Abuse of psychiatry

Copyright © 2006 John Wiley & Sons, Ltd 16: 77–86 (2006)DOI: 10.1002/cbm

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Abuse of psychiatry

Criminal Behaviour and Mental Health16: 77–86 (2006) Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/cbm.624

JOHN GUNN, Emeritus Professor of Forensic Psychiatry, Institute of Psychiatry, King’s College, London, UK

Note

This paper is based on the 2005 Peter Scott Lecture given at the Royal College of Psychiatrists’ Annual Meeting, Edinburgh, June 2005.

Peter Scott was a consultant forensic psychiatrist at the Maudsley Hospital, London, UK, through a critical phase of the development of forensic psychiatry in the 1970s and until his untimely death. He was the first psychiatrist I encoun-tered who believed that the responsibility of the forensic psychiatrist should extend to include the victims of crime and to note that most offenders are victims themselves. He wrote a good deal about delinquency; his comments about ‘psy-chopathy’ were an extension of his ideas about delinquency, its merging with normality and the necessity of understanding human development in order to understand the origins of crime and antisocial behaviour. Thus it was that the first forensic psychiatry training in Britain was concerned with adolescents. It is ironic to think how difficult it has been in my lifetime to establish a healthy subspecialty of adolescent forensic psychiatry.

It is easy to misuse the powers of psychiatry. I can think of at least eight ways:

1. social purification;2. people who are mentally normal treated as mad;3. psychiatric techniques used for oppression;4. the punishment of mentally disordered people;5. general maltreatment;6. excessive/inappropriate use of treatments;7. cruel and dangerous experiments;8. not treating mental disorder.

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1. Social purification

The concept of eugenics probably came from Malthus’s ideas of population control, but truly began with Sir Francis Galton’s ideas. He espoused social development policies, positive and negative, to improve the genetic composition of society; on the positive side he suggested encouraging the ‘most fit’ to repro-duce more often, and on the negative to discourage or prevent the ‘less fit’ from reproducing. He thought that all men are created unequal, and that those with an inherited advantage should prevail and pass it on to their children. This, according to the theory, is how evolution, Yale and the English aristocracy happened!

The eugenics movement affected much of the Western world, including Britain, which had the world’s first professorial chair in eugenics at University College London in 1909. New York State founded the Eugenics Record Office in 1910, under the direction of Harry Laughlin DSc. In 1914, his office published a model eugenical sterilization law, which encompassed a long list of conditions, from the feeble-minded and the insane to orphans and paupers, taking in the homeless and the deaf on the way (Laughlin, 1922). By 1924 approximately 3000 people in America had been involuntarily sterilized.

The German Nazi government borrowed this law and produced their own, in 1933. In 1936 Laughlin was awarded an honorary degree from the University of Heidelberg for his work in ‘the science of racial cleansing’.

During the 1930s thousands of German citizens were sterilized, many of them in psychiatric hospitals or asylums. So-called ‘mercy killings’ soon followed, then the deliberate starvation of psychiatric patients and finally a policy of mass murder of those who were deemed, under German racial laws, as ‘life unworthy of life’. Patients were selected by their doctors and gassed by medical personnel in special vans or centres (Burleigh, 2000). Burleigh notes: ‘people go into medi-cine for all sorts of reasons utterly unconnected with a vocation to do good. They are no more or less idealistic than people who become businessmen, chemists, engineers, historians, journalists, or lawyers.’

2 & 3. People who are mentally normal treated as mad and psychiatric techniques used for oppression

In the 1970s it was repeatedly alleged that so-called dissidents who were speaking out against the political system of the Soviet Union were diagnosed with mental illnesses, particularly schizophrenia, taken into secure psychiatric hospitals and forcibly treated with medications which had serious and disabling side effects. The World Psychiatric Association (WPA) was at first supportive of its member society. Eventually, however, the Soviet Society of Psychiatrists, foreseeing expul-sion from the WPA, pre-emptively resigned.

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This occurred at about the time Mr Gorbachev came to power, allowing draughts of fresh air into the USSR. He agreed to allow an American delegation of psychiatrists, lawyers and others to visit the Soviet Union and interview patients who were the subject of the controversy. A delegation of some 26 people visited the USSR and interviewed 28 patients, 16 of whom were still in hospital. The Soviets had diagnosed 24 of the 28 as having schizophrenia, but the Americans found that five of the inpatients did not meet DSM criteria for any diagnosis and only nine had a severe psychosis. Of the 12 outpatients interviewed, nine were thought to have no disorder and three had mild symptoms. Soviet psychiatrists were, thus, much more readily diagnosing schizophrenia than would occur in the West. The team pointed out, however, that US psychiatrists had made similar over-use of schizophrenia diagnoses, compared with UK psychia-trists, nearly 20 years earlier (Roth et al., 1989). The episode resulted in two important developments: the Geneva Initiative (now the Global Initiative) and the WPA Declaration of Hawaii (see Gunn and Taylor, 1993).

