáš Garrigue Masaryk, Ideály humanitní: Problém malého národa. Demokratism v politice (Prague: Melantrich, 1968). 29. Jiří Borek and Oldřich Starý, ‘O neurozách’, Vlasta, 36, 11.9.68, Archives of Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423. 30. Ibid. 31. Ibid. 32. Radovan Richta et al., Civilisace na rozcestí: společenské a lidské souvislosti vědeckotechnické revoluce (Prague: Svoboda, 1967). 33. Civilization at the Crossroads was significantly influenced by Western Marxist theory, in particular Herbert Marcuse’s One Dimensional Man, which carried similar messages. It is also significant to note that Richta, the primary author, was also the originator of the phrase which became synonymous with the Prague Spring, ‘Socialism with a human face’. See Sarah Marks, ‘Rewriting Marxism for the Computer Age: Cybernetics and the ScientificTechnological Revolution in Czechoslovakia’, in Visions of Socialism in Eastern Europe, ed. Nadege Ragaru (Oxford: Berghahn, 2015). 34. Letter from Oldřich Starý to Harry B. Friedgood, 12 January 1968. Archives of the Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IIb/1.1 Karton 1, č 60. 35. Ibid. 36. Letter from Harry B. Friedgood to Oldřich Starý, February 8, 1968, Archives of the Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IIb/1.1 Karton 1, č 60. 37. Letter from Harry B. Friedgood to Oldřich Starý, February 20, 1968, Archives of the Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IIb/1.1 Karton 1, č 60. There is some irony in Friedgood’s claim that Human Ecology was a politically neutral discipline, given that (presumably unbeknownst to him) the CIA’s mind control experiments in the 1950s and 1960s were funded by a front organisation under the name of the Society for the Investigation of Human Ecology. For an account of this funding programme and the consequent research, see David H. Price, ‘Buying a Piece of Anthropology, Part 1: Human Ecology and Unwitting Anthropological Research for the CIA’, Anthropology Today 23 (2007): 8–13. 38. Underlined in the original letter. 39. Letter from Harry B. Friedgood to Oldřich Starý, February 20, 1968. 40. Letter from Oldřich Starý to Harry B. Friedgood, March 28, 1968. Archives of the Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IIb/1.1 Karton 1, č 60. 41. Ludvík Vaculík, ‘Dva tisíce slov’, Literární listy 18, June 6, 1968, 1. 42. Letter from Oldřich Starý to President Gustav Husák, January 1969. Archives of the Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IIb/1.1 Karton 1, č 60. 43. ‘Report of the International Preparatory Committee for the Conference on the Influence of the Urban and Working Environment of the Health and

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44. 45.

46. 47.

48.

49.

50.

51.

52.

Behaviour of Modern Man’, Archives of Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IVa/339. G. E. Berrios, ‘E. H. Hare (21.8.17–8.12.96)’, History of Psychiatry 8 (1997): 61–62. A. V. Horwitz and G. N. Grob, ‘The Chequered History of American Psychiatric Epidemiology’, Milbank Quarterly 89 (2011): 639–640. This approach was taken up by the Czechoslovak psychiatrist and co-organiser of the Integrative Human Ecology conference, Josef Váňa in a study of District 8 of Prague for his PhD thesis: Josef Váňa, Studie o rozložení duševních poruch u obyvatelstva Prahy 8 evidovaných v psychiatrických zařízeních v letech 1956–1961 (Praha: s. n., 1965). For more on the history of American concerns with urban populations and psychiatric epidemiology see Hans Pols, ‘Anomie in the Metropolis: The City in American Psychiatry and Sociology’, Osiris 18 (2003): 194–211. Contemporaneous developments also occurred in the United Kingdom. See, for example, E. H. Hare and J. K. Wing, Proceedings of a Symposium on Psychiatric Epidemiology, 1969 (Aberdeen, 1970). William Gray, Frederick J. Duhl and Nicholas D. Rizzo, eds., General Systems Theory and Psychiatry (Boston: Little, Brown, 1969), 3. ‘Conclusions and Recommendations of the International Conference on the Influence of the Urban and Working Environment on the Behaviour of Modern Man’ Archives of Academy of Sciences of the Czech Republic, Oldřich Starý Fond 423, IVa/339. Ibid. UNESCO’s ‘Man and the Biosphere’ programme was initiated two years later in 1971, which did carry through the aim of ‘improving the relationship between human societies and their environments’, but the focus has since been primarily on protection of natural environment and improved management of natural resources, rather than a focus upon deepening an understanding of the influence of the environment on human societies. See http://www.unesco.org/new/en/natural-sciences/environment/ecologicalsciences/man-and-biosphere-programme/ accessed August 3, 2014. There is a burgeoning historiography on the cultural exchanges which took place between East and West during the Cold War, which cuts across narratives of polarities of opposition and uncovers the significant degree of both cooperation at a state institutional level in terms of universities and health organisations, as well as at more informal and ‘civil society’ levels. See, for example Simo Mikkonen, ‘Beyond the Superpower Conflict: Introduction to VJHS Special Issue on Cultural Exchanges during the Cold War’, Valahian Journal of Historical Studies 20 (2013): 5–14. Curt F. Beck, ‘Czechoslovakia’s Penetration into Africa, 1955–1962’, World Politics 15 (1963): 403–416. My thanks go to Bradley Matthys Moore for drawing my attention to Czechoslovak involvement in international health campaigns during this period. J. Dostalík, Ekologicky šetrné tendence v československém urbanismu a územním plánování v  letech 1918 až 1968. Unpublished PhD Thesis (Brno: Masaryk University, 2013), 253–254; Otakar Nový, ‘O jubilantovi ing. arch. Zdeňku Lakomém, CSc’, Architektura ČSR, 43 (1984): 232. Kimberly Elman Zarecor, Manufacturing a Socialist Modernity: Housing in Czechoslovakia, 1945–1960 (Pittsburgh: University of Pittsburgh Press, 2011), 127–128.

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53. Zdeněk Lakomý, ‘K problematice vztahu mezi společenskoekonomickým plánováním a péčí o Životní prostředí’, Sociologický Časopis 9 (1973): 637– 643. A number of these arguments were summarised from the Academy of Sciences report ‘The Living Environment for Man’, Miloš Černý, Zdeněk Lakomý and Otakar Nový, Životní prostředí pro člověka (Praha: Academia, 1973). 54. Zdeněk Lakomý, Človek Mění Sve ̌t: Civilizace, Kultura a Životní Prostředí, 1. vyd (Praha: Odeon, 1976).

8 Beyond the Therapeutic Revolution: Psychopharmaceuticals Crossing the Berlin Wall Volker Hess Translated from the German by Arthur Eaton

When the sedative qualities of promethazine were discovered in 1950, the Rhône-Poulenc laboratory developed a series of phenothiazine derivatives. Among them was chlorpromazine (RP 4560), which rapidly found entry in the so-called “lytic cocktail” because of its strong effects, and quickly found application in psychiatry as the instigator of an “artificial hibernation.” It was found in these experiments that among the different components of the cocktail, only chlorpromazine was responsible for the sedative effects on psychiatric patients. This appeared to all participants “as magical as the result achieved when penicillin was first used.”1 The first reports were published towards the end of 1952.2 In the subsequent intensive exchange among clinical workgroups, what had until then been understood as a sedating effect was now being specified as an attenuation of the typical symptoms of psychotic illnesses.3 Within a short time, with imipramine, reserpine and isoniazid, there followed further psychotropic working ingredients that would lay the foundation of the new discipline of psychopharmacology, as well as revolutionize the treatment and ways of dealing with the psychically ill. Their discovery and further development into today’s psychopharmacy was celebrated as a “therapeutic revolution” and counts as one of the great success stories of the history of medicine and science – one in which the participating actors especially have taken stringent positions.4 Only since the end of the 1990s has the historical profession started reflecting on the connection between this therapeutic revolution and the construction of medical-industrial structures.5 These aggregates of institutions, power and interests, and actors (and their social worlds), typical for western industrial states, are often described as innovation research using the model of a Triple Helix6 consisting of industry, state 153

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and science. This model is characterized by the close intertwining of clinical research and the industrial development of medicine. This results in commercial marketing of therapeutics, an economization of medical services, and intensifying lobbying and organizational politics, as well as the political use of the health care system, all of which are currently at the centre of debate.7

New history of pharmaceuticals going east Psychiatry is an especially good example of the development of medical-industrial structures. Even if, at first glance, it seems that the dependence on a particularly narrow cooperation between clinicians and pharmaceutical producers is due to the characteristics of mental illness that make it difficult to find proper animal models for laboratory experiments,8 it appears that the purposeful marketing of analog working components as indicated by newly created categories in the Diagnostic Statistical Manual (DSM) points to a far closer – epistemological and economical – intertwining of clinical research and industrial development.9 From this perspective, it seems fitting to see the establishment of quantifying, standardizing and normalizing procedures of medical regulations not only as professionalization or governmental disciplining, but as a form of technology of trust.10 The concomitant standardization of research protocols,11 the development of statistical evaluation procedures12 and, not least, the political dedication to quality management of medicine, have destroyed all illusions of a historiographical idealization of autonomous science.13 Experimental research strategies and clinical evaluation are reshaped through procedures of valuation and standardization.14 Finally, in the case of the psychopharmaceuticals, it has become especially evident that neurophysiological models such as the receptor theory of dopamine hypothesis are in the end a theoretical conceptualization of the new pharmacotherapy and thus a more or less legitimate child of the clinical-industrial intertwining of research and development.15 Besides categories such as “demand” and “the market,” further agents and actors across the “magical triangle” of industry, state and science have ended up in the limelight of historical research: be it the history of the medical representative, who for a long time has been an underestimated figure in the communication and creation of knowledge in research, industry and medical practice;16 the moral economy of growing cooperation between academic research and the pharmaceutical industry;17 the intertwining of ecological debates and industrial interests with

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a new form of politics of openness;18 or the growing meaning of victim aid and self-help organizations in the founding and carrying out of clinical experiments.19 New medical history has substantially broadened the spectrum of research categories and analytical concepts. However, the development of increasing interdependence and complexity of the modern health care system has led to the market gaining a central role. Especially in American analyses, the medical market – developed by the leading categories of supply and demand – plays a central role, as a place of interaction and a space of negotiation and regulation.20 Whether, and in what way, these models can be carried over onto the European situation remains an open question. In Western European countries some efforts have been made in the context of a large-scale research network to enhance or correct this market-centred perspective.21 It became clear that neither the West German model of a community of solidarity of health insurance, nor the French “assistance,” nor the British National Health Service function as liberal markets,22 but are regulated by other mechanisms. This question has to be addressed in particular for the Eastern Bloc states. How did the therapeutic revolution take place on the other side of the Iron Curtain? What was the role of Eastern European health systems in this development, which is considered a success of the liberal market model? Answering these questions is of particular interest because the GDR – at least in its own eyes – distanced itself decidedly from the capitalist economic system and its “excesses.”23 Even if – after realistically determining the influence of state-socialist intervention – one extends the notion of the market to a socialist variant,24 the development of modern psychopharmacology in the countries of the Eastern Bloc poses a challenge for the historiography of science and pharmacology.25

Drug regulation in the FDR26 The development of the pharmaceutical industry in the GDR was not addressed in the FRG until 1989, not even in professional circles, as Ulrich Meyer has concluded recently.27 The few, especially economically orientated, analyses of the 1950s are clearly shaped by the Cold War climate,28 but immediately after the fall of communism a marked interest in the peculiarities of the GDR’s medical market became evident,29 combined with a careful balancing of the complete dismantling of this East German division of industry.30 And yet recent historical studies of individual drugs systematically neglect their development in the GDR31 – when they are not concluding with astonishment that there was, in

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fact, considerable drug production there.32 An exception is the earlier mentioned work of Ulrich Meyer. In addition to comparatively studying the development of anti-allergenics, further questions are raised in his paper about the organization of pharmaceutical markets, socialist economic policies and an economy operating with limited resources. The pharmaceutical market was characterized by the general economic problems of the GDR. Added to that were the dire starting conditions: after the founding of the state, the major pharmaceutical companies and the chemical and pharmaceutical raw materials industry were situated in West Germany. Existing facilities were dismantled in the course of repair. On top of this, general economic planning initially rested on the structure of raw materials and heavy industry. To meet the demand for basic chemicals for the pharmaceutical sector, investments were made in the technical equipment of the pharmaceutical industry. An internal evaluation of the Ministry of Health states that even in 1960 the GDR was not yet in a position to meet the medical needs of its population adequately (MfG (12/11/1960)). Because the Staaten des Rates für gegenseitige Wirtschaftshilfe (RGW) was also unable to achieve self-sufficiency, many drugs were imported from the “class enemy.” Often the import plans were not met either, due to insufficient financial means. The construction of the Wall reinforced political efforts to become independent of imported products from “capitalist foreign countries.” According to East German pharmacologist Gerhard Alcer, the central economic organization of the pharmaceutical market was characterized by three maxims: (1) putting restrictions on pharmaceuticals and medically tested drugs, (2) eliminating product competition and (3) achieving a far-reaching national self-sufficiency.33 The rigid reduction of drugs, the ban on all products without trusted effects and the elimination of product competition characterized the first efforts of the Soviet Military Administration in Germany (SMAD).34 From today’s perspective they made a virtue out of necessity, culminating at least in the support of the WHO policy of “essential medicines” in the 1980s.35 While around 5,000 drugs were still produced in the Soviet Occupied Zone in 1949, their number was reduced by “cutting out needless specialties” to 1,700. The admission of new products was bound to an official authorization. Establishing the Zentralen Gutachterausschuss für Arzneimittelverkehr (ZGA) formed a central board of experts. The board was composed of doctors and pharmacists, as well as technical representatives of the pharmaceutical industry, the State Institute for Drug Tests and the Ministries of Health and of Heavy Industry

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combined.36 For specific cases subcommittees were established. The main task of ZGA was providing expert advice to the Gesundheitsministeriums (MfGe) for the admission or rejection of pharmaceuticals, vaccines and health care products. In August of the same year the first drug control report was released.37 Like the former Reichsgesundheitsrat in the Imperial Health Office, the officers, clinicians and pharmacists from universities and industry deliberated on the development, marketing and distribution of drugs. Balancing the admission and cancellation of drugs despite rising production quantities in the following years makes clear that the limitation of the drug market was part of a rational policy behind the economy of scarcity.38 The drug law of May 5th, 1964 summarized these new binding regulations (a new version followed in 1986).39 For the time, this designated a very extensive pharmacological and clinical assessment40 that was inspected by the Institute for Drug Testing (Berlin, Jena and Dresden) that was established in 1950.41 As a rule, domestically manufactured products were always available and were recorded in the so-called Nomenklatur A. Foreign products, on the other hand, only available for scarce foreign currency, were put under Nomenklatur C, and their availability was limited.42 The GDR was also treading a new path with its complete ban on any “promotional activities” (in other words: advertising) from the late 1950s.43 Soon the party and state leadership started to bring together the various branches of industry in Vereinigungen Volkseigener Betriebe (Associations of Enterprises owned by the People) (VVB). On October 1st, 1948, the VVB of the pharmaceutical industry was founded. It would organize the private and semipublic [half state-owned] drug producers, provide them with professional guidance and integrate them into central planning. With the so-called “Indikationsgruppenprinzip,” research, development and production were reorganized by indications, specialized, competition avoided and profits increased, through the concentration of production processes.44 Although the hydrogenation plant Rodleben had considerable experience in the field of Phenothiazin derivatives, due to their years of research and development of anthistamines, it was the Arzneimittelwerk Dresden (AWD) who became responsible for psychopharmaceuticals in general (including anti-epileptics) – a company that had grown out of the merger of the firms Madeus and GEHE (1958). After the nationalization of private and semi-public companies and their integration into industrial combinates (Jenapharm, Dresden, 1970), all companies of the pharmaceutical industry were

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united in a parent company under the name VEB Pharmazeutisches Kombinat GERMED Dresden in 1979.45 At the same time, drugs produced in the GDR from 1964 onwards were sold abroad under the collective name GERMED. The development, or rather the introduction, of new working ingredients was, like the development and post-development of known drugs, part of the planned economy. Research goals were centrally laid down into partial steps, including necessary materials such as intellectual resources.46 Nevertheless, the Zentrale Gutachterausschuss had little influence on any concrete planning of pharmaceutical research and development. Instead, planning was coordinated by four key groups during the 1950s (with the telling names of “synthetic remedies,” “herbal remedies,” “microbiology” and “protein, organ preparations and sera”) that had been established as instruments of state planning at the Zentralamt für Forschung und Technik. The central office was in turn subordinate to the Staatlichen Plankommission, the organ of the council of ministers that was responsible for general economic planning in the entire state, and for seeing that the plans were carried out. In regular meetings of work groups, in which research and development agencies were represented, as well as the pharmaceutical sector and ministry officials, development projects of the pharmaceutical industry were also discussed and evaluated. What criteria were used for the implementation of this requirement planning, who took responsibility for it and in what ways, has recently been worked out on the basis of the example of tranquilizers by Matthias Hoheisel and Ulrike Klöppel.47 Besides the political depiction of benzodiazepine as a typical capitalist consolation for inhumane working conditions, their work revealed that both the stakes of the pharmacologists working on post-production as well as the wishes of clinicians played a significant role in this bottom-up process. But economic considerations, such as avoiding the costs of importing drugs also played a substantial role in these bottom-up decision-making processes.48 In view of the active processing patent in the GDR, the patenting of alternative ways of synthesis was a common way of participating in the development of Western medicine. This form of patent law, already practised in the German Reich, allowed for the further development of working ingredients that had been patented abroad under the principle of product protection. Individual psychopharmaceuticals were included in this research plan in order to, as it was unadornedly termed, evaluate the “therapeutic value, patent

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status, possibilities for synthesis, procurement of raw materials, and the technology and economics involved in the process.”49

Psychopharmaceuticals in the GDR The testimonial interviews of David Healy hardly take into account the developments in the Eastern Bloc countries. This is all the more regrettable, as the only contribution on this topic (Oldřich Vinař) points out that the French experiments with chlorpromazine were picked up in the early 1950s in Czechoslovakia, and – because the working ingredients were not available – were continued with phenothiazines and antihistamines from other chemical groups, and then published.50 The individual steps of psychopharmacotherapy are usually presented by the introduction of the working ingredients or groups of working ingredients. The following synopsis is heavily based on my own research.

1955–1960: Chlorpromazine51 Chlorpromazine was not only the main substance of the new class of neuroleptics, it was also an example of the strength of the East German pharmaceutical industry. The first reports of the particular effectiveness of the new substance were carefully followed. In April 1953, Fritz Hauschild (1908–1974), who had been the director of the pharmacological institute of the university since 1949, put the ingredient on a list with which the laboratory research of the Rodlebener Forschungslabor named a list of therapeutically interesting working ingredients.52 In June the research was well under way – by the end of January the Rodlebener Forchungslabor could report to its former leader that the further development was a success.53 Also in June 1953, the above-mentioned work group “synthetic remedies” convened over the possible inclusion of phenothiazine-derivatives in research assignments for 1954. In 1954 the hydrogenation plant received an approval for the new drug, which (to date) is sold under the brand name Propaphenol. Chlorpromazine also provides an example of how an economy of scarcity destroyed good efforts: by the end of March 1955, the drug was finally being sold; manufacture was still executed on a laboratory scale.54 There were insufficient production funds to scale up the experimental methods of synthesis to an industrial level. The makeshift apparatus that was employed in the late summer of 1955 could not patch up the considerable holes in maintenance. From March 1956 onwards a new production facility was put into operation. The

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consequences for clinical care can be traced in the traditional medical records of the Charité:55 even in the East Berlin flagship hospital, only half of neuroleptic-treated patients could be supplied with preparations produced in the GDR; the others received the expensive imported product from Bayer. A primary reason for this was insufficient precautions with the necessary chemicals. The main chemical used was metachloroaniline, which could not be obtained in the quantities required for production on account of the centrally led cuts in production costs. The company responsible for the production of chloroaniline, Schering Adlershof, was in turn dependent on not yet imported raw materials and struggled to meet the performance requirements of the Worker’s Protection Department for the avoidance of chemical damage.56 Even the packaging of the preparation caused problems, since the delivery of glass ampoules had been halted.57 The hydrogenation plant failed to meet the soaring demand of the Ministry of Health’s planning schedule, especially as the basic chemicals remained scarce. The factory’s internal annual report drew devastating conclusions: “All efforts of our firm to at least meet the needs of the population for the most sought after drugs were unsuccessful. These findings also lead us to conclude that we were also unable to fulfil the hopes placed on DHW Rodleben by the medical profession at large.”58

1960–1965: Imipramine and MAO inhibitors59 The tricyclic antidepressant imipramine was introduced by Geigy under the trade name Tofranil in autumn 1957 in Switzerland, and in a number of other Western European countries in spring 1958. To date, imipramine has served as the gold standard for the testing of clinical efficacy.60 However, it would be the end of 1960 before the new therapy had been properly introduced in Western countries.61 In the GDR, the new product was first introduced in 1962. After the Berlin Wall was built, however, in the wake of the so-called “Störfreimachung” (during which the East German leadership attempted to render the country economically independent from West Germany by disrupting the country’s links with states of the western hemisphere), a halt on the importation of Tofranil was demanded. The Hungarian imipramine preparation “melipramine” was deemed an alternative.62 From our research, we know that the drug was very purposefully used in clinical research. For the psychiatrist Karl Leonhard, director of the Institute of Neurology at the Charité Hospital, the new drug served as a means to work out the postulated diagnostic and prognostic differences between

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various forms of psychosis. Still only a quarter of the manic-depressive patients interned at the Republic’s flagship hospital received the new preparation: only those patients who were treated in the wards of senior physicians who were interested in this clinical research. Here we see that it was not always only the economy of scarcity that stood in the way of the introduction of new pharmaceutical treatments. 1973 saw the introduction of the first imipramin-preparation, Pryleugan, in the GDR and, against its own guidelines, a parallel development on the market. The unwanted product competition was a result of the combined production of carbamazepine, which was delivered in a roundabout way to Basel and was labelled Tegretal there.63 Instead, the AWD put one of the first monoamine oxidase inhibitors, phenelzine, on the market in 1962, which was utilized in antidepressant therapy until it was removed from the drug list in 1971. At the Charité, imipramine was used in the following years, mainly in the form of melipramin.64 Only in 1973 did East German industry start marketing its own antidepressant, Pryleugan.65 A reason for this could be the (at first) relatively stable availability of imports from socialist Hungary.66 That was where most of the states that were a member of the Council for Mutual Economic Assistance (COMECON) obtained the drug. As of yet, we know nothing about the availability of the product in other hospitals and ambulatory care.

