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by Toma Tomov, Nikolai Butorin


This paper puts forward the idea that undergoing one's formative psychiatric years in a setting dominated by a totalitarian ideology puts an impact on one's professional identity. This is a different claim from the one which states that psychiatrists in the East practice a brand of psychiatry which is relevant to the culture of the East. The difference is in that this stronger statement implies that the totalitarian culture has had a constitutive effect on the professional identity of the psychiatrist as this identity has evolved in a dominant totalitarian discourse. To put this differently, a psychiatrist from the East constructs a reality in which psychiatry and its practitioners have a dominant opinion over the rest of the individuals on issues of mental life, including the personal mental life experience of these individuals. The authorisation given by the profession, is taken well beyond the limits of the consultation. A typical example would be the ease with which the control by the psychiatrist implicit in the consultation is extended to encompass encounters of all kinds on the hospital grounds, in the patient's home and even in the street. Persons raised outside a totalitarian setting often take it for granted that authorisation in the helping professions goes hand in hand with enlightenment and humility. Therefore they tend to have difficulties in comprehending such irrational expansion of, and hunger for, power.

Background and Definitions

For the purpose of this paper totalitarian settings are defined descriptively in terms of environments in which central control acquires a dominance, way out of proportion to the requirements that a setting should meet in order to remain compatible with good individual life and creative development. Paternal despotism is more often than not the ground on which totalitarianism flourishes and its one salient feature is preservation of the status quo at any cost, even at the cost of maladjustment and deterioration. This certainly is true for Bulgaria, for instance. Paternal despotism and totalitarianism in the case of this paper, as it happens, indicate one and the same thing: preoccupation with external (despotic/central) control resulting from concerns about survival.

Survivalism, we propose, is an essential part of the totalitarian legacy in Eastern Europe, and can help make sense of the huge difference between the psychiatric settings in the East and the West, between the activities and the relations that they host. For example, one fact from the psychiatric scene in the East, which is found bewildering by visitors from the West, is how stripped of privacy, personal space, tokens of individuality, etc. the psychiatric in-patient is in the East. When voiced, this concern of the visitors is dismissed as irrelevant or as being of minor importance by most psychiatrists in the East, their major preoccupation being how to reduce the dangerousness of the deluded behaviours or how to control the hallucinatory phenomena.

A lot has already been said in support of the view that misery in general and the economic collapse, in particular, resulting from incompetent and brutal social and economic policy imposed by oppression for decades can account for the poor state of affairs in the health sector in the East. Much has been said also on the health policy of systematically relegating psychiatry and mental health to the bottom of priority lists under the socialist system. A lot of light has also been shed on the devastating effects on academic and professional life of the ideological policing of scientific thought and research practice. And last but not least, much has come into the open about the political abuse of psychiatry and the violation of human and professional rights in the East, the most recent example of this practice being the closing down of the office of the Ukrainian Psychiatric Association by Dr. Lisovienko, head of the Pavlov hospital in Kiev and by Professor Chupricov, the person in charge of the psychiatric sector at the Ukrainian Ministry of Health, notorious for treating depression with coloured glass spectacles.

This paper will avoid getting into any of these topics but would rather keep the above facts and developments as a background and will stick to a working definition of totalitarian environments, psychiatric settings included, as communities and organisations perpetually plagued by concerns about survival at the expense of concerns about individual growth and development. When very strong and long-lasting, concerns about survival culminate in nothing short of a delusional construction of reality, central to which is the myth of constant persecution by enemies and disasters. On such grounds cultures of survival suspend moral imperatives, precipitate the release of aggression, brutality and violence, endorse destructiveness, looting, subversion, theft, murder and the like. This, in its turn, reinforces the arguments in favour of even stronger central control and the perspective on development is lost out of sight completely. Caught in a vicious circle of self-deterioration such communities and organisations, early or late, plunge in the orgy of survivalism. Bosnia and Chechnia are examples at hand. In totalitarian settings individual development - standing as it is in natural counterpoise to survivalism, gets totally eclipsed by the myth of persecution.

