Psychiatry, Abuses of
PSYCHIATRY, ABUSES OF•••
Abuse of psychiatry conjures up a situation in which a psychiatrist acts improperly, causing a patient to experience some sort of harm. The concept is more complex than it appears to be at first sight. This article examines psychiatric abuse in an effort to determine its accurate meaning so that steps can be taken to eliminate or prevent it.
Evidence has emerged of such practices as the abuse of psychiatry for political purposes in the former Soviet Union (Bloch and Reddaway, 1977, 1984), a similar pattern in Cuba designed to suppress political dissent (Brown and Lago), the deployment of psychiatric knowledge in torture and interrogation in Northern Ireland in 1971 (Bloch, 1990), and pursuit of financial profit as a priority in Japanese private psychiatric hospitals (Harding). The tragic perversion of psychiatry during the Nazi era, in which tens of thousands of chronic psychiatric and mentally retarded patients were gassed to death, and similar numbers were sterilized, is the most gross instance of abuse (Burleigh; Müller-Hill).
Commentary on psychiatric abuse has also referred to its prevalence elsewhere particularly in the United States and South Africa. But, as will become evident in the section on definition, care must be taken to distinguish between intentional misapplication of psychiatric knowledge, skills, and technology and inadequate or negligent practice. In the South African case, the policy of apartheid involved massive inequity in the provision of mental health services, with blacks allocated substantially lesser resources compared with whites despite equivalent need. On the other hand, the allegation of the misuse of psychiatry to squelch black political activism never had any basis (Bloch, 1984).
In the United States, discriminatory practices have also occurred but due to economic rather than explicitly political forces. With millions of Americans unable to afford health insurance and inadequate budgets for public psychiatric services, the result has been substandard care in state mental hospitals, particularly for minority groups and the poor (frequently the same population) (Green and Bloch; Torrey).
The abuse of psychiatry for political or other purposes in the United States has been sporadic, the examples of the poet Ezra Pound (1885–1972) and General Edwin Walker (1909–1993) being especially well known. In the case of Pound, psychiatry was recruited to deal with a politically sensitive situation. A celebrated poet, indicted for treason following his pro-Axis broadcasts in Italy during World War II, Pound faced possible execution. Although the evidence was equivocal, Pound was judged incompetent to stand trial on grounds of insanity and transferred to St. Elizabeth's Psychiatric Hospital where he spent the next thirteen years. The indictment was later dismissed and Pound released. Whether psychiatry was misused to extricate the U.S. government from a quandary or Pound was deluded and this accounted for his wartime behavior remains a baffling issue. Suffice to say, the case demonstrates the vulnerability of psychiatry to political exploitation.
Similar factors prevailed in the case of Edwin Walker, a decorated major general in the American army who adopted an extreme right-wing position during the civil rights campaigns of the 1950s and the 1960s. His competence became a matter of dispute after he had been charged with offenses related to his activism. Although declared competent to stand trial (the case was later dismissed for technical reasons), the possibility of the government's recourse to psychiatry to deal more conveniently with a troublemaker cannot be ruled out (Stone).
A final comment in this brief historical context concerns criticism of psychiatry for its patronizing attitude toward women. The dramatic case of Mrs. E. P. W. Packard in 1860 illustrates how prejudice may undermine clinical judgment. Upon the insistence of her husband, a fundamentalist clergyman, that she harbored dangerous religious beliefs, Mrs. Packard was committed to a mental hospital, where she remained confined for three years. Upon her release, she launched a campaign against the expression of opinions as a basis for psychiatric detention (Musto).
Over a century later in 1972, Phyllis Chesler was among the first to argue that psychiatry's view of women was so distorted as to impair its objectivity. Other feminist perspectives followed (e.g., Showalter; Luepnitz). According to this view, a male-dominated profession too readily regards women not conforming to stereotypic roles as psychologically suspect, even disturbed. Freud's contribution to gender psychology has no doubt been influential in the maintenance of such attitudes.
Psychiatric abuse can be defined according to specified criteria and differentiated from other undesirable activities, which are best termed malpractice. Abuse refers to the intentional, improper application of the knowledge, skills, and technology of psychiatry for a purpose other than serving the patient's interests or to harm, in diverse ways, people who do not warrant psychiatric status in the first instance. Abuse is invariably perpetrated by psychiatrists (and other mental health professionals) in collaboration with other persons or agencies, such as a state security service or political authority and, then, usually as part of a totalitarian system.