1965–1970: Benzodiazepine67 It took longer for the first tranquilizers to become available in the GDR. Miltown arrived on the market in the USA in 1955, where it quickly gained a reputation as “the penicillin for anxiety.” Philopharm Quedlinburg introduced the drug for approval in the GDR in 1960, but it was met with political scepticism. However, benzodiazepine, developed in early 1960, played a greater role. Chloridazepoxid (Rö 476), marketed under the brand name Librium by Hoffman La-Roche in 1960, was prepared for further development by the research department of AWD in the Volkswirtschaftsplan of 1966 (licensing as Radepur followed in 1967).68 Increased government recognition also sensitized the authorities to legal issues, as the report of the responsible head of research made clear to the work group “psychopharmaceuticals” in 1968: the patented process developed by the AWD for the synthesis of Diazepam (Valium, 1963) was similar to the patent of the firm Dolmar Chemicals Limited (which was not protected in the GDR). Also the synthesis in the AWD was being done in intermediate steps patented by

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Hoffman-Laroche. “Although in both cases, formally speaking, different starting materials are being used, … a risk remains … that already exists in production in the GDR, and that is repeated in export, as soon as one is confronted with the relevant patent laws abroad.”69 From 1971, the “US-top-seller” of the years 1969 to 1982 was still available in the GDR under the trade name Faustan.70 Nitrazepam (Mogadan), introduced as a sleep aid by Horrman-LaRoche in 1965, also found its way into GDR pharmacies in a surprising way, where it was sold from 1971 under the trade name Radedorm. This happened even faster with Medazepam (Nobrium). Benzodiazepine, introduced by Roche in 1968, was approved in 1973 as Rudotel.

1970–1975: Haloperidol While the GDR’s pharmaceutical industry built up a wider range of both tranquilizers and antidepressants (enriched even further by imports from countries that were a part of the COMECON),71 in the case of neuroleptics they limited themselves mainly to the production of phenothiazine derivatives. Until 1970, only chlorpromazine (propaphenin [1954]); reserpine (Rausedan [1954]), promazine (Sinophen [1962]) and methophenazin (Frenolon [1962]) were produced. Until the mid-1980s only butaperazine (Tyrylen [1970]) and fluphenazine (Lyorodin [1973]) were introduced additionally by the VEB Deutsches Hydrierwerk Rodleben. Development of the butyrophenone derivatives, however, was not taken up,72 beginning with the introduction of Haloperidol (Haldol or Serenace) in 1965.73 The first and most important representatives of this drug group – still the gold standard in acute psychoses – was imported instead from Hungary from 1976 onwards, while other butyrophenones, such as Droperidol or Trifluoperidol, remained in Nomenklatur C.74 The targeted further development of perazine (Taxillan), another standard medication, did not materialize either.75 Instead, a perazine derivative, Tyrolon, was put on the market in 1968. Thus, psychiatrists in the GDR often remained dependent on imported preparations if they wanted to take part in new developments.76

1975–1980: Atypical neuroleptics The best example of this class of drugs was clozapine (Leponex). The atypical antipsychotic was introduced in Western Europe in the early 1970s, as a representative of a whole new generation of psychopharmaceuticals which showed surprising effects without producing the usual,

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Parkinson-like side effects, even in so-called “non-responders.”77 This atypical work spectrum was accompanied by massive side-effects. In 1975, clozapine was taken off the market in Finland because of damage to blood formation, and its clinical use in the USA was suspended. Nevertheless atypical neuroleptics developed into a market success, when in the 1990s further generations of atypical neuroleptics followed.78 In the GDR, psychiatrists urged for wider use of the imported preparation.79 They even argued for limited use – if applied under special precautions – in out-patient settings, with the option, after systematic evaluation of clinical experience, of widening the indication.80 In this way, clozapine was introduced in 1976 under Nomenklatur C, despite the high treatment costs for special trial clinics in the West.81 Further development was successful and in 1982 it was recorded on the drug list.

1980–1985: Depot medication No later than 1973, the production of depot neuroleptic Lyorodin (fluphenazine) was taken up after the ZGA had recommended adding it to Nomenklatur A in 1971. In 1982 Antalon (pimozide, Orap) followed as another depot medication produced domestically. Other depot medicines were obtainable on Nomenklatur C.82 Usually depot medication is a typical form of medication of the out-patient psychiatric sector. In fact, with the development, approval and distribution of depot medication, the number of publications about the relationship of social psychiatry and psychopharmaceuticals increased. Yet the development of depot medication in the GDR was not accompanied by a fundamental shift to more out-patient care.

Psychopharmaceuticals in psychiatric care The steps of psychopharmacotherapeutical development mentioned in the previous section stake out a vast field of research that has, as yet, only been partially addressed.83 For the East as well as the West it holds that the history of psychiatric practice is a blind spot of historical research.84 Individual aspects, such as reorganization, composition and structure of institutionalized care, have been researched, in connection with broader investigations into health care after 1945 – usually in a comparison between the two Germanys.85 There are also some regional historical studies that trace the different implementations of health policy.86 Few studies have focused on psychiatric care,87 despite great

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public interest in GDR psychiatry after the fall of the Berlin Wall.88 A commission set up by the Ministry of Health was specifically interested in the issue of political abuse of psychiatry.89 This allegation may now be considered withdrawn.90 That the complex history of GDR psychiatry cannot be reduced to the aspect of political instrumentalization is still overlooked at times.91 All in all it can be concluded that psychiatry in the GDR had a singular development that also showed progressive elements.92 However, the supply of psychopharmaceuticals remained a problem until the end of the GDR, as detailed studies show.93 The delayed or sluggish introduction of new drugs had a reason: by the end of the 1960s, the GDR produced only four neuroleptics and two tranquilizers of its own.94 Around 1970, four new tranquilizers were introduced.95 Until the mid-1980s, the number of regularly available psychopharmaceuticals was increased to 19.96 In the mid-1970s, the Ministry of Health predicted a doubling of the consumption of psychopharmaceuticals by 1980.97 In fact, the use of antidepressants increased tenfold by 1981, and the use of neuroleptics tripled. The economic stabilization of the 1960s procured a sufficient supply for psychiatric university clinics, but the peripheral institutions, especially district hospitals, suffered from the scarce economy and inadequate drug budgets. With shortage came excess: some medicines, such as the RGW-imported Trioxin and Tripthazin (trifuloperazine), resulted in large reserves that were not used by psychiatrists.98 The supply of imported medicines did, however, remain precarious for university hospitals. In 1970, psychiatrists complained about the glaring shortages of the neuroleptic drugs Haloperidol, Lithium and Amiltriptyline.99

Psychopharmaceuticals and mental health reform100 A first glance can be deceptive: even when all calls for reform of psychiatry orbit around therapeutic alternatives, psychiatric reform and psychopharmaceuticals are closely connected.101 That was especially the case for the GDR, where the discussion about the need for institutional reform took place much earlier than in West Germany – reflected in a symposium in Rodewisch in 1963 where the leading psychiatrists from the GDR asylums formulated requests and claims of mental health reform.102 Testimonials make clear that there was an intensive discussion of social psychiatric approaches and methods in the GDR.103 That the Rodewischer theses did not receive the same support from the state

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as the psychiatry-enquete in the BRD was less the result of a lack of will than of economic deficiency.104 In 1965 the Minister of Health promised the expert committee on psychiatry that a new commission would be set up to develop “a unified concept in the diagnostic, therapeutic, and medical attitude.” Additionally, the commission would also consider aspects of “psychiatric care” and social psychiatric care in a special work group. But it did not happen like that. Despite this lip service, the Ministry openly favoured an organic orientation within psychiatry. This was not only because of the university psychiatrists, who did not see themselves represented in the Rodewischer initiative and now used their influence in the technical committee [Fachausschuss].105 Rather, the Ministry pointed to limited financial resources. The construction of out-patient psychiatric care seemed – in comparison to the expansion of pharmaceutical production – unmanageable. Advocates of a social psychiatry approach were pushed aside with the argument of the technical committee that: “the scientific research tasks, especially for example the biochemical processes that are perhaps connected to mental illness, are not taken into account in the proposals set forward by the scientists of related fields.”106 Indeed the list of members consisted mostly of representatives who favored an organic approach to psychiatry. It remains an open question as to what changes these tentative approaches, whether in the form of personal engagement of individuals107 or as partial institutional reorganizations, brought about in structural terms for psychiatric care.108 In 1979 there were approximately 32,500 psychiatric beds, a quarter of which were filled by children. About two-thirds of those beds stood in general hospitals. That means nearly 20 per cent of all hospital beds were reserved for mentally ill people; but these were overcrowded by 30 per cent. At the same time, the discharge rate was very low: 50 per cent of psychiatric patients remained more than two years and a third of all patients stayed for 10 years or more. In outpatient psychiatric care, one doctor had roughly 30,000 patients to care for.109 The GDR remained far removed from the goal of psychiatric reform: namely, to provide sufficient communitybased care. Instead, psychiatry in the GDR made greater use of sedatives. From the late 1960s, supervisors observed a prescribing practice that no longer followed the required “rational drug therapy.” In the out-patient

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sector especially, almost half of all psychopharmaceuticals were used for “exhaustion-related illness of the nervous system.” Mental illness, in the strict sense of the term, accounted for only a small part.110 This point was presented in a 1981 study by the Medizinische Akademie Magdeburg. The work group, appointed by the Ministry, pointed out that by then, 10 times more antidepressants and tranquilizers were being prescribed, while the consumption of sedatives and sleeping aids had only doubled. Even compared to the Scandinavian countries, to which the GDR liked to compare itself, this difference was impressive: the GDR had a higher per capita use than Finland, but less than Sweden, and thus ranked in the middle of the international field. The trend remained: while in Finland the use of sedatives and tranquilizers had rapidly declined by the beginning of the 1970s, the demand for socalled “happy pills” in the GDR reached a certain saturation by the last decade of its existence. Accordingly, the costs for medicine rose steadily in the GDR: the cost per case increased by 50 per cent in psychiatric clinics between 1970 and 1984, while the average length of stay shortened by 10 days.111 However, the consumption of neuroleptics remained stable at a low level. Compared internationally, physicians in the GDR prescribed surprisingly little medicine for delusional hallucinations or paranoia.

Psychiatry of the GDR, or psychiatry in the GDR? The growing number of research publications on the history of the GDR in the field of contemporary history is usually – either explicitly or implicitly – constructed as comparative studies. Whether it is the reconstruction of the health system in the occupied zones, developments after the founding of the two German states, or the limits of the welfare state or mental health care practice – the comparison of the two Germanys is a recurring and systematic element of modern historiography of the GDR. In fact, one can hardly tell a history of the GDR without a discussion of developments in the FRG. This comparison of systems was, in a double sense, constitutive for the political self-understanding of the GDR (“überholen ohne aufzuholen” – overtaking without catching up): while it was consciously distinguishing itself as the newer, more humane, more progressive Germany, in hindsight it is clear that in terms of science, social politics, economics and consumption, it remained fixated on West German standards.112 Some authors even postulate that the GDR had “essentially never been able to get away

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from comparing itself to West German society,” while, on the other hand, the FRG did not really orientate itself towards the GDR from the 1950s onwards.113 Although perhaps an exaggeration, this means that one could write a history of the FRG without knowledge of the history of the GDR, but not vice versa.114 This is particularly true of the field of medicine. The internationalization (and Americanization) of scientific and clinical innovation since the 1950s made an orientation towards the capitalist nations necessary, and as a door onto those nations, towards the FRG too.115 Until the building of the Wall, the exchange between the two countries was extensive: most doctors and scientists were organized in common medical-scientific societies. Referencing West German journals was only forbidden by decision of the council of ministers of August 21st, 1961; in the period before, it is hardly possible to distinguish a specialized scientific discourse of East or West Germany. Especially in the early 1950s, one can rely on the fact that knowledge of new drugs, as well as the methods of preparation and stabilization of this knowledge, did not show a marked difference between East and West, if one ignores the economic and institutional environments. And yet despite, or perhaps because of, the history of this German– German relationship, the comparison is not a historiographical must. On the one hand, there is a danger of replicating the past: of replicating the GDR’s constitutional system comparison in historiographical terms, when the development of one state, either consciously or implicitly, becomes the measure for the other. On the other hand, in a comparison the independence and typical characteristics may get lost. In contrast to the West German development, the GDR is generally shown as a totalitarian, politically constructed, undifferentiated and bureaucratic society in which there was no, or only a little, room for manoeuvring of individual social systems.116 However, this debate has not been settled yet.117 This is brought into sharp relief by the history of the “psychopharmacological revolution.” On the one hand, the GDR participated in “medical progress.” The new psychopharmaceuticals all more or less found their way to the other side of the Wall. Surely, the central working ingredients took some time to be introduced: although the development of chlorpromazine was virtually simultaneous, the distance in time before the introduction of post-production increased over the years. That was not always a disadvantage, as the example of the contergan (Thalidomide) scandal shows. The GDR was spared this misery because of its sluggish post-production. On the other hand, the medical-industrial complex

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of the GDR did not develop any psychopharmacological innovations. While some companies, such as the above-mentioned Rodlebener Hydrierwerk, promoted the screening of new working ingredients on its own account – and partly beyond planning – no similar efforts were to be observed in the subsequent decades. Instead, there was a limiting to a careful screening of medical publications on the development of new ways of synthesis, an exploration of the patent situation and a focus on the sales of these post-productions, also in the West. As was the case in the West, the interaction between research departments of pharmaceutical companies, state representatives and the representatives of the medical community made sure that they had a voice in the new psychopharmacology. Even the consumer had a say in this, although via different routes and intermediaries.118 The fact that the GDR started to lag behind other psychopharmacological developments in the 1980s may also have been the result of its transformation. As the examples in the West show, scientific marketing became an increasing driving force for the raising of indication profiles and the development of working ingredients.119 But this history can hardly be counted as the “therapeutic revolution.” From this perspective, a view across the Wall can help us to further develop analytical models for understanding the modern medicalindustrial complex. As the example of psychopharmaceuticals shows, neither the industry nor the market (in the neoliberal understanding of the word) played the role of a strong actor in the state socialist system of East Germany. It therefore requires finer models to understand the interconnected parties – health administration, drug manufacturers, physicians, consumers and the law.120

Notes This contribution summarizes findings from a three-year research project undertaken on the basis of a concept published in the Medizinhistorischen Journal 2007 (Volker Hess, “Psychochemicals crossing the wall. Die Einführung der Psychopharmaka in die DDR aus der Perspektive der neueren Arzneimittelgeschichte,” Medizinhistorisches Journal 42 (2007)). The project was promoted by the Deutschen Forschungsgemeinschaft (HE 2220–2227). I thank Ulrike Klöppel, Viola Balz and Matthias Hoheisel for their productive and stimulating cooperation that is presented here. 1. J. Swazey, Chlorpromazine in Psychiatry: A Study in Therapeutic Innovation (Cambridge, MA: MIT Press, 1974). 2. J. Delay, et al., “Utilisation en thérapeutique psychiatrique d´une phénothiazine d´action centrale elective,” Annales Medico-Psychologiques 110 (1952): 112–31.

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3. Colloque International sur la Chlorpromazine et les Medicaments Neuroleptiques en Thérapeutique Psychiatrique in Paris vom 22–23. Oktober 1955. Vgl. J. Delay and P. Deniker, “Chlorpromazine and Neuroleptic Treatments in Psychiatry,” Journal of Clinical and Experimental Psychopathology 17 (1956):19–24. 4. Zu Chlorpromazin s. Jean Thuillier, Les dix ans ont qui changé la folie (Paris: R. Laffont, 1980); zu Tranquilizern s. M.C. Smith, A Social History of the Minor Tranquilizers (New York: Haworth Press, 1991); Ottfried K. Linde (ed.), Pharmakopsychiatrie im Wandel der Zeit – Erlebnisse und Ergebnisse (Klingenmünster: Tilia Verlag, 1988). 5. In Germany the immediate costs of treatment for mental and behavioral disorders amounted to ca. 16 billion euros in 2011. Mental disorders have led to a production loss of about six billion euros (2012). The indirect costs because of absence from work are estimated at 10.5 billion euros. 6. Helmuth Trischler, “Wachstum – Systemnähe – Ausdifferenzierung. Grossforschung im Nationalsozialismus,” in Wissenschaften und Wissenschaftspolitik. Bestandaufnahmen zu Formationen. Brüchen und Kontinuitäten in Deutschland des 20. Jahrhunderts, ed. Rüdiger vom Bruch and Brigitte Kaderas (Stuttgart: Steiner, 2002): 241–252. 7. Marcia Angell, The Truth About the Drug Companies. How They Deceive Us and What to do About it (New York: Random House, 2004); Jeremy A. Greene and Scott H. Podolsky, “Keeping Modern in Medicine: Pharmaceutical Promotion and Physician Education in Postwar America,” Bulletin of the History of Medicine 83 (2009): 331–377; “Senators Who Weakened Drug Bill Got Millions From Industry,” USA Today May 10 (2007); B. Lo, “Serving Two Masters: Conflicts of Interest in Academic Medicine,” The New England Journal of Medicine 8 (2010): 669–671. 8. For large areas of psychopathology there is no experimental animal equivalent. Experiments with healthy volunteers usually fail. It was (and is) impossible to observe the antipsychotic effect of neuroleptics in self-tests, as the discovery of chlorpromazine shows. 9. A good example is the introduction of the Hamilton Rating Scale. Vgl. David Healy, The Antidepressant Era (Cambridge, MA; London: Harvard University Press, 1997), 99–119; Michael Worboys, “The Hamilton Rating Scale for Depression: The Making of a ‘gold standard’ and the Unmaking of a Chronic Illness, 1960−1980,” Chronic Illness 9 (2013): 202–219; see also the separate debates of Allen Frances, Saving Normal: An Insider’s Revolt Against Out-ofControl Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (New York: William Morrow, 2013). 10. Jean-Paul Gaudillière and Volker Hess, “General Introduction,” in Ways of Regulating Drugs in the 19th and 20th Centuries, ed. Jean-Paul Gaudillière and Volker Hess (London: Palgrave Macmillan, 2012): 1–16. 11. Stefan Timmermans and Marc Berg, “Standardization in Action: Achieving Local Universality through Medical Protocols,” Social Studies of Science 27 (1997): 273–305. 12. Harry M. Marks, The Progress of Experiment. Science and Therapeutic Reform in the United States, 1900–1990 (Cambridge: Cambridge University Press, 1990); Peter Keating and Alberto Camprosio, “Cancer Clinical Trials: The Emergence and Development of a New Style of Practice,” Bulletin of the History of Medicine 81 (2007): 197–223.

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13. Stefan Timmermans and Marc Berg, The Gold Standard. The Challenge of Evidence-Based Medicine and Standardization in Health Care (Philadelphia, PA: Temple University Press, 2003). 14. Examples in: Anne I. Hardy, “Paul Ehrlich und die Serumproduzenten: Zur Kontrolle des Diphterieserums in Labor und Fabrik,” Medizinhistorisches Journal 41 (2006): 51–84; Axel C. Hüntelmann, “Das Diphtherie-Serum und der Fall Langerhans,” Medizin, Gesellschaft und Geschichte 24 (2006): 71–104; Ulrike Klöppel, “Enacting Cultural Boundaries in French and German Diphtheria Serum Research,” Science in Context 21 (2008): 161–180. 15. David Healy, “Some Continuities and Discontinuities in the Pharmacotherapy of Nervous Conditions Before and After Chlorpromazine and Imipramine,” History of Psychiatry 11 (2000): 393–412. 16. Jeremy A. Greene, “Attention to the ‘Details’: Etiquette and the Pharmaceutical Salesman in Postwar American,” Social Studies of Science 34 (2004): 393–412.; Ulrike Thoms, “Fachmann oder Buhmann? Der Pharmareferent als Marketinginstrument im 20. Jahrhundert,” Zeitschrift für Unternehmensgeschichte, Sonderheft Vertreter & Reisende 2015 (2015): 196–219. 17. Nicolas Rasmussen, “The Moral Economy of the Drug Company. Medical Scientist Collaboration in Interwar America,” Social Studies of Science 34 (2004): 161–185; Jean-Paul Gaudillière, “Une marchandise scientifique? Savoirs, industrie et régulation du médicament dans l’Allemagne des années trente,” Annales. Histoire, Sciences Sociales 65 (2010): 89–120. 18. Jordan Goodman and Vivien Walsh, The Story of Taxol: Nature and Politics in the Pursuit of an Anti-cancer Drug (Cambridge: Cambridge University Press, 2001); Ilana Löwy and Jean-Paul Gaudilliere, “Médicalisation, mouvements féministes et régulation des pratiques médicales: les controverses sur le traitement hormonal de la ménopause,” Nouvelles Questions Féministes 25 (2006): 48–65. 19. S. Jasanoff, Risk Management and Political Culture (New York: Russell Sage Foundation, 1986); S. Epstein, Impure Science: AIDS, Activism, and the Politics of Knowledge (Berkeley: University of California Press, 1996). 20. David Healy, Let them eat Prozac. The Unhealthy Relationship Between the Pharmaceutical Industry and Depression (New York: New York University Press, 2004); Andrea Tone, The Age of Anxiety: A History of America’s Turbulent Affair with Tranquilizers (New York: Basic Books, 2009); Jeremy A. Greene, Prescribing by Numbers. Drugs and the Definition of Disease (Baltimore: Johns Hopkins University Press, 2007). 21. The European Science Foundation research-network was supported by 13 research groups. For the scope of the project see: Christian Bonah, Christophe Masutti, Anne Rasmussen, and Jonthan Simon., eds., Harmonizing 20th Century Drugs: Standards in Pharmaceutical History (Paris: Glyphe 2009). 22. Jean-Paul Gaudillière and Volker Hess, eds., Ways of Regulating Drugs in the 19th and 20th Centuries, Science, Technology and Medicine in Modern History (London: Palgrave Macmillan, 2012). 23. Anna-Sabine Ernst, “Die beste Prophylaxe ist der Sozialismus”: Ärzte und medizinische Hochschullehrer in der sowjetischen Besatzungszone/DDR 1945–1961 (Münster: Waxmann, 1997). 24. André Steiner, “Das DDR Wirtschaftssystem: Etablierung, Reformen und Niedergang in historisch-institutionenökonomischer Perspektive,” in Die

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26.

27.

28.

29.

