On May 6th 2012 Mikhail Kosenko was one of the demonstrators on Moscow’s Bolotnaya Square. His recent trial in a Moscow courtroom and the ensuing decision that he should be sent to a psychiatric hospital for compulsory treatment was one of the more depressing sensations in today’s Russia. The public immediately concluded that punitive psychiatry, such a feature of dissident repression in Soviet days, was back.

Dr Alexander Kotsyubinsky, my father, is a psychiatrist and professor at the Bekhterev Psychoneurological Research Institute. In the early 1990s he was part of the team that carried out the posthumous review of the psychological and psychiatric aspects of the case of Pyotr Grigorenko [a well-known Soviet dissident], which led to Grigorenko’s subsequent rehabilitation. Dr Kotsyubinsky offers his expert opinion on the Kosenko case.

The sentence passed down to Mikhail Kosenko for his part in the "Bolotnaya Affair" has been widely condemned by human rights defenders. The police officer he was accused of assaulting refused to testify against him. Image: rosuznik.org

Dr Alexander Kotsyubinsky (AK): When people talk of punitive psychiatry, they usually have the following series of events in mind: the security services initiate a case against an opponent of the government, the psychiatrists then come up with the required diagnosis, on the basis of which the court dispatches a normal healthy person, who happens to have opinions which don’t fit, for compulsory treatment in a psychiatric hospital, where he is force fed psychoactive drugs, which destroy his health.

In reality, however, this stereotypical kind of punitive psychiatry, so well illustrated in Milos Forman’s film "One Flew over the Cuckoo’s Nest" is fairly rare. 

At the request of the security services, psychiatrists diagnose someone with psychiatric disorder(s) as more seriously ill than he is.

Firstly, a completely healthy person is not just given a false psychiatric diagnosis. What happens is that, at the request of the security services, psychiatrists diagnose someone with psychiatric disorder(s), which are not dangerous for either him or those around him, as more seriously ill than he is. As far as I can see, this is what happened with Mikhail Kosenko, who has had mental health problems for some years.

Second, psychiatrists in hospitals, where these ‘patients’ end up when they have been sentenced, don’t always behave like executioners. If a responsible psychiatrist sees that the patient who has been sent for compulsory treatment is not actually ill, then he simply goes through the motions, as it were, so as not to damage the health of this person. This is what happened with Soviet dissident Pyotr Grigorenko: twice he was sent to special clinics for compulsory treatment, but the doctors managed to avoid prescribing strong drugs for him.

Third, a separate question, which presents a greater risk for someone with mental health problems and to which there is no simple answer - Can he spend six months in a psychiatric hospital and have a chance (if, of course, the doctors are humane and honourable) of being released because he has been ‘cured’ – or will he end up in a real prison for several years?

Inmates in Moscow's Serbsky Institute for Forensic Psychology in 1992. While Doctors in Leningrad and Kiev refused to make false diagnoses, Doctors at the Serbsky Institute did not. Photo (c) RIA Novosti/ Vladimir Vyatkin

I am not in any way trying to justify punitive psychiatry. I simply consider that to address this evil, one should have a realistic view of what it is, rather than the mythologised version which exists in the public consciousness.

In reality (as far as I can judge), Russia’s authoritarian government is not putting members of the opposition into psychiatric hospitals so as to turn them into zombies.  Their aim is slightly different: firstly, to humiliate the unruly activists and punish them by exploiting fears of the ‘madhouse.’ Secondly, to scare the opposition as a whole and third, to ensure that the activists appear unbalanced in the eyes of the public. In this sense, one can talk of the return of punitive psychiatry in Russia today. If society, including doctors and psychiatrists, fails to offer united resistance to this negative tendency, then there is a real possibility that it will continue to develop.’

Paranoia and schizophrenia

Daniil Kotsyubinsky (DK): Do you think there is a real risk of a return to punitive psychiatry on the same scale and in the same forms as in Soviet days?

AK: No, I don’t, mainly because psychiatry these days is more transparent and can be monitored by outside institutions, which was not the case in Soviet times. Even the special psychiatric institutions now come under the Health Ministry, rather than the Interior Ministry, as they did before. Incidentally, Mikhail Kosenko is to be sent for compulsory treatment to an ordinary clinic, which is even more open for public monitoring than a special hospital.

In addition, it seems to me that the doctors in ordinary psychiatric hospitals are actually just that, doctors, rather than associates of the security services. Even at the height of the KGB use of punitive psychiatry in the USSR, false diagnoses for dissidents were only issued by staff members of a particular department in a particular psychiatric institution – Moscow’s Serbsky Institute of Forensic Psychiatry. Psychiatrists in Leningrad and Kiev effectively refused to make wrong diagnoses.

Official statistics from the Serbsky Institute show that 95.5% of dissidents diagnosed with signs of querulous paranoia were deemed to be of sound mind, though the result was almost always that they were pronounced certifiable.

DK: What was the diagnosis usually given to dissidents?

AK: The usual ‘diagnostic masks’ used to deal with dissidents were ‘paranoia querulans’ or constant complaining and ‘schizotypal personality disorder.’ Other diagnoses were rarely used for dissidents, though if someone who had never shown any signs of psychosis was subsequently pronounced mentally ill, then the diagnosis was sometimes ‘paranoid schizophrenia.’