The Study

This paper is a report on a study of attitudes among psychiatrists. The study compares an index group (IG)of 125 psychiatrists from Eastern Europe (Bulgaria and Ukraine) and a control group (CG) of 36 psychiatrists from Western Europe (Netherlands). The study proceeds from the assumption that the survivalist concerns, having dominated massively and as an end in themselves the totalitarian cultures in Eastern Europe, have had, among other effects, a distorting pressure on the identity of the psychiatrists in Eastern Europe. More specifically, the study wants to demonstrate that generally held values which dominate the totalitarian cultures, such as despotic paternalism, penetrate the professional realm of psychiatry as well. To this end it undertakes to compare the expression of the attitude of victimisation (blaming the patient for being ill) in the IG (Eastern Europe) and the CG (Western Europe).

We picked up victimisation because as an attitude of mind it is one of the most pronounced mechanisms by virtue of which cultures of paternalistic despotism (as opposed to pluralistic and individuality concerned cultures) perpetuate the hierarchy of power structures in society. Sexism, racism, child abuse, human rights violation, institutionalism, discrimination, marginalisation and a host of other developments dwell on attitudes of victimisation. The expression of this attitude in the context of professional relationships, such as with persons referred for psychiatric assessment, could be interpreted as an indicator of the degree of awareness within the professional community of the risks involved in psychiatric work of violating patients' rights as a result of deeply imbedded cultural stereotypes which are outside conscious control.

The study utilises a vignette which describes a course of events central to which is a young man suffering from a mental breakdown. The relationships in which he was involved eventually culminate in an act of physical assault. The respondents for the study were asked to rank order the six characters in the vignette (including the boy referred for psychiatric assessment) in terms of how much each had contributed to the occurrence of the act of the assault. For the purpose of the analysis, a score from 1 (lowest responsibility) to 6 (highest responsibility) was assigned to each character according to their rank order. Statistical analysis of the data was carried out using ANOVA and post hoc Tukey HSD test.

The study is based on the assumption that the attitude of victimisation (the victimisation mind set) of the respondent will find expression in a tendency of stripping the patient of responsibility for acting in a socially deviant way: exculpation on the basis of incompetence. On this basis it was hypothesised that the IG (Eastern Europe)will differ significantly from the CG (Western Europe) in terms of assigning less responsibility to the designated patient in the vignette for his deviant aggressive behaviour. In other words, the respondents form the IG will attribute the deviant act more to "the illness" and less to the person than will the respondents from the CG.

The Results

The distribution of the respondents by age, gender and years of professional practice indicated that the younger age groups are somewhat over-represented in the Bulgarian cohort and under-represented in the Dutch cohort, whereas the Ukrainian cohort is composed of psychiatrists of longer professional practice than the rest. These differences were judged not to be a result of systematic bias in the cohorts composition.

The 2-way ANOVA with factors "country" and "character" was performed on five of the characters, excluding the character "doctor" in order to avoid multicollinearity of the data matrix. It revealed significant main effect of factor "country", F(2, 158) = 12.228, p < 0.0005, significant main effect of factor "character", F(4, 632) = 162.872, p < 0.0005 as well as significant interaction between "character" and "country", F(8, 632) = 18.151, p < 0.0005.

Having thus ascertained the existence of significant differences between the countries in the performance on the task we proceeded to examine these differences in detail.

The post hoc Tukey HSD (Honest Statistical Differences) Multiple Comparisons test reveals the differences between the three countries in terms of the scores, which resulted from the rank ordering of the story characters on the dimension of responsibility for the occurrence of the socially deviant act as assigned to them by the respondents. Many of these differences are statistically significant.

What particularly interests us, however in view of the victimisation hypothesis of the study, is the score assigned to the boy referred for psychiatric assessment (the "designated patient") who is the actual perpetrator of the violent act, as compared to the scores assigned to the rest of the characters. The existing differences in this respect become obvious when the scores of the CG (Western Europe) and the IG (Eastern Europe) were juxtaposed. The respondents from the control group clearly assign to the perpetrator, the "Boy Character", who also happens to be referred for psychiatric assessment, the highest responsibility for the violent act. By doing so they indirectly validate him as a person, i.e. as somebody expected to be capable to bear responsibility for the choices he makes. This is not the case however with the IG, the respondents from which assign far less responsibility for the violent act to the perpetrator, presumably because he happens to be also referred for psychiatric assessment. The graphic representation of this difference illustrated this clearly.