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Wirtschaftsgeschichte vor der Herausforderung durch die New Institutional Economics, ed. Karl-Peter Ellerbrock and Clemens Wischermann (Dortmund: Ardey-Verlag, 2004): 113–131. G. Langer and H. Heimann, “Ausschnitte einer Geschichte der Psychopharmaka im 20. Jahrhundert,” in Psychopharmaka: Grundlagen und Therapie, ed. idem (Wien, etc.: Springer, 1983): 21–37; Olfried K. Linde, ed., Pharmakopsychiatrie im Wandel der Zeit. Erlebnisse und Ergebnisse. Wissenschaftsanekdotisches von Forschern und ihren Formeln (Klingenmünster: Tilnia-Verlag, 1988); 7b DIREKT Apothekerservice AG, ed., 45 Jahre Pharmazie in Deutschland Ost. Beiträge zur Geschichte des Arzneimittel- und Apothekenwesens der Deutschen Demokratischen Republik (Fürstenfeldbruck, Berlin: 7b-Direkt-Apothekenservice, 2007) don’t do justice to links between the pharmaceutical industry, clinical research, markets and drug regulation. For the prehistory of modern psychopharmacy in Germany, see: Frank Hall, “Psychopharmaka. Ihre Entwicklung und klinische Erprobung. Zur Geschichte der medikamentösen Therapie in der deutschen Psychiatrie von 1844 bis 1952” (Diss. med., FU Berlin, 1996). Viola Balz and Ulrike Klöppel, “Psychopharmaka im Sozialismus. Arzneimittelregulierung in der Deutschen Demokratischen Republik in den 1960er Jahren,” Berichte zur Wissenschaftgeschichte 33 (2010): 382–400. Ulrich Meyer, Steckt eine Allergie dahinter? Die Industrialisierung von Arzneimittelentwicklung, -herstellung und -vermarktung am Beispiel der Antiallergika, vol. 4, Schriften zur Geschichte der Pharmazie und Sozialpharmazie (Stuttgart: Wiss. Verl.-Ges., 2002), 254. Exceptions include the comparative research project of Jürgen Harders, Arzneimittelforschung und Industrieorganisation: DDR und Ungarn im Vergleich, Ökonomische Studien, 37 (Stuttgart, etc: Fischer, 1985), 3286. Das Gesundheitswesen in der Sowjetzone (Bonn: o. J.); “Die chemische Industrie in der sowjetischen Besatzungszone,” ed. Sozialdemokratische Partei Deutschlands: (Bonn: 1951); “Das Arzneimittelwesen in der Sowjetzone: Kurzreferat,” Pharmazeutische Industrie 15 (1953): 150–153. Gerhard Alcer, “Entwicklung der Pharma-Industrie in der DDR,” Pharmazeutische Zeitung 139 (1994): 102–105; “Zum Konzentrations-und Spezialisierungsprozeß in der pharmazeutischen Industrie der DDR,” in Materialien zur Pharmaziegeschichte: Akten des 31. Kongresses für Geschichte der Pharmazie; Heidelberg 3–7. Mai 1993, ed. Wolf-Dieter Müller-Jahncke, et al. (Stuttgart: Wissenschaftliche Verlags-Gesellschaft, 1995): 169–177; Klaus Krug, “Sicherung, Konservierung und Präsentation von Sachzeugen der chemischen Industrie Mitteldeutschlands”; and Gerhard Alcer, “Zum Konzentrations-und Spezialisierungsprozeß in der pharmazeutischen Industrie der DDR,” in Zeitzeugenberichte: Chemische Industrie, ed. Klaus Krug and Hans-Wilhelm Marquart (Frankfurt am Main: Gesellschaft deutscher Chemiker, 1998); Reinhard Schnettler, “Die Pharma-Industrie in der DDR: Deutsch-deutsches Pharma-Symposium” Pharmazeutische Industrie 52 (1990): 527–530; Reiner Karlsch, “Von der Schering AG zum VEB Berlin-Chemie: die Folgen der Teilung Berlins für die chemische Industrie im Ostteil der Stadt,” in Wirtschaft im geteilten Berlin 1945–1989, ed. Wolfram Fischer and Johannes Bähr (München etc: Saur, 1994): 224–258; for the position of science in the GDR see the anthology: Dieter Hoffmann and Kristie Macrakis, eds., Naturwissenschaft und Technik in der DDR (Berlin, 1997).

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30. Beilicke, W., “Die Transformation des VEB Pharmazeutisches Kombinat GERMED Dresden aus der Zentralverwaltung in die Marktwirtschaft,” in Umbruch: Beiträge zur sozialen Transformation in den alten und neuen Bundesländern. H. 7, ed. I. Kurz-Scherf and G. Winkler (1993). 31. Dietrich Redeker, Zur Entwicklungsgeschichte der Tuberkolostatika und Antituberkulotika (Stuttgart: Deutscher Apotheker-Verlag, 1990). 32. Ingrid Pieroth, Penicillin. Von den Anfängen bis zur Großproduktion (Stuttgart: Wissenschaftliche Verlags-Gesellschaft, 1992); vgl. Meyer, Steckt eine Allergie dahinter? Die Industrialisierung von Arzneimittelentwicklung, -herstellung und -vermarktung am Beispiel der Antiallergika 4, 255. 33. Alcer, “Entwicklung der Pharma-Industrie in der DDR.” 34. See K. Pritzel, “Die Neuordnung des Arzneimittelmarktes in der sowjetischen Besatzungszone: Zur Durchführung der Arzneimittelgesetze der Länder der Deutschen Demokratischen Republik,” Die Pharmazie 4 (1949): 563–565. 35. The DGR entered the WHO in 1972. The concept of “essential drugs” was launched in 1977 and became a main pillar of the “Primary Health Care” strategy of the United Nations. 36. Among, f.e. Joachim Richter (Institut für Arzneimittelwesen), Dietrich Baumann (Ministerium für Gesundheitswesens); see “Arbeitsordnung des Zentralen Gutachterausschusses für Arzneimittelverkehr beim Ministerium für Gesundheitswesen,” Medicamentum 2 (1961): 218–221. For selfrepresentation of the ZGA see “35 Jahre Zentraler Gutachterausschuß für Arzneimittelverkehr beim Minister für Gesundheitswesen der DDR,” Medicamentum 27 (1986): 77–83. 37. Hauschild, “Der zentrale Gutachterausschuß und die Arzneimittelgesetzgebung der DDR.” Die Pharmazie 6 (1951): 313–316 38. On the one hand, the GDR was responsible for standardization in the pharmaceutical sector within the RGA; on the other it sought a “world standard,” which is modeled on the WHO policy of a basic assortment of meaningful and effective drugs (Bericht Dr. Carstens vom 24 May 1968 “Einschätzung der RGW-Arbeit und Darlegung des derzeitigen Standes,” Protokolle über Beratungen und Berichte des Arbeitskreises “Psychopharmaka,” VEB AWD, No 239. 39. “Sonderheft Arzneimittelgesetz,” Medicamentum 28 (1987); for the important laws see “Die wichtigsten Gesetze und Verordnungen der DDR auf dem Gebiete des Arzneimittel-und Apothekenwesens,” Pharmazeutische Praxis 13 (1958): 41–43. Zur Arzneimittelgesetzgebung s. Joachim Richter, “Das neue Arzneimittelgesetz der Deutschen Demokratischen Republik und seine Bedeutung für die Begutachtung von Arzneimitteln,” Zeitschrift für ärztliche Fortbildung 59 (1965): 413–420 and (from another perspective) Paul U. Unschuld, “Die Grenzen der Therapiefreiheit: ein Vergleich der Arzneimittelgesetzgebung der DDR und der Bundesrepublik Deutschland mit historischem Rückblick,” Pharmazeutische Zeitung 124 (1979): 1976–1990. 40. Consequently, the responsible medical officers commented on the drug scandals in the West with a degree of self-satisfaction (on the Stalinon-Affäre 1954 see Klaus Ruckpaul, “Zur deutschen Arzneimittelgesetzgebung,” Das Gesundheitswesen 13 (1958), 1297; for the Contergan-Katastrophe see Joachim Richter, “Arzneimittelgesetzgebung und Arzneimittelqualität,” in Arzneimittel und Gesellschaft, ed. F. Jung, P. Oehme, and H. Rein (Berlin: Akademie-Verlag,

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42. 43.

44. 45. 46. 47.

48.

49. 50.

51.

52.

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1971), 43; B. Becher, “Lehren aus der Thalidomid-Katastrophe? – Zur Neugestaltung des Arzneimittelrechts in der Bundesrepublik,” medicamentum. Informationen für Ärzte und Apotheker 16 (1975): 93–95, although such accidents were also known in the GDR; Ulrich Meyer and Andreas Schuhmann, “Zur Geschichte der oralen Antidiabetika,” Geschichte der Pharmazie 51 (2001): 1–9. With the 12th Durchführungsbestimming of 1 July 1976 the conduct of clinical trials was regulated as well as the education- and consent duties were concretized (F. Hackenberger and H. Koch, “Prüfung von Arzneimitteln zur Anwendung in der Humanmedizin: die 12. Durchführungsbestimmung zum Arzneimittelgesetz der DDR,” Medicamentum 18 (1977): 130–135). Despite some exemplary cases, in practice it was often lacking. In quality assurance some exceptions were made for drugs produced in the GDR. (Meyer, Steckt eine Allergie dahinter? 4, 325–326). J. Richter and M. Wolski, “40 Jahre Regelung und Überwachung des Arzneimittelverkehrs in der Deutschen Demokratischen Republik,” Die Pharmazie 44 (1989): 666–671. Nomenklatur, C. was first set up in 1984 and actualized in 1986, 1987, 1989. Joachim Richter, “Die Entwicklung des sozialistischen Arzneimittelwesens” Medicamentum 10 (1969), 259. Instead, the state institutions of drug control were required to inform the medical staff (H. Probst and H. Möller, “Aufgaben und Organisation der Arzneimittelinformation in der DDR,” Die Pharmazie 41 (1986): 350–353). Alcer, “Entwicklung der Pharma-Industrie in der DDR.” “Die pharmazeutische Industrie in den 30 Jahren des Bestehens der DDR,” Medicamentum 20 (1979): 258–261. Volkswirtschaftsplan 1 May 2002 of 1966 with number 060606/6-03/4 for the development of antidepressants (VEB AWD, Nr. 302). Mathias Hoheisel and Ulrike Klöppel, “‘Wunschverordnung’ oder objektiver ‘Bevölkerungsbedarf’? Zur Wahrnehmung des Tranquilizer-Konsumenten in der DDR (1960–1970),” Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin 21 (2013): 213–244. Viola Balz and Volker Hess, “Psychopathology and Psychopharmacology Standardization from the Bottom Up, Using the Example of Neuroleptics,” in Harmonizing 20th Century Drugs: Standards in Pharmaceutical History, ed. Christian Bonah et al. (Paris: Glyphe, 2009). Volkswirtschaftsplan 1966, Forschungsplan der Forschung 1, VEB AWD, No 302. After promazine, containing a limited neuroleptic potential, Maxastine was used (Oldřich Vinař, “A psychopharmacology that nearly was,” in The Psychopharmacologists, ed. David Healy (London: Arnold, 2000), 58). For the interview series see David Healy, The Psychopharmacologists: Interviews, Vol. 3 (London, etc.: Arnold, 1996–2000). Ulrike Klöppel, “1954: Brigade Propaphenin arbeitet an der Ablösung des Megaphen. Der prekäre Beginn der Psychopharmakaproduktion in der DDR,” in Arzneimittel des 20. Jahrhunderts. Historische Skizzen von Lebertran bis Contergan, ed. Nicolas Eschenbruch, , Viola Balz, Ulrike Klöppel, and Marion Hulverscheidt. (Bielefeld: Transcript, 2009): 199–227. Only during the war did the plant start to manufacture drugs (sulfonamides). These were also important in the immediate postwar period, which

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60. 61. 62.

63.

64.

65. 66.

67.

68. 69.

70. 71.

72.

Volker Hess is why the Russian military administration largely spared the plant from dismantling. Internal report of Hydrierwerkes Rodleben of 20 January 1954. Annual report 1954 VEB Deutsches Hydrierwerk Rodleben. The Archives of the Charité psychiatry comprises a total of 80,000 patient records from 1880 to 1980. DHW (12.8.1954b), DHW (17.8.1954a). DHW (27.10.1955). DHW (Januar 1959: 1). Viola Balz and Matthias Hoheisel, “East Side Story: The Standardization of Psychotropic Drugs at the Charité Psychiatric Clinic 1955–1970,” Studies in History and Philosophy of Biological and Biomedical Sciences 42 (2011): 453–466. Benkert, Hippius 1986, 67. Healy, The Antidepressant Era, 54. University Archives of the Humboldt-University 039012/4, File 1960–69: With Notes and provided revised minutes of the extraordinary Protokoll der außerordentlichen Dienstbesprechung der Verbindungsärzte, Versorgungsausschuss der Charité am 31 October 1961, undated, 5; see also “Importpräparate aus sozialistischen Ländern: Frenolon,” Medicamentum 7 (1962): 224–225. Wunderlich states on 21 August 1968; Protokolle über Beratungen und Berichte des Arbeitskreises “Psychopharmaka,” VEB AWD, No 239, o.P. 5 Mio Mark import costs will be saved. In the patient files after 1961 we find the Western brand name “Tofranil” from time to time. This could be due to greater familiarity of the doctors with that name. But these findings also suggest the possibility of importing Tofranil, maybe due to periods of deficiency. Why the GDR industry finally provided its own drug is a question of current research. Protokoll der Dienstbesprechung der Verbindungsärzte, Versorgungsausschuss der Charité, from 18 September 1962, UAHU undated: “Es wurde festgestellt, daß sich die Versorgung mit Importmedikamenten wesentlich gebessert hat. In den meisten Fällen erfolgte die Belieferung in Höhe der vorliegenden Planzahlen”; Protokoll der Dienstbesprechung der Verbindungsärzte, Versorgungsausschuss der Charité, of 20 August 1963, UAHU undated: “Planmäßig versorgt wurde die Nervenklinik mit Melipramin Drag.” Balz and Hoheisel, “East Side Story,” and Mathias Hoheisel, “Von der Suchtdroge zum Therapeutikum,” Medizinhistorisches Journal 47 (2012): 62–98. DDR Patent 57126 Akz Wp 12p/119 794. Vertrauliche Dienstsache (1968): Patentsituation Faustan, Protokolle über Beratungen und Berichte des Arbeitskreises “Psychopharmaka.” VEB AWD, No 239, o.P. In the USA alone, in 1978 2.3 billion valium pills were sold. Counting Frenolon® (Methophenazin/Marophen, Zulassung 1962) and the tranquilizer Trioxazin from Hungary, Amitryptilin from the ČSSR (approved 1982) as well as Azaphen® from Russia (approved 1977). Neuroleptics of thioxanthen-derivatives were also not manufactured by the domestic industry, but in befriended socialist countries (chlorprothixene

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73. 74. 75.

76.

77.

78.

79. 80. 81.

82. 83.

84.

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from Czechoslovakia). Moreover, thioridazine (Melleril®) was available under the trade name Sonapax® from Poland (registration 1979) and Trifluperazin under the trade name Triphthazin® from the USSR. The 1958 butyrophenone (R1625), synthesized by Paul Janssen, was marketed in 1965 by the McNeill Pharmaceutical Company. Droperidol was used in the Neurolept-anaesthesia. Bericht Wunderlich vom 21 August 1968 im Arbeitskreis “Psychopharmaka,” Protokolle über Beratungen und Berichte des Arbeitskreises “Psychopharmaka,” VEB AWD, No 239, o.P. In Nomenklatur C., levomepromazine (Neurocil) was listed, which was replaced by the RGA import Tiscerin in 1984; the decanoate from fluphenazine and fluspirilene (Imap): also a depot preparation. The property that was labeled “atypical” by Hanns Hippius referred less to the chemical structure than to the lack of extrapyramidal symptoms with a simultaneous effect on those patients that only responded insufficiently to the “typical” neuroleptics of the phenothiazine and butyrophenon series. Clozapine therefore provides a good example of the epistemologically problematic status of pharmacological models in psychopathology. The substance that was produced from 1961 onwards by the Wander Chemie firm had not shown the effects (Apomorphine-antagonism; extrapyramidal symptoms) typically expected from neuroleptics. Only in clinical trials did the high antipsychotic effect appear, running against the belief that the antipsychotic potential of neuroleptics correlated with extrapyramidal symptoms (Parkinsoïd). Leponex’s success immediately led to a further refining of the dopamine-receptor theory. It was not until the early 1970s that there was sufficient clinical data to show a promising application, despite the risk of agranulocytosis. The manufacturer Sandoz-Wander achieved more profit with Leponex® than with any other psychopharmaceutical; cf. David Healy, The Creation of Psychopharmacology (Cambridge, MA: Harvard University Press, 2002), 243. “99. Mitteilung des Zentralen Gutachterausschuss für Arzneimittelverkehr (Klozapin),” Medicamentum 18 (1977): 50–53. “97. Mitteilung des Zentralen Gutachterausschusses für Arzneimittelverkehr (Klozapin),” Medicamentum 18 (1977): 15–18. In the United States one year totaled over $9,000, while the standard therapy with chlorpromazine was available for $100. See Healy, The Creation of Psychopharmacology, 243. See note 78. Udo Benzenhöfer, Bibliographie der zwischen 1975 und 1989 erschienenen Schriften zur Geschichte der Psychiatrie im deutschsprachigen Raum (Tecklenburg1992); Ulrike Hahn, Strukturtransfer und Eigensinn. Die Psychatriereform in Sachsen nach 1990 (Aachen: Shaker, 2007); Kathrin Franke, “Die Transformaton der Psychatrie in Ostdeutschland nach 1989 aus der Perspektive des Klinikpersonals,” in Abweichung und Normalität, ed. Christine Wolters, Christof Beyer, and Brigitte Lohff (Bielefeld: Transcript, 2013): 385–401. Sabine Hanrath, Zwischen “Euthanasie” und Psychiatriereform. Anstaltspsychiatrie in Westfalen und Brandenburg: Ein deutsch-deutscher Vergleich: 1945–1964, Vol. 41, Forschungen zur Regionalgeschichte (Paderborn: Schoeningh, 2002): 31–62.

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85. Winfried Süß, “Gesundheitspolitik,” in Drei Wege deutscher Sozialstaatlichkeit: NS-Diktatur, Bundesrepublik und DDR im Vergleich, ed. Hans Günther Hockerts (München: Oldenbourg , 1998); Udo Schagen and Sabine Schleiermacher, “Gesundheitswesen und Sicherung bei Krankheit und im Pflegefall. Geschichte der Sozialpolitik in Deutschland seit 1945,” in Geschichte der Sozialpolitik in Deutschland seit 1945. Hrsg. vom Bundesministerium für Arbeit und Sozialordnung und dem Bundesarchiv. Band 8: DDR 1949–1961. Im Zeichen des Aufbaus des Sozialismus, ed. Dierk Hoffmann and Michael Schwartz (Baden-Baden: Nomos-Verlagsgesellschaft, 2004): 55–100. 86. Gabriele Moser, “Das Gesundheitswesen in Mecklenburg-Vorpommern nach 1945: Nationalsozialistisches Erbe, politischer Anspruch, medizinischer Versorgungsnotstand,” Rostocker medizinische Beiträge (1995); Wolfgang Rose, “Zur Entwicklung des Gesundheitswesens in der Stadt Lübben,” in Krankenhäuser in Brandenburg: vom mittelalterlichen Hospital bis zum Krankenhaus in der Moderne, ed. Kristina Hübener and Wolfgang Rose, Schriftenreihe zur Medizin-Geschichte des Landes Brandenburg (Berlin: be.bra wissenschafts verlag, 2007): 165–196. 87. Limited studies deal with Berlin-Brandenburg: Anstaltspsychiatrie in der DDR. Die brandenburgischen Kliniken zwischen 1945 und 1990 (Berlin: be.bra wissenschaft, 2005), Beatrice Falk and Friedrich Hauer, Brandenburg-Görden. Geschichte eines psychiatrischen Krankenhauses, Schriftenreihe zur MedizinGeschichte des Landes Brandenburg (Berlin: Bebra, 2007). For Sachsen see: Holger Steinberg and M.M. Weber, “Vermischung von Politik und Wissenschaft in der DDR. Die Untersuchung der Todesfälle an der Leipziger Neurologisch-Psychiatrischen Universitätsklinik unter Müller-Hegemann 1963,” Fortschritte der Neurologie Psychiatrie 79 (2011): 561–569; for Thüringen and Anhalt see E. Kumbier and K. Haack, “Psychiatrie an den Mitteldeutschen Universitätsnervenkliniken 1945–1961,” in Biogenese und Psychogenese, ed. A. Marneros and D. Röttig (Regensburg: Roderer, 2008): 126–135. 88. Achim Thom and Erich Wulff, eds., Erfahrungen und Perspektiven in Ost und West (Bonn: Psychiatrie-Verlag, 1990), Jürgen Mauthe and Ingrid Kruckenberg-Bateman, eds., Psychiatrie in Deutschland: Tagungsband zu den 8. Psychiatrie-Tagen Königslutter 1990, 2. ed. (Königslutter: Vereinsverlag des Vereins zur Hilfe für Seelisch Behinderte, 1992): 91–96; Siegfried Schirmer, “Anmerkungen zur DDR-Psychiatrie: Ein Beitrag zur jüngsten Psychiatriegeschichte,” Krankenhauspsychiatrie 3 (1992): 188–189; Ursula Plog, “Über den Mißbrauch der Psychiatrie durch den Staatssicherheitsdienst der DDR,” Mabuse (1993), 30–34. In this context especially the television documentation by Ernst Klee (“Die Hölle von Uckermünde”) should be mentioned. Its generalizing undertone fueled the debate considerably; see Hanrath, Zwischen “Euthanasie” und Psychiatriereform. Anstaltspsychiatrie in Westfalen und Brandenburg: Ein deutsch-deutscher Vergleich: 1945–1964, 41, 6f. 89. Bundesminister für Gesundheit, Zur Lage der Psychiatrie in der ehemaligen DDR: Bestandsaufnahme und Empfehlungen (Bonn: Eigenverlag, 1991); Sonja Süß, Politisch mißbraucht? Psychiatrie und Staatssicherheit in der DDR (Berlin: Ch. Links Verlag, 1998). 90. Ernst, “Die beste Prophylaxe ist der Sozialismus”: Ärzte und medizinische Hochschullehrer in der sowjetischen Besatzungszone/DDR 1945–1961.