4. The punishment of mentally disordered people

People with mental disorder who offend have, in theory, been excused punish-ment altogether or had their punishment mitigated because of mental disorder, since Roman times. Nevertheless, punishment of such people is still common, and psychiatrists collude with it all over the world. Prisons in every country house large numbers of mentally disordered people. Data I have collected over years, on more than one occasion, suggest that between one-third and one half of all prisoners are mentally disordered and that, when the prison population of England and Wales was about 50,000, at least 1000–1500 people needed immediate trans-fer from prison to psychiatric hospital (Gunn etal., 1978,1991). The situation is much worse in the United States (Torrey, 1995). Furthermore, in the USA, offenders with mental disorder are being put to death (Amnesty International, 2005).

5. General maltreatment

General maltreatment is, in some ways, the root of other types of psychiatric abuse. It encompasses inhumane conditions, a lack of respect for patients, and taking advantage of their vulnerability. In 1965, a letter was written to TheTimes in London, complaining about the treatment of geriatric patients in some institu-tions. One of them, Barbara Robb (1967), wrote a book SansEverything; a book which was castigated as containing wild and irresponsible allegations. Other damning reports followed, well described by John Martin (1984) in his bookHospitalsinTrouble.

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In the early 1980s, a young Japanese lawyer, Etsuro Totsuka, asked me for shelter in my university department for a few months. Evidence had been uncov-ered, in Japan, of patients being beaten to death and buried in hospital grounds. There was no mental health law to protect the patients. One hospital had had 222 deaths among 944 patients in four years. Eventually a manager was sent to prison. Mr Totsuka used this case to launch his campaign for mental health reform in Japan. Over about eight years he persuaded the Japanese government, through skilful involvement of the United Nations, to introduce new laws to safeguard the rights of mental patients in Japan.

6. Excessive/inappropriate use of treatments

Excessive and inappropriate use of medication and other treatments is tempting in poorly resourced hospitals that are left to their own devices. We are lucky in England and Wales in having the Mental Health Act Commission to check on conditions and treatments. We are also lucky in Europe in having the Committee for the Prevention of Torture (CPT) – see below.

North America does not have these advantages. In about 1970, I visited the Oakridge forensic psychiatry unit at Penetanguishene mental hospital in Ontario. At that time they could get few trained staff, but had quite a large number of behaviourally disordered young men (they called them psychopaths) to look after. The part-time psychiatrist in charge decided that he had to use the patients as therapists and had to devise imaginative forms of psychotherapy. His original ideas included handcuffing men together in pairs for long periods, so that they would learn to think of somebody else beside themselves. Another treatment was ‘the capsule’, a room without furniture, but well heated, in which patients would stay for days, in a group, without clothes or other possessions. They were moni-tored by closed-circuit television and fed through a hatch. This was an experi-ment in social education. I met one young man rolling on the floor in delirium and was told he was undergoing regression treatment. This meant he had had an injection of scopolamine sufficient to produce delirium and incontinence. He was then expected to recover from these toxic effects whilst in the company of his fellow inmates who would ‘look after his bodily needs’. This was ‘to correct his adverse childhood by allowing him to be reborn into a caring group’ (I am not making this up). I inquired about his diagnosis. I was told he was a ‘psycho-path’. I asked the nature of his offence. I was told that he had repeatedly stolen money from his mother!

In 1984 I sat on an inquiry panel, set up to look into problems at Oakridge. By then the bizarre ‘treatments’ just described had stopped, but we noted its ‘outmoded facilities’ and offered four possible improving options – all of which involved knocking it down (Hucker etal., 1986). It is still there.