Such institutional abuse is always unethical in that the protagonist intentionally carries out an act in the knowledge that the act is intrinsically wrong (whether or not it turns out to harm), explicitly violating professional ethics. A psychiatrist who acts in this way, claiming that he is obliged to follow the orders of superiors and in that sense is heteronymous, is inexcusably rejecting a responsibility to ensure that regulations serve good, not bad, professional goals. In these circumstances, even if psychiatrists covertly seek to ameliorate the welfare of the patient, claiming that this is the sole means to maintain an ethical stance, their behavior, by virtue of colluding in an abusive practice, becomes an inherent part of the abuse.
Reference to institutional abuse, on which this article focuses, does not negate the possibility of individual psychiatrists abusing one or more of their own patients. A similar ethical violation takes place in both cases, psychiatrists in the latter exploiting patients to meet their personal needs on the pretext that the practice applied is clinically indicated. A clear-cut example is sexual involvement, but other forms of abuse of power intrinsic to the psychiatrist–patient relationship, such as financial and religious, are relevant here. This sort of abuse may mar any doctor–patient relationship, but the not uncommon situation in psychiatric treatment of an excessively vulnerable patient seeking comfort from an ostensibly all-caring professional is arguably more conducive to its occurrence than in other medical spheres.
Abuse can also be perpetrated by a psychiatrist in conjunction with, or acceding to, attempts by lay people to exploit the discipline for nonmedical purposes. Consider this example: A husband who knows that his wife is not mentally ill, but is determined to gain custody over their children in an impending legal tussle, persuades a psychiatrist to commit her to a mental hospital. His interests are other than the welfare of his wife; he desires to wield power over her for his own purposes and recruits the psychiatrist as an accessory (Robitscher).
Malpractice is distinguishable from abuse with respect to intent. Although the term is used in diverse ways, an alternative remains elusive; inadequate practice comes closest in meaning. A psychiatrist who does not set out to use knowledge, skills, or technology improperly but who deploys these in an unskilled fashion is engaging in malpractice. An example is prescribing psychotropic drugs for patients upon the request of nursing staff, who claim they are otherwise unable to manage "difficult behavior," in cases where patients do not need such medication. Psychiatrists do not pervert their science in these circumstances but fail to adhere to a standard of practice that requires the application of drugs only when clinically indicated. Malpractice should be differentiated from "errors in clinical judgment" when that judgment has been made in good faith. Psychiatrists, like any other professionals, are prone to err on occasion. Although the consequences may simulate the effects of malpractice, malpractice is not actually carried out.
The Vulnerability of Psychiatry to Abuse
Abuse is more common in psychiatry than elsewhere in medicine, probably because it is inherently more vulnerable to it in at least three respects: (1) its boundaries remain illdefined; (2) diagnosis is often made in the absence of objective criteria; and (3) the psychiatrist is granted immense power by society to determine the fate of other people, even to the extent of detaining them in hospital or imposing treatment on them.
The lack of a well-demarcated conceptual boundary in psychiatry leads to a correspondingly ill-defined role for its practitioners. Debate has long continued among psychiatrists themselves, and in the wider community, as to what constitutes their legitimate role (Dyer). Attitudes vary considerably, even to the point of contradiction. The following views, expressed by former presidents of the American Psychiatric Association, reflect this diversity. In 1969 Ewald Busse argued for a limited role whereby psychiatrists restrict their focus to the suffering patient, and services are accordingly confined to reducing pain and discomfort. In 1970 his colleague Raymond Waggoner had a much wider perspective, calling upon the profession to pursue "fundamental social goals," and for psychiatrists to be visionaries.
Definitions of health and ill health are pertinent to the above positions. Thus, a visionary outlook brings psychiatrists into the domain of social policy. Their potential participation in a context beyond hospital and clinic is boundless, leading to professional judgements, ostensibly derived from expertise, on social issues like unemployment, racism, poverty, torture, religious cults, child-rearing practices, sexual expression, and indigenous rights. Psychiatrists may assume roles, including those of social commentator, political activist and lobbyist, that extend well beyond the traditional role of clinician.
Whatever the role adopted, psychiatrists are buffeted by the demands of multiple loyalties. They are caught ineluctably between responsibilities to patients and to society, the latter potentially including, among others, a patient's family, an employer, the courts, prison officials, and military authorities. In these circumstances they have to weigh the interests of patients against those of social agencies. In so doing, they may be subject to such intense pressure as to subordinate themselves to social forces, and so neglect their obligation to patients.