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91. Francesca Weil, Zielgruppe Ärzteschaft. Ärzte als inoffizielle Mitarbeiter des Ministeriums für Staatssicherheit der DDR (Göttingen: V&R unipress, 2008); for criticism of this generalizing critique, see Hansjörg Rothe, “Rezension von Francesca Weil, Zielgruppe Ärzteschaft. Ärzte als Inoffizielle Mitarbeiter,” Horch und Guck 59 (2008): 78–79. 92. Sabine Hanrath, “Strukturkrise und Reformbeginn: Die Anstaltspsychiatrie in der DDR und der Bundesrepublik bis zu den 60er Jahren,” in Psychiatriereform als Gesellschaftsreform. Die Hypothek des Nationalsozialismus und der Aufbruch der sechziger Jahre, ed. Franz-Werner Kersting, Forschungen zur Regionalgeschichte (Paderborn; München; Wien; Zürich: Ferdinand Schöningh, 2003). 93. As shown by Luise M. Köhler, “Entwicklungsprobleme im Fachgebiet Neurologie/Psychiatrie im Land Brandenburg in der Zeit vom Mai 1945 bis 1952” (Diss. med. Leipzig, 1986), from historical perspective Hanrath, Zwischen “Euthanasie” und Psychiatriereform. Anstaltspsychiatrie in Westfalen und Brandenburg: Ein deutsch-deutscher Vergleich: 1945–1964, 41. 94. The neuroleptics chlorpromazine, reserpine, promazine and Methophenazin (imported from Hungary) and the tranquilizers benactyzine and meprobamate (since 1961/62 an import from Hungary, gradually replaced by GDR-production). The MAO-I phenelzine was approved in 1963 as an antidepressant. 95. The antipsychotic chlorpromazine, reserpine, promazine and Methophenazin (imported from Hungary). The tranquilizers benactyzine and meprobamate were after 1961/62 replaced as an import from Hungary by East German production. 1963, the MAO-inhibitor phenelzine was approved as an antidepressant. Also chlorprothixene (replacing the regulated import of Librium), diazepam, nitrazepam and medazepam. 96. These included imipramine imported from Hungary; from 1971 produced in the GDR), Butaperazin, fluphenazine, pimozide (from 1972 imported from Hungary), haloperidol (imported from 1976), clozapine (1982 East German production, previously available as an import for “Prüfkliniken”), fluspirilene (1982 East German production, previously imported), levomepromazine (imported from 1982). 97. Toedtmann, Vorlage für die Ministerdienstbesprechung des MfG: Grundorientierung zur langfristigen Entwicklung des Gesundheitswesens und der medizinischen Forschung bis 1980 und darüber hinaus, 19 November 1974, BArch: DQ 1/6567, hier p. 20 98. Hanrath, Zwischen “Euthanasie” und Psychiatriereform. Anstaltspsychiatrie in Westfalen und Brandenburg: Ein deutsch-deutscher Vergleich: 1945–1964, 41, 441–413; Ehrig Lange an Rat für Planung, Protokoll der Sitzung der Problemkommission Psychiatrie am 09.11.1970, o.D. [09 November 1970], BArch: DQ 109/277. 99. Ehrig Lange an Rat für Planung, Protokoll der Sitzung der Problemkommission Psychiatrie am 09.11.1970, o.D. [09 November 1970], BArch: DQ 109/277. 100. This section is mainly the result of the work of Ulrike Klöppel and Viola Balz, whom I thank sincerely. 101. Volker Hess and Benoît Majerus, “Writing the History of Psychiatry in the 20th Century,” History of Psychiatry 22 (2011): 144–154.

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102. E. Kumbier, K. Haack, and Holger Steinberg, “50 Jahre Rodewischer Thesen – Zu den Anfängen sozialpsychiatrischer Reformen in der DDR,” Psychatrische Praxis 40 (2013): 313–320; Volker Hess, “The Rodewisch (1963) and Brandenburg (1974) propositions,” History of Psychiatry 22 (2011): 232–243; especially Sabine Hanrath, Zwischen “Euthanasie” und Psychiatriereform. Anstaltspsychiatrie in Westfalen und Brandenburg: Ein deutsch-deutscher Vergleich: 1945–1964, 41. In the BRD a commission of experts presented the Bundesregierung with their conclusions in a psychiatry survey in 1975. 103. For example Klaus Weise, “Sinn und Unsinn des Begriffs Sozialpsychiatrie,” Psychiatrie, Neurologie und medizinische Psychologie 38 (1986): 689–693; and “Psychiatrie-Reform in der DDR – am Beispiel der sektorisierten Betreuung eines Leipziger Stadtbezirks,” in Psychiatrie-Reform in Europa. Beiträge zum Europäischen Symposium zur Entwicklung der Psychiatrie vom 25. Mai bis 30. Mai 1990, ed. Manfred Bauer, et al. (Bonn: Hessische Landeszentrale für Politische Bildung, 1991): 59–87. 104. Michael Seidel, “Interview,” in Zeitzeugen Charité. Arbeitswelten der Psychiatrischen und Nervenklinik, 1940–1999, ed. Isabel Atzl, Volker Hess and Thomas Schnalke, (Münster: LIT, 2005): 88–101. 105. Holger Steinberg, “Karl Leonhard hat ‘kein Interesse!’ – Hintergründe über das Rodewischer Symposium aus neu aufgetauchten Quellen,” Psychatrische Praxis 1 (2014): 3–57. 106. Wagner, Aktennotiz betr. telefonische Rückfrage bei A III, Genossin Hosse, wegen Bildung der Problemkommission Psychiatrie und geistige Gesundheit, 12 March 1965, BArch: DQ1/23058 107. Otto Bach, ed., Sozialpsychiatrische Forschung und Praxis (Leipzig: Thieme, 1976). Hanrath also comes to the conclusion that the (few) successes were the result mainly of the committed workers in the psychiatric institutions (Hanrath, Zwischen “Euthanasie” und Psychiatriereform. Anstaltspsychiatrie in Westfalen und Brandenburg: Ein deutsch-deutscher Vergleich: 1945–1964, 41, 442). 108. Klaus-Dieter Waldmann, “Psychiatrie in der ehemaligen DDR – eine widerspruchsvolle Bilanz,” Sozialpsychiatrische Information 28, no. 4 (1998): 18–22; Helmut Haselbeck, “Sozialpsychiatrie und das biologische Krankheitsmodell. Von der Konfrontation zur Integration,” in Psychiatrie im Wandel. Erfahrungen und Perspektiven in Ost und West, ed. Achim Thom and Erich Wulff (Bonn: Psychiatrie-Verlag, 1990): 13–21. For local initiatives, see: A. Lerner and H. Steinberg, “Zur Geschichte einer sozialpsychiatrischen Versorgungsform: Die Familienpflege am Beispiel der Heil- und Pflegeanstalt Leipzig-Dösen,” Psychiatrische Praxis 38 (2011): 274–279. 109. OMR Dr. Münter: Erste Konzeption der Entwicklung der Betreuung nach 1980, 29 May 1979, BArch DQ1-24219, 10. 110. W. Hanzl, Untersuchung über den Verbrauch von Psychopharmaka im Kreis Zittau (Monat August 1968). Das Deutsche Gesundheitswesen 25 (1970): 322–324. According to this study, only 13.2 per cent of the prescriptions were for “nervous illnesses” such as “depression,” schizophrenia, neurological syphilis, paralyses, neuritides and migraines. 111. Doris Panzer, Die Entwicklung der Kapazitäten und Leistungen in der Fachrichtung Psychiatrie und Neurologie – staatlich-örtlich geleitete stationäre Einrichtungen in der DDR im Zeitraum 1970–1984 sowie ein Vergleich zur BRD,

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112.

113.

114.

115.

116.

117.

118.

119.

120.

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o.D. [17 July 1985], BArch: DQ 1/14245. At the same time the number of cases went up 2 per cent during the time of the study. The increase in costs for institutions was also the reason for the shortening of treatment trajectories. Hans Günther Hockerts, “Soziale Errungenschaften? Zum sozialpolitischen Legitimationsanspruch der zweiten deutschen Diktatur,” in Von der Arbeiterbewegung zum modernen Sozialstaat: Festschrift für Gerhard A. Ritter zum 65. Geburtstag, ed. Jürgen Kocka (München: Saur, 1994): 790–804. Hans Günther Hockerts, Drei Wege deutscher Sozialstaatlichkeit: NS-Diktatur, Bundesrepublik und DDR im Vergleich (München: Oldenbourg, 1998), Einführung. Christoph Kleßmann, “Verflechtung und Abgrenzung: Aspekte der geteilten und zusammengehörigen deutschen Nachkriegsgeschichte,” Aus Politik und Zeitgeschichte 29–30 (1993): 30–41. Greg Eghigian, “Was There a Communist Psychiatry? Politics and East German Psychiatric Care, 1945–1989,” Harvard Rev Psychiatry 10 (2002): 364–368; Konrad H. Jarausch, “Die USA und die DDR: Vorüberlegungen zu einer asymetrischen Beziehungsgeschichte,” in Umworbener Klassenfeind: das Verhältnis der DDR zu der USA, ed. Uta A. Blabier (Berlin: Links, 2006): 26–31. Thomas Lindenberger, “Die Diktatur der Grenzen: Zur Einleitung,” in Herrschaft und Eigen-Sinn in der Diktatur: Studien zur Gesellschaftsgeschichte der DDR, ed. Thomas Lindenberger (Köln: Böhlau, 1999): 13–44. Richard Bessel and Ralph Jessen, eds., Die Grenzen der Diktatur: Staat und Gesellschaft in der DDR (Göttingen: Vandenhoeck & Ruprecht, 1996), Ralph Jessen, “Die Gesellschaft im Staatssozialismus: Probleme einer Sozialgeschichte der DDR,” Geschichte und Gesellschaft 21 (1995): 96–110. Viola Balz, “‘Für einen Aktivisten wie mich müssen Sie doch eine effektives Mittel haben’. Patienteninteresse und Psychopharmakakonsum an der Chariténervenklinik in 1960er Jahren,” Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin 21 (2013): 245–271. See Jean-Paul Gaudilliére and Ulrike Thoms published Special Issue of History and Technology 29 (2013) zu Pharmaceutical Firms and the Construction of Drug Markets: From Branding to Scientific Marketing. Compare with the scheme of “Five Ways of Regulating” in Gaudillière and Hess, General Introduction, in Ways of Regulating Drugs in the 19th and 20th Centuries, ed. Gaudillière and Hess.

9 Blame George Harrison: Drug Use and Psychiatry in Communist Yugoslavia Mat Savelli

In 2009, reporters from a Serbian news magazine posted a video from the Crna Reka monastery in the south of Serbia. Shot within a room adorned with Orthodox icons, the video showed a young drug addict being repeatedly beaten with a shovel and brutally punched in the face by a man wearing brass knuckles, while another “therapist” orders the young man to stay in place. The release of further videos revealed that such “treatment” was a typical component of a rehabilitation programme which had been running since 2005 at seven locations across the country. As one former patient recounted, “[i]n the yard, they gather the addicts in a circle to watch the ‘bad one’ get beaten …. They hit him with clubs, shovels, fists, bars, belts, whatever they get their hands on.”1 Upon its release, the footage shocked many within Serbia, leading members of the government and most of the Church hierarchy to condemn the Crna Reka programme. Yet despite the fact that much of the country was appalled by the revelations, the “spiritual-rehabilitation centre” was not immediately shut down. The programme’s administrator – a priest named Branislav Peranovic – was removed from his post, but he was not defrocked, later moving on to set up another church-run rehabilitation centre at Jadranska Lesnica. Although many members of the public were outraged, others voiced their support in letters to the editor and comments on news websites. Most importantly, not all of the families of patients registered at Crna Reka were shocked either. After all, they had each been paying roughly 350 euros a month to have their relatives (usually adult children) treated, some signing a contract acknowledging that light and “somewhat more severe” beatings might be required in order to restore the patient to health. More than 200 families subsequently issued a public statement of support for the controversial programme, 180

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noting that Peranovic’s methods had “secured safety for our children, took them off the streets and snatched them from certain ruin,” further stressing that the problem of addiction was one that could “knock on the door of any home as soon as tomorrow.”2 Nor was the Ministry of Health entirely put off by the scandal, signing a cooperation agreement with the Orthodox Church in 2011 which gave official sanction to the Church-sponsored “Land of the Living” programme, provided the worst abuses of Crna Reka were not repeated. Thus, although reactions to the scandal were initially characterized by shock, events in the subsequent weeks, months, and years demonstrated that, for a sizeable portion of the population, such harsh methods were understandable, perhaps even preferable. If anything, the events in Crna Reka served to fuel national discourse regarding the social threat of “narkomani.” The tone of these discussions echoed a wider moral panic over drug use that had been unfolding since the dissolution of Yugoslavia in the 1990s, with addicts widely assumed to be responsible for an impossibly large number of crimes and strange events. This chapter examines the psychiatric discussion over drug use, abuse, and addiction within Yugoslavia from the 1960s until the country’s collapse in 1991. At its core, the paper suggests that the later moral panic over drug use (and relative passivity regarding the Crna Reka events) can be understood as part of a longer trend whereby drug taking was framed as a social act that threatened the well-being of society, rather than a personal choice that might harm the individual. During the Communist era, many influential psychiatrists (with a few notable exceptions) testified that drug addiction was an increasingly dangerous menace, one linked specifically to a deviant youth subculture. Eventually coming to the conclusion that a narrow medical approach could never successfully tackle the issue, psychiatrists would instead appeal for a sweeping societal intervention that paired the actions of physicians with those of broader social, political, and religious organizations. Thus, although drug addiction did undergo a period of medicalization, it was subsequently (and swiftly) de-medicalized by psychiatrists themselves; instead, they placed responsibility for confronting and controlling drug use on the entirety of society. *** Illicit drug use did not make a significant imprint within the psychiatric field until the late 1960s and early 1970s. Although some earlier works, such as a pioneering 1961 textbook on general psychiatry, discussed

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the issue of “toxicomania,” the primary concern during this period related to the abuse of substances linked to formal medicine, especially morphine.3 On the whole, however, drug use rarely registered as a serious problem in the eyes of practitioners and the country did not bother keeping statistics on drug consumption. By the early 1970s, however, much had changed and an emerging body of literature testified to the growing threat posed by illicit drug addiction. Rather than the accidental morphine addict of the past, the new “narkoman” (from narkomanija – narcomania) represented a novel and more sinister danger to society, one capable of robbing pharmacies, setting up private production laboratories, and engaging in international drug smuggling.4 The new drugs of choice – marijuana, LSD, cocaine, and heroin (among others) – and the new user profile sparked increasing debate over the exact nature of the drug threat facing Yugoslavia.5 Concern over the use of illegal drugs continued to crescendo, culminating in 1972 with the First Yugoslav Symposium on the Prevention and Treatment of Narkomanija, held in the Serbian city of Nis. One of the primary concerns of the conference was the establishment of a profile of the typical addict. Uniformly, presenters suggested that the overwhelming majority of drug users were comprised of urban youth. In one of the conference’s introductory papers, Belgrade-based Slobodan Stojilkovic outlined the broad contours of the youth drug problem.6 When thinking about Yugoslavia’s burgeoning drug threat, he argued, it was necessary to do away with the old image of the opiate addict overcome with dependency. Instead, drug users were young people who had essentially set up their own alternative form of society within their circle of friends, with special rules, language, and values. Chief among these values was the loosely defined concept of “freedom” – a goal which had been denied to them by society (or so they imagined) and which might only be achieved through drug use. Indeed, drug-taking youth were engaged in what he characterized as a generational conflict, with young people attempting to carve out a new existence diametrically opposed to that of their parents and grandparents. From Stojilkovic’s point of view, the repulsion felt by older generations was not merely a consequence of youth drug-taking but rather the primary point of it. From the testimonies of his patients, it was clear that young people saw drug use as an instrument in the creation of a “better, more beautiful, and happier future.”7 The only positive he could draw from the situation was that drug use among youth was fashionable and, like all trends, it might eventually pass. Military psychiatrist Krtso Vujosevic echoed many of these sentiments in his discussion of marijuana usage.8 He noted that the previous

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“narkoman” of middle age was no longer the reality. Instead, young people disillusioned by broader social changes such as industrialization and urbanization were now taking to drug use, despite the fact that many marijuana users, in his view, came from “wealthy families” and lived in “rich surroundings.” With too much money in their pockets and time on their hands, young people were using drugs to combat boredom and rebel against society. According to one former psychiatrist, sons and daughters of Communist Party functionaries comprised a large number (perhaps even the majority) of young drug users during this era.9 Later research confirmed that drug use was inherently a youth phenomenon, with most people beginning to consume between the ages of 16–20 and those under 25 years of age representing nearly 86 per cent of all drug consumers.10 Such figures were especially problematic in light of the fact that drug-using students’ grades suffered and many quit school altogether, thereby compromising their employment prospects.11 If psychiatrists were going to successfully confront the issue of drug taking, it was crucial that they mastered the lexicon of Yugoslav youth (which typically drew upon English slang). As Stojilkovic warned, the “secret language” of using drugs like “Meri Džejn” (designed to facilitate communication between users and foreigners) meant that it was virtually impossible to understand exactly what young people were talking about without inside knowledge.12 Consequently, academic psychiatrists sometimes included reference material to help practitioners grapple with youth-speak. For example, Bruno Gacic’s extensive list of terminology included “fiks” (fix), “staf” (stuff), “bed trip” (bad trip), “stond aut sajd” (“to be stoned out of your world”), and the somewhat comical example “hev ju litl pis from paip for mi?” (“have you little piece from pipe for me?” translated as “do you have some hashish?”).13 Drug-taking (and its associated jargon) was consequently framed as an important and dangerous part of an emerging youth culture. By the late 1960s, Yugoslav youth had adopted their own modified version of the hippie subculture, with the associated taste in dress and music. Young people followed international stars such as Bob Dylan and the Beatles along with domestic bands such as Grupa 220.14 For psychiatrists, drug taking was thus inherently linked to hippiedom. As early as 1970, travellers on the hippie trail (which typically involved a stopover in Yugoslavia en route from Western Europe to India) were identified as sources of both inspiration and the actual drugs themselves.15 When hippies were not arriving in Yugoslavia, they were supposedly corrupting young Yugoslav men and women in such seemingly far flung locales as Nepal, Afghanistan, Amsterdam, and India – all places that

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young Yugoslavs apparently favoured frequenting.16 Like their Western counterparts, Yugoslav youth were believed to have taken up the practice of free love. According to Stojilkovic, narkomani relied upon drugs to bring them to a different plane of sexual existence. While high, they took part in orgies that “dehumanized man” and brought these individuals down to a bestial state, totally devoid of love and emotion. This form of youth drug taking was itself apparently responsible for a sharp rise in rates of venereal disease.17 Thus, the influence of Western hippies was often cited as the foremost reason behind the prevalence of drug-taking among Yugoslav youth.18 Not all commentators took such an inherently critical view of youth drug use and the hippie subculture. Lev Milcinski, the country’s most prominent suicidologist and a leading Slovene psychiatrist, saw youth drug consumption as something invested with meaning beyond mere rebellion. In a fascinating article, Milcinksi argued that drug use (especially hallucinogenics) among adolescents was, in some ways, an unconscious effort to achieve religious ecstasy and undergo a mystical experience.19 Nodding to Timothy Leary’s “psychedelic revolution,” he suggested that the emerging youth culture was a part of young people’s progressive search for existential meaning. Youth (in the West but also in Yugoslavia) had been failed by Western religions and consumer culture, thus explaining why young people were turning to George Harrison, Bob Dylan, and LSD. In a later article entitled “Treating Narcomania: Repression or Therapy?,” Milcinski continued this line of thinking, arguing that it was a complete fallacy and mistake on the part of fellow practitioners, police services, and the public to imagine that all illicit drugs could be understood as a homogeneous group. LSD and marijuana, especially, were deserving of their own category, since the reasons that youth turned to these drugs were radically different than the recreational use of opiates or amphetamines.20 Young people, disappointed with Western society’s (and here he included Yugoslavia) drive towards efficiency at all costs, used drugs to form an identity and to protest against the hypocrisy and prudishness of “traditional society.” Underscoring the fact that these two drugs did not produce the hallmarks of “true” narkomanija (dependence, withdrawal, craving leading to criminal acts), Milcinski proffered that these substances were instead part of a quest to achieve peace. As such, marijuana and LSD might be a “hellish lullaby” for some, but for youth they were a “heavenly guide.” Consequently, he railed against Article 208 in the newest federal Criminal Code as being excessively harsh, needlessly forcing long prison sentences upon individuals (almost always young people)

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for using drugs that were, in his view, less damaging to Yugoslav society than alcohol. Beyond Milcinski (and perhaps the Sarajevo-based Ziso Catovic), mental health workers rarely saw any sort of positive goal or utility in youth drug use.21 For Stojilkovic, youth drug use threatened the very fabric of social life. Even the supposed “soft drugs,” like marijuana and hashish, led to social degradation and a diminishment of people’s essential humanity.22 Ignjatovic and Kovacevic, meanwhile, stressed that the majority of theorists did not really believe that narcomania was a disease itself; rather, drug use was an indication of underlying personality disturbances, ranging from psychopathy to neurosis.23 Society’s lack of ethical values (evidenced by a widespread tolerance of those pursuing naked self-interest) had created a situation in which drug taking and other illegal activities were accepted. Krasojevic-Janjetovic warned that narcomania was an ever-increasing problem, now beginning to threaten even women and children. Drug use thus presented the possibility of causing a complete breakdown, not only in the individual but in the entire family structure.24 One practitioner went as far as warning that drug users threatened Yugoslavia’s very security, noting that addicts weakened the country’s overall defence capabilities!25 The social danger of youth drug use was perhaps elucidated in greatest detail by Ilija Simic in a 1977 article published in Social Psychiatry.26 The opening of Yugoslav borders and the arrival of substantial numbers of Asian and African students (largely from the Non-Aligned world) had brought about an immense increase in the number of narcomaniacs in the country.27 In Belgrade, for example, only 269 individuals were registered as drug users in 1970; by 1976, that number had risen to 1,649.28 Addicts were, he underlined, necessarily prone to committing crimes such as robbing pharmacies, falsifying doctor’s papers, and petty theft. Sooner or later, he continued, all drug-using individuals came into contact with the law. To illustrate his point, he revealed that only four individuals in the entirety of the country had been charged under Article 208 of the Criminal Code (the primary drug law) in 1965. By 1976, that number had increased nearly 50-fold to 187 people.29 As drug addiction was concomitant with other deviant behaviours, such as homosexuality and prostitution, it was clear that addicts were not only a drain on the family but on society more broadly. Because they tended to leave school early, such individuals lacked any sort of work habits or skills, becoming an even larger economic burden. Worse still, treatment was lengthy, expensive, and ultimately unlikely to succeed. Thus, drug users represented “losses” for their workplace, their families, and

