Here's another oldie but goodie. It contains an interview, of sorts, with not only Dr.
Andrei Snezhnevsky, but also his chief deputy, Dr.
Marat Vartanyan, conducted at
Kashchenko Psychiatric Hospital, which houses the
Institute of Psychiatry of the Soviet Academy of Medical Sciences. Also in attendance were Dr.
Ruben Nadzharov, Snezhnevsky's clinical deputy, and Dr.
Andrei Pyatnitsky, who was in charge of the institute's international activities.
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The New York TimesJanuary 30, 1983THE WORLD OF SOVIET PSYCHIATRYBy WALTER REICH
Dr. Walter Reich, a psychiatrist, is a fellow at the Kennan Institute for Advanced Russian Studies of the Woodrow Wilson International Center for Scholars in Washington.The building in one of Moscow's older neighborhoods seemed ordinary enough to me, familiar in the drab way so many psychiatric hospitals are familiar, its grounds tended by patients and its gates manned by guards. Yet there was something special about this particular building, something that had drawn me to it from half a world away. It was the source of theories of mental illness that, since the late 1960's, had been applied to Soviet dissidents with results that shocked the West. And it was the headquarters of the author of those theories, whose life and work I had been studying for a decade. Waiting for me inside that building was the man in charge of the Soviet Union's psychiatric profession, Dr. Andrei V. Snezhnevsky.
I was hurried past a dark lobby, through long corridors, into a bright office. The white-coated man who stood up behind his ornate desk, smiling broadly, had not changed much from the last time I had seen him, five years earlier, at the 1977 congress of the World Psychiatric Association in Hawaii. He and his delegation had come under strong attack at that meeting, and the conference had voted to condemn ''the systematic abuse of psychiatry for political purposes in the U.S.S.R.'' In the interim, Western concern over pyschiatric abuse in the Soviet Union had only grown, and the Russians were in danger of being suspended or even expelled from the international psychiatric organization at its scheduled conference in Vienna next July.
Snezhnevsky's deputy, Dr. Marat Vartanyan, entered the room briskly, with two other psychiatrists. A robust man of about 50, Vartanyan looked younger than he did in Hawaii; he had slimmed down by at least 30 pounds, his movements were faster and surer, and he was dressed in a well-fitting pin-stripe suit of Western cut. He had developed, in those five years, an appearance of prosperous success.
''You remember Dr. Reich,'' Vartanyan said to Snezhnevsky. ''You met him in Honolulu.'' Snezhnevsky acknowledged the memory. He arranged us around his elegant conference table. His secretary rushed in with a delicate china service.
Though 78 now, and heavier than the last time we met, Sneznevsky still commanded the look his former students and colleagues had described to me as sardonichesky - scornful, derisive, sardonic. It was a look, I remembered, made up of a dismissive grin that would burst into a mocking laugh the moment he would hear something he didn't like.
The Soviet psychiatrists asked me about my own recent professional activities, and I told them of my work on a research conference on the effectiveness of psychotherapy. Vartanyan smiled tolerantly. Snezhnevsky guffawed: Psychotherapy - now there's something that needs some research!
There is, in fact, little of what Americans know as psychotherapy in Soviet psychiatry. Nor is that state of affairs accidental. Soviet distrust of psychotherapy has been strong ever since the 1930's, when the ideas of Sigmund Freud, the originator of insight-oriented talk therapies, were declared inconsistent with Marxist science.
But there are other ways, too, in which Soviet psychiatry differs from its American counterpart. In the United States, psychiatric treatment has become acceptable enough during the last few decades for people in emotional distress to seek it out. In the Soviet Union, the need for psychiatric care is more likely to be seen as a cause for shame. Treatment there emphasizes medication rather than talk.
The concepts of mental illness are, in some respects, similar in the two countries. The same illnesses exist in the two populations roughly with the same frequency. But their definitions differ, as do, sometimes, their presumed causes. While American practitioners, on the whole, tend to pay greater attention to illnesses generally known as neuroses, their Soviet colleagues concern themselves to a greater extent with the more severe psychiatric conditions known as psychoses.