Two other amazing differences between the IG and the CG have to be reported. One of them concerns the responsibility of the victim (the "Girl Character"). Whereas in the view of the Western psychiatrists it is virtually none, in the view of their colleagues from Eastern Europe it is quite significant, when compared to the rest of the characters. The second difference concerns the distribution of the scores assigned by the individual respondents within each of three cohorts. The figures suggest much less unanimity among Eastern European psychiatrists as to issues of responsibility in matters concerning human rights and their violation vis-à-vis mental illness. In other words, psychiatrists in the East constitute a less consistent and predictable cohort than those in the West wit regards to professional ethics. The limitations of the method used, i.e. ranking procedure, should caution us against dwelling too much on these findings. The study reveals enough, however, to suggest that further and more precise research is indicated.


This study by and large supports the hypothesis that an attitude of victimisation in a subtle way penetrates the professional judgements of psychiatrists in Eastern Europe to a degree that sets them apart in terms of professional identity from their colleagues in the West. It suggests that the victimisation mind-set has deep social and cultural roots, patriarchal despotism and survivalism being of special significance among them. At the same time, however, it stands out as a particular way of being in the world and going about psychiatric work, a way which gives one the uneasy feeling of not wanting to have much to do with it.

The study raises a number of issues concerned with the fact that the differences between the psychiatric settings in the East and the West, which are well documented in terms of clinical procedures and norms, staff-patient relationship patterns and numerous other aspects of psychiatric practice, are also discernible in terms on the dimension of professional values, attitudes, roles and other aspects of individuality.

One such issue is the scope of training which doctors receive in the East to become psychiatrists, and more specifically whether this training touches sufficiently upon matters of emotional experience and personal self-knowledge and thereby systematically contributes to the building up of a professional identity that will be immune to the chance effects of family background, individual developmental effects and parochial idiosyncrasies.

A second and related issue concerns the public space in which one begins a discourse on such matters in Eastern Europe. The problem here is that fundamentally this is a discourse on development, individual development in particular, which is a forbidden topic in survivalist cultures, as this paper attempts to demonstrate. If national psychiatric associations in Eastern European countries live up to this need of their members, they automatically declare themselves illegal, if not with respect to the formal laws, certainly so with respect to the indigenous customs. What ensues from there is a difficult time for the associations and the individuals who identify with them and an acute need for moral and financial support.

The ethical issues that this study raises are huge. One should think it only natural to suppose that no profession in Eastern Europe is spared the distorting influence on the part of the cultural context, similar to the one that psychiatry is beginning to suspect it has been submitted to. This suggests a need of much broader and more ambitious research of a kind that is very unlikely to meet with enthusiasm. Proceeding from the fact that despotic paternalism has identifiable manifestations in terms of psychological characteristics which persist outside situations of paternal despotism, one should expect that the transfer of advanced technologies concerned with health, research or other matters, to the countries of Eastern Europe may become problematic. Western inputs may meet with a failure on the part of the recipients to grasp the crucial importance of individual responsibility in a modern world mature to face the moral implications of advanced technologies.

Experience may prove replete with disappointing encounters with what may appear irrational, perverse or evil behaviour. We do not even want to begin to describe the emotional developments that can follow and do follow in such cases: disillusionment, distrust, contempt, revulsion, hate, envy - this is the mild end of the spectrum of experiences that people, well-intended but naive, are increasingly reporting. Xenophobia, racism, aggression follow in no time.

A conclusion that seems warranted from this report is that cross-cultural endeavours should not be taken lightly. There are many more deep and frightening things going on than what international events like the congress that just ended want to admit. Work with these processes, as Geneva Initiative for Psychiatry knows well, is hardly ever in the limelight.

The authors want to express deep gratitude to Angelique Heerdink and Oleg Nassinik, whose contributions made this study possible. The full version of this paper contains statistical data and graphs. They are available from the authors on request.

Paper delivered to Fourth Meeting of Reformers in Psychiatry, Madrid, August 29-31, 1996.

Copyright: The Authors

Address for correspondence: Medical Academy, 15 Dim. Nestrov, 1431 Sofia, Bulgaria




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