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their community. With the exception of the discussion on alcoholism, Yugoslav psychiatrists rarely utilized such moralistic language in their discussion of patients.30 It is no surprise that, as one former practitioner testified, drug users faced the harshest stigmatization both within the medical system and from the public more broadly.31 Despite their moralizing tone, most psychiatrists favoured rehabilitative treatment rather than a punitive approach. In the early discussions on the subject, treatment regimens focused on the individual. Many physicians advocated strict in-patient treatment to wean individuals off addictive substances and to prevent them from re-entering the social environment which had brought them to drug use in the first place.32 By the early 1970s though, it was becoming apparent to many health workers that the classical “repressive” methods of treating addiction were ultimately useless.33 One option explored at psychiatric meetings and within the pages of the medical literature was the possibility of adapting the country’s leading approach to alcoholism treatment to the issue of narkomanija. Articulated chiefly by Zagreb’s Vladimir Hudolin, the “social psychiatric” approach to alcoholism treatment rested on six key tenets: widespread societal involvement in the struggle against alcoholism; the utilization of psychotherapy; out-patient therapy where possible; the involvement of the family in the therapeutic process; the “Therapeutic Community” as a guiding principle; and the formation of post-treatment groups of former alcoholics.34 At the Stojanovic hospital in Zagreb, Hudolin created a special ward for narkomani, applying many of the same principles.35 A central component of such treatment (whether for drug users or those who drank to excess) was group-oriented activity. On the one hand, this meant group therapeutic sessions in which a psychotherapist would serve as a facilitator for discussions between individuals facing similar issues. Yet the notion of the group went well beyond structured therapy; during the envisioned six months in which a person might join a clinic as an in-patient, they were expected to engage with the Therapeutic Community, a concept adapted from British physicians such as Maxwell Jones.36 Conceptually, the Therapeutic Community aimed to replace the authoritarian and top-down approach to treatment with a more democratic model in which patient and therapist existed on a more even level. This method relied heavily on a groupbased approach (with patients and therapists sharing the same common space), and patients were charged with responsibility in their own treatment and that of others. To facilitate patient self-treatment, therapists emphasized education relating to psychiatric illness under

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the assumption that patients could better deal with their illness if they understood the key psychiatric precepts behind it. The community aspect of the Therapeutic Community required good mutual relations between patients and practitioners, and decisions related to life within the community were taken in large daily group meetings. Patients were expected to become more self-reliant than in classical psychiatric approaches; tasks such as cooking, laundry, and organizing recreational activities fell under the auspices of patients, rather than staff. In this way, group-oriented treatment could “resocialize the passive-dependent personality” of the patient.37 Hudolin’s model gained in popularity not only within Yugoslavia but also abroad; as a leader of the global social psychiatry movement, Hudolin successfully exported his approach to more than 30 countries around the world. Yet the alcoholism approach could not simply be transplanted without alteration. Although similar, the conditions (alcoholism and drug addiction) were not identical. Dusan Petrovic, one of the country’s senior psychiatrists, identified a few commonalities in the personalities of alcoholics and drug addicts, namely weakness, uncertainty, and high amounts of dependency and suggestibility.38 Yet there were, he reminded his fellow practitioners, some underlying distinctions between the two groups. Specifically, drug addicts tended to be more aggressive and more given to impulsivity. Moreover, while an alcoholic might very occasionally be driven to antisocial behaviour on account of the effect of alcohol on the brain, drug users possessed a basic emotional underdevelopment that pushed them to engage in antisocial activities. Finally, the profile of alcoholics (typically married men with children) differed from the adolescents who typically made up narkomani; treatment consequently had to be adjusted to include parental involvement. Petrovic and others developed this theme, noting that the ecology of the family served as the basis for narkomanija and thus ought to be the locus of treatment as well. Despite appearances to the contrary, according to Stojilkovic, the “good” economic and family circumstances into which most hippies were born were, on closer inspection, marked by a lack of warmth between parent and child, often because parents were preoccupied with activities outside the household. The children of these homes lacked the parental attention necessary for healthy mental development and drug-taking was the sad consequence of such a situation.39 Indeed, the disintegration of the family as a social unit was among the most frequently cited causes behind the rise in drug addiction.40 In Petrovic’s view, the patriarchal structure that characterized most Yugoslav families served as a protective element against narkomanija;

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in families lacking such structure, drug use was almost always more likely.41 Because of the psychological and emotional interconnectedness of the group, individual problems among family members (such as drug-taking) should instead, he argued, be conceptualized as problems of the whole. Unless the entirety of the family was brought in for treatment, recidivism would be a near certainty. Nearly two decades later, a spate of studies of the “narcophilic” family further underlined the role of family members in creating, sustaining, and ultimately alleviating drug addiction.42 As one group of researchers reminded, drug abuse threatened the very survival of the family itself; against such a backdrop, it is no surprise that practitioners sought to involve all family members in treatment.43 With such firm groundings in social psychiatry, involving the family was never going to suffice for most practitioners; only the cooperation (and even transformation) of wider society could help to stem the escalating danger posed by youth drug use. Rejecting any goal for a psychiatric monopoly on drug addiction, Milan Ignjatovic and Vladimir Kovacevic implored sociologists and cultural anthropologists to become invested in the struggle; their expert knowledge regarding society would be central to combatting what was, in their eyes, a social illness.44 Petrovic, meanwhile, saw key roles for organizations such as the Red Cross and the Society for the Struggle against Alcoholism. He even went as far as to include church groups as important agents in the anti-drug crusade, a remarkable suggestion within the context of Tito’s Yugoslavia (where religion was shunned, although not to the extent seen elsewhere in the Communist world).45 Although most researchers quickly accepted prevention as the central plank of drug policy, not everyone had faith in the utility of “traditional” preventative approaches. As early as 1971, Milan Berkes lamented the failure of prevention in Western countries; he advocated for greater vigilance and enhanced use of public resources, including the education system, television, radio, and other elements of the press. In short, he called for a unified approach encompassing the health services, security services, courts, and other public bodies.46 These sorts of arguments, all of which relied upon the application of a deeply engaged socio-medicine in combination with expert training and the creation of specialist centres for the treatment of drug addiction, were explained in greatest detail by Aleksandar Despotovic and Milan Ignjatovic in their 1980 book Zavisnost od Droga i Lekova – Narkomanija (Drug and Pharmaceutical Dependence – Narcomania).47 Despite the fact that many, if not most, within academic psychiatry had already been arguing for a broadly similar system based upon the

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principles of prevention, widespread societal involvement, and a modified version of Hudolin’s alcoholism treatment, calls for a uniform approach became deafening by the early 1980s. Despite nearly 20 years of discussion on the phenomenon of young narkomani, it was clear that psychiatrists, psychologists, and general practitioners, especially at the local level, were utilizing ad hoc measures in their interactions with drug users. When combined with the fact that diverse (and frequently divergent) strategies were employed across other sectors connected to the youth drug problem (especially education and the security services), it became clear that the patchwork approach to drug use could never resolve the issue. The Yugoslav drug problem (or at least the panic over it) was even making international headlines by the 1980s. In 1981, an Associated Press article described how the spillage of drugs moving from the Middle East to Western Europe was beginning to wreak havoc upon Yugoslavia, with estimates that Belgrade alone was home to 3,000 heroin addicts (up from six known addicts in the mid-1960s). Within the article, Stevan Petrovic (a physician specializing in youth drug use) bemoaned the fact that many authorities had hitherto perceived addiction as a byproduct of capitalism.48 As a consequence, the specialist treatment centres and widespread social engagement envisioned by adherents to the social psychiatry movement had never materialized; instead, small voluntary clinical teams frantically struggled to keep up with the rising tide of users. In January 1984, a New York Times headline pronounced “Drugs Dulling Golden Youth in Yugoslavia,” an allusion to the fact that the sons and daughters of Communist party officials were widely believed to be substantially over-represented among the country’s roughly 10,000 registered addicts. As one young Yugoslav woman remarked, “They don’t want to work. They’d rather sleep until noon and get money from their parents … Our acquaintances, they don’t believe in anything. Not in politics, the party or the state. Just clothes and music.”49 The panic over drugs continued to build. The following year, a Chicago Tribune piece reported Yugoslav authorities as suggesting that more than 60,000 addicts were using heroin alone. On account of the drug scare, Yugoslav authorities were apparently enthusiastically cooperative with officials from the United States’ Drug Enforcement Administration.50 The rising scope of the problem, combined with psychiatric protestations over the profession’s impotence (at least without a unified socio-medical approach), prompted the Yugoslav government to draw up a more cohesive drug strategy in the mid-1980s. In 1983, the federal government passed new laws with the dual aim of cracking down on supply as well as designing a singular medical doctrine for guiding the

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treatment and rehabilitation of users.51 In 1984, the government held a grand summit to determine the details of the official approach to drug use.52 Stakeholders from a wide variety of backgrounds, including the health, educational, and security services as well as social, political, and youth organizations, the judiciary, and customs and border patrol, put together a comprehensive outline on how best to tackle the addiction threat. Most of the basic tenets for which social psychiatrists had been arguing over the preceding decade and a half became central planks of this policy: recognition of the special and unique nature of addiction and addicts, the creation of special dispensary units for treatment, the use of a multidisciplinary approach to prevention and rehabilitation, mandatory participation in mutual self-help groups (such as Therapeutic Communities), and the involvement of the family and wider society in all of these processes. As summarized by the chief figure at the head of the country’s drug control strategy, only such an approach could succeed: “combating illicit drug trafficking and providing treatment for drug addicts are not enough to solve the problem of drug abuse … emphasis should be placed on prevention, primarily involving parents and other members of the family, the school, the community, the work place, and social and non-governmental organizations.”53 Beyond those measures long suggested by psychiatrists, the new strategy also called for control and censorship of key components of youth culture, such as song lyrics and album covers. Film was of particular concern: “With regard to films dealing with drug abuse, experience shows that they quite frequently present drug addicts as tragic and romantic heroes, which in turn may tempt adolescents to imitate such heroes.”54 Finally, the harsh attitudes held by most Yugoslavs (professional and layperson alike) towards drug users meant that rehabilitation was a near impossibility.55 Until the public stigma against drug users abated, former drug users would continue to be rejected by society. Whether this grand strategy for tackling drugs and addiction could succeed was never truly tested. The economic disaster of the mid-late 1980s, the collapse of Communism across Eastern Europe, and the wars of the 1990s meant that the issue of drug use largely disappeared from the public radar until the turn of the millennium, after which point the panic that marked the 1970s and 1980s resumed in many post-Yugoslav societies. Attitudes towards drugs and drug users did not soften and the public discourse over the threat posed by narkomani remained relatively unchanged. ***

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The Communist-era discussion over drug use and abuse can serve as a microcosm of trends and facets characteristic of Yugoslav psychiatry more broadly. Although a fairly niche subject (in comparison to alcoholism, depression, and suicide – all of which garnered far more attention from mental health practitioners), many of the key themes and processes through which mental health practitioners worked remained the same. Most significantly, blatant ideology rarely penetrated the discourse found in medical journals and textbooks, especially after Yugoslavia’s break from the Soviet sphere of influence in 1948. This is not to say that politics and ideology had no bearing on mental health debates, but rather that they did not overtly influence psychiatric debate. Yugoslavia escaped Pavlovization, and references to Marx, Engels, Tito or any other heralded figure were extremely rare within psychiatric literature. Indeed, one could much more easily find citations of the writings of libertarian American psychiatrist Thomas Szasz than any of the aforementioned individuals. One result of the “de-ideologized” discourse within the mental health world was that no “official line” developed. From the late 1940s onwards, psychiatrists freely engaged in (sometimes heated) debates, invoking even some of the Party’s best-known bugbears such as religion and ethnicity. For example, throughout the late 1960s and 1970s, psychiatrists introduced faith into their debates on the so-called suicide epidemic, wondering if some religions offered a “greater protective factor” against suicide than others.56 On the subject of ethnicity, meanwhile, Lev Milcinski contrasted Slovenes (who internalized their aggression in the process of becoming “civilized”) with the backwards and outwardly aggressive population in Kosovo (who rarely committed suicide, but more frequently attacked and murdered each other).57 Thus, psychiatry tended to find space for dissenting voices; in the case of drug addiction, Milcinski provided a clear counter-narrative to the moralizing viewpoint from which most practitioners wrote. With that in mind, certain overarching themes permeated much (but never all) psychiatric debate. In particular, the social psychiatry movement enjoyed substantial acclaim in Yugoslavia. As mentioned previously, however, the notion that the broad structures and organization of society were central contributing factors to mental illness was not the result of a slavish devotion to Marxist ideology. Instead, practitioners looked westward for inspiration. Many leading figures spent months training in London, Paris, and New York. Thus, the West (rather than the Soviet Union) was the reference point for most psychiatric theoreticians, and medical journals were replete with references to a wide

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spectrum of American, French, German, and especially British practitioners. Perhaps most evident in discussions over drug addiction and alcohol abuse, the main tenets of social psychiatry peppered the most important debates in the world of Yugoslav mental health. As a final point, it should be noted that Yugoslav practitioners were not simply acolytes for mainstream Western psychiatry. While undoubtedly owing an intellectual debt to figures ranging from Karl Menninger and Maxwell Jones to R. D. Laing and even Freud (psychoanalytic ideas, albeit in a modified form, were central to mental health care in Yugoslavia58), Yugoslav psychiatrists developed original theses and approaches which were picked up in the West, the Soviet bloc, and the Non-Aligned world. Hudolin’s method for treating alcoholism and drug dependence, for example, was adopted in countries ranging from Brazil to Italy to India. Although not one of the “inner family,” Yugoslavia was still a fellow-traveller on the road to Communism and the frequent participation of Soviet bloc psychiatrists at Yugoslav conferences and on the editorial boards of Yugoslav journals meant that the country served as a sort of psychiatric transmitter, a safe meeting point for ideas on mental health, whether they originated in Chile or Czechoslovakia.

Notes 1. “Serb Addicts Beaten at Church ‘Rehab’ Centre,” Balkan Insight. Published May 22, 2009. Accessed at http://www.balkaninsight.com/en/article/ serb-addicts-beaten-at-church-rehab-centre. 2. “Parents Support Controversial Rehab,” B92.net. Published May 23, 2009. Accessed at http://www.b92.net/eng/news/society-article. php?yyyy=2009&mm=05&dd=23&nav_id=59344. 3. R. Lopasic, S. Betlheim, and S. Dogan, Psihijatrija (Belgrade: Medicinska Knjiga, 1961). 4. B. Gacic, “Neka zapazanja o toksikomaniji kod beogradske omladine,” Prvi Naucni Sastanak Psihijatara Srbije “Zbornik Radova” October 1–3, 1970 Vrnjacka Banja, ed. S. Stojilkovic, 175–179. Belgrade: Neuropsihijatrijska Sekcija SLD i Neuropsihijatrijska Klinika Medicinskog Fakulteta u Beogradu, 1970; A. Despotovic “Sudsko-Psihijatrijski Znacaj Narkomanija,” Engrami 2, no. 2 (1980): 67–84. 5. In later years, solvent abuse was identified as a far greater problem. See Z. Petrovic, “Zloupotreba inhalanasa, solvenasa, i volatilnih sredstava,” Psihijatrija Danas 16, no. 3–4 (1984): 273–280; M. Dragovic, “Problem Zavisnosti od Lepila i Isparljivih Rastvaraca,” Engrami 6, no. 1 (1984): 105–108. 6. S. Stojilkovic, “Narkomanija kao Socijalno-Medicinski Problem,” Zbornik Radova Prvog Jugoslavenskog Simpozijuma o Prevenciji i Lecenju Narkomanija, ed. S. Stojilkovic, 7–20. Nis: Institut Jugoslovenske i Inostrane Dokumentacije Zastite na Radu, 1972.

Drug Use and Psychiatry in Communist Yugoslavia 193 7. Stojilkovic, 14. 8. K. Vujosevic, “Marihuana u Danasnjem Svetu,” Zbornik Radova Prvog Jugoslavenskog Simpozijuma o Prevenciji i Lecenju Narkomanija, ed. S. Stojilkovic, 87–94. Nis: Institut Jugoslovenske i Inostrane Dokumentacije Zastite na Radu, 1972. 9. Interview with Ljubomir Eric. Belgrade, September 10, 2007. 10. I. Simic, “Narkomanija kao vid onesposobljavanja produktivnog stanovnistva,” Socijalna Psihijatrija 5, no. 3 (1977): 337. 11. J. Bukelic, “Problem Rehabilitacije i Resocijalizacije Narkomana,” Zbornik Radova: Internacionalni Simpozijum o Rehabilitaciji u Psihijatriji, June 21–24, Belgrade, 1972, ed. A. Ilic, 93–96. Belgrade: Selo, 1972 12. Stojilkovic, 18. 13. Gacic, “Neka zapazanja o toksikomaniji kod beogradske omladine.” 14. For some insight into Yugoslav hippie culture, see G. Tomc, “A Tale of Two Subcultures: A Comparative Analysis of Hippie and Punk Subcultures in Slovenia,” in Remembering Utopia: The Culture of Everyday Life in Socialist Yugoslavia, ed. B. Luthur and M. Pusnik, 165–198. New York: New Academia Publishing, 2010. 15. Gacic, “Neka zapazanja o toksikomaniji kod beogradske omladine.”. Beyond the hippie trail, Yugoslavia’s open borders made the region a prime entry point into Europe for the various drugs (especially opium-based substances) arriving from the East. See C. Vasev, “Drustveno-Ekonomski Aspekti Narkomanija,” Zbornik Radova Prvog Jugoslavenskog Simpozijuma o Prevenciji i Lecenju Narkomanija, ed. S. Stojilkovic, 99–108. Nis: Institut Jugoslovenske i Inostrane Dokumentacije Zastite na Radu, 1972. 16. Simic, 334. 17. Stojilkovic, 12. 18. J. Bukelic, “Narkomanija Mladih,” Psihijatrija Danas 8, no. 3–4 (1976): 353–360. 19. L. Milcinksi, “Pojava Novih ‘Religija’ Medu Mladima I Njihova Etiogenetskia Pozadina,” Socioterapija u Psihijatriji: Zbornik Radova sa II Seminara Socijalne Psihijatrije. June 7–9, 1973, ed. Lj. Eric, 65–74. Belgrade: Zavod za Mentalno Zdravlje, 1973. 20. L. Milcinski, “Tretiranje Narkomanija – Represija ili Terapija,” Socijalna Psihijatrija 2, no.1 (1974): 61–68. 21. Catovic’s work typically applied existentialist philosophy to the question of why young people consumed illicit drugs. For example, see Z. Catovic, J. Mesic, and N. Pajkanovic “Zasto se Mladi Drogiraju?,” Zbornik Radova Prvog Jugoslavenskog Simpozijuma o Prevenciji i Lecenju Narkomanija, ed. S. Stojilkovic, 125–132. Nis: Institut Jugoslovenske i Inostrane Dokumentacije Zastite na Radu, 1972.; Z. Catovic, “Da li je narkomanija demant anticipacije egzistencijalnog finaliteta?,” VIII Kongres Psihijatara Jugoslavije, Zbornik Radova, 175–176. Novi Sad: Udruzenje Psihijatara Jugoslavije 1988. 22. Stojilkovic, 9. 23. M. Ignjatovic, and V. Kovacevic, “Etiopatogenetski Cinioci u Nastanku I Sirenju Narkomanija,” Zbornik Radova Prvog Jugoslavenskog Simpozijuma o Prevenciji i Lecenju Narkomanija, ed. S. Stojilkovic, 29–40. Nis: Institut Jugoslovenske i Inostrane Dokumentacije Zastite na Radu, 1972. 24. Lj. Krasojevic-Janjetovic, “Neko Problemi Rehabilitacije i Resocijalizice Narkomana,” Zbornik Radova Prvog Jugoslavenskog Simpozijuma o Prevenciji

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25. 26. 27.

28. 29. 30.

31. 32. 33.

34. 35.

36.

37.

38.

39. 40.

41. 42.

Mat Savelli i Lecenju Narkomanija, ed. S. Stojilkovic, 289–294. Nis: Institut Jugoslovenske i Inostrane Dokumentacije Zastite na Radu, 1972. D. Nikolic, “Osnovi jedinstvene medicinske doktrine o lecenju i rehabiltaciji narkomana,” Socijalna Psihijatrija 13, no. 2 (1985): 149–154. I. Simic, “Narkomanija kao vid onesposobljavanja produktivnog stanovnistva,” Socijalna Psihijatrija 5, no. 3 (1977): 333–340. Yugoslavia played a central role as one of the founding members of the NonAligned Movement – an organization of states that sought a “third option” in the face of the American and Soviet quest for dominance and ideological supremacy. In the early years, most member states came from Africa and Asia. Simic, 334. Ibid., 335. For more on alcoholism in Yugoslavia, see M. Savelli, “Diseased, Depraved, or just Drunk? The Psychiatric Panic over Alcoholism in Communist Yugoslavia,” Social History of Medicine 25, no. 2 (2012): 462–480. Personal communication with M. Kobal, March 6, 2009. R. Lopasic, S. Betlheim, and S. Dogan, 266; Bukelic, “Problem Rehabilitacije I Resocijalizacije Narkomana.” M. Berkes, “Prevencije Narkomanije,” Zbronik: III Kongresa Lekara Jugoslavije, Bled October 5–8, 1971, ed. S. Mahkota, 188–190. Ljubljana: Savez Lekarshih Drustava Jugoslavije, 1972; V. Hudolin “Rehabilitacija Alkoholicara i Narkomana,” Zbronik: III Kongresa Lekara Jugoslavije, Bled October 5–8, 1971, ed. S. Mahkota, 172–178. Ljubljana: Savez Lekarshih Drustava Jugoslavije, 1972. V. Hudolin, “Prevencija alkoholizma, lijecenje i rehabilitacija alkoholicara,” Lijecnicki Vjesnik 82, no. 6 (1960): 473–485. V. Hudolin, “Pozdravna Rijec,” Zbornik Radova: Prvi Bosansko-Hercegovacki Simpozijum o Alkoholizmu i Narkomanijama, Zenica, March 24–26, 1972, ed. G. Ceh, 23–24. Zenica: Dom Stampa, 1972. In the late 1950s, two of the country’s most respected psychiatrists, Vladimir Hudolin and Dusan Petrovic, attended eight-month courses in London where they studied under Maxwell Jones and others, picking up the fundamentals of social psychiatry, such as the Therapeutic Community. Interview with Dusan Petrovic in Belgrade, August 9, 2007. D. Papic, “Rehabilitacija Narkomana,” Zbronik: III Kongresa Lekara Jugoslavije. Bled October 5–8, 1971, ed. S. Mahkota, 190–192. Ljubljana: Savez Lekarshih Drustava Jugoslavije, 1972. D. Petrovic, “Uloga Porodice i Drustva u Lecenju i Rehabilitaciji Narkomanija,” Zbornik Radova Prvog Jugoslavenskog Simpozijuma o Prevenciji i Lecenju Narkomanija, ed. S. Stojilkovic, 209–216. Nis: Institut Jugoslovenske i Inostrane Dokumentacije Zastite na Radu, 1972. Stojilkovic, 14–15. For example, see M. Ignjatovic and V. Kovacevic, “Etiopatogenetski Cinioci u Nastanku i Sirenju Narkomanija”; Krsto Vujosevic “Marihuana u Danasjem Svetu.” Petrovic, 211. M. Vukov, and S. Mijalkovic, “Osobitosti porodice u kojoj se pojavljuje narkomanija,” Socijalna Psihijatrija 17, no. 3 (1989): 239–248; M. GoldnerVukov, and M. Eljdupovic “Family Life Cycle and Substance Abuse,” Socijalna

Drug Use and Psychiatry in Communist Yugoslavia 195 Psihijatrija 17, no. 4 (1989): 327–338; B. Dukanovic, “Osnovna Obiljeza Porodicne Sredine Narkofila,” Socijalna Psihijatrija 18, no. 2 (1990): 85–94; M. Vukov, J. Marinkovic, and S. Mijakovic, “Kohezivnost i adaptabilnost u narkomanskim porodicama,” Socijalna Psihijatrija 18, no. 3 (1990): 219–226. 43. C. Hadzi Nikolic, M. Jovanovic, and Lj. Mirkovic, “Sindrom PBC – Zloupotreba bazicne paste kokaina,” Psihijatrija Danas 16, no. 1 (1984): 55–64. 44. M. Ignjatovic and V. Kovacevic, 38–39 45. D. Petrovic “Uloga Porodice i Drustva u Lecenju I Rehabilitaciji Narkomanija.” 46. Berkes, 190. 47. A. Despotovic and M. Ignjatovic, Zavisnost od Droga I Lekova – Narkomanija (Nis: Institut za dokumentaciju zastite na radu, 1980). 48. Associated Press, “Yugoslavs Alarmed by Sharp Increase in Drug Use,” October 4, 1981. 49. D. Binder, “Drugs Dulling Golden Youth in Yugoslavia,” New York Times, January 12, 1984. 50. B. Weidrich, “East, West Face Same Enemy: Drugs,” Chicago Tribune, December 8, 1985. A more sober estimate, coming from the head of the drug control wing of the Federal Committee on Health, Labour, and Social Welfare, put the total number of Yugoslav narcotic users at roughly 10,000. See M. Skrlj, “Programme Base for the Prevention of Drug Abuse in Yugoslavia,” Bulletin on Narcotics 38, no. 1–2 (1986): 105–112. Accessed at: http://www.unodc.org/ unodc/en/data-and-analysis/bulletin/bulletin_1986-01-01_1_page012.html. 51. Sluzbeni list SFRJ, br. 57/1983. 52. Details from the summit can be found in D. Nikolic “Osnovi jedinstvene medicinske doktrine o lecenju i rehabiltaciji narkomana,” Socijalna Psihijatrija 13, no. 2 (1985): 149–154. 53. Skrlj, http://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_ 1986-01-01_1_page012.html. 54. Ibid. 55. For example, a late 1980s survey of young people in Croatia found that 91 per cent of respondents equating drug-taking with “evil.” See N. Mandic and J. Barkic, “Narkomanija i srednjoskolska omladina u Osijeku,” Socijalna Psihijatrija 16, no. 3 (1988): 223–238. 56. See the roundtable debate at the Second Yugoslav Symposium on the Prevention of Suicide. “Diskusija za Okruglim Stolom,” II Jugoslovenski Simpozijum o Prevenciji Suicida, ed. L. Milcinski, 99–108. Belgrade: Galenika, 1975. 57 L. Milcinski “Razmisljanja o Specificnostima Samoubistva u Jugoslaviji,” II Jugoslovenski Simpozijum o Prevenciji Suicida, ed. L. Milcinski, 99–108. Belgrade: Galenika, 1975. 58. For more on how psychoanalytic ideas developed in Yugoslavia, see Mat Savelli, “The Peculiar Prosperity of Psychoanalysis in Socialist Yugoslavia,” The Slavonic and East European Review, 91, no. 2 (2013): 262–288.