In recent years, Soviet psychiatry has devoted the greatest part of its energy to the most important and prevalent of the psychoses, schizophrenia. And, in large measure, it has been through his concept and definition of schizophrenia that Snezhnevsky has transformed the Soviet psychiatric profession - transformed it and taken ownership of it. He has managed to do so not because of a ukase from above but because his researchers, students and followers, who together comprise what has come to be known as the Moscow school of psychiatry, have spread his teachings into every corner of the country and have made them the standard and genuinely accepted Soviet approach to the understanding, diagnosis and treatment of mental illness.
Coffee was served, the finest I had tasted in the Soviet Union. There were linen napkins, good brandy, black caviar. The large, high-ceilinged office was appointed with prerevolutionary antiques, Oriental rugs, leather chairs, figurines. There were pictures of Snezhnevsky's Russian medical heroes on the wall. A large photo of Ernest Hemingway in a turtleneck sweater dominated the room. ''My favorite writer,'' Snezhnevsky offered. ''He's very popular in our country.'' A bust of Lenin watched from afar.
The meeting had been arranged for their sake as well as for mine. The charge of psychiatric abuse was a longstanding one. For years, Soviet psychiatrists had been accused in the West of diagnosing as mentally ill political dissidents they knew to be mentally well. According to both Western critics and Soviet dissidents, the K.G.B. - especially after it was taken over in 1967 by Yuri V. Andropov, now the top Soviet leader - had regularly referred dissidents to psychiatrists for such diagnoses in order to avoid embarrassing public trials and to discredit dissent as the product of sick minds. Once in psychiatric hospitals, usually special institutions for the criminally insane, the dissidents were said to be treated with particular cruelty - for example, given injections that caused abscesses, convulsions and torpor, or wrapped in wet canvas that shrank tightly upon drying.
In 1971, at the World Psychiatric Association's fifth congress in Mexico City, Western psychiatrists made their first attempt to censure their Soviet colleagues. But the accusations of psychiatric abuse were new, the campaign was unorganized, and Snezhnevsky, who led the Soviet delegation, was unscathed. The charges, he said in rebuttal, were a ''cold-war maneuver carried out at the hands of experts.''
At the 1977 world congress in Honolulu, Snezhnevsky again defended his country's psychiatric practices; but by then the accusations were familiar and the sentiments they aroused were strong, and the censure motion passed by a narrow majority. Snezhnevsky returned home wounded, with members of his delegation blaming their defeat on the ''Zionists.''
An even greater setback may await the Russians at the association's seventh congress in Vienna in July. There are, at this writing, two resolutions before the World Psychiatric Association. One, put forward by the national psychiatric association of the United States, proposes that the Soviet association, the All-Union Society of Psychiatrists and Neuropathologists, be suspended. The second, offered by the psychiatric association of Britain, proposes that the Soviet association be expelled.
It was, I think, primarily because of the Soviet authorities' desire to avert such action that Snezhnevsky and Vartanyan agreed to meet with me last spring. They knew, to be sure, that I had written critically of Soviet psychiatry. Nevertheless, with official scientific exchanges between the United States and the Soviet Union all but severed in the wake of the Soviet invasion of Afghanistan, any contact with an American psychiatrist - even one who had come to Moscow, as I had, on a private visit - would serve to demonstrate that Soviet psychiatrists were reasonable professionals willing to discuss differences and explain their views.
In addition, Snezhnevsky had, I am sure, his own reasons for wanting to see me. He had long been under attack in the West as an exemplar of psychiatric abuse in the Soviet Union. He had himself diagnosed or been involved in a number of famous dissident cases, including those of the mathematician Leonid Plyushch and the biologist Zhores Medvedev, and he had been accused of cynically devising a system of diagnosis that could be bent for political purposes. Seeing himself as a great clinician and theoretician, heir and contributor to a psychiatric tradition stretching back to 19th-century German medicine, Snezhnevsky had often complained bitterly about these accusations, which tarnished his prestige abroad and even among some of his Soviet colleagues. Moreover, he was facing the possibility of being stripped of his honorary fellowship in the American Psychiatric Association, conferred on him 12 years before, in better times.
