The labelling of dissent - politics and psychiatry behind the Great Wall

The practice of forced incarceration of political dissenters in psychiatric institutions in the former Soviet Union and Eastern Europe undermined the credibility of psychiatric practice in these states and drew forceful condemnation from the international community. Blatant misuse or distortion of

The practice of forced incarceration of political dissenters in psychiatric institutions in the former Soviet Union and Eastern Europe undermined the credibility of psychiatric practice in these states and drew forceful condemnation from the international community. Blatant misuse or distortion of diagnoses for political purposes may appear to be the ready explanation for such commitment decisions. Anti-psychiatrists would argue, however, that such forced hospitalisations are consonant with Western psychiatric practice, which conceptualises deviant behaviour in terms of mental illness. Whether or not one accepts that political power is intrinsic to the social role of a psychiatrist (Szasz, 1994), there is little doubt that the potential for exploiting psychiatry to reinforce social norms and even political interests, is enormous. The practice in China of labelling nonconformists as mentally ill has as long a history as the People's Republic itself, but this abuse of psychiatric practice has hitherto received little comment in the West. The July 1999 crackdown by Chinese authorities against members of the Falun Gong movement has raised fears that political motivations are behind a new wave of involuntary committals of its followers to psychiatric institutions.

What is Falun Gong and why the crackdown?
Falun Gong (also known as Falun Dafa) is a popular movement that advocates channelling energy through mental concentration and exercises. It is a meditative discipline that draws from Buddhism, Taoism and the traditional Chinese doctrine of Qigong, and it has been valued for its mental and physical health benefits. Practitioners are encouraged to practise the exercises (that span from slow-moving standing gestures, stretches and postures to sitting in meditation) indoors or outside and to adhere to the core principles of truthfulness, compassion and forbearance. Adherents of Falun Gong are free to practise the exercises, privately or in groups, and are free to participate in any other religious observances. Initial Chinese government reaction to the increasing popularisation of this spiritual community in the early 1990s was positive, and potential health benefits for older practitioners were cited by officials as a useful and cost beneficial spin-off effect. Attitudes changed, however, when increasing official criticism aimed at the group's founder led to an unannounced peaceful protest by members in central Beijing in April 1999. By July of that year, the government had announced that Falun Gong was a proscribed organisation and that it should be 'outlawed and extirpated throughout China' (Ministry of Public Security, 1999). Since then, tens of thousands of the group's followers have been detained in a protracted campaign to eradicate it. Treatment meted out to practitioners of Falun Gong has been noteworthy for its brutality, with routine beatings and physical torture contributing to a rising death toll of detained members. Amnesty International's report in December 2000 stated that 77 members had died in custody since July 1999 as a result of ill-treatment, and it condemned the Chinese authorities for failing to investigate such gross violations of human rights (Amnesty International, 2001). The scale of this abuse is in the context of an estimated 3000 people being sent to mental hospitals for expressing political views in the past two decades (Munro, 2000a). This toll surpasses even the excesses of the Soviet state psychiatric system.
The rationale behind official attempts to liquidate Falun Gong may relate to a state-sponsored survey before the crackdown which revealed that approximately 70 million Chinese were practitioners of the exercises, a number which exceeded Communist Party membership at that time. Although Falun Gong as a movement has never made any demands for political reform or change, its large following and 'unsupervised' activities may have attracted official suspicion and hostility. Chinese authorities have frequently asserted that Falun Gong is an 'evil cult' and have waged a propaganda campaign to discredit the movement and justify the group's suppression.

