Forensic psychiatry in Russia: past, present and future

At the beginning of the 20th century Russian psychiatry had entered a more humane phase, with the leading psychiatrist Korsakow having campaigned against the use of physical restraints for the mentally ill (Bloch & Reddaway, 1977). A successor of Korsakow, Vladimir Serbsky, played a key role in founding the Russian Association of Psychiatrists, campaigned for better social and economic conditions and saw the origins of mental illness as rooted in unjust social and economic conditions in Russian society. In the USSR there was then a new socialisation process aimed at the creation of the new Soviet atheist man (Anderson, 1994). The Russian Association of Psychiatrists was among the first of the professional bodies to offer its support to the newly formed Soviet Government (Lader, 1977). The main forensic psychiatric centre, the Serbsky Clinic, opened in Moscow in 1922 and has assumed a dominant role to this day. Based on Marxist philosophy, crime was seen as a product of capitalism, which would subside under communism (Mikheyev, 1996). The Soviet view also held that mental illness would decline under communism — hence its ongoing presence was seen as implying a lack of full socialist development of man (Fry, 1969).

With the passage of time, however, the early humanitarian ideals of the communist system were obscured by the totalitarian aspects of the regime. Repression during the Stalinist period resulted in millions of people being killed or imprisoned (Rummel, 1997). Allegations of the abuse of psychiatry for political purposes began to emerge in the 1960s (Bloch & Reddaway, 1977). However, the first case of such misuse in Russia dates from Tsarist times in 1836 with the detention of a Russian philosopher, Peter Chaadayev, who was critical of the regime (Smith & Oleszczuk, 1996). In early post-revolutionary times, psychiatric abuse was also used sporadically to silence political critics. In the mid-1950s a special Soviet commission found that repressive misuse of psychiatry had been occurring for some years, especially in the special hospitals in Kazan and Leningrad (Amnesty International, 1975). During the 1960s with the détente period, however, such abuse had escalated, the Soviet Government requiring methods more acceptable than killing its opponents. Other factors implicated in such misuse have included the application of unduly wide concepts in the diagnosis of schizophrenia, (and the infamous ‘delusions of reform’), the problems within psychiatry itself of defining the boundaries of mental illness, the degree to which some prominent Soviet psychiatrists were influenced by the KGB, and the extent to which they genuinely believed the diagnosis they were making (Smith & Oleszczuk, 1996).

With increasing international concern about Soviet psychiatric practice in regard to dissidents, the Soviet All-Union Society of Psychiatrists resigned in 1983 from the World Psychiatric Association rather than risk expulsion, being readmitted subsequently in 1989 (Bloch & Chodoff, 1991). During the Gorbachov era, political dissenters were released and their potential to be arrested was reduced by amendment of the articles of the criminal code relating to anti-Soviet activity and propaganda. In 1988 the Soviet special hospitals, which had previously been administered by the Ministry of the Interior, were transferred to the Ministry of Health. Even before the fall of communism in 1991 attempts to rectify the aberrant psychiatric practices had been initiated.

During the last eight years the transition from the communist system has not been easy. Economic and political complexity, rising levels of crime (Dashkov, 1992), increases in drug misuse (Fleming, 1991) and a general decline in the health of Russia's general population have been recorded (Ingram, 1996). Conditions in Russia's prisons are known to be well below the international standards, and the rectification of this situation will require huge sums of money Russia does not have (King, 1994).

A link, however, between Britain and Russia in forensic psychiatry has been evolving for over a decade (Gordon & Meux, 1994; Meux & Gordon, 1996; Bowden & Snowden, 1996). Psychiatrists and other health professionals in forensic psychiatry from both countries have undertaken a series of exchange visits to relevant centres. The visits to Russia have included high, medium and low secure and corrective labour colonies, a medical school and government ministry allowing an unequalled contemporary insight into forensic psychiatry in Russia. The links have culminated most recently in a joint conference in Moscow in October 1998, sponsored by the British Council, and attended by over 160 personnel from throughout Britain and Russia. British psychiatry played a prominent and appropriate role in the condemnation of earlier Soviet practice in regard to the dissidents and it now seems equally appropriate to rebuild the professional relationship. To this end, one Russian forensic psychiatric trainee has attended and completed the Diploma in Forensic Psychiatry course held at the Institute of Psychiatry in London, while another Russian forensic psychiatrist lectured at the Annual Meeting of the Royal College of Psychiatrists, when it was held in Glasgow in 1994 (Kachaeva, 1995). British psychiatrists have lectured at Russian conferences and broader medical links have been fostered via medical school liaisons. The Russian project coordinator, a professor of forensic psychiatry, recently spent a period as Minister of Health for Russia.