But if the meeting was an opportunity for Soviet psychiatry and for Snezhnevsky, it was also one for me. I had been following reports of Soviet psychiatric abuse since the early 1970's, soon after they first reached the West. Disturbed by the news that fellow professionals were distorting their knowledge and their trust, and wanting to understand what had happened and why, I interviewed many of the dissidents who were then beginning to emigrate from the Soviet Union, including dissidents who had been diagnosed and hospitalized as mentally ill. In time, I met Soviet emigres who were psychiatrists themselves - some of them dissidents escaping political trouble but most of them people who had simply wanted to leave. Among the latter, several had worked as scientists and clinicians at the heart of Soviet psychiatry, either in Snezhnevsky's institute or in other important research centers.
Soon enough, it became apparent that the experience of Soviet psychiatry had a lot to teach - not only about Soviet political repression but about the ways in which people who have spent their lives in the Soviet environment think, talk and perceive each other. And, too, it had a lot to teach about the vulnerabilities of psychiatry to misuse wherever it is practiced. Some of the characteristics of Soviet psychiatry that had resulted in the misdiagnoses of dissidents were distortions of standard psychiatric logic, theory and practice. In short, the story of Soviet psychiatry was a case study in what could go wrong in a profession and in a society.
What emerged most forcefully from my interviews and research was that one factor - Snezhnevsky's theory of schizophrenia - accounted more than any other for the diagnoses and hospitalizations of Soviet political dissidents. It was that theory that I wanted to discuss with its author. In going to Moscow, my goal was to raise the questions about his approach that had troubled me ever since I began to study it, and to see what he had to say in response.
I called Vartanyan from my room at the Intourist Hotel the morning after my arrival in Moscow. ''Yes, Dr. Reich,'' Vartanyan responded eagerly, in his fluent English. ''Of course we should meet. I'll arrange it right away.'' He said he had just returned from a trip, and only that morning had come across a month-old letter from a mutual acquaintance, an American, informing him that I would be arriving in Moscow and calling him.
The black Volga sedan he sent for me the following week waited outside my hotel. The chauffeur drove wordlessly, crossing the Moscow River into the old Zamoskvorechiye section of Moscow. Turning at a guardhouse, we passed through a gate and entered the precincts of the Kashchenko Psychiatric Hospital, on whose wooded grounds the Institute of Psychiatry of the Soviet Academy of Medical Sciences is situated. The driver stopped, and I found myself in front of the institute's main building, a building whose inhabitants I had been studying from afar for so many years.
I had not brought a tape recorder to the meeting, and none, so far as I could see, was used. The following account is based primarily on a summary that I set to paper immediately upon returning to my hotel. The quotations and paraphrased exchanges are as faithful to what was said as I could make them. Besides Snezhnevsky and Vartanyan, the meeting was attended by Dr. Ruben Nadzharov, Snezhnevsky's clinical deputy, and Dr. Andrei Pyatnitsky, who was in charge of the institute's international activities. In the main, I spoke in English, with Vartanyan translating. The first question I asked Snezhnevsky and Vartanyan had to do with an article that had appeared in Pravda a week before I left for the Soviet Union. The article reported that Snezhnevsky's institute was to be transformed into a much larger Center for Health and Psychiatry, which would contain three institutes, one of them devoted to the problem of preventive psychiatry.
I asked my Soviet hosts which psychiatric illnesses they thought could be prevented. One set of preventable illnesses, they answered, is made up of ''borderline'' cases - persons whose illnesses were relatively mild and without the symptoms of a psychotic break with reality, such as hallucinations or delusions, that are typical of what has been known for seven decades as schizophrenia. This gave me an opportunity to challenge Snezhnevsky's concept of that illness - or set of illnesses, since there may be several schizophrenic conditions that display similar symptoms but have separate (and, in large measure, unknown) causes, probably both biological and environmental.
