Psychiatry as an instrument of the state

A diagnosis elastic enough to hold dissent

In the Soviet Union, the diagnostic category "sluggish schizophrenia" — systematised in the 1950s and 1960s by Andrei Snezhnevsky's Moscow school from earlier concepts including Eugen Bleuler's "latent schizophrenia" — was drawn broadly enough that features such as a "delusion of reformism" or a "heightened sense of self-esteem" could be offered in support of a schizophrenia diagnosis.

The category was applied overwhelmingly to ordinary patients. But its elasticity made political misuse possible and left it unchecked. The Serbsky Institute in Moscow was the leading institution conducting forensic psychiatric examination of dissidents.

The official 1989 US delegation put it this way: "Some of the symptoms incorporated into Soviet diagnostic criteria for mild ('sluggish') schizophrenia are not accepted as evidence of psychopathology in the U.S. or under international diagnostic criteria."

[45] Bonnie RJ, J Am Acad Psychiatry Law 2002;30(1):136-144, quoting the 1989 US delegation report verbatim

It withdrew before it could be expelled — and returned in Athens

The All-Union Society of Neuropathologists and Psychiatrists withdrew from the World Psychiatric Association in January 1983, citing a "slanderous campaign". Western participants in the campaign against Soviet psychiatric abuse — Sidney Bloch and Helsinki Watch, both writing in 1990 — state that the withdrawal pre-empted an expulsion vote.

The Society was readmitted at the WPA's Eighth World Congress in Athens on 17 October 1989, by 291 votes to 45 with 19 abstentions, on terms the resolution called "full membership with conditions": a Review Committee site visit within one year, and a special General Assembly to consider suspension if political abuse were found to continue.

We declare the gap: the WPA's own General Assembly records were not obtained for this account. The figures come from two independently published 1990 sources.

[46] Bloch S. "Athens and beyond: Soviet psychiatric abuse and the World Psychiatric Association", Psychiatric Bulletin 1990;14(3):129-133 · [47] Helsinki Watch, "The Legacy of Psychiatric Abuse in the USSR", May 1990

Fourteen of twenty-seven — and what that does not mean

The 1989 US delegation examined 27 people whose names had been supplied by human rights organisations, the US Helsinki Commission and the State Department — cases referred because abuse was already suspected. It was not a random sample of Soviet patients.

US psychiatrists found 14 of the 27 to have no mental disorder: 5 of the 15 then hospitalised, and 9 of the 12 already released. Soviet psychiatrists examining the same people concurrently also found no current evidence of schizophrenia in those 14.

The distinction that changes the meaning: among those actually hospitalised — the population the phrase "no disorder justifying hospitalisation" points at — the finding was 5 of 15. A third, not a majority. The claim that "most people in Soviet psychiatric hospitals were well" is not supported by the delegation's own breakdown.

[45] Bonnie RJ, J Am Acad Psychiatry Law 2002;30(1):136-144 · [58] van Voren R, Schizophr Bull 2010;36(1):33-35

China: confinement on a police decision — what four UN bodies recorded over eighteen years, and what the 2012 law says

The second example has neither the numbers nor the ending of the Soviet one. Richard Bonnie, in the same 2002 article cited above, writes that "in the 1980s, China also established a system of maximum-security forensic hospitals (Ankang), modeled after the Soviet 'special hospitals'", and relays, via Robin Munro's review of the Chinese psychiatric literature, two measurements from published Chinese studies: at a Shanghai hospital in 1970–71, 73% of forensic assessments concerned "political" cases; at a Hangzhou hospital, the proportion of examinees arrested for "antisocial political speech" was 54% in 1977 and 6.7% in 1987. Bonnie himself notes that Munro's account of the Falun Gong "is limited to case reports, and is presented tentatively". Here we keep only what the UN's own bodies have written since.

