The extension of psychiatry to society
In the immediate aftermath of the revolution in Russia, Semashko stated that the work of doctors was particularly valuable as it directly affected people’s lives and contributed to the construction of socialism.[1] He prioritized prevention, and dispensaries were to be the primary tool, satisfying the demand for care of the sick and providing information on the state of health of the population.[2] The first measure toward developing outpatient psychiatry was the division of Moscow into eight “sectors” (raiony) in 1919. Replacing the four sectors that existed in the prewar period, each of the capital's new districts was provided with a health clinic (dispanser). The “dispensarization” (dispanserizatsid) aimed at avoiding placement of patients in facilities that did not meet their needs and limiting overcrowding in hospitals. The psychiatrist in each sector was responsible for caring for the sick in their homes, providing follow-up for individuals who were returned to society by the hospitals, and having people admitted to a hospital if their condition required it.[3] Starting in 1923 at the initiative of a psychiatrist in Baumanskii raion, Izrail’ Berger, the sector became the site of a policy to raise awareness about mental illness. After a few months, a commission was formed under the auspices of the Department of Health of the local Soviet to carry out inspections, protect patients, and defend their rights. This model was adopted by other sectors when Moscow oificials decided to extend the awareness-raising policy to the entire city.[4] In order to oversee the outpatient psychiatry in the Russian Soviet Federative Socialist Republic (RSFSR), Rozenshtein obtained the creation of the State Health Center of Neurology and Psychiatry which, located within the National Institute of Neurology and Psychiatry in Moscow, opened in June 1924. When the National Institute was closed down, the State Health Center became an autonomous institution. Bringing together practice and research, it was made up of three units: outpatient services, a laboratory, and an office for on-site assistance and counsel.[5] [6]
Outpatient psychiatry wanted to act as a break away from the asylum, which operated according to a specific concept of the individual and society. The tradition of asylums was based upon the premise that, deep down, every lunatic maintains an element of reason. It sought to rediscover the latter by removing patients from their pathogenic environments and isolating them in an orderly and regulated place which presented itself as an ideal form of society. Patients were completely dependent upon the psychiatrist, whose authority was absolute, by virtue of his specific knowledge. If the psychiatrist’s responsibility was to find a form of treatment adapted to each patient’s needs, his function went further: he must enforce the asylum’s rules and maintain its orderly character, notably through its omnipresent wardens.1. Outpatient psychiatry not only rejected the principle of isolation as an essential condition of treating madness, but also redefined the role of psychiatrists. It privileged the link between the patient and his social environment while rendering him more autonomous with regard to the institution. Maintaining the patient within the network of his ordinary, day-to-day relationships was considered more efficacious than confining him within hospital walls. Preoccupied by the environment in which patients lived, the psychiatrist delegated his authority in order to work directly with the population at large, in collaboration with various social actors, with a view to ensuring the equilibrium of the social environment. The resolutions of the second congress of neurology and psychiatry thus required that neurologists and psychiatrists maintain ‘a closer link with daily life, their participation in the organization of work and lifestyles with the introduction of layers of workers through organizations’.[7] Thanks to outpatient psychiatry, doctors henceforth present themselves as social workers whose ambit is extended to all of society. Their goal is to control the latter in order to reduce, if not eradicate, the causes of nervous and psychological disorders.
This ambition leads them to intervene in the workplace, rivalling the neurologists who are already very active in this field. Semashko eloquently sang the praises of their respective competences:
We speak of the regeneration of our antediluvian, barbarous lifestyle. In this regard, it is very important to carefully listen to neurologists. We speak of the good education of the younger generation. What better teacher (now known as a paedologist) could there be than the neurologist and the psychiatrist![8]
The intrusion of psychiatry in the field of neurology resulted in the redefinition of the concepts of neurasthenia and nervousness as borderline states with social origins rather than organic ones. Psychiatrists drew upon three large-scale studies of telephone operators, teachers and workers. The study of workers was carried out among the 300 employees of a knitting factory. Berger and his colleague sought to measure the phenomenon of nervousness, which they claimed had never really been studied as a social pathology. The study did indeed reveal the scale of the problem. Workers in good health constituted 22.3% of the total, whereas workers who were ill presented symptoms ranging from important (17.7%) to medium (22%) and weak (38%): 34.3% were neurasthenic, 15.9% hysterical, 15.1% psychopaths and 8.3% suffered from arteriosclerosis. Berger and his colleague argued that the causes of nervousness were not so much to be found in the organization of production as in the working conditions themselves. In order to improve the latter, they recommended that preventative measures be strengthened, that ambulatory and consultative medical services be opened, and reiterated the importance of a rest period.[9]
- [1] Nikolai Semashko, Osnovy sovetskoi meditsiny, Kharkov, Vseukrainskoe Gosurdarstvennoe Izdatel'stvo, 1920, p. 3.
- [2] Tricia Starks, The Body Soviet. Propaganda, Hygiene and the Revolutionary State, Madison, University of Wisconsin Press, 2008, pp. 49-51.
- [3] State Archives of the Russian Federation (GARF) f. a-482, inv. 3, d. 130, f. 12; Vladimir Grom-bakh, ’Moskovskaia psikhiatricheskaia organizatsiia’, in Zhurnal nevropatologii i psikhiatri imeni S. S. Korsakova, n° 1, 1925, p. 108.
- [4] Izrail’Berger, ‘O psikhosanitarnom prosveshchenii', in Aleksandr Miskinov. Leonid Prozorov, Lev Rozenshtein (eds), Sovetskaia meditsina v bor'bc za zdorov’ie nervy. Trudy I vsesoiuznogo soveshcha-niia po psikhiatrii i nevrolqgii i gosudarstvennogo nevro-psikhiatricheskogo dispansera, Ul'ianovsk, Izdanie Ul’ianovskogo Kombinats PPP, 1926, pp. 75—76.
- [5] G. la. Tartakovskii, ‘Otchet po rabote Moskovskogo Gosudarstvennogo Nevro-Psikhiatritcheskogo Dispansera’, in Aleksandr Miskinov. Leonid Prozorov, Lev Rozenshtein (eds.), Sovetskaia meditsina v bor'bc za zdorovye nervy, op. cit., p. 38.
- [6] Michel Foucault. Histoire de la folie ù l'âge classique, Paris, Gallimard. 1972; Le pouvoir psychiatrique. Cours au Collège de France, 1973—1974, Paris, Gallimard. Seuil, 2003; Robert Castel, L’ordre psychiatrique. L’âge d’or de l’aliénisme, Paris, Editions de Minuit, 1976.
- [7] 'Resoliutsn 2-go Vserossiiskogo Soveshchaniia po voprosam psikhiatrii i nevrologii. Po voprosam Nevro-psikhicheskoi Gigieny i Profilaktiki’, in Aleksandr Miskinov, Leonid Prozorov (eds.), ll-oe Vserossiiskoe soveshchanie po voprosam psikhiatrii i nevrologii, Moscow, 1924, p. 59.
- [8] Nikolai Semashko, ‘O zadachakh obshchestvennoi nevrologii i psikhiatrii', in Sotsial'naia gigiena, n” 3-4, 1924, p. 94.
- [9] Izrail' Berger, I. D. Dobronravov, ‘O psikhigigienicheskoi dispanserizatsii (materialy po psikhogi-gienicheskoi dispanserizatsii rabochikh Trikotazhnoi chulochno-viazal’noi fabriki ini. Bauniana)', in Zhnrnal nevropatologii i psikhiatrii imeni S. S. Korsakova, n° 2, 1925, pp. 49-72.