Snezhnevsky has argued that there are three main forms of schizophrenia. In the ''continuous'' form, he has said, the illness grows progressively worse. In the ''recurrent'' or ''periodic'' form, there are acute episodes of illness but, after each episode, the patient returns to health. And in the ''shiftlike'' form, there are also acute episodes, but the patient usually emerges from each episode more damaged than before, and his condition progressively worsens. Each of these states of illness, according to Snezhnevsky, has a broad range of severity. Thus, a person could suffer from a ''malignant'' type of continuous schizophrenia, in which there is very rapid mental deterioration, or, at the opposite end of the clinical spectrum, from a very mild type, which Snezhnevsky has called ''sluggish.''
It is this category of ''sluggish schizophrenia'' that has been most prominently used in dissident cases. But it has been commonly employed in everyday Soviet psychiatric practice as well. What is most troubling about it is that, by Snezhnevsky's criteria, ''sluggish schizophrenia'' may be diagnosed as such on the basis of very mild, nonpsychotic characteristics of behavior - characteristics that would not fit into the West's definition of ''psychotic'' and could even be considered normal.
Also disquieting is the quality of the research that was carried out by the institute's staff after Snezhnevsky became its director in 1962, research designed to prove his theories valid. The researchers' strategy was to examine the relatives of schizophrenic patients to see if they, too, displayed any psychiatric abnormalities, particularly schizophrenic ones. If the researchers did find such abnormalities, they almost always concluded that the relatives either had the same Snezhnevskyan form of schizophrenia as the original patient or some milder version of it. In other words, if the original patient had been found to suffer from ''shiftlike'' schizophrenia, then, if he had schizophrenic relatives, those relatives would almost invariably be found to have the same shiftlike form of the illness. And if he had relatives who, though not schizophrenic, displayed certain psychopathological traits, those traits were found to be similar, in some sense, to the symptoms and other characteristics that, Snezhnevsky had taught, were typically displayed by shiftlike schizophrenics.
Hundreds of patients and thousands of relatives, including children of schizophrenic parents, were examined in these studies. Theoretically, the studies provided remarkable validation of Snezhnevsky's concepts, since they seemed to demonstrate to a very significant extent that the forms of schizophrenia he had described ''bred true'' - that is, were hereditarily (which is to say genetically, and therefore biologically) distinct.
If this were correct, it would represent a revolution in psychiatry. Many psychiatric theoreticians, particularly in Europe, have sought to classify different forms of schizophrenia on the basis of the patients' clinical characteristics - that is, on the basis of the way they talk and behave. Thus, in the most widely used classification scheme, paranoid schizophrenics are distinguished from, say, catatonic schizophrenics on the grounds that, while the two forms of the illness share certain characteristics, the first is characterized especially by one set of symptoms, such as hallucinations, extreme suspiciousness and grandiosity, while the second is more clasically characterized by pronounced stupor or excitement.
But it has never been possible to prove that those two forms of illness breed true. It has not been found that if, for instance, a paranoid schizophrenic has a schizophrenic cousin, that cousin will invariably be afflicted with the paranoid variety of the illness. Snezhnevsky's researchers, however, left the clear impression that their chief had discovered clinical principles in accordance with which any schizophrenic can be assigned to one of three categories of schizophrenia, each having a distinct genetic basis.
When my hosts began to describe the work on ''borderline'' conditions being planned for the new center - conditions that seemed to me to be indistinguishable from some of the mild types of schizophrenia in Snezhnevsky's classification scheme, particularly the ''sluggish'' - I saw the opportunity to challenge them about Snezhnevsky's theories and about the research that had been designed to prove those theories true.
I started with the research. As far as I was concerned, I said, their institute's studies were unacceptable: The results were too perfect and the methods too flawed. I pointed out that, in the family studies, the psychiatrists who had diagnosed the original patients were the same ones who diagnosed the relatives and knew who was related to whom. They were not, in other words, experimentally ''blind,'' as they should have been by commonly accepted principles of research methodology. And, therefore, it was just too easy for them, even if they were honest, to be swayed by their mission to prove Snezhnevsky right - to be swayed enough, at any rate, to discern the same form of schizophrenia in both patient and relative.