Psychiatry's role is more clear-cut when limited to an exclusively medical function. But this depends on the psychiatrist's ability to conduct diagnostic assessments that are relatively objective and value-free—for example, in the case of a person with a brain disorder like Alzheimer's Disease. This brings us to the second feature of psychiatry that contributes to its vulnerability to abuse, lack of objective criteria in clinical evaluation.
Although psychiatry has evolved as a scientific discipline for over a century and a half, including progress in classification, the discipline still faces the key question of what constitutes mental illness (Fulford, 1989). No satisfactory criteria exist to define precisely many of the conditions with which psychiatry deals. Compared with those in other medical fields, many currently used psychiatric diagnoses derive from clinical observation alone, and lack identifiable pathophysiological correlates. Objective tests to confirm the presence of a psychiatric condition are rare.
Moreover, in the diagnostic task psychiatrists rely in uncomfortably large measure on social criteria and value judgments. As the British sociologist Kathleen Jones reminds us, society would not be able to determine what was normal if it failed to designate certain acts and certain people as abnormal or antisocial. William Fulford and Walter Reich have contributed handsomely to the question of what constitutes a mental disorder by dissecting the complex process psychiatrists use to determine whether a diagnosis should be applied to a specific constellation of mental or behavioral features. Fulford (1999) stresses the place of values in clinical practice overall, positing that diagnoses in both physical and psychological medicine are an admixture of the factual and the evaluative. For him the concept of mental illness is on the same logical platform as the concept of physical illness.
Reich makes explicit the vulnerability of the diagnostic process in psychiatry to error given its reliance on subjective criteria, the intrusion of bias and prejudice and shifting criteria leading to inconsistency and frequent change. Consider the illustrative diagnostic controversies which buttress Reich's contentions: the deletion of homosexuality as a condition following a poll of members of the American Psychiatric Association in 1973; intense debates over whether a concept like attention-deficit hyperactivity in children or in adults is valid; and the question of whether antisocial personality disorder is a valid disorder of personality functioning or mere social deviance (and therefore belongs within the sphere of crime and delinquency). Many more examples could be added to this list.
In the context of an ill-defined professional framework and the vague criteria for diagnosis, the psychiatrist is sanctioned by law to manage the situation in which a person suffers or is suspected of suffering from mental illness that may require enforced hospitalization and/or treatment to protect a person's welfare or that of others (Peele and Chodoff). This is an awesome responsibility in that a person may be deprived of his liberty, lose basic civil rights, and be subject to a range of legal regulations.
Although commitment statutes in many jurisdictions, particularly those pertaining to determining the risk of dangerousness to self and/or others, have been rigorously scrutinized, a disconcerting uncertainty persists as to what constitute relevant criteria. Psychiatrists are caught in a dilemma of having to arrive at a judgment about a person's clinical needs and protecting her civil rights at the same time. The civil libertarian would insist that an inalienable right to liberty should be guaranteed above all other considerations whereas those with a paternalistic outlook would aver that society, through its legally sanctioned agents, has an obligation periodically to take measures, undesirable as they may be, to protect patient, society, or both from harm.
Soviet Psychiatric Abuse
In summary, ill-defined boundaries, the subjective basis of assessment, and the authority to treat a person involuntarily combine to make psychiatry especially vulnerable to abuse. The most clear-cut illustration of this was the use of psychiatry in the former Soviet Union to suppress political, religious, and other forms of dissent. These practices have been analyzed at length by several observers (Bloch and Reddaway 1977, 1984; see also Bukovsky; Plyushch).
Soviet psychiatry's boundaries were drawn in such a way that made the entire discipline subordinate to the pervasive influence, overt and covert, of the Soviet state and, more particularly, of the Communist Party. The monolithic form of the administrative structure, with power wielded by a small, compliant group of psychiatrists, allowed a political authority to mould the functions of all Soviet psychiatrists. Even if professional boundaries had been clearer, the totalitarian nature of the Soviet state prevented psychiatrists from functioning autonomously. The fact that boundaries were blurred made it all the easier for the state to exert control and influence the profession in terms of its ideology. The Soviet government's avowal that the interests of society were as pertinent as those of the individual paved the way for the principle of respect for autonomy to be undermined.
The Soviet abuse is a blatant reminder that psychiatrists may function in a state whose interests do not serve those of the society. The corollary is obvious—psychiatrists must act independently with regard to ethical standards.