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7. Cruel and dangerous experiments

Canada’s most renowned, and eventually most notorious, psychiatrist was Ewan Cameron. He was a President of the APA, a President of the Canadian Psychiatric Association, and the first President of the WPA – a veritable pillar of the psy-chiatric establishment. In 1950 the first Director of the CIA, Admiral Roscoe Hillenkoetter, launched ‘Project Bluebird’. It began by using sedative drugs to get suspected spies and prisoners of war to reveal secrets and make confessions. When this was not too successful it was decided to add ECT. When Allen Dulles, the second CIA director, took over he decided to make the programme more radical and he renamed it operation ‘Artichoke’. Mr Dulles was worried, though, that his experiments might be unacceptable to the American public if they leaked, so he contracted them out to Dr Cameron who worked at the Allen Memorial Institute in Montreal, Canada. The idea was to use drugs, ECT, sensory depriva-tion, sleep deprivation and isolation, together with repeatedly playing back selected words to a subject, in order to break his/her resistance. In 1953 this project was renamed ‘MKULTRA’. Subjects wore helmets with internal speakers for up to 22 hours a day, for six or seven days a week for about two months. Later Dr Cameron experimented with LSD as a truth drug. Test subjects were told that that their LSD downers would be extended unless they divulged certain military secrets (Project MKULTRA, 2005).

Many subjects have sought compensation for long-term mental damage caused by these experiments; so far 78 have succeeded, the most recent being a woman who was awarded $100,000 in June 2004 (CBC News, 2004).

8. Not treating mental disorder

The eighth abuse on my list is a huge topic and is almost universal. Sadly it receives very little attention from professional clinicians or human rights cam-paigners, and, as it is largely an absence of activity, it can be argued that it is not really abuse. As I turn to the main topic of this paper, China, I will preface my remarks by saying that in my view the absence of psychiatric treatment for mil-lions of Chinese people is China’s greatest mental health problem.

Forensic psychiatry in China

In 2004, the World Psychiatric Association (WPA) and the Chinese Society of Psychiatrists (CSP) agreed to an extraordinary meeting to discuss clinical, ethical, legal and diagnostic issues arising out of allegations of political misuse of psychia-try against practitioners of Falun Gong and political dissidents. Robin Munro has alleged, in several papers and a book (2002), that China is using psychiatry to

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have political dissidents declared insane, which he compared to the policy of the former Soviet Union. He said, further, that little is known to the outside world of China’s ‘gulags’, the Ankang (forensic psychiatry) hospitals. Robin Jacoby, who among other roles holds the chairmanship of the Geneva (Global) Initiative, wrote an article with Robin Munro saying that the ‘Chinese authorities have resorted to false psychiatric diagnosis to stigmatise all kinds of people, including political dissidents, independent trade unionists, and those who complain about official corruption. Since . . . July 1999 more than 300 detained members of Falun Gong, the officially banned religion, have also reported receiving the same treat-ment’ (Jacoby and Munro, 2002).

These matters were debated at the Royal College of Psychiatrists’ 2001 annual meeting, and a resolution passed saying that psychiatric abuse in China today is worse than in the former Soviet Union, and demanding a fact-finding visit led by the WPA. If abuse of psychiatry were discovered in China, then perhaps the WPA should reconsider the membership of the Chinese Society of Psychiatrists.

Inevitably the Chinese government did not agree to a fact-finding visit, but they did agree to an educational visit for mutual benefit between Western and Chinese psychiatrists. This took place in February 2005, and I was the British member of the delegation.

I had previously been to China in 1987, as part of a WHO delegation that was seeking to help Chinese psychiatrists get a national mental health law to protect psychiatric patients. The conference called for this purpose was held at the first of the Ankang (security) hospitals, in Tianjin. Several of us looked round and realized that the hospital was a large surgical unit with active operating theatres. It was a leucotomy processing plant! All the patients were escaping the death penalty because of mental illness, but were required to have a leucotomy.

That was 1987. No country in the world has changed as much in the inter-vening years. Mud roads have given way to wide boulevards, cycles have been replaced by motor-cars and shantytowns have been replaced by Western-style houses and high-rise hotels and offices. Now China is a capitalist country with an authoritarian central government, although regional governments have great autonomy. The cultural revolution of 1966–76 destroyed professional activity at that time. Psychiatry now has a very low status; forensic psychiatry an even lower one. Psychiatric illness is a big social disgrace and suicide is preferable.

Before this 2005 visit to China, I met my old friend and trainee Professor Liu, probably the most senior forensic psychiatrist in China. He is a man older than me, who came to Britain in the middle of his career to train in forensic psychiatry at the Maudsley. He was a leading light behind the 1987 WHO visit to China, and he has been struggling ever since to persuade the Chinese authorities to introduce the mental health bill we drafted at that time. It has now reached its 15th revision and still shows no sign being introduced. So there are clear similari-

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ties between Britain and China! There is, however, a new mental health law being introduced in Shanghai.