10 Over the Cuckoo’s Nest: Russian Variations on a Psychiatric Theme Rebecca Reich

In September 2011, as Russia was moving toward parliamentary elections, the blogger and activist Aleksei Naval’nyi announced a contest for the best music video protesting the ruling party United Russia. Several weeks later, he shared a submission by the band RabFak called “Our Loony Bin Is Voting for Putin.”1 The song is set in a psychiatric hospital and is sung from the perspective of a patient whose madness evidently stems from the contradiction between Vladimir Putin’s rhetoric of order and the disorder he notices in everyday reality. It begins with a list of questions: “Why don’t we have a key to the ward?”; “Why is there a hole in my head and the budget?”; and “Why, instead of tomorrow, is today yesterday?” The patient turns to authority figures for answers: He questions the doctor, writes letters to officials, beseeches Putin to set things right. What he does not do is call on these figures to step down. The chorus confirms: It’s all so complicated, it’s all so mixed up, But there’s no time to figure it out, brother. Our madhouse is voting for Putin. Our madhouse is glad to have Putin. The representation of society as a madhouse is a vital and enduring theme in Russian culture, but so is the song’s related contention that the individual who questions the senselessness of society is precisely the individual whom society calls mad. According to RabFak’s lead singer Aleksandr Elin, “The person who sees all of this begins to ask questions that no one answers; ‘instead they give you a shot in the ass.’”2 What is needed for a communal return to sanity, the song implies, is for people to channel their “crazy” questions into organized action. 196

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RabFak’s invocation of the political connotations of madness struck a chord with opposition-minded listeners, who turned the song into a hit. Indeed, “Our Loony Bin” was chosen to open the December 10, 2011, gathering that drew tens of thousands of citizens to Moscow’s Bolotnaia Square to protest the parliamentary elections that had just taken place. Affirming its assumption of the madman’s persona, RabFak headlined its website “Warning: Non-Normative Psyche!” and illustrated it with an image from Miloš Forman’s 1975 film One Flew Over the Cuckoo’s Nest (hereafter shortened to Cuckoo’s Nest).3 In October 2013, the Sakharov Center in Moscow similarly used an image from Cuckoo’s Nest to advertise a roundtable discussion of what it described as the possible resurgence of a human rights problem more commonly associated with the late Soviet period: the use of psychiatric hospitalization to suppress dissent. “Those who are best informed say that [punitive psychiatry] hasn’t gone anywhere; it has just steered clear of widely publicized political trials in recent years,” the Center declared. Responding to news of the activist Mikhail Kosenko’s psychiatric hospitalization, organizers invited the dissident Viacheslav Bakhmin, a founding member of the Soviet-era Working Commission on the Use of Psychiatry for Political Purposes, to comment on the links between past and present.4 The recurrence of images from Cuckoo’s Nest is no coincidence. From the late 1970s to the present day, Soviet and Russian citizens have invested Forman’s psychiatric narrative with political and national significance. Condemned if not ignored by official critics after its release, Cuckoo’s Nest was one of the first foreign films to draw a broad unofficial following in the USSR. For the citizens who gathered to watch it in clubs and homes in the late 1970s and early 1980s, the film helped to define a political community by articulating a protest against totalitarianism and the hospitalization of dissidents. As Russians struggled to achieve stability in the wake of communism’s collapse, however, Cuckoo’s Nest came to represent their search for a national identity. Only by coming together as a people, a 2005 theatrical production of Cuckoo’s Nest suggested, might post-Soviet Russians “cure” themselves. The unofficial popularity of Cuckoo’s Nest in the late Soviet period cannot be separated from contemporary revelations in samizdat of the use of psychiatry to suppress dissent. Even as the first copies of Forman’s film were circulating in the USSR, members of the Working Commission on the Use of Psychiatry for Political Purposes were collecting and releasing evidence that Soviet citizens who questioned the status quo were being hospitalized with diagnoses such as “sluggish” schizophrenia and “paranoid development of personality.”5 A common

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feature of these diagnoses was the possibility that symptoms might manifest so mildly that only a psychiatrist could identify them. Patients were also considered to be prone to displaying delusions of “reformism” or “litigiousness” – traits which mapped neatly onto the landscape of political protest.6 This chapter builds on previous work showing that the perceived threat of diagnosis presented activists with a choice: They could either avoid actions that might be construed as pathological or engage in psychiatrically suspect behaviour with the goal of redefining it. Despite the threat of hospitalization, many chose the second option. They were not madmen, they indicated in poems, memoirs, letters, and other samizdat writings, but inakomysliashchie: “differently thinking” people whose actions indeed reflected their psychological – but not pathological – singularity. Together, their narratives of psychiatric hospitalization invoked a community in which inakomyslie, or “thinking differently,” was the norm.7 It was not just Soviet writers who redefined insanity as inakomyslie, however. The meaning of madness was also determined by how psychiatric narratives were received. This chapter looks to the work of Wolfgang Iser to suggest that reception can double as a form of social action when it binds a community together. Iser argues that the meaning of a text is determined by an “implied reader” who unites “both the prestructuring of the potential meaning by the text, and the reader’s actualization of this potential through the reading process.”8 While Iser is primarily concerned with literary reception, the interaction of the producer and the receiver similarly comes to the fore in works that are staged before live audiences. Performances, after all, highlight the moment of reception and thus the audience’s co-creation of meaning. By interpreting madness in historically specific ways at cinematic and theatrical showings, the “implied audiences” of Cuckoo’s Nest defined themselves.

A solidarity of silence: the Soviet era One Flew Over the Cuckoo’s Nest appeared in the United States at a turning point in American psychiatric history. By the end of the 1950s, the discipline’s prestige had reached new heights with the success of psychoanalysis and other forms of psychiatric therapy, and, in the sphere of severe illnesses, the development and dissemination of psychoactive drugs. The tide turned in the early 1960s, however, when Michel Foucault, Erving Goffman, R. D. Laing, Thomas Szasz, and others began to argue that psychiatry was a pseudoscience – a coercive means of social control.9

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The anti-psychiatry movement contributed to the deinstitutionalization of psychiatric patients while also alerting Western activists to news of Soviet psychiatric abuse. If the comparatively autonomous institution of American psychiatry could be criticized for morally policing the populace, then the state-sanctioned hospitalization of Soviet dissidents appeared to take this quality to extremes. It was against this backdrop that Ken Kesey’s novel One Flew Over the Cuckoo’s Nest became a bestseller when it appeared in 1962. Set in a psychiatric hospital in Oregon, the novel is narrated by Chief Bromden, a Native American patient whom the other patients believe is deaf and dumb. The arrival of R. P. McMurphy, a hard-drinking, foul-mouthed convict who has feigned insanity to avoid a prison sentence, sparks conflict with the head of the ward, Nurse Ratched. McMurphy challenges the nurse’s authority despite discovering that the other patients accept their treatment voluntarily, whereas he will only be released at her discretion. Unable to repress his free nature, he organizes a night-long bacchanal during which he intends, but ultimately fails, to escape from the hospital. In the morning, he attempts to strangle Nurse Ratched and is punished with a lobotomy. The novel ends with the silenced McMurphy’s mercy killing by Chief Bromden, who, having recovered his own voice, breaks through the window and escapes to freedom. By contrast with Kesey’s evocation of American counterculture, Forman’s adaptation presents the psychiatric hospital as a metaphor for the madness of contemporary society and for the subordination of the individual to a totalitarian regime. In this sense, Forman may be said to have drawn not only on his experience of American life, but also on his memories of growing up in communist Czechoslovakia, from which he defected in 1968. Dispensing with Chief Bromden’s first-person perspective, Forman allows the other patients to emerge more distinctly, highlighting their depersonalization by diagnostic labels and hospital practices.10 Starring Jack Nicholson as McMurphy and Louise Fletcher as Nurse Ratched, the film swept the Oscars in 1976, with awards for Best Actor, Best Actress, Best Director, Best Picture, and Best Adapted Screenplay. In the Soviet Union, however, it was greeted with near silence, its Oscars mentioned in Izvestiia only as a footnote to the news that a Soviet production had won the award for Best Foreign Film.11 A rare review that appeared in a 1978 book about contemporary American cinema sheds light on the film’s official reception. According to authors T. Golenpol’skii and V. Shestakov, the genius of Kesey’s novel had been precisely in its concrete, satirical critique of American reality. Forman’s adaptation, by contrast, lost itself in “Freudian” concepts

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and that “all-embracing humanism” behind which bourgeois societies conceal their class agenda. By promoting individualism as a universal ideal, the critics argued, Forman was furthering the fragmentation of the masses on which so-called democracies like the United States thrived. Nor was Forman averse to anti-Soviet propaganda, they wrote. “It is no accident that the filmmakers, as if in passing, insert a scene in which a commentator’s voice pontificates on the ward radio about the ‘Soviet threat’ and the ‘Iron Curtain.’”12 Significantly, Golenpol’skii and Shestakov did not mention Forman’s Czech origins or discuss the film’s portrayal of psychiatric abuse, though it would have been surprising if they had done so. In 1977 – just one year before Golenpol’skii and Shestakov’s book was published – the World Psychiatric Association had formally condemned Soviet psychiatric practices.13 The heightened controversy surrounding psychiatric abuse may well have contributed to Golenpol’skii and Shestakov’s avoidance of the topic. Yet the same sensitivities played a role in securing the film’s popularity among politically nonconformist citizens. By the late 1970s and early 1980s, the spread of privately owned video players had made it possible for films to circulate on an unofficial basis, and Cuckoo’s Nest became one of the first foreign films to be viewed widely in this manner.14 Citizens organized unsanctioned screenings in apartments, film centres, galleries, and other institutional settings.15 As the critic Lev Karakhan wrote in 1988: The first showings were like rationed goods – you got them under the counter. But for those in the know, they were like secret meetings, like reading illegal literature. And like a blow at what seemed your very core. There was no arguing. Just like-minded glances and the solidarity of silence.16 The showings of the film shaped “like-minded” communities of inakomysliashchie who creatively read their own experiences into the events depicted onscreen. The “solidarity of silence” that Karakhan described ironically became a form of expression. It was perhaps due to the film’s cult popularity that the journal Novyi mir responded to the onset of glasnost by quickly publishing a translation of Kesey’s novel. The translator, Viktor Golyshev, recalled in an interview that he first read the novel in the early 1980s after finding a copy on his mother’s shelf. Although he had seen the film, he did not judge the novel publishable at the time. With the relaxation of censorship, however, Golyshev approached Novyi mir and the novel’s first

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instalment appeared in July 1987.17 As the critic Aleksei Zverev stated in his introduction: Even after Miloš Forman’s famous film of the same name, which was made 13 years later, the novel in no way looks like a mere draft for a screenplay from which a major director would make a truly great work. No, the novel possesses its own – and entirely independent – artistic significance.18 Kesey’s novel, Zverev continued, would “become a Bible for those who formed the avant-garde of the youth protest movements in the 1960s.”19 The publication of Cuckoo’s Nest in Novyi mir signalled the long-awaited legitimization of the dissident struggle against psychiatric abuse. Yet the book’s translation into Russian ultimately did little to displace the cultural importance of the film. The same month that the novel appeared in Russian, the Moscow International Film Festival hosted the film’s official premiere at the Luzhniki Palace of Sports before an audience of thousands. Describing the scene a few months later, the critic Andrei Plakhov emphasized the sense of unity that gripped the audience: “The massive hall gave the picture a standing ovation, and the public’s enthusiasm seemed like it would never run dry.”20 Forman, who attended the premiere incognito, later said: It was probably the most memorable part of my stay in Moscow. Because it’s not often that a director gets to see his own film in the company of 9,000 viewers who react as one to every frame, every detail, with the sensitivity and precision with which I, as director, would have wanted them to react when I made the film.21 Forman’s interest in watching Soviet citizens watch his film was natural for a filmmaker who had been criticized if not altogether ignored by Soviet commentators since his defection from communist Czechoslovakia. Now Forman was being feted as an official guest of the Moscow Film Festival and Cuckoo’s Nest was slated for distribution across the country. Even after Cuckoo’s Nest’s commercial release, local screenings were reportedly interrupted by applause. As one critic later wrote, the appearance of Cuckoo’s Nest was “a shock, a blow,” a defining experience.22 What did Soviet citizens see in the film? And why did they identify so strongly with it? The flood of reviews and articles that followed its official release indicates that viewers in the early 1980s linked it to the

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Soviet experience. Writing for the Latvian journal Kino in February 1988, Andrei Plakhov predicted that the film’s impact would only become clear when “glasnost reaches the psychiatric institutions and we read in that same Komsomol’skaia pravda about the harassment, humiliations and downright criminal methods that prevail in certain psychiatric hospitals of ours.”23 Karakhan was more circumspect in his August article for Iskusstvo kino. Looking back to the film’s unsanctioned screenings, he wrote: It must be said that the story of how an American psychiatric hospital over-treated a healthy person who did not fit into the hospital routine was anyway taken unambiguously, and it gave rise to a sense of guilt. A metaphysical one, as the specialists say. Guilt for silently colluding in the systematic destruction of “enemies of the state”: the “differently thinking” people.24 Karakhan’s choice of words – psikhushka for “psychiatric hospital” and inakomysliashchie for “‘differently thinking’ people” – connected the dots for a readership that was by then familiar with reports of punitive psychiatry. By viewing Forman’s film through a local lens, Karakhan argued, Soviet audiences had confronted their own experiences. Yet even as he acknowledged the film’s specific resonance for Soviet viewers, Karakhan urged readers to remember that the director’s real focus was American society: “Forman has presented a vivid model of American freedom, the two hypostases of which are not only in conflict, but also in communion and interdependence on all social levels, from the individual act to social morality.”25 No longer should Soviet citizens filter their understanding of Cuckoo’s Nest through their experience of totalitarianism or psychiatric abuse, Karakhan implied; in an age of glasnost and perestroika, they had to broaden their horizon. Karakhan’s emphasis on the universality of the issues discussed in the film was likewise reflected in Valentin Mikhalkovich and Lev Anninskii’s respective reviews of Forman’s Ragtime (1981) and Amadeus (1984), which ran alongside Karakhan’s article in Iskusstvo kino. According to Mikhalkovich, the protagonist of Cuckoo’s Nest was neither McMurphy nor Nurse Ratched, but the manipulative, impersonal “system” that the hospital symbolized.26 For Anninskii, all of Forman’s films were, in essence, about the weakness of the human spirit: “In Forman’s work, the spirit warps, twists, and tortures the unfortunate flesh, drives it out of its mind, dislodges it from its salutary norm.”27 The theme of madness, Anninskii concluded, was of universal concern.

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Not all audiences were ready to set aside what they saw as the film’s implications for Soviet society, however. As Georgii Kapralov lamented in a 1988 article for Pravda: Yet here at the editorial office we have received a letter about One Flew Over the Cuckoo’s Nest from S. Sycheva, a reader from Gvardeisk. “The very fact that this film has been bought is a sheer travesty,” writes she. V. Kuznetsov from Groznyi is of the same opinion; he thinks there was no call to show this “madhouse.” Alas, the authors of these letters have not grasped the deep meaning of this allegorical film about a society where man must think and feel only in line with the compulsory formulations of the “witch doctors.”28 By citing letters from far-flung reaches of the USSR, Kapralov conveyed his disappointment that Moscow’s reforms had yet to permeate the country. Indeed, he noted, certain regions had gone so far as to bar the film from local screens: “In their confusion they forgot that times have changed, and resorted by habit to their old banning measures. One would like to think this is simply the result of their temporary bewilderment at the still unfamiliar situation of democracy and glasnost.”29 For Kapralov and others writing in the late 1980s, Forman’s psychiatric narrative transcended the political. Those who continued to filter the film through the prisms of state interests or inakomyslie were equally behind the times. Despite these critics’ dismissals of what they presented as outdated interpretations of Cuckoo’s Nest, their approach to Forman’s psychiatric narrative was historically specific in its own way. Glasnost looked outward to the world, so analyses of the film looked outward, too. Just as Golenpol’skii and Shestakov critiqued the film from the perspective of the state, and just as unofficial screenings of Cuckoo’s Nest gave receptive expression to inakomyslie, reactions to the film in the late 1980s mirrored the opening up of Soviet society. What united these changing interpretations was the persistent currency of the theme of madness. As Oleg Sul’kin noted in Kino mekhanik in 1988: A madhouse, a parade of freaks, an exhibition of human pathologies – what could be more painful for our consciousness, which has been left entirely unprepared by our own cinematic tradition and therefore unprotected and easily wounded? For this reason I will not be surprised if One Flew Over the Cuckoo’s Nest provokes sharp displeasure among some of our viewers.30

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If the theme of madness was potent enough to incite “sharp displeasure” in certain audiences, then it could also transform Forman’s film into a rallying call for openness and renewal. The reinterpretation of Cuckoo’s Nest in the spirit of glasnost demonstrates the ongoing relevance of psychiatric narratives.

