From Empire to Autocracy: Francisco Balbuena Rivera on Political Psychiatry in Russia
Psychiatry as a medical discipline began to develop in the late 18th and early 19th centuries, while the term psychiatry was first used in 1808 by the German physician Johann Christian Reil to describe the medical field dedicated to the treatment of mental disorders. However, over time, the development of this discipline was intertwined with social and political circumstances, which makes understanding its historical context crucial for understanding the evolution of psychiatry.
It is precisely this connection between medicine, society, and politics that forms the basis of the analysis in the scholarly article “Political psychiatry in Russia: From empire to autocracy” by PhD Francisco Balbuena Rivera. Associate Professor Balbuena Rivera is a Spanish psychologist and philosopher and a full-time faculty member in the Department of Clinical and Experimental Psychology at the University of Huelva, Spain. His work explores the history of psychoanalysis and psychiatry, emphasizing pioneering approaches to psychosis and mental illness and their ethical and philosophical implications.
This work was the focus of our interview, in which Professor Francisco Balbuena Rivera discussed the history of psychiatry in Russia, its connection with politics, and the ethical dilemmas that arise from it. The interview covered the importance of protecting human rights and professional independence in the field. Throughout Russian history, psychiatry was at times intertwined with state ideology and political control. In certain periods, especially during the Cold War, there were cases in which psychiatric diagnoses were used against political opponents. One of the examples was the concept of so-called “sluggish schizophrenia,” which in some instances was employed to label political dissent. Balbuena Rivera’s article highlights the need for international ethical standards, the protection of human rights, and professional independence.
The central message is that psychiatry has the potential to heal but can also be misused, making it crucial to safeguard medical ethics and the autonomy of the profession continuously.
When Psychiatry Serves Power
Why did you decide to choose this topic in particular, and what are, in your view, the most striking historical facts when it comes to the political trajectory of psychiatry in Russia?
Francisco Balbuena Rivera: I chose this topic because, although I am not a specialist in the history of Imperial Russia or the former Soviet Union, I have long been deeply interested in the history of the Russian people and their intellectual traditions. This interest has resulted in two previous works: one co-authored with Dr. Antonio Sánchez-Barranco Ruiz, published in Spanish under the title A brief history of psychoanalysis in Russia (2004), and another as sole author, published in English, Sabina Spielrein: From being a psychiatric patient to becoming an analyst herself.
As for the most striking historical facts, I would highlight, on the one hand, the initially promising climate of intellectual and scientific renewal following the October Revolution of 1917, and, on the other, the gradual yet relentless subordination of psychiatry to political power after the consolidation of the communist regime. I use the term “communists” here in a broad sense, ranging from Stalinism to the current autocratic system under Putin, where troubling continuities can be observed in the instrumentalization of psychiatric knowledge.
How do you think all of this influenced the development of psychiatry in Russia, and how might it have influenced Europe?
Francisco Balbuena Rivera: This is not an easy question to answer, nor do I intend to offer a definitive response. At best, I can only sketch a few reflections. Even today, historians interested in the historical development and current state of psychiatry in Russia still have a great deal of work ahead of them. My impression is that totalitarian regimes—China, North Korea, Cuba, among others—tend to shield their internal realities from external scrutiny, and Russia has been no exception. This opacity has fostered mutual distrust between Russia and the West, which has also affected mental health systems and divergent conceptions of what it means to care for citizens living under a particular Zeitgeist, or spirit of the time. These tensions have shaped not only the internal development of Russian psychiatry but also how it has been perceived and understood in Europe.
When we talk about the development of Russian psychiatry, what is the greatest lesson for politicians, and what is the greatest lesson for scientists?
Francisco Balbuena Rivera: For both, the fundamental lesson is to learn from history. For politicians, this means allowing scientists and mental health professionals to carry out their work independently, free from ideological interference. Helping others should not be conceived as an instrument of power, but as a profoundly human task that requires empathy and responsibility. The problem is that politicians, in many cases, prioritize personal gain or the perpetuation of power, whereas scientists should be guided by the patient’s well-being and by ethical and professional standards.