The Falun Gong organization is one of the groups to complain that their members are mistreated in Ankang hospitals. The Chinese government largely disapproves of all religions except communism. Practice of a religion is allowed, but it is necessary to be registered, approved and to pay a fee.

Falun Gong is definitely not approved. It was founded by Li Hongzhi, who now lives in New York and claims to have 60 million followers. Li believes he is the living Buddha, with supernatural powers; thus, he can walk through walls and make himself invisible. He describes the Falun as a miniature of the cosmos that he installs in the abdomens of followers telekinetically; it rotates and throws off bad karma and gathers good qi. Many followers say they can feel the wheel rotating (Chang, 2004). Like Scientology it is an anti-medical religion. Practitioners believe illness to be caused by the indwelling of an intelligent entity from another dimension. The body’s qi can be focused to cure it; many followers will not have medical attention even for problems such as a broken arm.

China has a population of 1,300,000,000, with some 16,000,000 severely ill psychiatric patients and about 156,000 inpatient beds. That is a very low bed ratio in international terms, but it is growing (Lecture notes, 2005). There are five types of psychiatric hospital:

(1) hospitals run by local health authorities;(2) hospitals run by the local civil administration system, mainly for homeless

mental patients;(3) security (Ankang) hospitals run by the local public security system for treat-

ment of offenders with mental illness;(4) private hospitals;(5) training centres affiliated to universities.

The Ankang hospitals have 7–8% of available psychiatric beds. There are very few psychiatric nurses and very few psychiatrists. Young psychiatrists in China have a five-year residency programme, but there are no national standards or exams. Psychiatrists are proud of the fact that they managed to break away from the neurologists and the neurosurgeons in 1994 (Lecture Notes, 2005).

It was very encouraging during our visit to meet the young, enthusiastic medical staff who were knowledgeable about both old German psychiatric litera-ture and modern developments. I also met staff who run the local Ankang hos-pital in Beijing; they said that psychiatrists rather than surgeons are now in charge of the Tianjin Ankang hospital and leucotomies are not now performed in China except in one private hospital near Shanghai. They would welcome a visit from any Western psychiatrist who wishes to visit an Ankang hospital, but they would need a week or two’s notice to get clearance from the police who are in charge of the hospitals. They pointed out that Jim Higgins (a British forensic

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psychiatrist) and his psychologist wife Louise are regular visitors to China’s Ankang hospitals, and they have hosted some return visits in Liverpool. Chinese psychiatrists want free-and-easy exchanges with the UK. The only inhibition is money.

We asked about evidence for the allegations in Munro’s book. The Chinese Society of Psychiatrists said they had investigated seven of these cases. During our conference we examined one in detail.

A young professional man fell ill and joined Falun Gong. He left home and wandered to another part of the country. He was arrested for vagrancy. The police thought he was mentally disordered and sent him home, but he deteriorated and his relatives admitted him to the local mental hospital. He was diagnosed as suffering from a ‘Qigong induced mental disorder’ (a disease that is defined in the Chinese classification of mental diseases). He was treated with haloperidol and hyoscine, then perphenazine, and he began to eat and drink. He also returned to expressing Falun Gong ideas, so the dose of per-phenazine was increased (to 60 mg/day), before reduction (to 36 mg/day) because of side effects. His suicidal ideas disappeared so he was sent home and back to work.

The allegations about his case led to its being reviewed by the vice-chairman of the Chinese Society of Psychiatrists (Lecture notes, 2005). The patient refused to be interviewed; the patient’s work colleagues said that he was working nor-mally. The CSP decided that this man should not have been diagnosed as men-tally ill, but said they understood why he had been admitted to hospital for a period. Is this a case of a mentally normal man being treated as mad? He was given a diagnosis that may seem strange outside China, and he was treated with hyoscine and phenothiazines. We are at an early stage of dialogue, but this case is the only one we have found so far with any evidence for the type of abuse alleged by Munro.

Other kinds of political abuse?

Amnesty International is complaining that the Chinese execute proportionally more of their citizens than any other country in the world. The figures are not clear, but perhaps 4–5000 people are killed each year (SydneyMorningHerald, 2004). This will include an unknown number of drug addicts, other mentally disordered people, and some who are innocent (Xiao Qiang, 2004). There are 12 capital offences, from drug offences to aiding Tibetan border crossings and tax fraud. Most of the condemned people are summarily shot in public.