After all, I pointed out, the researchers were testing their own director's theories, theories upon which he was staking his international reputation. Many of the studies were of Snezhnevsky's own design or had been developed at his direct inspiration. Some of the researchers were working toward advanced degrees, and getting those degrees depended on the success of their research. Others were just beginning their careers at the institute and wanted to stay on the permanent staff. A momentum of research findings developed, all moving in the same direction - that of ''proving'' Snezhnevsky's theories. In the midst of such a uniform and focused culture of validation, the pressure on researchers to prove yet another Snezhnevskyan category true must have been considerable. And that pressure could hardly have been eased by the fact that the Korsakov Journal of Neuropathology and Psychiatry, the only psychiatric periodical in the Soviet Union - the only such periodical in which they could publish their findings - happened to have as its editor none other than Andrei Snezhnevsky.
''Look,'' I said to Vartanyan, who, as I understood it, had not been personally involved in this research, ''you're a scientist. You understand that the material of psychiatry is extraordinarily vague, and that even the most honest researcher's objectivity is stretched beyond acceptable limits if he's testing a hypothesis that was developed by his own director and that is the accepted and dominant hypothesis in his environment. You understand that, under such conditions, researchers have to protect their work against their own biases in every way possible. But in these studies, no such protection was put into force.''
Vartanyan shrugged. He said the studies I had described were over and done with and new studies, more sophisticated and reliable, and focusing on other matters, were under way.
I sat up. Vartanyan seemed to be distancing himself from his chief's theories. But his chief, unaware of this ripple in the conversation - since Vartanyan had not translated his own response to me - continued to maintain the sardonic smile that had animated his face for most of our talk. I smiled, too, but at Vartanyan, hoping to elicit from him some confirmation of subtle disloyalty. He did not smile back.
I went on to question the clinical usefulness of Snezhnevsky's ideas. Even if his diagnostic system were valid, I said, it was too dangerous to use. It was too broad, too inclusive, too likely to result in the application of the schizophrenic label to persons with other illnesses, such as the ''borderline'' conditions his new prevention institute was planning to study.
Perhaps, I said, some relatives of schizophrenics exhibit mild symptoms because they have a mild version of the same illness. But what about the person walking down Gorky Street who exhibits the same mild symptoms but has no schizophrenic relatives? Why call him a schizophrenic? Maybe he's an eccentric artist. Maybe he had a difficult upbringing. Maybe he's under some kind of stress. It may well be, I told Snezhnevsky, that many or even most people with symptoms that satisfy his criteria for ''sluggish schizophrenia'' do not have that illness, never will, and exhibit the behavioral characteristics that ought to be considered, instead, signs of a neurotic condition, of a personality disorder, or even of normality.
Snezhnevsky irately denied the importance of these diagnostic dangers. A good clinician, he insisted, should be able to distinguish between mild schizophrenia and a nonschizophrenic condition.
I disagreed. Relying on a diagnostician's acumen begs the question, I said, since clinical judgments are themselves determined, in great measure, by the diagnostician's theoretical orientation. Vartanyan, I noticed, was making little effort to defend his boss. It occurred to me that this meeting was important to him, too, but for his own reasons.
For many years in Snezhnevsky's shadow, Vartanyan, an Armenian by nationality, was now developing what promised to be a spectacular career. Trained as a psychiatrist, he had specialized in biological research on mental illness, and for a long time had headed the main biological research laboratories at Snezhnevsky's institute. With Snezhnevsky moving toward retirement, Vartanyan was poised to inherit the older man's mantle of power as director of the grand new psychiatric center that Pravda had just announced.
There was, apparently, some opposition to Vartanyan in Moscow, led by his chief rival, Dr. Georgi V. Morozov, head of Moscow's Serbsky Institute of Forensic Psychiatry, where some of the most notorious dissident cases had been sent for diagnosis. Morozov, according to my informants, had supporters high in the K.G.B. Yet his name had become so widely linked to the worst cases of psychiatric abuse that his usefulness in the international arena was badly compromised, and, I was told, his opposition to Vartanyan's advancement stood little chance.