A soul-sick nation: The post-Soviet era Following the collapse of communism in 1991, the metaphorical frame of reference for interpreting Cuckoo’s Nest shifted from the political to the national. As Angela Brintlinger has shown with reference to Viktor Pelevin’s novel Chapaev and Pustota (1996) and Vladimir Makanin’s novel Underground, or A Hero of Our Time (1999), post-Soviet writers used the image of the psychiatric hospital to depict the chaos of Russian reality and explore the country’s search for a new heroic identity.31 Yet the meaning of madness in post-Soviet culture was also determined by the input of readers and viewers – input that realized itself in parallel ways of interpreting Cuckoo’s Nest. As the critic Sergei Dobrotvorskii wrote in 1992: From [Anton] Chekhov to Venedikt Erofeev, our understanding of the social universe is linked to the madhouse. The exceptions only prove the rule: Only an East European director like Forman would squeeze Ken Kesey’s stylized, psychedelic One Flew Over the Cuckoo’s Nest into four walls and a palpable opposition between orderlies and patients. The loony bin, the psikhushka, the madhouse gives form to the general madness of life and to its real, entirely unmasked division into victims and tormenters, the insulted and the injuring.32 Describing Forman as an East European director who knows a thing or two about life behind the Iron Curtain, Dobrotvorskii retreated from both the political prism of the late Soviet period and the universalist orientation of the glasnost years to redefine madness in national terms as a metaphor for contemporary reality. The participatory way in which Cuckoo’s Nest was watched during the late 1970s and early 1980s prepared audiences to welcome a series of dramatic adaptations. Under the direction of Viacheslav Gvozdkov, a translation of Dale Wasserman’s 1963 play based on Kesey’s novel premiered in 1984 at the Russian Academic Dramatic Theater of Uzbekistan. “Daring as a dissident, he staged a celebration of disobedience,” the critic Alena Karas’ recalled in 2006. “There were ovations at

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every trenchant line, and in the last scene, when the Big Chief broke through the window and escaped the hospital, there was no limit to the audience’s jubilation.”33 Karas’s account is particularly telling for what it reveals about perceptions of the audience’s response: The production was seen to bind its viewers into a political community. Gvozdkov similarly stressed the audience’s politicization in his own recollections: “We suddenly realized that this play raised those very questions whose solution and understanding would determine the fate of the individual and the fate of mankind as a whole.”34 Premiering in Tashkent, or on what Karas’ later called the “edge of the empire,” Gvozdkov’s play about a psychiatric hospital turned marginalization into a platform for self-expression. It was thus with trepidation two decades after the premiere of Gvozdkov’s play that Moscow critics greeted advance publicity of a new theatrical production of Cuckoo’s Nest at the Lenkom Theater.35 Testifying to her investment in the film, one critic recalled a sense of alarm: “The Lenkom promised that Forman himself would come to direct it, and that was the most frightening thing of all. Did he really not understand that you shouldn’t step into the same river twice?”36 Such fears proved groundless, however, when the theatre hired another Eastern European to helm the play, the Bulgarian director Aleksandr Morfov. Quick to separate his adaptation from the iconic film, Morfov retitled it Over the Cuckoo’s Nest (Eclipse) and appended a subtitle pointing back to Kesey’s original: A Theatrical Fantasy on the Themes of Ken Kesey’s Novel “Over the Cuckoo’s Nest.” The play opened in 2005 to rave reviews and, a decade later, is still in repertory. The second section of this chapter examines the critical reception of the play while analyzing the work as an example of interpretive reception in its own right. Whereas many late Soviet viewers used unsanctioned screenings of Forman’s film to validate inakomyslie, Morfov’s production depicts “thinking differently” as a disorienting and alienating state from which many Russians retreat to psychiatric care. “Think back to when democracy came,” Morfov told an interviewer. “The world changed. Everything was different. Some were overjoyed; others went crazy. The framework disappeared, and with it the most basic guarantees.”37 The fall of communism dismantled the binary political oppositions – state vs. dissident, collective vs. individual – that had given definition to inakomyslie; without them, the pathological implications of “thinking differently” run rampant through Russian society. Indeed, if the opposition of “normality” and “abnormality” once carried significance, here it too is ironed out: Nurse Ratched faults McMurphy for being “too

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normal,” while McMurphy tries to convince the other patients that they are just as “normal” as he.38 Where Forman underscored the distinction between nurse and patient by depicting Nurse Ratched as sexually frigid by contrast with McMurphy’s vitality, Morfov portrays the two characters as equally libidinous. McMurphy even manages to seduce Nurse Ratched – an act he ponders in the novel and film but, significantly, fails to carry out.39 As a result of this plot change, the central conflict between nurse and patient seems less a metaphor for political resistance than a symptom of the disintegration and chaos of post-Soviet society. What appears to concern Morfov is that “cursed question” at the heart of the “Grand Inquisitor” section of Fedor Dostoevskii’s The Brothers Karamazov: Do people really want to be free? Or does freedom itself become a source of oppression once it is achieved? The pathological connotations of “thinking differently” are realized on a societal level now that there are no external checks on freedom. Disoriented and desperate for an authoritative framework that would keep their madness in check, these characters take refuge in what one calls “the black square, the full eclipse” of psychiatric diagnosis.40 Morfov stresses this line by subtitling his play “Eclipse” and devoting a sustained stretch of dialogue to the theme. “Every person is a little moon,” one character says. “Sometimes they shine brightly, and the person is well, and sometimes the moon can barely be seen.” The challenges of post-Soviet existence are such that citizens cannot maintain their mental equilibrium on their own; only by coming together will they regain a measure of psychological wholeness. Playing on the cultural association between the moon and madness, Morfov turns his patients into self-described “lunatics” who prefer the eclipse of diagnostic labels to the alienating instability of freedom. As was the case in the 1970s and 1980s, then, the stigma of diagnosis is negated by the assertion of community – both the community of patients depicted onstage and the community of reception that the actors create by encouraging the audience to join them in reinterpreting Kesey’s and Forman’s work. Here, however, that community is defined by a spiritual sense of national belonging. As one character emphasizes, the Russian word for “madmen” is dushevnobol’nye, which derives from dusha, or “soul,” and bol’noi, or “sick,” and literally translates to “sick in the soul.” Redefined in the vernacular that Russians share, madness paradoxically offers salvation. The character continues: “Dushevnobol’nye: that means we’re officially acknowledged to be sick in the soul, you see? What could be more important? It’s categorical proof that we have a soul after all – a soul that got sick.”41 The presence of a soul – however

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damaged by the chaos of post-Soviet reality – testifies to the possibility of a cure. Hence the despair in the same patient’s cry upon seeing McMurphy at the end of the play, and his significant choice of words: “His soul is gone!” or in Russian: Dushi net!42 It is not McMurphy’s brain but his proverbial “Russian soul” that is irrevocably lobotomized in this post-Soviet adaptation of Cuckoo’s Nest. With regard to characters other than McMurphy, however, the continued presence of a soul leaves hope for a happier ending. The patients accordingly embrace their diagnoses by translating them into idioms that they and their fellow Russians jointly understand. Gathered with the other inmates around a campfire fuelled by the pages of the ward ledger in which they informed on each other to the nurse, the patient Cheswick announces: Cheswick: Terkel: Harding: Cheswick: Martini: McMurphy: Scanlon:

I’m not sick! I’m sick in the soul [dushevnobol’noi]! You’re a psycho! What’s the difference? In Greek “psycho” means “soul.” So we’re all little souls… I like “lunatic” better. I’m a lunatic, how pleasant… What about you, Scanlon? I am a manic sociopath with a pronounced psychosthenic paranoid syndrome. McMurphy: And in human language? Scanlon: Oh, just out of my mind. But that’s how I like it. Doesn’t it sound nice? Scanlon, the guy who went out of his mind. Terkel: Well, I’m bonkers! Bonkers doesn’t sound half bad, either. Martini: Or coo-coo. Cheswick: Going off the rails sounds good to me. Martini: Or going off the deep end! McMurphy: Or losing your marbles. Harding: I prefer being out to lunch.43 As this colloquial translation suggests, the identities that the patients assume – choknutyi, s”ekhal s katushek, krysha poekhala, ia ne v sebe – are rooted in that Russian language that binds the actors, characters, and audience together. Setting an example for their viewers, the patients revel in their madness by translating it into native terms. Where late Soviet cinematic and theatrical showings of Cuckoo’s Nest shaped political communities, then, Lenkom’s post-Soviet rendition emphasizes the importance of national unity. Only by reverting to the “human language” that they share will citizens learn to express themselves in a

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stable and sustainable way. Inviting the audience to join them around the campfire, the actors and characters invest Cuckoo’s Nest with contemporary meaning. In addition to uniting the actors, characters, and viewers through the Russian language, Morfov invokes a common cultural frame of reference. For example, McMurphy responds to the doctor’s admonition that he sit down during therapy sessions by exploiting the double entendre of the verb sidet’ – to “sit” as well as to “be” in prison – and noting that he has already been “sitting” for five years.44 The patients are refused permission to watch not baseball, as was the case in Kesey’s novel and Forman’s film, but football, a sport much closer to Russians’ hearts.45 Though other details locate the action in the United States, McMurphy blurs the play’s geographical setting by describing the hospital as being located “past the Ring Road” – a wink at Moscow’s Kashchenko Hospital.46 Told that the psychiatric ward is run like a democratic commune, McMurphy hears the word “communist.” Told that it is curative for patients to report on each other in the ward ledger, he links these reports to Soviet-era denunciations by calling them stukachestvo, or “snitching.”47 The cultural frame of reference that the actors, characters, and audience share is further thickened by references to Russian literary history. One patient, for instance, dubs the ledger zapiski sumasshedshego, or “notes of a madman,” alluding to Nikolai Gogol’’s iconic story of that name about a civil servant who is confined to a psychiatric hospital.48 United by these linguistic and cultural references, the patients and the theatregoers effectively merge. The onstage madhouse mirrors the madhouse of contemporary Russian reality from which the audience presumably also seeks shelter. “The Lenkom production’s little model of a soul-destroying world acquires the – if not literal, then certainly palpable – contours of the place in which we live,” Nataliia Kaminskaia wrote for Kul’tura.49 Further narrowing the distance between actors and audience, Morfov urged the former to play their roles through the prism of their personal experiences. When the play premiered in 2005, he told an interviewer that he and his actors were still adjusting the script to incorporate the latter’s individual input. “Sometimes during rehearsal I watch and think about how to make it so they don’t act at all, but rather are themselves onstage,” he said.50 By encouraging the members of the cast to play themselves, Morfov projected a shared plane of reality on which the actors, the characters and the audience could interact. The resulting collaboration both illustrated and invoked the creative interaction of producer and receiver.

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Indeed, many of the reviewers who praised the play focused precisely on its aura of authenticity – an authenticity that, they repeatedly stressed, facilitated audience participation. “Each person brought something of his own, from his very own self, and as a result, from all of us, from our soil, from our – and not someone else’s – reality,” Karas’ wrote.51 Moving away from the dissident subtexts of Gvozdkov’s play, Karas’ argued, the Lenkom production captured the murkier morals of contemporary Russia: “There is a different tone to the story that Morfov tells. A melancholic one. An answer to those moods that now overtake people who have experienced both jubilation and disappointment. And who are no longer capable of being flooded by social passions of any kind.”52 The critical reception by Karas’ and others indicates that post-Soviet viewers admired the play precisely for what they saw as its deconstruction of the political oppositions that had captured viewers’ imagination in the late 1970s and early 1980s. As several critics emphasized, Aleksandr Abdulov’s older McMurphy was no countercultural rebel; rather he resembled a tired bon vivant who resorts to resistance only when encountering violations of common sense.53 Reviewers similarly presented Elena Shanina and Anna Iakunina’s alternating Nurse Ratched as a quintessential Russian mother figure who crushes her patients’ souls out of a benevolent conviction that she knows what is best for them.54 Mirroring Morfov’s emphasis on the contemporary relevance of Kesey’s novel, these critics indicated that it was precisely in its attention to Russian reality that the production achieved its success. The Lenkom production’s focus on national identity testifies to a shift away from the political frame of reference through which Cuckoo’s Nest was interpreted in the late Soviet period. That freedom of thought and action for which the dissidents fought has been realized so chaotically that the country is left grasping for a sense of self. As Morfov said: It’s an impossible contradiction. If you have a government that tries to guarantee conditions that are acceptable to all, then it establishes its order, deprives a person of freedom. And if you give a person freedom, then division immediately set in. […] Some will want to read the books they like, watch the films they like, dash off to another country. And others won’t need any books, newspapers, or the rest of the world. They’re fine as long as they get their pension, their medicine is free, and they have some security for the future.55 Morfov’s psychiatric hospital may darken its patients’ souls with diagnostic labels, but it also shields them from that divisive freedom with

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which they are unable to cope. What is needed to cure the madness of contemporary society, the play implies, is a basis for coming together as a people. In addition to providing a model of national unification on the stage, Morfov invoked the creative interaction of characters, actors, and audience in a way that was palpable to the play’s reviewers. The production promoted a uniquely collaborative atmosphere, Kaminskaia noted not long after its premiere. “Imagine,” she wrote: “A patient who has been victimized by the hospital’s totalitarian regime acquires a sense of selfworth for a fleeting moment; he says a few words in his defence, and the hall erupts into applause. It’s practically a miracle.”56 Pointing to the enthusiasm of the audience, Kaminskaia added her own enthusiasm to the mix. The show had enabled audience members to commune not only with each other but also with the patients onstage, she wrote: The fatal party in the psikhushka is played as among friends by a campfire in a forest near Moscow; it would not have been surprising if they had taken out a guitar and sung us a song. Perhaps this is why one still believed that McMurphy would escape to freedom? It felt so warm by the ‘campfire’ that things should really have turned out right.57 These wistful musings serve as firsthand evidence of critics’ sense of the inclusive atmosphere of Morfov’s play. The audience joins the actors in building a community of reception that mirrors the national community needed for a cure.

Conclusion The changing reception of Cuckoo’s Nest from the late Soviet era to the present day suggests a series of fundamental shifts in the interpretation of psychiatric narratives. Reactions in the late 1970s and early 1980s were primarily political, ranging from official disapproval of the film to the unofficial interpretation of Forman’s hospital as an allegory of the pathologization of inakomyslie. The onset of glasnost and perestroika created a new community of reception, as the now-sanctioned audiences of Forman’s film and Kesey’s novel interpreted both works in keeping with the universalist values of the day. With the collapse of the Soviet framework, however, the psychiatric theme took on new relevance as a reflection of both Russia’s search for a new identity and the perceived madness of post-Soviet life. The Lenkom production

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that premiered in 2005 called for the creation of a national, rather than political, community that could tame this post-Soviet madness together. “In the end,” one of the play’s reviewers wrote, “compulsory treatment in psychiatric clinics belongs somewhere in the past, however recent. The important thing is what is in the present: other monsters, new systems that are no worse at lobotomizing a person, and possibly even better and harder to detect.”58 It was only during the protests of 2011 that the political connotations of Cuckoo’s Nest again came to the fore as groups like RabFak and institutions like the Sakharov Center invoked memories of Soviet psychiatric repression to define a new community of inakomysliashchie. All of these communities challenged the stigma of what they variably defined as madness by turning a single psychiatric narrative into a forum for expressive reception. As Iser and other reception theorists have noted, the meaning of a work of art is determined not only by those who produce it, but also by those on the receiving end. Building on the speech-act theory of J. L. Austin and John Searle, Iser writes that artistic texts provide a “repertoire” of social, cultural, and political conventions that suggest a range of interpretive strategies.59 Forced to choose among these strategies in order to make sense of the text, the reader must also reassess the conventions underlying them. “The reader is thus placed in a position from which he can take a fresh look at the forces which guide and orient him, and which he may hitherto have accepted without question,” Iser writes.60 The creative collaboration between producer and receiver opens up a space for reflection and change, with the text stirring its receiver to action and the receiver in turn activating the text. Yet as attention to the cinematic and theatrical reception of Cuckoo’s Nest reveals, the co-production of meaning is by no means limited to the interaction of producer and receiver; audiences can themselves take action by forming interpretive communities. Moreover, a single psychiatric narrative has the capacity to activate multiple communities of reception. As Oleg Sul’kin of Kino mekhanik wrote about Cuckoo’s Nest in 1988: The madhouse as a symbol of a repressive society, of inakomyslie forced out of the brain? A eulogy to that intoxicating freedom that stands up against blind submission to power? A polemical challenge to philistine definitions of madness as any departure from the norm? Each person will likely add something of his own: The film doesn’t support a linear, clear-cut reading.61

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For Sul’kin, the ongoing currency of Forman’s film rests precisely in the semiotic flexibility of the theme of madness. If psychiatric diagnosis and hospitalization could lend themselves to such startlingly variant interpretations, then madness was indeed a potent sign. Its wealth of connotations transformed the reception of Cuckoo’s Nest into a barometer of the changing times. Responses to Cuckoo’s Nest in both the Soviet and the post-Soviet eras point to this psychiatric narrative’s power to define and activate communities of reception. These communities have tended to challenge each other, yet this in no way invalidates the interpretation of each. Rather, the successive reinterpretations of Cuckoo’s Nest may be said to form a composite “text” that points to the core narrative’s multiplicity of meanings. In Iser’s words: As the reader uses the various perspectives offered him by the text in order to relate the patterns and the ‘schematized views’ to one another, he sets the work in motion, and this very process results ultimately in the awakening of responses within himself. Thus, reading causes the literary work to unfold its inherently dynamic character.62 Iser is referring to the capacity of a single text to change its meaning upon being reread by one individual. Yet the composite text of Cuckoo’s Nest is no less dynamic for revealing itself through communal re-readings over time. A creative collaboration of its producers and receivers, One Flew Over the Cuckoo’s Nest testifies to the psychiatric narrative’s enduring resonance.

Acknowledgements I am grateful to Jonathan Bolton, Svetlana Boym, Rory Finnin, John Freedman, Susan Larsen, Stephanie Sandler, William Mills Todd III and Emma Widdis for their feedback or assistance on this project. Research was supported in part by the Andrew W. Mellon Foundation/American Council of Learned Societies Early Career Fellowship Program.

Notes 1. Aleksei Naval’nyi, “Spoem?,” September 28, 2011, http://navalny.livejournal. com/625374.html. 2. Alla Zhidkova, “Durdom golosuet za Putina,” Moskovskii komsomolets, October 27, 2011.

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3. RabFak, “Ostorozhno, nenormativnaia psikhika!,” accessed at, http://www. rabfak.com/, October 30, 2012. 4. Sakharovskii tsentr, “Diskussiia ‘Prigovorennye k Galoperidolu: prinuditel’noe lechenie i prava cheloveka’,” accessed at http://www.sakharov-center.ru/ discussions/?id=2372, October 11, 2013. 5. On the frequency of these diagnoses, see A. Korotenko and N. Alikina, Sovetskaia psikhiatriia: Zabluzhdeniia i umysel (Kiev: Sfera, 2002), 18–19, 46. On the punitive uses of Soviet psychiatry, see also Sidney Bloch and Peter Reddaway, Psychiatric Terror: How Soviet Psychiatry Is Used to Suppress Dissent (New York: Basic Books, 1977); Sidney Bloch and Peter Reddaway, Soviet Psychiatric Abuse: The Shadow Over World Psychiatry (London: V. Gollancz, 1984); Semyon Gluzman, On Soviet Totalitarian Psychiatry (Amsterdam: International Association on the Political Use of Psychiatry, 1989); Theresa C. Smith and Thomas A. Oleszczuk, No Asylum: State Psychiatric Repression in the Former USSR (New York: New York University Press, 1996); Robert van Voren, On Dissidents and Madness: From the Soviet Union of Leonid Brezhnev to the “Soviet Union” of Vladimir Putin (Amsterdam: Rodopi, 2009); Robert van Voren, Cold War in Psychiatry: Human Factors, Secret Actors (Amsterdam: Rodopi, 2010). 6. For psychiatry manuals from the period, see O. V. Kerbikov, M. V. Korkina, R. A. Nadzharov, A. V. Snezhnevskii, Psikhiatriia (Moscow: Meditsina, 1968); A. V. Snezhnevskii, ed., Spravochnik po psikhiatrii (Moscow: Meditsina, 1974); A. V. Snezhnevskii, ed., Rukovodstvo po psikhiatrii, 2 vols (Moscow: Meditsina, 1983). For forensic psychiatry manuals, see Ia. M. Kalashnik and G. V. Morozov, eds., Sudebnaia psikhiatriia (Moscow: Iuridicheskaia literatura, 1967); G. V. Morozov, ed., Sudebnaia psikhiatriia (Moscow: Iuridicheskaia literatura, 1978). 7. This article explores the reception of a foreign psychiatric narrative. For further discussion of how psychiatric narratives produced in the USSR challenged the stigmatization of inakomyslie, see Rebecca Reich, “Inside the Psychiatric Word: Diagnosis and Self-Definition in the Late Soviet Period,” Slavic Review 73, no. 3 (2014): 563–584; Rebecca Reich, “Madness as Balancing Act in Joseph Brodsky’s ‘Gorbunov and Gorchakov,” The Russian Review 72, no. 1 (2013): 45–65. 8. Wolfgang Iser, The Implied Reader: Patterns of Communication in Prose Fiction from Bunyan to Beckett (The Johns Hopkins University Press, 1978), xii. 9. See Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason, trans. Richard Howard (New York: Pantheon Books, 1965); Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (New Brunswick: Aldine Transaction, 2007); R. D. Laing, The Divided Self: A Study of Sanity and Madness (Chicago: Quadrangle Books, 1960); Thomas Stephen Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: Hoeber-Harper, 1961). 10. On Forman’s rejection of Chief Bromden’s perspective, see C. Kenneth Pellow, Films as Critiques of Novels: Transformational Criticism (Lewiston: E. Mellen Press, 1994), 67–90. 11. TASS, “Oskar – sovetskomu fil’mu,” Izvestiia, March 31, 1976, 4. 12. T. Golenpol’skii and V. Shestakov, SShA: Kinematograf 70-X (Moscow: Znanie, 1978), 50–53.

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13. Bloch and Reddaway, Soviet Psychiatric Abuse, 45–71. 14. Galina Kompanichenko, “‘Khoroshii siuzhet nuzhen budet vsegda…’ Beseda s Miloshem Formanom,” Sovetskii ekran 1987, no. 18: 21–22; Andrei Plakhov, “Polet vo vremeni i prostranstve,” Kino 1988, no. 2: 4. 15. L. Karakhan, “Amerikanskaia istoriia,” Iskusstvo kino 1988, no. 8: 114; Galina Kompanichenko, interview by Rebecca Reich, Moscow, Russia, July 21, 2009; Marina Zaionts, “Ku-ku!,” Itogi, January 9, 2006, 64. 16. Karakhan, “Amerikanskaia istoriia,” 114. 17. Viktor Golyshev, interview by Rebecca Reich, Moscow, Russia, September 2, 2012. 18. A. Zverev, “Predislovie romanu ‘Nad kukushkinym gnezdom’,” Novyi mir 1987, no. 7: 145. 19. Ibid., 146. 20. Plakhov, “Polet,” 4. 21. Reports on the number of viewers vary. Forman cites 9,000 in one interview and 15,000 in another. See Kompanichenko, “Khoroshii siuzhet,” 22; Mikhail Brashinskii, “Milosh Forman: ‘Istoriia dolzhna byt’ rasskazana interesno’,” Iskusstvo kino 1988, no. 8: 111. Nikolai Savitskii refers to 6,000 viewers, but Kompanichenko notes that the film was shown several times, indicating that there were likely more overall. Kompanichenko, interview; Ianush Gazda, Vladimir Dmitriev, Devid Robinson, Khans-Ioakhim Shlegel’, Andrei Plakhov, Nikolai Savitskii, Konstantin Shcherbakov, “Diskussii: Kak eto bylo, kak eto budet?,” Iskusstvo kino 1987, no. 12: 10. 22. Zaionts, “Ku-ku!” 23. Plakhov, “Polet,” 6. 24. Karakhan, “Amerikanskaia istoriia,” 114. 25. Ibid., 117. 26. V. Mikhalkovich, “Bunt konformista,” Iskusstvo kino 1988, no. 8: 121. 27. L. Anninskii, “Dukh letiashchii’ i dukh mostiashchii,” Iskusstvo kino 1988, no. 8: 124. 28. Georgii Kapralov, “Kinofil’my vsego sveta,” Pravda, April 19, 1988, 3. 29. Ibid. 30. O. Sul’kin, “Polet nad gnezdom kukushki,” Kino mekhanik 1988, no. 1: 25. 31. Angela Brintlinger, “The Hero in the Madhouse: The Post-Soviet Novel Confronts the Soviet Past,” Slavic Review 63, no. 1 (2004): 43–65. 32. Sergei Dobrotvorskii, “Crasy-movie,” Iskusstvo kino 1992, no. 12: 27. 33. Alena Karas’, “Mak-Melankholik. ‘Zatmenie’ (‘Nad gnezdom kukushki’ Kena Kizi) v Lenkome,” Teatr 2006, no. 1: 28. 34. Akademicheskii Russkii Dramaticheskii Teatr Uzbekistana, “Istoriia,” accessed at http://ardt.uz/index.htm, October 1, 2013. 35. See Marina Davydova, “Vypal iz gnezda,” Izvestiia, December 30, 2005; Dina Goder, “Zaodno i pomylis,” January 25, 2006, accessed at http://www.gazeta. ru/culture/2005/12/29/a_508660.shtml; Zaionts, “Ku-ku!” 36. Zaionts, “Ku-ku!” 37. Elena Grueva, “K prem’ere v ‘Lenkome’: Dushevnaia klinika,” December 20, 2005, accessed at http://www.vashdosug.ru/msk/theatre/article/9414/. 38. Aleksandr Morfov and Teatr Lenkom, “Proletaia nad gnezdom kukushki (Zatmenie): P’esa v dvukh deistviiakh” (Moscow, 2005), 23, 38. I am grateful to the Lenkom Theater for making the script available.