To improve efficiency in executions some states have devised a new system of execution vans. Only four people are needed, one of them a doctor! When a capital case is being heard the van waits outside the court and after a sentence

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of death is passed the offender is taken out to the van where he or she is strapped down and given a lethal injection by the doctor (Sheridan, 2005).

Excessive or inappropriate use of treatment?

Psychiatrists in China are concerned that physicians and surgeons still have too much influence over psychiatry. They also worry that it might be inappropriate to lock up large numbers of drug abusers as mentally disordered offenders as happens at present, but those not locked up in this way may be executed.

Conclusions

It is clear that psychiatric abuse in the categories I have adopted can occur in different places at different times. It may be worse in totalitarian countries, but it is not confined to them. It may be more common in the context of forensic psychiatry, but it is not confined to this specialty.

So, are we doomed to continue to mistreat our patients from time to time? Not necessarily. Events in Germany were so extreme that they produced a col-lective rage and guilt across Europe, which led to the first pan-European institu-tion, the Council of Europe (Council of Europe, 2005a). It was founded in 1949 and now consists of 45 countries.

Perhaps the Council’s most significant achievement is the European Convention on Human Rights, which was adopted in 1950 and came into force in 1953. A further convention, in 1989, established a European Committee for the Prevention of Torture (CPT) (Council of Europe, 2005b). The CPT visits any places of detention it chooses – prisons, police stations, psychiatric institu-tions – to see how persons deprived of their liberty are treated, then draws up a report on its findings and makes recommendations. This is sent to the state concerned and eventually published.

If Guantanamo Bay were in Europe it would be visited by the CPT. If China were in the Council of Europe, then Ankang hospitals would be visited.

For the present, all we can do is to continue to monitor, develop good pro-fessional contacts and exchanges, and ultimately enlist the support of the United Nations for any problems that are encountered.

References

Amnesty International (2005) Abolish the death penalty. TheDeathPenaltyDisregardsMentalIllness. http://www.amnestyusa.org/abolish/mental_illness.html

Burleigh M (2000) TheThirdReich. Houndmills: Macmillan.Chang MH (2004) FalunGong:TheEndofDays. New Haven, CT: Yale University Press.

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Council of Europe (2005a) About theCouncilofEurope. http://www.coe.int/T/e/Com/about_coe (19 November 2005).

Council of Europe (2005b) AbouttheCPT. http://www.cpt.int/e/about.htm (19 November 2005).Galton F (1869/1892/1962) HereditaryGenius:AnInquiryintoitsLawsandConsequences. London:

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A Review and an Alternative Ontario. Toronto: Ministry of Health, unpublished.Jacoby R, Munro R (2002) Beijing needs to get a stern lesson. InternationalHeraldTribune 27

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by Chen Y, He Y, Hu J, Ma H, Xie B, Yu X, Zhang N, Zou Y, et al. Unpublished, selected material obtainable from author.

Laughlin HH (1922) Eugenical Sterilization in the United States. Chicago, IL: Psychopathic Laboratory of the Municipal Court of Chicago.

Martin JP (1984) HospitalsinTrouble. Oxford: Blackwell.Miller KS, Radelet MJ (1993) ExecutingtheMentallyIll:TheCriminalJusticeSystemandtheCase

ofAlvinFord. Thousand Oaks, CA: Sage Publications.Project MKULTRA (2005) From Wikipedia, the free encyclopedia.http://www.en.wikipedia.org/wiki/MKULTRA (19 November 2005).Robb B (1967) SansEverything:ACasetoAnswer. London: Nelson.Roth LH, Regier DA, Reshetov Y, Keith SJ (eds) (1989) Report of the US delegation to assess

recent changes in Soviet psychiatry. SchizophreniaBulletin15(4, Suppl.).Sheridan M (2005) Chinese executed with ‘death vans’. SundayTimes 20 March.Sydney Morning Herald (2004) China carried out 90% of world’s executions. Report. 5

December.Torrey EF (1995) Jails and prisons: America’s new mental hospitals. American JournalofPublic

Health 85: 1611–1613.Xiao Qiang (2004) Death penalty debate grips China after wrongful execution. China Digital

Times 4 July. http://www.chinadigitaltimes.net.

Address correspondence to: John Gunn, Emeritus Professor of Forensic Psychiatry, Institute of Psychiatry, King’s College, London, PO Box 725, Bromley BR2 7WF, UK. Email: J. [email protected]

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