Already Vartanyan was beginning to take over as Soviet psychiatry's chief spokesman to the world. Meeting with me in advance of next July's international psychiatric congress was almost surely seen by him as an opportunity to fulfill his new responsibility. The Soviet Union's suspension or expulsion would denote, in official Soviet eyes, a certain failure on his part in the exquisitely vital task of protecting Moscow's interests. Any possibility of averting such a catastrophe was, at the least, worth exploring.
And so it was Vartanyan, not Snezhnevsky or I, who brought up the matter of psychiatric abuse. Soviet dissidents, Vartanyan insisted, were not being misdiagnosed. ''Too much has been made of the matter in the West,'' he said, ''all of it for political purposes.''
Soviet psychiatrists, he went on, were well acquainted with my own writings on the subject, including my report on the re-examination of Gen. Pyotr Grigorenko.
The Grigorenko case was, of course, very much to the point. A Soviet Army war hero who joined the dissident movement in the 1960's and spoke up on behalf of the Crimean Tatars, a small ethnic group expelled by Stalin from the Crimea during World War II for disloyalty and resettled in Central Asia, Grigorenko was arrested and committed twice to psychiatric hospitals and finally exiled. In 1978 he was re-examined in New York and Boston by a team of psychiatrists, psychologists and other medical and mental-health specialists from Columbia, Harvard and Yale, myself among them. We concluded that Grigorenko was not mentally ill when we examined him, and had probably not been mentally ill when his Soviet examiners had said he was. My report on the re-examination appeared in this magazine.
''Look,'' Vartanyan said, ''Grigorenko, when he was here, was sick. He's a remarkable man, but he got involved with the Crimean Tatars - he just got fixed on them and on a few other causes. When you and the others re-examined him, he was in the States, away from that setting and that stress, and he was O.K.''
The same was true, Vartanyan said, of the dissident Vladimir Bukovsky, who had also been found ill in the Soviet Union and well in the West. ''I'd like you to see his hospital records. If we sat down, four or five of us from our two countries, and looked at them, you'd see that he was sick.''
I demurred. If Grigorenko and Bukovsky had really suffered from the illnesses that had been diagnosed in the Soviet Union, at least some signs of those illnesses should have been recognizable even after a long period of time and a change in their social surroundings.
Vartanyan shifted his line of argument. To show up the absurdity, as he called it, of the West's accusations, he pointed out that some of the Western critics had gone so far as to say that Snezhnevsky had developed his concept of schizophrenia, including its mild, ''sluggish'' category, with the deliberate aim of providing the Soviet authorities with a diagnostic niche within which dissidents could easily be placed.
Snezhnevsky, with a laugh, expressed his contempt for that accusation. I replied that, having studied the development of Snezhnevsky's theories, I agreed that this particular charge was probably untrue. Snezhnevsky's theories, I recognized, had emerged during the 1940's and 1950's under the influence of a number of his teachers, and had achieved mature form in his mind and in his writings during the late 1950's and early 1960's, well before the commitment of dissidents to psychiatric wards began to take place with any frequency. In short, I acknowledged, the theories had developed independent of their purported usefulness in the diagnosis of Soviet dissenters.
But that did not mean, I added, that Snezhnevsky's theories had nothing to do with such diagnoses. It was precisely the flaws in those theories that had resulted in their easy applicability to dissidents. Snezhnevsky's concepts, I said, were only part of the reason that dissidents were being diagnosed as mentally ill in the Soviet Union, but they were an important part.
It was my belief, I said, that, in some cases, dissidents were hospitalized as a result of deliberate misdiagnosis. I also suspected, I added, that some hospitalized dissidents were mentally ill. Dissent is, after all, a marginal activity in the Soviet Union, with its highly repressive political system, and the margins of any society contain a disproportionately high number of people with mental illnesses. But it seemed to me that most hospitalized Soviet dissidents were pronounced ill not because the K.G.B. had ordered the psychiatrists to make that diagnosis and not because they were really ill, but for other reasons.