For Soviet psychiatrists, querulous paranoia was a form of psychosis. The view was that after a real psychological trauma (conflict situations in particular), this pathological condition could present in the form of paranoid reactions, which subsequently became the basis for systematic ravings, where the dominant idea is replaced by an idée fixe, and then delusion.

In these cases the concept of ‘querulous ravings’ was manifested in the conviction of the ‘sick mind’ that his or her personal rights were being infringed; writing endless complaints and statements demanding the reinstatement of justice was adduced as the necessary proof of the condition.

Dissent in Soviet times

It’s not hard to show that this was simply a question of stamping out dissent, rather than of treating people who were ill. Official statistics from the Serbsky Institute show that 95.5% of dissidents diagnosed with signs of querulous paranoia were deemed to be of sound mind, though the result was almost always that they were pronounced certifiable.

Soviet psychiatry’s unscrupulous use of paranoia querulans as a tool of repression resulted in international discreditation of the condition and, consequently, a refusal to include it in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD10).

The diagnosis of ‘sluggishly-developing schizophrenia’ was one that was used particularly often as grounds for certifying dissidents to be of unsound mind. Dissidents with this diagnosis were usually sectioned, though the condition has very ill-defined diagnostic criteria and was frequently linked to the ‘patient’s’ successful activism in society.

ICD10 currently includes these conditions, although they are dealt with under the heading of schizophrenia and delusional disorders, are recognised as a discrete condition – a schizotypal personality disorder.

Soviet scientist and dissident Vladimir Bukovsky. In 1971 Bukovsky smuggled 150 pages of documents to the West detailing punative psychiatry in the Soviet Union against prominent dissidents like Grigorenko. Photo: Creative Commons Yuri Fedorov

DK: There is a theory that sluggishly-developing schizophrenia was a Soviet invention to deal with dissent…

AK: That’s not right and, moreover, the view that it was the Soviet professor A.V. Snezhnevsky who came up with this concept on the orders of the KGB is also mistaken. The actual person who first expressed a view that psychological disorders can develop in less serious, as well as extremely grave, form was the author of the term ‘schizophrenia’, Eugen Bleuler, who talked of ‘latent schizophrenia’ (1911). After that, the borders of schizophrenia shrank and expanded in accordance with this idea, leading to world psychiatric thinking developing the concept of a schizophrenic spectrum of disease, in which schizophrenia itself has quite a limited place.

So if Snezhnevsky’s concept had not been deployed by the totalitarian state to deal with dissent, the theory would simply have been one of the developmental stages in the doctrine of the proximity of ‘soft’ schizophrenic conditions (schizotypal personality disorders) to real schizophrenia. But unprincipled psychiatrists exploited the theory on the one hand, and repressive government organisations on the other, which put a negative slant on the term.

Kosenko’s diagnosis

DK: What about the diagnosis of ‘paranoid schizophrenia’ given to Mikhail Kosenko?

AK: I’m not in possession of all the details, but, if I’m honest, the work of the Serbsky Institute has surprised me. The psychiatrists ignored the fact that for the last twelve years Mikhail Kosenko has been taking one of the least strong antipsychotic drugs, Sonapax, and his symptoms are really more those of an astheno-hypochondriac disorder than delusion. The doctors only saw the patient once in an out-patient situation (which I consider to be woefully inadequate) and didn’t ask for any objective back-up information. They then ‘amplified’ i.e. exaggerated some of the incomplete and unformulated things Kosenko said, demonstrating his tenuous hold on reality. As far I can see, the experts promoted the secondary psychopathological symptoms to become the main, and on that dubious basis produced a highly controversial diagnosis of paranoid schizophrenia. 

The experts’ decision that Kosenko must have compulsory treatment as an in-patient seems completely inexplicable.

Kosenko’s disorder was exaggerated. The asthenic aspect (intense defensiveness or vulnerability, shyness, impressionability and reserve, which result in limited interpersonal skills and social isolation, do not generally go hand in hand with serious personality disorders, although they do produce increased anxiety and heightened self-consciousness with a tendency to self-analysis) was falsely classified as apathy-abulia [a disorder of diminished motivation, or DDR].

The problem is that this diagnosis doesn’t really fit with Kosenko’s social activism, as the main characteristic of apathy-abulia is a steady decrease in motivational activity, paucity of movement and listlessness or apathy.

The experts’ decision that Kosenko must have compulsory treatment as an in-patient seems completely inexplicable. When the condition is chronic, the criterion for a ‘cure’ is very vague, so it would be more correct to talk of remission or improvement. As far can be ascertained from Kosenko’s rational behaviour in court, he is actually in remission at the moment, so why was he deemed to need compulsory treatment and what is meant by that?

The court’s refusal to order a second expert opinion would seem to be based on prejudice too. The court actually referred to the second opinion incorrectly, describing it as ‘additional’, which is by no means the same thing. Hard to imagine that this confusion was an accident….

DK: What effect would many years of taking antipsychotic drugs have on someone’s mind?

AK: These drugs should be treated with great caution. Taking them for a long time and without proper monitoring can result inneuroleptic malignant syndrome on the one hand, or metabolic disorders on the other. And a healthy person is even more susceptible to these drugs than someone with a disturbed psyche. 

Conclusion

So is punitive psychiatry once more to become an instrument for punishing people who have stepped out of line? Only time will tell. Dr Kotsyubinsky’s revelations are both interesting and chilling; the case of Mikhail Kosenko is simply chilling.