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39. Ibid., 18, 32. On the sexual dynamic between Nurse Ratched and McMurphy in Kesey’s novel, see Laszlo K. Géfin, “The Breasts of Big Nurse: Satire versus Narrative in Kesey’s ‘One Flew over the Cuckoo’s Nest,’” Modern Language Studies 22, no. 1 (1992): 96–101; Barbara Tepa Lupack, Insanity as Redemption in Contemporary American Fiction: Inmates Running the Asylum (Gainesville: University Press of Florida, 1995), 63–98. 40. Morfov and Teatr Lenkom, “Proletaia nad gnezdom kukushki,” 49. 41. Ibid. 42. Ibid., 54. 43. Ibid., 49–50. 44. Ibid., 11. 45. Ibid., 29. 46. Ibid., 37. 47. Ibid., 6. 48. Ibid., 8. 49. Nataliia Kaminskaia, “Psikhi i terapevty,” Kul’tura 2006, no. 2: 1. 50. Grueva, “Dushevnaia klinika.” 51. Karas’, “Mak-Melankholik,” 29. See also Zaionts, “Ku-ku!” 52. Karas’, “Mak-Melankholik,” 28, 30. 53. See Davydova, “Vypal iz gnezda”; Goder, “Zaodno i pomylis’”; Karas’, “MakMelankholik,” 29–30. Since Abdulov’s death in 2008, the role has gone to Aleksandr Lazarev and Andrei Sokolov. 54. See Davydova, “Vypal iz gnezda”; Elena Grueva, “Lenkom: Zatmenie konchilos’,” January 19, 2006, accessed at http://www.vashdosug.ru/msk/theatre/article/9452/; Zaionts, “Ku-ku!” 55. Grueva, “Dushevnaia klinika.” 56. Kaminskaia, “Psikhi i terapevty.” 57. Ibid. 58. Kristina Matvienko, “Begi, Makmerfi, begi!,” Peterburgskii teatral’nyi zhurnal 2006, no. 44, accessed at http://ptzh.theatre.ru/2006/44/46/. 59. See J. L. Austin, How to Do Things with Words (Cambridge, MA: Harvard University Press, 1975); Wolfgang Iser, The Act of Reading: A Theory of Aesthetic Response (Baltimore: Johns Hopkins University Press, 1978), 53–85; John R. Searle, Speech Acts: An Essay in the Philosophy of Language (Cambridge: Cambridge University Press, 1970). 60. Iser, The Act of Reading, 74. 61. Sul’kin, “Polet nad gnezdom kukushki,” 25. 62. Iser, The Implied Reader, 275.

Index Aczél, György, 124, 128–9 Addiction (Narcomania) as social problem, 75, 79,84–5, 181–5, 189 causes of, 83, 86, 182–5, 187–8 definition of, 73–4, 184 treatment of, 80–3, 186–9, 190 Africa, 146, 151, 185 Albania, 12 alcoholism, 11, 19, 186–188, 189, 191, 192 and social psychiatric treatment approach, 186–7 Alekseevskaya Hospital (see also Kaschenko Hospital), 31, 33–4 American Psychiatric Association, 145 Ammar, Sleim, 18 Angyalföld Asylum, Hungary, 118 Anninskii, Lev, 202 Antidepressant (see also psychopharmaceutical), 68, 160, 161, 164, 166 frequency of use, 68 increased use of, 164, 166 anti-epileptic, 157 antihistamine, 159 antipsychiatry, 4, 19, 198–9 Applebaum, Paul, 5 architecture, 146–7 Aronson, Jason, 2–3, asthenic neurosis (see also neurasthenia), 93–116 asthenic syndrome, 101 Astrup, Christian, 17 Asylum, 9–10, 28–9, 30, 32, 60, 117–9, 164 history of, 9–10, 60, 117–9 and work, 28–9 and reform, 164 Avar, Pál, 127 Bakhmin, Viacheslav, 197 Bálint, István, 126

Beard, George Miller, 138 Beck-Dvorzak, Maja, 14 Bekhterev Psychoneurological Institute, Leningrad, 6–7 Benedek, István, 125, 131 Berkes, Milan, 188 Bertalanffy, Ludwig von, 145 Betlheim, Stjepan, 9, 19 Bierer, Joshua, 13 biological psychiatry, 9, 15, 53–4, 57–8, 64, 117, 122, 128 Bloch, Sidney, 3, 22 Bohnice Psychiatric Hospital, Prague, 138 bodily humours, 75–6 brainwashing, 6 Brintlinger, Angela, 204 Bucharest, 93 Budapest Psychotherapeutic Methodology Centre, 129 Bugaiskii, V.P., 38 Bukharin, Nikolai, 8 Bukovsky, Vladimir, 4 Burden Neurological Institute, Bristol, 14 Bustamante, José Angel, 18 Butske, Viktor Romanovich, 31, 33 Calloway, Paul, 6–7 campaign against indigenous medicine, 75, 77–8, 79, 82 Cassell, John, 145 Catovic, Ziso, 185 centre-periphery relations, Moscow and ‘regions’, 74–5 centre-periphery relations, USSR and satellites, 20 Ceylon, 18 Charcot, Jean-Martin, 14 Charité Hospital, East Berlin, 10, 160–1 Charles University, Prague, 15, 139, 141, 143–4 216

Index child psychotherapy, 128 childhood, 7, 34, 119, 124, 181 China, 78, 94, 98, 140 CIA, 150 Cividini-Stranic, Eugenija, 14 Civilization at the Crossroads, 142, 150 classification systems, 17, 93, 98–9 Cold War, 2, 20, 143, 148, 151, 155 Collective as central to treatment, 36, 39, 85 collectivization of agriculture, 34, 123 Communist Party (Hungary) and Pavlovism, 122 attitudes towards psychoanalysis, 121–2 Communist Party (Romania) and Pavlovism, 95–6 Communist Party (USSR) attitudes towards psychoanalysis, 8–9 attitudes towards mental hygiene, 53 and Pavlovism, 7–8, 65–6 community care, 2–3, 17, 30, 165, Council for Mutual Economic Assistance, 161, 162 Crna Reka monastery, 180–1 Croatia, 17, 195 Crocetti, Guido, 17 Csécsy, Imre, 127 Cuba, 18 cybernetics, 140, 142, 148 Czechoslovak Academy of Sciences, 142, 145 Czechoslovakia, 6, 16, 20, 94, 134–152, 159, 192, 199, 201 deinstitutionalization, 10, 19–20, 199 delusion, 5, 52, 59, 166, 198 of “reformism”, 5, 198 Despotovic, Aleksandar, 188 destalinisation, 135 Diagnostic and Statistical Manual, 154 Diatkine, René, 13 diet, 102 dissidence, 3–6, 42, 93, 110, 127, 197, 199, 201, 204–5, 209 Dobrtvorskii, Sergei, 204

217

doctor-patient relationship, 2 Dostoevskii, Fedor, 206 Drugs, narcotic amphetamine, 184 cocaine, 182 hallucinogenic, 184 hashish, 183, 185 heroine, 79, 182, 189 LSD, 182, 184 marijuana, 85, 182–3, 184–5 opiate, 74, 75, 79–89, 182, 184 Dubček, Alexander, 141 East Germany (see GDR) ecology, 142, 187 education, 6, 38–9, 102, 118–9, 122, 124, 128–130, 133, 186, 188 Eghigian, Greg, 1, 19 Electro-convulsive therapy (see electroshock therapy) Electroshock therapy, 54, 64–7, 109 Elin, Aleksandr, 196–7 Ershov, N.N., 79 Etkind, Alexander, 8 Fabinyi, Rudolf, 120 fall of Communism, 4 Family Fostering Programme, 34–7 Field, Mark, 2–3 Finland, 163, 166 Fireside, Harvey, 4 Fitzpatrick, Catherine, 22 Ford Foundation, 143 Forman, Miloš, 197, 200–2 Foucault, Michel, 27–9, 198 Free Trade Union of Hungarian Physicians (MOSZSZ), 120, 123 Freud, Sigmund, 1–2, 8–9, 14, 51, 98, 192, 199 Friedgood, Harry B., 142–4 frigidity, 136, 138 Füredi, János, 128 Gach, John, 134 Gacic, Bruno,183 Galilei Circle, 124, 127 GDR, 8, 9, 10, 15, 17, 138, 155–6, 158–168, 171

218

Index

General Systems Theory, 145 Germany, see GDR and West Germany Giliarovskii, V.A., 29, 64 Gimes, Miklós, 124 glasnost, 4, 89, 124, 200, 202–3, 210 global mental health, 18–19 Gluzman, Semyon, 4, 213 Goffman, Irving, 198 Gogol, Nikolai, 207 Goldschmidt, Dénes, 129 Golenpol’skii, T., 199–200 Gólyavár University of Budapest, 126 Golyshev, Viktor, 200 Gorbachev, Mikhail, 4–5 Great Britain, 134, 140–1, 148 group therapy, 6, 132 Guinea, 18 Gvozdkov, Viacheslav, 204–5, 209 György, Júlia, 128 Hadlik, Josef, 19 Hajdu, Lili, 122, 124, 127–8 Hallucination, 52, 166 Hamburg, David, 145 Hare, E.H., 145 Haškovec, Ladislav, 14 Hauschild, Fritz, 159 Healy, David, 159 Hegel, G.W.F., 28 Hermann, Imre, 122, 124, 127 Hinkel, Lawrence E., 144 Holland, Jimmie, 17 Höschl, Cyril, 15 hospital-colonies, 31–42 Hospital no. 9, Bucharest, 94 Hudolin, Vladamir, 11, 13, 16, 186–7, 188–9, 192 and social psychiatric approach, 186–7 human rights, 3–6, 22, 197 humanism, 140–1, 146 Hungarian Psychoanalytical Association, 122 Hungarian Revolution of 1956, 127 Hungary, 9, 15, 17, 117–121, 161, 162 hypnosis, 6 hysteria, 100, 137

Ibn Sina, 80 Ignjatovic, Milan, 185, 188 Imad al-Din Shirazi, 82 impotence, 138 inakomysliashchie, 198, 200, 202–4, 210 industrialisation, 38, 40, 139, 141–2, 144, 147 as a cause of mental illness, 107, 139–140, 183 infection as aetiology, 7, 100 Institute for Group Analysis, London, 14 Institute of Endocrinology ‘C.I. Parhon’, Academy of the Romanian People’s Republic, 95 Institute of Neurology ‘I.P. Pavlov’, Academy of the Romanian People’s Republic, 94–5 Institute of Psychiatry, London, 14 insulin coma therapy, 50–72, 122 Intaháza, 129 Integrative Human Ecology Conference, 142–7 International Classification of Disease, 93, 95 Iser, Wolfgang, 198, 211–2 Ishoni Maleh-tabib, 79–80 Islamic medicine, 75–7, 80 Iudin, T.I., 33, 61–3 Ivanov-Smolenskii, 8 Jakovljevic, Vladimir, 18 Jones, Maxwell, 13 Kádár, János, 117, 124 Kaminskaia, Nataliia, 208–10 Kapralov, Georgii, 203 Karakhan, Lev, 200, 202 Karas’, Alena, 204–5, 209 Kaschenko Hospital, 34–40 Kaschenko, Piotr, 31, 33 Kesey, Ken, 199 KGB, 5 Klajn, Vladislav, 9 Klimková-Deutschová, Eliška, 138, 141 Knobloch, Ferdinand, 135 Kondratchenko, A.N., 83, 85

Index Kosenko, Mikhail, 197 Kovacevic, Vladamir, 185, 188 Kovács, Vilma, 124 Kovai, Melinda, 9–10 Kreindler, Arthur, 95, 102–4, 107 Kun, Miklós, 129 Laing, R.D., 198 Lakomý, Zdeněk, 146–7 Lauterbach, Wolf, 6–7 Lavretsky, Helen, 5 Lebovici, Serge, 13 Leigh, Denis, 144 Lemkau, Paul, 17 Leningrad University, 7 Lenkom Theatre, 205–11 Leonhard, Karl, 160 Leuenberger, Christine, 9 Lipótmezo Institute of Psychiatry and Neurology, Budapest, 117 lobotomy, 54, 64–5, 66, 72, 199 Luria, Alexander, 16 Macedonia, 18 Macek, Zdeněk, 135, 138, 141 madness, 206 Makanin, Vladimir, 204 malingering, 106 manic-depressive, 6, 161 Márciusi Front, 121, 124 Marcuse, Herbert, 150 Mária, Béla, 126, 128 Marxism, 140–1, 147 Masaryk, Tomáš Garrigue, 141 Matic, Vojin, 13 Maudsley Hospital (see also Institute of Psychiatry, London), 16 Mazurin, Boris Vasilievich, 35 Medical Chamber (Hungary), 120 medical-industrial complex, 167–8 medical school curriculum, 5, 40, 139 Medvedev brothers, 3 Mental Health Inspectorate (Hungary), 121 mental health policy, 21 mental hygiene movement, 53, 73–74 Mental Research Institute, Palo Alto, 142 Mérei, Ferenc, 122, 129

219

Midtown Manhattan Study, 145 Mikhlakovich, Valentin, 202 Milanovic, Dmitrie, 13 Milcinski, Lev, 184–5, 191 Miller, Martin, 8 monoamine oxidase inhibitor, 161 Moral Treatment, 27–8, 32 ˝, 124 Moravcsik, Erno Morfov, Aleksandr, 205–10 Morocco, 18 morphine, 81, 182 Moscow International Film Festival, 201 Munro, Robert, 6 music therapy, 6 Myasischev, Vladimir, 7 Nagykállo Asylum, Hungary, 118 Narkomzdrav, 77, 79 National Association of Hungarian Doctors (MONE), 119–20 National Institute for Pedagogy (Hungary), 122 Naval’nyi, Aleksei, 196 neurasthenia, 93–116, 137 neuroleptic, 68, 106, 109, 159, 160, 162–3, 164, 166 frequency of use, 68 inappropriately prescribed, 106 production, 162 atypical neuroleptics, 162–3 increased use of, 164 neurosis, 6, 93–116, 105, 137 New Socialist Man, 103 Non-Aligned Movement, 18 North Korea, 18 nosology (see classification systems) O’Connor, Neil, 16 occupational therapy, 12 opium, 75, 79–83, 86 oral history, 24 Orthodox church, 180–1 addiction programme, 181 otnoshenie, 7 Palach, Jan, 142 paranoia, 60, 166 Parhon-Ştefănescu, C., 105

220

Index

Parhon, Constantin I., 97–8 Pataky, István, 126, 129 patient rights movement, 19 Pavlov, 7,16, 66–8, 96–100, 122, 125, 135–9, 191 Pavlov Sessions, 51, 135 Pelevin, Viktor, 204 penicillin, 125, 153, 161 and syphilis, 125 comparing effects on patients, 153, 161 Peranovic, Branislav, 180–1 personality, 3, 7, 185, 187, 197 Petőfi Circle, 126 Petrova, M.K., 137 Petrovic, Dusan, 13, 187–8 Petrovic, Stevan, 189 pharmaceutical industry, 10, 20, 154–8, 159, 161–2 and scarcity, 64, 161 and GDR market, 156–8, 162 compared to out-patient care, 165–6 Pharmacological Revolution, 153, 167 pharmacology, 31, 153, 155, 168 psychopharmacology, discipline of, 153, 155 state voice in, 168 Pharmacotherapy, 154, 159 Pinel, Phillipe, 14, 27–8 Plakhov, Andrei, 201–2 Podrabinek, Alexander, 42 political abuse of psychiatry, 2–6, 10, 12, 16, 19, 42, 93, 111, 164, 199–202 Prágai, Dezső, 126 Prague Spring, 141, 144, 148 pseudoneurasthenia, 138 psychasthenia, 100, 137 psychiatric epidemiology, 93, 145, 151 psychic conflict, 102 psychoanalysis, 7–9, 13, 18–20, 68, 97, 119, 122, 124, 128, 130, 134, 136, 192 psychogymnastics, 6 psychopathy, 185

Psychopharmaceutical, 10, 12, 13, 19, 153–179 Aminazin, 41, 62 Amiltriptyline, 164 Benzodiazepine, 158, 161–2 Butaperazine, 162 Butyrophenone, 162 Carbamazepine, 161 Chloridazepoxid, 161 Chloroaniline, 160 Chlorpromazine, 10, 68, 125, 153, 159–160, 162, 167 Clozapine, 162, 163 Diazepam, 161 Droperidol, 162 Faustan, 162 Fluphenazine, 162, 163 Frenolon, 162 Haldol, 162 Haloperidol, 162, 164 Imipramine, 153, 160–1 Isoniazid, 153 Leponex, 162 Lithium, 164 Lyorodin, 162, 163 Medazepam, 162 Melipramin, 160, 161 Miltown, 161 Mogadan, 162 Nitrazepam, 162 Nobrium, 162 Perazine, 162 Phenelzine, 161 Phenothiazine, 153, 157, 159, 162 Promazine, 162 Propaphenol, 159 Pryleugan, 161 Rausedan, 162 Radedorm, 162 Reserpine, 68, 153, 162 Rudotel, 162 Serenace, 162 Sinophen, 162 Taxillan, 162 Tofranil, 160 Tegretal, 161 Trifluoperidol, 162 Trifuloperazine, 164

Index Trioxin, 164 Tripthazin, 164 Tyrolon, 162 Tyrylen, 162 psychosis, 67, 124, 16 psychosurgery (see also lobotomy), 69, 72, 109 psychotherapy, 6, 9, 14, 29, 40–1, 94, 107–9, 119, 122, 126, 129–30, 139, 142, 186 punitive psychiatry (see political abuse of psychiatry) Purkyně Society, 135–6 Putin, Vladimir, 196 RabFak, 196–7, 211 Rákosi, Mátyás, 117 Ranschburg, Pál, 119 rational therapy, 40, 107–8 Red Cross, 188 Reddaway, 3 rehabilitation of political prisoners, 125, 127 Rennie, Thomas, 145 Richta, Radovan, 150 Rockefeller Foundation, 13 Rokhlin, L.L., 29, 41 Romania, 8–9, 17, 93–116, 149 Romanian Association for Strengthening the Association with the USSR, 96 Rose, Wolfgang, 9 Russia (Tsarist period), 8, 58, 77, 82 Russia (see also Soviet Union), 2, 6, 8, 29–44, 51–68, 83–4, 86, 196–8, 200–212 Russian Federation Law of Mental Health Care, 42 Sakharov Centre, Moscow, 197, 211 Salpêtrière, Paris, 14 samizdat, 197 Sartorius, Norman, 19 Schizophrenia, 17, 36, 37, 38, 39, 57, 61, 62, 63, 65, 67, 68, 124 Schönberger, István, 124 scientific-technological revolution, 140, 142, 144–5, 150

221

sedative, 58, 153, 165–6 in Soviet hospitals, 58 frequency of use, 165–6 Serbia, 180, 182 Serzhanov, Efim Moiseevich, 35 sexuality, 102 Shakhmatova, Irina, 17 Shapiro, Monte, 16 Shestakov, V., 199–200 Sholomovich, Aleksandr, 73–4 Simic, Ilija, 185 Siminovits, István, 128 Skala, Jaroslav, 11 sleep therapy, 8, 50, 54–5, 57, 63, 66–7, 108, 135, 139 sluggish schizophrenia, 3, 5–6, 12, 197 Smith, Roger, 7 Snezhnevsky, Andrei, 5, 12 social psychiatry, 10, 18, 122, 163, 165, 187–8, 189, 191–2 social workers, 40, 109 socialist competition, 39 Society for the Struggle Against Alcoholism (Yugoslavia), 188 sociology, 140, 146–7 Šorm, František, 142 Soviet Academy of Medical Sciences, 7 Soviet Invasion of Czechoslovakia, 142 Soviet Union, 2–6, 16–8, 30, 42, 50, 53–4, 57, 61, 68, 73, 96, 140, 147, 197 Soviet Union (collapse), 3, 5–6, 25, 42, 197, 204, 210 sovietisation, 73, 95, 135 Spielrein, Sabine, 8 Sri Lanka (see Ceylon) Stalin, Joseph, 135 Starý, Oldřich, 14, 139–146 Stekel, Wilhelm, 132 Stief, Sándor, 120, 125 Stojanovic Hospital, 186 Stojilkovic, Slobodan, 182, 183–4, 185, 187 Streliukin, A.K., 75, 80 Stupin, S.S., 31–3 suicide, 127, 191 Sul’kin, Oleg, 203, 211–2

222

Index

Sweden, 141 Switzerland, 93, 127, 160 syphilis, 125 Szasz, Thomas, 191,198 Szinetár, Ernő, 129 Szondi, Lipót, 119 Tabibs, 75–85 Tajikistan, 75, 77–9, 84–85 Tariska, István, 121, 126–7 Tavistock Institute, London, 14 Therapeutic Community, 186–7 therapeutic nihilism, 50, 54, 56, 62, 118, 125 therapeutic optimism, 107 Tichý, Josef, 9 Todes, Daniel, 8 Tolstovtsy Commune, 35–36 town planning, 144–7 toxins as aetiology, 7, 67, 100, 138, tranquillizers, 125, 158, 161–2, 164, 166 (see also psychopharmaceutical) transcultural psychiatry, 18 Troparevo Colony, 35–37 Trotsky, Leon, 8 tuberculosis, 79, 118 Tuke Family, 27, 32 Turkmenistan, 77, 81, 83, 85, 86 UNESCO, 146, 151 United Nations (and mental health), 42 urbanisation, 144

USA, 141, 161, 163 USSR (see Soviet Union) Uzbekistan, 77, 78, 84–5, 204–205 Van Voren, Robert, 4–5 Váňa, Josef, 151 Vianu, Ion, 93, 110 Vujic, Vladimir, 13 Vujosevic, Krtso, 182–3 Vygotsky, Lev, 16 Wallon, Henri, 133 West Germany, 10, 13, 155, 156, 160, 164, 166–7 Windholz, George, 8 Work therapy, 29–44 Working Commission on the Use of Psychiatry for Political Purposes, 197 World Congress of Psychiatry, 4 World Health Organization, 18–19, 144, 156 World Psychiatric Association, 4, 144 World War II, 40, 56 Wortis, Joseph, 2 Wulff, Moshe, 8 York Retreat, 27, 30, 32 Yugoslavia, 9, 11, 12, 17–20, 94, 180–192 Zajicek, Benjamin, 8 Zsáko, István, 120–1 Zverev, Aleksei, 201