In the context of Soviet society, I reasoned, dissidents constitute a deviant element. They behave and speak in ways that are different from other Soviet citizens, and, for that reason, they come to be seen as strange. After all, I asked, isn't it strange when someone openly does and says things that, under the conditions of Soviet political life, everyone knows to be dangerous? In fact, there is good evidence, based on dissident accounts, that, upon encountering dissidents, many K.G.B. and other Soviet officials are often struck by a sense of strangeness, a sense that is compounded when the dissidents start lecturing them about their rights under the Soviet Constitution. The sense that someone is strange is not infrequently followed by the suspicion that the strangeness may be due to mental illness. And as soon as that suspicion arises in the minds of Soviet authorities, they have powerful reasons to call upon psychiatrists to examine the dissidents.
First of all, the official Soviet code of criminal procedure requires that in all cases - not only political ones - psychiatrists be consulted if any doubt exists in the mind of an investigating official about the mental health of the accused. Given the bureaucratic nature of the Soviet legal system, an official would rather protect himself by requesting a psychiatric consultation than worry about being criticized someday for not having done so. Besides, the trial of a dissident who has been pronounced ill and in need of hospitalization is usually less demanding on the prosecutor than an ordinary trial, since the testimony comes mostly from the psychiatrists who diagnosed the alleged illness. That provides another reason for calling in the doctors if there is even the smallest doubt about the dissident's mental health.
My argument was turning into a lecture, to which my Soviet hosts were listening in silence, but I continued. The Soviet psychiatrists who are called upon to render their diagnostic judgments are themselves Soviet citizens. They grow up in the same culture, are affected by the same political realities and develop the same social perceptions. And since the way in which a psychiatrist goes about determining whether a person is ill depends to a great extent on the psychiatrist's assumptions about what is usual and expected in his society, he may, upon coming into contact with the dissident, have the same sense of strangeness felt by the K.G.B. agent - and may go on to suspect that the defendant may be ill.
Should such a suspicion develop in the psychiatrist's mind, it would not be hard for him to resolve his doubts by finding a category of illness to apply to the dissident. That category, I reminded Snezhnevsky, is most often his category of ''sluggish schizophrenia.'' And this entire process could occur even without a conscious intent to misdiagnose.
Snezhnevsky was scowling; the others seemed no more pleased. Vartanyan had been nodding agreement during the initial stages of my argument, when I talked about the way Soviet dissidents are seen in Soviet society, but stopped nodding when I brought the argument home.
My ideas, it seemed, were at once welcome and disturbing. Unlike most other Western critics, I was not saying that all diagnoses of mental illness in dissident cases were made by psychiatrists who knew that the dissidents were well. Some of these psychiatrists did know that dissidents they had diagnosed as ill were healthy - but, I believed, not all of them knew that; perhaps not even most. Nor was I saying that Snezhnevsky had deliberately created the tools that had made those misdiagnoses possible. I was saying that, because of the nature of political life in the Soviet Union and the social perceptions fashioned by that life, dissenting behavior really does seem strange there; and that, because of the nature of Snezhnevsky's diagnostic system, this strangeness has, in some cases, come to be called schizophrenia. In other words, I was saying that in many and perhaps most instances of such diagnosis, not only the K.G.B. and other responsible officials but the psychiatrists themselves really believed that the dissidents were ill.
This, I said, was even more frightening to me than the usual picture of Soviet psychiatric abuse, the monochromatic picture of the K.G.B. ordering and the psychiatrists obeying. What does it mean, both about Soviet psychiatry and about Soviet society, that such a state of affairs could have developed? My hosts were silent. Then Vartanyan spoke. ''What we need,'' he said, ''is to sit down and settle this matter. We should go over the cases and get some understanding. This shouldn't be used for political purposes.''