Psychiatric abuse
A distinctive aspect of the Chinese government's campaign against Falun Gong has been the forced incarceration of large numbers of its followers in psychiatric hospitals, despite evidence from families refuting the presence of mental illness in most cases. Since the crackdown began, it is estimated that at least 600 practitioners (Munro, 2000b) have been forcibly assigned psychiatric treatment, in an effort to compel them to renounce their beliefs. This could be a gross underestimate, as government reports have acknowledged that increasing numbers of practitioners account for a growing proportion of admissions to institutions like the Beijing University of Medical Science. Accounts of treatment meted out in these hospitals make frequent reference to forced administration of antipsychotic drugs and electroconvulsive therapy (ECT), deep insertion of acupuncture needles, and physical and psychological deprivations such as the use of seclusion and physical restraints. The socalled 'concentrated reformation process' involves forcing detained practitioners to write confessional statements renouncing their belief in Falun Gong, with this often being a precondition of their release.
The interweaving of the practice of forensic psychiatry and the workings of the judicial system in China has created a ripe climate for the simultaneous criminalisation and medicalisation of dissenting activity. Being heavily influenced by Soviet interpretation of mental pathology (Munro, 2000a), Chinese forensic psychiatrists have been all too ready to embrace a similarly wide concept of mental illness in general and schizophrenia in particular. Chinese law includes 'political harm to society' as not only a threat to state security but also legally dangerous mentally ill behaviour. Terms such as 'document crazies' and 'paranoiacs' are readily interchanged by forensic psychiatrists to describe those who make anti-government speeches or write reactionary letters. This is redolent of the 'reformist delusions' said to have emanated from ideological dissenters whom Soviet psychiatrists branded as suffering from 'paranoid psychosis' (Wing, 1974). A forensic-psychiatric appraisal of those whose public behaviour attracted the attention of the authorities was made mandatory, under recent changes to Chinese criminal law. Such detentions in psychiatric hospitals of people who have never been mentally ill by international standards are a clear abuse of the psychiatric process. The network of special police psychiatric hospitals or Ankangs, meaning 'peace and happiness', is set to expand, raising further questions about conditions of detention and treatment in these secretive institutions.
What ethical standards of psychiatric practice should China adhere to?
Recognition of the status and needs of all concerned with mental health issues has been given by the United Nations, the World Psychiatric Association (WPA) and the psychiatric and professional organisations of different countries. Principles underpinning an ethical framework for the practice of psychiatry have been articulated in documents such as 'Principles for the protection of persons with mental illness and for the improvement of mental health care', which was adopted by the UN General Assembly in December 1991 (United Nations, 1991). Principle 4 states that 'A determination of mental illness shall never be made on the basis of political, economic or social status, or membership in a cultural, racial or religious group, or for any other reason not directly relevant to mental health status'. It goes on to state that 'non-conformity with moral, social, cultural or political values or religious beliefs prevailing in a person's community, shall never be a determining factor in the diagnosis of mental illness'. It is difficult to gauge the extent to which non-forensic psychiatrists in China are aware of, or are complicit in, the departure from these internationally recognised norms of practice. However, violation of these core principles undermines the integrity of the entire profession there.
What can and should be done?
The term 'psychiatric abuse', such as we usually associated with the practice of forced hospitalisation of dissenters in the former Soviet Union, was rightly regarded as a horrifying distortion of this medical speciality. Investigations and inspection of hospitals by Western psychiatric delegations, coupled with political reforms of the glasnost era led to hopes that psychiatric imprisonment would largely be a historical phenomenon. However, attempts by Chinese authorities to discredit the Falun Gong movement by labelling a proportion of their membership as mentally ill has refocused the energies of bodies such as the Geneva Initiative on Psychiatry in highlighting political misuse of the speciality. Mental illness is recognised to be one of the greatest causes of human suffering in the world and psychiatrists everywhere need to promote their art by cultivating an ethos of caring and sensitivity. By failing to satisfy professional criteria of practice, our Chinese colleagues risk undermining the credibility of the psychiatric profession in general. As individuals, we must condemn the use of psychiatry as part of any apparatus of political repression and call on the WPA to investigate claims of abuse. Hard evidence is needed, not only regarding conditions of detention in the Ankangs and other psychiatric institutions, but also about the psychological consequences for those who are forcibly subjected to treatment there. Were these detainees ever mentally ill, and if they were, did it warrant, under international standards, compulsory admission to hospital? Independent scrutiny prior to the WPA Congress next year could reassure us and our Chinese counterparts that the term 'psychiatric abuse' will not enter everyday clinical parlance.