Protect psychiatry from politicization and abuse on a global level
“The Soviet legacy of punitive psychiatry — marked by the diagnosis and forced treatment of political dissidents — continues to resonate in contemporary Russia, where recent reports document a resurgence of similar practices aimed at suppressing opposition, especially in the context of the war in Ukraine.”
Given that all of this is still happening today, does it mean that legally not enough has been done to change things and learn from history, or does the fact that this is still happening mean that we have failed to protect psychiatry from politicization and abuse on a global level?
Francisco Balbuena Rivera: I believe that, to a large extent, not enough has been done at the legal level. As an international community—particularly among countries that define themselves as democratic—we tend to avoid intervening in the internal affairs of other states, even in cases of serious human rights violations. Instead, we limit ourselves to condemning, denouncing, or expressing concern, often based on fragmentary information, while reassuring our consciences by appealing to international law and abstract principles. Paraphrasing Thomas S. Szasz, the psychiatric order can become corrupted and cease to recognize itself when its decisions depend on political power that designs and imposes them under the false protection of supposed medical legitimacy. This is the moral and professional dilemma I address in the section of my article entitled Between Scylla and Charybdis that of the psychiatrist caught between professional ethics and political obedience.
As you point out: “In 1914, on the eve of the First World War, the Russian Empire — which then housed more than 160 million people — had only 350 practicing psychiatrists and neurologists.” Could you explain to readers why this was the case and what it meant for strengthening a particular regime or political influence?
Francisco Balbuena Rivera: This was probably due to the limited interest that mental health attracted in the vast Russian Empire. At that time, neurology focused mainly on diseases of the nervous system, while parts of psychiatry were beginning to broaden their perspective toward personal and sociocultural factors, thus laying the groundwork for psychotherapy. As Loren R. Mosher once reminded us, psychiatrists do not work with neurons, but with human beings. A political regime attentive to this dimension could realize that increasing the number of psychiatrists not only alleviated human suffering but also offered a potential instrument of social control—something that indeed occurred later under Stalin.
The best antidote is to foster a critical citizenry
“A set of letters published in the 1970s in the American Journal of Psychiatry, written anonymously by a Soviet psychiatrist, revealed that the first Special Psychiatric Hospital in Kazan was used exclusively for political cases.”
Since there are people who, for example, do not believe in the accuracy of these data and might say, “Why anonymous and why specifically in the American Journal? Is this some kind of data manipulation?” Nowadays, it is very easy to manipulate data, so I am interested in knowing what we can do as a society to help people avoid political influence in the way they think and perceive history.
Francisco Balbuena Rivera: This is a very good question. Although many people claim not to be interested in politics, it operates like a shadow, silently influencing everyday life. In my view, the best antidote is to foster a critical citizenry: reading both pro-government and critical media, cross-checking information, questioning data when reasonable doubts arise, and being guided by a moral conscience grounded in democratic values. We still need to build a genuine sense of community oriented toward the common good, rather than toward uncritical adherence to political discourses whose sole aim is to perpetuate themselves in power.
“After Stalin’s death in 1953, forced labor camps were closed, and a new form of repression emerged: declaring dissidents insane and confining them to psychiatric institutions. Although the exact number remains uncertain, it is estimated that thousands were diagnosed with conditions such as ‘sluggish schizophrenia’ and subjected to forced treatment, often for years. Many did not survive. At this point, one wonders what Soviet psychiatrists could have done. Without the freedom to choose the best therapeutic options, they were forced to follow party directives. Looking back, Soviet psychiatrists faced a dual loyalty: adhering to professional ethical standards or obeying party orders. Although ethical judgment is easier from a distance, understanding the intense pressures these professionals faced — reflected in testimonies, not personal experience — is essential. Even so, the debate about these ethical dilemmas is crucial if psychiatry wants to learn from its recent history.”
After more than 70 years, what needs to change?