''It hasn't just been a matter of taking political advantage,'' I returned. The fact that he thought the cases were being used in the West for purely political purposes was, I said, part of the problem. These charges of psychiatric abuse have not been raised as a convenient ploy but because psychiatrists and others in the West really believe that something terribly wrong has been happening in Soviet psychiatry. If Vartanyan really wanted a discussion of the problem - a discussion that would represent a risk for his Western opponents, since it could blunt their plans for suspension or expulsion next July - then he, too, would have to take risks. He would have to accept the possibility of having to acknowledge publicly that, at the least, misdiagnoses may have occurred.
''You can enter into a dialogue with us on this,'' I said, ''only if you're willing to recognize that what the other side says, or at least some of what it says, may be correct. And if you're willing to recognize this and concede it, then, at the very least, you risk having to acknowledge mistakes.''
''We're ready,'' Vartanyan replied. He stood up and ate the last of the caviar. Snezhnevsky seemed tired. He allowed me to photograph him and the others, and Vartanyan took me on a tour of his laboratories. What Vartanyan is ready for is still far from the exchange that the problem requires. The proposal he made to me was merely to go over case histories prepared by Soviet psychiatrists about persons identified in the West as having been hospitalized for political reasons. But how can we be sure that the information in these documents represents a true account of a person's life and psychiatric symptoms? How can we even be sure that some tampering with the records has not taken place? A real discussion of the problem of psychiatric abuse would have to begin with nothing less than a re-examination, by Western specialists, of the hospitalized dissidents themselves. The dissidents to be studied would have to be chosen by the Western, not the Soviet, participants in this effort.
As for the best course for Western psychiatrists to follow in Vienna next July, the choices are difficult. It is questionable whether either the suspension or the expulsion resolution has much chance of passing. In Honolulu in 1977, the resolution to condemn Moscow was passed by only two votes, 90 to 88, and only because the Poles were absent and the Russians, having been tardy in their dues payments, were not permitted to cast all of their allotted votes. This situation is hardly likely to repeat itself in Vienna.
My own view is that an attempt to remove the Soviet psychiatrists from the organization would be a mistake. If the attempt failed, the Russians would surely exploit the failure as an international vote of confidence in Soviet psychiatry and a repudiation of the infamous canard of psychiatric abuse. If, on the other hand, the attempt succeeded, the Russians would be out of range of effective, concerted, face-to-face international criticism. That would hurt Snezhnevsky and Vartanyan but it would not, as I see it, contribute to a change in Soviet psychiatric practice or belief.
A wiser course, I think, would be to pass a resolution empowering the World Psychiatric Association to send representatives to any member country to examine persons reported to have been hospitalized for political reasons. If permission for such examinations were withheld, the association would hold that country's pyschiatric establishment in official international contempt. This would provide a mechanism for continuing to press for re-examination of Soviet dissidents believed to have been the victims of misdiagnoses. The Russians would either have to allow such re-examinations or acknowledge that they have something to hide.
The ancient Greeks took it for granted that, in a civilized state, people not only have the right to speak but the duty to listen. Taking away Soviet psychiatry's right to speak before the world by removing it from the World Psychiatric Association might be no great loss for civilization; it could be argued that the Russians have forfeited that right by their record of psychiatric abuse. But removing them from the world body would also take away their duty to listen - to attend meetings, to hear criticisms, to be asked about this dissident or that, and to receive visitors, such as myself, who might ask them fundamental questions about their habits, beliefs and perceptions.
And that, I think, would be a real loss. It would be a loss for Soviet psychiatry, which would have no spur to examine its own maladies and no pressure to heal them. It would be a loss for Western psychiatry, which can learn, from an active engagement with the Soviet experience, the worst potential of its own vulnerabilities. And, most of all, it would be a loss for those dissidents now in Soviet psychiatric hospitals who are really healthy.
If I am right - if the tragedy of Soviet psychiatry is part of the tragedy of Soviet society, a tragedy that has caused distortions of the ways in which Soviet people perceive each other - then at least some of those healthy dissidents are sincerely seen to be mentally ill, not only by the psychiatrists and the K.G.B. but by much of the population of that historically wounded land. And if this, in fact, is the case, then some way must be kept open to tell Soviet psychiatrists of their destructive role in that greater tragedy - to explain it to them, and, if they don't listen, to explain it to them again.
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