The lack of objective criteria for diagnostic evaluation permitted the evolution of an idiosyncratic taxonomic scheme in Soviet psychiatry for virtually four decades. Andrei Snezhnevsky rapidly ascended to the pinnacle of the psychiatric establishment during the 1950s, and from that impregnable position launched a unique classificatory system of mental illness. A crucial result was the profound shift in the way schizophrenia was conceptualized. Snezhnevsky advanced several claims, among them the notion that since the illness could be present in a person showing minimal features, schizophrenia was much more common than previously thought. A form of the illness, sluggish schizophrenia, named thus because of its slow progression, accounted for the wider limits placed on the use of the diagnosis. When suppression of dissent by psychiatric means escalated in the 1960s, the label sluggish schizophrenia, was commonly applied to political, religious, and other dissidents whom the state wished to disempower and punish (Reich; Bloch and Reddaway, 1977).
Although this framework was not originally devised to curb dissent, the vagueness of its concepts enabled application of a disease label to people whom psychiatrists elsewhere would have regarded as normal, mildly eccentric or, at worst, neurotic.
The inadequacy of criteria to appraise the risk of harm of a person to himself and/or to others makes psychiatry open to the improper use of its sanction to detain. As an element of the Soviet pattern, the notion of "social danger" was promulgated. In a letter to the Western press in 1973 (Guardian), the psychiatric establishment, fending off allegations that psychiatry was being misused, asserted that in a proportion of patients, their disease process could result in antisocial activity, including "disturbances of public order, dissemination of slander, and manifestations of aggressive intentions." They commented further on the "seeming normality" of these patients when they committed dangerous acts. Aggression in the mentally ill leading to self-harm or harm to others was conflated with disturbance of public order and slander. Well-documented cases of dissenters in Soviet hospitals pointed to an obvious conclusion: Psychiatrists there had broadened the concept of dangerousness in an ethically dubious way.
The allegation of the systematic, political abuse of psychiatry in China, comparable to what occurred in the former Soviet Union, has been widely debated since Robin Munro, a Research Fellow in the University of London and formerly an observer of the human rights situation in China employed by Human Rights Watch, produced a report detailing most methodically its prevalence and procedures (Munro, 2001; Dangerous Minds).
According to Munro, a small number of political dissenters were arrested as enemies of the state, diagnosed with a major psychiatric disorder and then compulsorily hospitalized as far back as the 1950s. Having stumbled across evidence of this practice in 1989 in a Chinese textbook on legal aspects of psychiatry, Munro scrutinized the official psychiatric literature—books and journals in the main—only to find repeated references to political patients. In one series of forensic psychiatric assessments, no less than one in five related to counterrevolutionary behavior.
The Cultural Revolution from 1966 to 1976 saw further ethical disarray in psychiatry. On the one hand, genuine patients forced by the Red Guards into confessing that they were truly counterrevolutionary, were thereupon promptly imprisoned or even executed. Conversely, genuine political dissidents were dispatched to institutions for the criminally insane. As one prominent forensic psychiatrist, Zheng Zhanpei, put it in 1988, the turmoil within Chinese psychiatry "… had to do with the particular historical circumstances of the time" (Munro, 2002, p.102). Munro provides extracts from Chinese psychiatric publications during this turbulent period which reveal just how politicized the profession became. For instance, mental illness was seen as being bound up with the class struggle and, given the tussle between the proletariat and capitalist positions, most patients had a bourgeois outlook.
Following the Cultural Revolution, the Soviet pattern of abuse returned but became more prominent in the late 1990s in association with the state-led campaign to stamp out the religious Falun Gong movement. As the pressure began to mount against the movement's members, so a proportion of them were falsely detained in general psychiatric hospitals under the rubric of a newly devised psychiatric condition with the bizarre title of "evil cult-induced mental disorder."
The response of Western psychiatrists to Munro's findings and conclusions have differed substantially, ranging from total incredulity that any country would be silly enough to repeat the Soviet saga and thus earn universal disapproval and condemnation to a solid conviction that the allegations are well-founded.
The Royal College of Psychiatrists for instance resolved at its 2001 Annual General Meeting to call on the World Psychiatric Association to organize a fact-finding visit to China.