Francisco Balbuena Rivera: I will answer simply, even though the issue is enormously complex. Political power must not interfere with clinical judgment. Therapeutic decisions should be made based on the patient’s needs, through a consensual process between patient and clinician, in a personalized and ethical manner—much like what we now call personalized medicine. Without such independence, psychiatry risks repeating the tragic mistakes of the past.
The past and present: the invasion of Ukraine
“The contemporary Russian Federation, especially since 2014 and with greater intensity after the invasion of Ukraine in 2022, shows a resurgence of punitive psychiatry practices reminiscent of repression during the Soviet era.” Where do you think the solution lies, what should be done, and what does this mean for the new generations of psychiatrists? Could all of this undermine ordinary people’s trust in psychiatry?
Francisco Balbuena Rivera: I insist that no form of knowledge—whether scientific or sociocultural—should be subordinated to political power, and psychiatry is no exception. In a context where the biological model predominates, as it does in contemporary psychiatry, it is essential to monitor how psychopharmacological treatments are used and how psychiatrists reconcile their Hippocratic oath with the patient’s best interests. When freedom of thought is not viable, as in dictatorial regimes, the population tends to conform to what is dictated from above, and those who dissent are forced into silence for fear of reprisals, denunciation, or persecution.
Human rights, medical ethics, and politically motivated abuses
When we talk about human rights and medical integrity, how much have politicians helped, and how willing are they to help?
Francisco Balbuena Rivera: Honestly, I do not know. My impression is that politicians are primarily driven by strategic and partisan interests, which means that their support is rarely disinterested. Defending human rights as a slogan does not save lives, nor does it generate genuine collective awareness. Just as science and religion should not be analyzed through the same lens, human rights and politics—or mental health and politics—should remain conceptually distinct. When one encroaches upon the other, the risk of instrumentalization increases significantly, often with serious consequences.
“Medical ethics, based on the Hippocratic tradition, requires globalization to protect vulnerable populations exposed to politically motivated abuses.” How can this be achieved?
It may sound idealistic, but perhaps the first step is to build a global consciousness that is sensitive to what is happening in other parts of the world, especially in authoritarian regimes. International monitoring and public denunciation can act as a brake—however limited—on systematic abuses.
Psychiatry has a dual potential to heal or to harm, depending on its relationship with power
“Psychiatry has a dual potential to heal or to harm, depending on its relationship with power.” Is the psychiatric community strong enough to resist, and is there sufficient political will to support it?
Francisco Balbuena Rivera: In democratic countries, I believe this dilemma has been mitigated thanks to historical learning and the development of a more critical, less invasive psychiatry that is more respectful of patients’ rights. In non-democratic countries, by contrast, harm can be justified under multiple ideological pretexts.
“Political psychiatry in Russia: From empire to autocracy,” what does the future hold in this case?
Francisco Balbuena Rivera: I would like to be moderately optimistic and believe that the future is built collectively. Psychiatry should serve to alleviate psychological suffering, combining psychotherapy and pharmacological treatment when appropriate, always within a voluntary and collaborative framework. Very different is a psychiatry imposed by political imperative, which betrays its very reason for being.
The history of psychiatry in Russia demonstrates how this discipline has been and remains sensitive to political pressures and ideological influences. From the period of Imperial Russia, through the Soviet Union, and into contemporary Russia, there has been a constant tension between scientific independence and the instrumentalization of psychiatry as a tool of political control. Examples such as the diagnosis of “sluggish schizophrenia” and the forced treatment of political dissidents during the Soviet era clearly illustrate the dangers of misusing professional knowledge.
Balbuena Rivera’s analysis reminds us that the lessons drawn from this history are manifold, but the key takeaway is the importance of safeguarding the independence of science and professionals—ensuring that they can work without ideological interference and preventing the use of medicine as a tool of control. Through international cooperation, respect for human rights, adherence to ethical standards, and active civic engagement, it is possible to ensure that psychiatry remains a discipline dedicated to the well-being of people, rather than an instrument of political manipulation.
Image: Psychiatry, The University of Health Sciences, Antigua
