Psychiatry's utility as a device for suppressing political dissent has not been lost on totalitarian regimes. The best-known example occurred in the Soviet Union during the post-Stalin era (1,2). Khrushchev and his successors, no longer comfortable with the widespread use of overt repression, looked to confine dissidents in psychiatric facilities instead of labor camps. Psychiatric hospitalization, in addition to its "gentler" face, offered the advantage of discrediting the dissidents and their causes as "crazy" and thus unworthy of world support.

The latest allegations about the systematic misuse of psychiatry for political purposes come from China. They have recently been catalogued by Robin Munro, formerly director of the Hong Kong office of Human Rights Watch and now senior research fellow at the Centre of Chinese Studies of the University of London (3). As was the case when word of Soviet psychiatric abuses first reached the West, most of the available reports come from dissident religious and political groups, and independent verification is lacking. Nonetheless, Munro has assembled an impressive analysis of the ways in which Chinese law facilitates the misuse of psychiatry as well as a collection of individual cases. The description that follows is drawn from his account.

Munro suggests that the political use of psychiatry in China has passed through three stages. It began in the 1950s as Chinese psychiatry was reconstructed on the Soviet model after the communist takeover. Although psychiatric abuses were not extensive in this era, perhaps because the psychiatric system itself was so rudimentary—there were reportedly only 50 to 60 psychiatrists in China immediately after the revolution—some dissidents were apparently diagnosed under broad Soviet standards and subjected to confinement. For example, they were said to have "sluggish schizophrenia," the diagnosis of which did not require psychotic symptoms.

During the decade of the Cultural Revolution, which began in the late 1960s, a strange inversion of this process took place. With Maoist ideologues attributing behavioral abnormalities to an incorrect appreciation of the class struggle, the reality of mental illness was denied, and study of Mao's works was substituted for other forms of therapy. Persons with genuine mental disorders whose delusional ideation manifested a political component found themselves taken from psychiatric facilities and incarcerated in labor camps and prisons for "counterrevolutionary" offenses. Only with the ascension of Deng Xiaoping in 1979 was the cruelty of this practice acknowledged and a majority of its victims freed.

In contrast, from the 1980s to the present, China has again seen persons who challenge the political and cultural hegemony of the Communist Party being labeled as mentally ill and being confined, often for substantial periods, in psychiatric facilities. Recent cases appear to fall into two groups: political dissenters and members of the quasi-religious Falun Gong movement. The former tend to be confined in special forensic hospitals—known as Ankang, which means "peace and health"—operated by the Ministry of Public Security, and the latter have been reported to be hospitalized primarily in ordinary public facilities.

Chinese criminologic and psychiatric writings provide evidence of the theoretical underpinnings that facilitate the misuse of psychiatry to crush dissent. For example, a contemporary Chinese textbook of forensic psychiatry offers the following discussion of the symptoms of one disorder: "Paranoid psychosis manifests itself … [in one of two ways, including] 'political mania,' where a dominant role is played by 'political delusions.' The content of delusions in 'political mania' concerns the line and policies of the State; those afflicted do avid research into politics and put forward a whole set of original theories of their own, which they then try to peddle by every means possible…. For this reason, such people are sometimes viewed as being political dissidents" (3). It is easy to imagine how any dissident could fall afoul of the psychiatric system if behaviors such as these are the sole basis on which a diagnosis is made.

Another example with a particularly pernicious twist is drawn from the work of a prominent Chinese forensic psychiatrist, who discusses crimes committed by persons with schizophrenia: "Among the cases under discussion … the person would often display absolutely no sense or instinct of self-preservation, for example by openly mailing out reactionary letters or pasting up reactionary slogan-banners in public places—and even, in some cases, signing his or her real name to the documents … " (3). By these criteria, political dissenters who openly attempt to build a democratic structure in China, rather than conspiratorially trying to undermine the communist state, are especially susceptible to being called mentally ill.

In a review of ten Chinese psychiatric journals from 1976 to 1995, Munro found reports of the forensic psychiatric evaluations of nearly 4,000 persons, 3.8 percent of whom were classified as having committed "political" crimes. Extrapolating conservatively to the entire country over the past decade, he estimated that no fewer than 3,000 political cases have been referred for forensic evaluation and that the great majority of those individuals were subjected to "some form and duration of forced psychiatric custody and treatment."