How prominent Western figures in psychiatry have arrived at their conclusions, one way or the other, is difficult to fathom. Alan Stone, Professor of Law and Psychiatry at Harvard University, sharply criticizes Munro's research and regards Chinese psychiatrists as more victims than victimizers. It is relevant here that Stone remains adamant that Soviet psychiatrists also did not misuse their knowledge and skills to curb dissent. Sing Lee, and Arthur Kleinman, a distinguished anthropologist and psychiatrist, also at Harvard, similarly argue that "… there is simply no evidence of systematic abuse of mental hospitals for reasons of political oppression by the profession as a whole" (p.124) although they do concede that some psychiatrists are more open to "abusive practices" (p.124) when under police or Communist Party pressure.
Among psychiatrists who contend that abuse almost certainly has taken place and continues are Jim Birley, past President of the Royal College of Psychiatrists, who opines thus: "There is certainly a strong case, more than a suspicion, that psychiatry is once again being used for political purposes" (p. 147); and Sunny Lu and Viviana Galli, two American psychiatrists, who have provided a detailed account of the role of Chinese psychiatrists in dealing with the Falun Gong specifically. The latter conclude that the psychiatric gambit is part of a "… comprehensive and brutal campaign to eradicate Falun Gong" (p. 129).
Western psychiatrists and human rights organizations had to toil long and hard before the abuse of psychiatry ceased in the former Soviet Union. The toll of suffering was tragically high as thousands of dissenters were victimized through psychiatry. In the case of the Chinese allegations, a similar delay should not ensue.
Legislation, professional self-regulation, establishment of watchdog committees, and adherence to appropriate codes of ethics are complementary means to deal with and prevent psychiatric abuse. Legislation has the potential to safeguard patients's civil rights, hold psychiatrists accountable, and specifically define their functions. Such mental health laws promote patients's rights and protect them from abusive psychiatry, and set requirements of practice whose transgression is tantamount to illegal conduct (e.g., Mental Health Act, 1986).
Peer review and quality assurance may help identify ethically suspect judgments or actions. Many national associations of psychiatrists have procedures to discipline members who violate principles of clinical care: informal warning, reprimand, suspension, or expulsion (see for example, Royal Australian and New Zealand College of Psychiatrists). The Royal College of Psychiatrists in Britain and the American Psychiatric Association have developed procedures to investigate abuse.
As a professional collective, psychiatrists, both nationally and internationally, need to maintain vigilance when governmental or nongovernmental entities try to exploit them to apply their knowledge and skills for purposes other than serving the interests of patients and the community at large. Psychiatrists operating in totalitarian states may not be in an equivalent position without jeopardizing their professional or personal interests. For instance, Semyon Gluzman and Anatoly Koryagin experienced years of incarceration for condemning the misuse of psychiatry in the former Soviet Union.
As part of their ethics, psychiatrists have an obligation to protest against the misuse of their profession wherever and whenever it occurs. Such action points to a political role psychiatrists may be required to play.
Finally, psychiatrists need to familiarize themselves with, and adhere to, relevant ethical codes, from the Oath of Hippocrates which stipulates that the doctor will "keep [the sick] from harm and injustice," to their own national and international codes, many of which affirm that they should never use their professional authority to maltreat people.
The 1998 ethical code of the Royal Australian and New Zealand College of Psychiatrists explicitly covers abuse by incorporating the principle that "Psychiatrists shall not allow the misuse of their professional knowledge and skills." A series of annotations follows which deal with such issues as never diagnosing a person as mentally ill solely on the basis of political, religious, ideological, moral, or philosophical belief; the impermissibility of using nonconformity with a society's prevailing values as the determining factor in diagnosis; and the unacceptability of participation in torture and executions.
The history of psychiatry has been dreadfully tarnished by the occurrence of gross abuses, the Soviet and Nazi cases being especially prominent. Attention to such cases has led to greater ethical sensitivity among psychiatrists and beyond. Although this may serve as a safeguard against abuse now and in the future, both the profession and society need to maintain a vigorous defense against any malignant force that is tempted to exploit psychiatry and thus jeopardize its integrity.
sidney bloch (1995)
revised by author
SEE ALSO: Autonomy; Coercion; Deep Brain Stimulation; Electroconvulsive Therapy; Holocaust; Informed Consent: Issues of Consent in Mental Healthcare; Insanity and Insanity Defense; Institutionalization and Deinstitutionalization; Mental Illness: Conception of Mental Illness; Mental Illness: Cultural Perspectives; Mental Institutions, Commitment to; Mistakes, Medical; Paternalism; Patients' Rights; Psychosurgery, Medical and Historical Aspects of; Race and Racism; Technology; Women, Historical and Cross-Cultural Perspectives
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