2004–2016, in the documents' words. The UN Working Group on Arbitrary Detention, after its mission to China in September 2004, recorded that "Public Security also have the power to commit individuals to psychiatric facilities called ankang ('Peace and Health')" and that "there exists no genuine right to challenge administrative detention, including … detention in a psychiatric facility"; it asked for "an effective judicial remedy" for everyone held against their will. The Special Rapporteur on torture, Manfred Nowak, in his mission report (2006), lists the ankang hospitals as the location of 8% of the torture allegations that he and his predecessors had transmitted to the Government since 2000 (314 cases, well over 1,160 individuals) — with the express caveat that allegations "reflect the state of information" and not necessarily the state of the country — and recommends that "any decision regarding deprivation of liberty must be made by a judicial and not administrative organ". The Committee against Torture in 2008 "notes with concern that this provision [article 18 of the Criminal Law] has been misused to detain some people in psychiatric hospitals for reasons other than medical", and in December 2015 lists "compulsory psychiatric institutionalization" among four forms of administrative detention "which have been allegedly used to detain suspects without accountability" and which, according to reports, "the local police impose … without any judicial process". The Committee on the Rights of Persons with Disabilities, in 2012: "involuntary civil commitment is perceived as a tool to maintain the public order" and "many persons with actual or perceived impairments are involuntarily committed to psychiatric institutions for various reasons, such as being petitioners" — people who file complaints with higher authorities.

The law, and the same Committee ten years later. On 26 October 2012 China adopted its first national mental health law, in force from 1 May 2013. Article 30: "inpatient treatment of mental disorders shall generally be voluntary"; involuntary only for a "severe mental disorder" with recent self-harm or a risk to the safety of others. Article 32: a person confined as a danger to others, or their guardian, may within three days of the diagnosis request a reassessment and then an "independent, legally-binding certification". Article 78: compensation for "deliberately treating persons without mental disorders as if they have mental disorders and sending them to medical facilities". Article 82: the right to sue. Nowhere does the law put in a judge: the decision belongs to the facility's psychiatrists (Article 29), and the police keep the role of bringing people in (Article 28) and of helping to enforce admission (Article 35). Whether that suffices was judged by the same UN Committee in September 2022: the 2012 law contains "discriminatory provisions … which allow for the arbitrary deprivation of liberty of persons with psychosocial disabilities, forced institutionalization and non-consensual psychiatric treatment … on the grounds of medical assessments and diagnoses such as 'severe mental disorder'" — the same reading of Article 14 of the Convention that Part C explains the UN Human Rights Committee and the European Court of Human Rights do not share.

And one case decided by name. Xing Shiku, a former employee of a state-owned company in Harbin, went to Beijing in February 2007 to petition against local authorities. According to the complaint, he was arrested on 15 February at Beijing South Railway Station and taken to a psychiatric hospital in Harbin; the Chinese Government denied any arrest at the station, replied that a district official had "escort[ed] Mr. Xing back to Harbin" for examination "on humanitarian grounds", that he suffered from schizophrenia and that he "could have posed a threat to or adversely affected the maintenance of public order in Beijing". The Working Group kept to the common ground — "the Government confirmed that Mr. Xing had been detained and placed in a psychiatric institution after he went to Beijing to petition" — and found, in April 2014: "there are no facts in the Government's response which would indicate that Mr. Xing posed 'a threat to other persons or their property'", as, by the response's own account, national law requires; "psychiatric detention shall not be used to jeopardize someone's freedom of expression"; he had been deprived of his liberty "for over seven years because of the peaceful expression of his views". Arbitrary detention, "without any legal basis", with a recommendation of release and compensation. What became of him is not recorded in any UN document we could find.

What this exhibit does not say: how many. None of the documents gives a number of people held in psychiatric hospitals for reasons other than medical, and any number in circulation does not come from them. It says something narrower and steadier: that over eighteen years four different UN bodies recorded psychiatric confinement for reasons other than medical — two of them, with the police as the decision-maker and no judge — and that the 2012 law took the decision away from the police and gave it to psychiatrists, not to a judge. The 2004 and 2006 recommendation, "a judicial organ", remains unimplemented.

[45] Bonnie RJ, J Am Acad Psychiatry Law 2002;30(1):136-144 · [112] UN Working Group on Arbitrary Detention, mission to China, E/CN.4/2005/6/Add.4, summary and §41 · [113] Deliberation No. 7, E/CN.4/2005/6, §§47–58 · [114] Nowak M, E/CN.4/2006/6/Add.6, §§40–44, 82(u)–(v) · [115] CAT/C/CHN/CO/4, §35 · [116] CRPD/C/CHN/CO/1, §§25–28 · [117] Mental Health Law of the PRC 2012, Articles 28–30, 32, 35, 78, 82 · [118] Opinion No. 8/2014 (Xing Shiku), A/HRC/WGAD/2014/8, §§3–7, 20–23, 39–46 · [119] CAT/C/CHN/CO/5, §§42–43 · [120] CRPD/C/CHN/CO/2-3, §§32–33