In 1992, the Russian Federation adopted a new law on Psychiatric Care and Guarantees of Citizens' Rights, while in April 1994 the Russian Society of Psychiatrists produced a Code of Professional Ethics (Polubinskaya & Bonnie, 1996). The new code is more consistent with international guidelines. Indeed, in this regard Russian psychiatry may be ahead of its British counterpart which has no such specific code. Within the new code the psychiatrist's main role is the health of the patient, while concurrently contributing to the promotion and protection of the mental health of the population as a whole. This contrasts with the perspective during communist times when the doctor gave an oath to communist morality and his responsibilities to the state (Alexeyeff, 1976). The Code seeks to overcome, therefore, the Soviet heritage of the professional community being the agent of State control. Acceptance in the Code of the concept of informed consent is a remarkable reform in Russian psychiatry, requiring psychiatrists to change their attitudes towards their patients and their treatment practices and respect the autonomy of the patient. Stricter guidelines on disclosure of medical information are also encompassed as well as on the use of psychiatric patients in research. Additionally, Russian law now incorporates greater safeguards for the detained patient to appeal against his detention and treatment.

Soviet and post-Soviet practice on the issue of criminal responsibility has evolved in stages during this century. In the early Soviet period, the Serbsky Institute found the mentally ill and many ‘psychopaths’ to have been ‘non-responsible’ for their offences (Bloch & Reddaway, 1977). However, by the 1930s the concept of individual responsibility became more emphasised and far lower numbers of ‘psychopaths’ were felt to be nonresponsible. The Russian special hospitals, known as ‘strict security’ hospitals, mostly contain patients diagnosed as suffering from mental illness, and have fewer ‘psychopaths’ than their equivalents in England and Wales. Up until 1996 an offender could be found to be either responsible or non-responsible, but in the last two years a new law has introduced the notion of diminished responsibility. Unlike the English concept, which applies only to cases of homicide, the Russian law applies to all offences (further details available from the author upon request).

The future of forensic psychiatry in Russia depends on a range of factors, not least of which is the stabilisation of the economy. However, Russia is now also a member of the Council of Europe and a signatory to its convention concerning the prevention of torture and inhumane and degrading treatment. This associated European Committee for the Prevention of Torture and Inhumane or Degrading Treatment or Punishment (CPT) was instrumental in resolving chronic deleterious conditions in certain British prisons within recent years despite all efforts to do so by British professionals (King, 1994). The first CPT visits to Russia have recently occurred and will seek to identify issues relating to Russian police cells, prisons, psychiatric hospitals and other places of detention, which may be regarded as resulting in brutal, inhumane or degrading treatment. It will, as a result of its visit which has the cooperation of the Russian government, make comments and recommendations for positive change and evolution in these areas. The rising crime levels in Russia will impose great strain on Russia's prisons and the death penalty remains an issue. Russia will need time to reposition itself effectively in the international economic and political community. We have, however, learnt from our professional contacts with Russian psychiatric colleagues that they have a strong desire to be fully integrated in the world psychiatric community. In our view this is best achieved by links being continued, nurtured and enhanced in order to avoid any risk of slippage back into professional isolation. Within Russia itself, the training of psychiatrists and other psychiatric clinicians, particularly nurses, needs to be further fostered. Some decentralisation from the dominance of the Serbsky Institute and other leading centres is also being encouraged, while bearing in mind the forensic psychiatric experience accumulated in such centres. Ultimately however, albeit within an international context, it will be for the Russian psychiatrists themselves, and indeed the Russian people, to fashion for themselves a system of forensic psychiatry of which they can feel proud. Various events and inquiries in Britain over the last two decades have shown just how complex such a process can be.