Munro cites an example from the previously mentioned textbook of forensic psychiatry (3). A 57-year-old former coal miner, referred to as Zhu, who had been an enthusiastic participant in Mao's Cultural Revolution, began to write extensively on political matters after he retired. He spoke to local political leaders and sent his writings to political journals, always signing his own name. His speech was logical, his behavior polite, and his lifestyle orderly. However, when subjected to psychiatric evaluation he was found to be suffering from paranoid psychosis on the basis that his theories were "conceptually chaotic" and in conflict with the principles laid down by the Central Committee. Moreover, "Zhu's views and utterances were incompatible with his status, position, qualifications, and learning; the great disparities here clearly demonstrated his divorcement from reality."

In the past two years, reports of actions against members of the Falun Gong movement, which is being aggressively persecuted by Chinese authorities, have been publicized widely in the Western media. Some of these accounts indicate that members of the sect are being taken to psychiatric facilities, where three of them allegedly have died. One judge who practiced Falun Gong and who apparently was hospitalized on that basis reported that he was told, "Let us see which is stronger, Falun Gong or our medicines" (3). Of particular concern is that these confinements are said to be taking place in general psychiatric hospitals, not in the special hospitals that are more directly under the authority of the state security apparatus. This observation suggests that the propensity to misuse psychiatric diagnosis and treatment is spreading to the broader psychiatric system.

To his credit, Munro forthrightly acknowledges that it is nearly impossible to determine, on the basis of the fragmentary data available in the West, whether any of the dissidents—political or religious—who have been confined to Chinese psychiatric facilities are genuinely mentally ill. A definitive conclusion would require the same kind of direct examination by impartial psychiatrists that ultimately was conducted in the Soviet Union shortly before its fall (4). However, published descriptions of Chinese diagnostic practices—only a small number of which have been quoted here—and the absence of firm legal controls over detention for forensic purposes are certainly compatible with this suspicion. With regard to the latter, for example, police and prosecutors can request forensic evaluations of persons thought to have committed crimes in the absence of standards that regulate how long such persons can be detained without trial (3).

However, even if they have not been misdiagnosed, both political and religious dissenters clearly are being arrested, hospitalized, or incarcerated for behaviors that under international standards are neither crimes nor indications for involuntary commitment. Indeed, persons detained by the police for "counterrevolutionary activities" or participation in banned religious groups face a no-win situation. If diagnosed as mentally ill, they face indefinite confinement in psychiatric facilities; if deemed not mentally ill and thus responsible for their behavior, they are likely to be sentenced to the penal system.

Assuming that the allegations Munro has assembled are valid, how are we to understand the role that at least some Chinese psychiatrists have played in these abuses? Are they deliberately engaging in what Munro terms hyperdiagnosis—knowing their patients to be mentally healthy—or honestly applying politically tinged diagnostic criteria to political and religious dissidents whom they believe to be ill? At least some of the evidence cited by Munro suggests deliberate use by psychiatrists of diagnoses of mental disorders to facilitate the system's efforts to crush challenges to its social and political domination of the populace.

Western psychiatrists are understandably concerned when their discipline is used for political purposes. To condone such abuses anywhere is to give credence to the claim that all psychiatric diagnoses are suspect and that involuntary commitment is nothing more than a transparent effort to confine those who give voice to ideas that the dominant members of society would prefer not to hear. Thus, with the encouragement of the American Psychiatric Association and comparable organizations in other countries, the World Psychiatric Association is seeking China's permission for a delegation of foreign psychiatrists to visit the country and examine persons who claim they have been subjected to unjustified detention and treatment.

At this writing, the World Psychiatric Association's efforts have not met with success. The Soviet Union's acquiescence in a visit by Western psychiatrists in 1989 came only when the leaders perceived it as being in their interests to rein in the hard-liners who were then in control of the psychiatric system. China's leaders today, at the helm of an economically vigorous nation, are in a very different political position from that of the heads of the tottering Soviet state. Nonetheless, should they become persuaded that international concern about allegations of psychiatric abuse is harming their long-term interests, they too may either permit an investigatory body to visit China or order a halt to the use of psychiatry for repressive purposes.

Dr. Appelbaum, who is editor of this column, is A. F. Zeleznik professor and chair in the department of psychiatry at the University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655 (e-mail, appelbap@ummhc.org).