Cultural Therapy In The Work Of Psychiatric Hospitals In Leningrad (1930s)

Abstract

In modern psychiatry, one of the main trends is the transition from a biomedical model of mental disorders treatment to a biopsychosocial one. Cultural therapy is considered to be an effective method of influencing the mentally ill. The purpose of the article is to analyze the practice of its implementation in the work of psychiatric hospitals in Leningrad in the 1930s. During this period, the point of view became widespread among doctors, according to which a set of cultural activities that are consistent with the general course of treatment, aimed at restoring health and maintaining social communication skills of patients, can be considered therapy (along with physiotherapy, medication and surgery). The article provides data on various forms of cultural therapy. Depending on the degree of participation of patients in them, they were divided into active and passive. This allowed us to involve patients with different diagnoses in the work. Cultural therapy was aimed not only at the personality of a particular person, but also at forming relationships in the hospital team, as well as at correcting the attitude to patients in psychiatric hospitals in Soviet society. The study leads to the conclusion that in the psychiatric hospitals of Leningrad in the 1930s, this activity was mainly applied and experimental in nature, with a clear weakness in the theoretical understanding of its results.

Keywords: Cultural therapymental illnessespsychiatry

Introduction

The number of mental illnesses in any society is one of the indicators of its biological and social health. That is why in the conditions of the new Soviet system in the 1920s, the point of view expressed by the people's Commissar for Health of the RSFSR Semashko (1926) became widespread, according to which “healthy nerves” are more important than “healthy muscles”. Closer attention to the problem, the expansion of the range of scientific research, and the transition from a purely symptomatic to a biomedical model of treatment have led to some improvements in the treatment of mental illnesses.

In Leningrad, the largest industrial and political center of the country, the number of people who needed to be placed in psychiatric hospitals decreased during the 1930s from 3.3 to 2.2 people per 1,000 inhabitants (CSASTD SPb, n.d. f). But the absolute figures remained high. According to the observations of a doctor of the 2^nd Leningrad Psychiatric Hospital, Naumov (1929), at the end of the 1920s up to 15-20 people a day were admitted to their emergency room, including those with acute mental illness, with reactive and manic-depressive psychoses, twilight epileptic states, psychopathies, psychasthenias, alcoholic psychoses (Naumov, 1929). During 1940, the city psychiatric hospitals received 11,216 patients, and the total number of referrals to psychoneurological dispensaries was 166,663, of which 62,791 cases were due to psychiatric diseases (CSASTD SPb, n.d. e).

Most of the burden on the reception and treatment of the mentally ill fell on the psychiatric hospitals of Leningrad: 1^st – named after O. Forel (form. name – the Hospital of All Who Sorrow), 2^nd (former St. Nicholas the Wonderworker), 3^rd – named after I. I. Skvortsov-Stepanov, 4^th – named after P. P. Kashchenko, 5^th – named after I. M. Balinsky (former Private hospital of A. V. Shultz). A certain number of mentally disturbed people were being treated in a Psychiatric clinic at The V. M. Bekhterev Institute and in two psychocolonies for chroniclers in the village of Lomaha and the village of Vyritsa. During the 1930s the hospitals were profiled with the allocation of departments for “primary” patients and patients with exacerbations, as well as departments for convalescents (sanatorium), for those suffering from neurosis and borderline conditions.

The pre-war decade in Soviet psychiatry was characterized by the use of so-called active forms of treatment, the most common of which were malarial, hormonal, vitamin, insulin, and convulsive therapy. Patients’ involvement in work and cultural and educational work were supposed to promote healing.

Problem Statement

Neuropsychiatric disorders entail a violation of the entire habitual course of human life, cause misunderstanding and stigmatization on the part of others. Even today, the mentally ill person often finds himself at the bottom of the social ladder; his personal connections are limited to neighbors on the ward and medical staff. In the 1930s in the USSR, many doctors held the opinion that these diseases are “the result of the body's inability to adapt to the social environment, the conflict with it” (Yampolsky, 1931, p. 5). Therefore, psychiatrists were tasked to systematically “introduce the patient into a system of collective existence... that makes it impossible for him to social isolation and socio-biological disorganization”, to create an acceptable environment for him in which he would not feel alienated (Yampolsky, 1931). This result could not be achieved only by medication. An important role in preserving the communication skills of patients was assigned to cultural and educational work, which under certain conditions could acquire the character of therapy.

Research Questions

In our research we consider the following questions:

3.1. What part did cultural and educational work take in the treatment of the mentally ill?

3.2. What were the forms of these methods?

3.3. Is it appropriate to talk about cultural therapy, or can we only talk about cultural services for the hospital patients?

Purpose of the Study

The purpose of the article is to analyze the practice of introducing cultural and educational activities in the work of psychiatric hospitals in Leningrad in the 1930s: to establish their place in the complex of medical procedures; to determine the forms of cultural work and the theoretical provisions underlying it.

Research Methods

The questions of cultural therapy of the mentally ill in the USSR were not the subject of special attention of researchers, some attention is paid to this in works on the history of specific hospitals (Limankin, 2009; Svistun, 2012). Western researchers who have traditionally noted the “repressive” bias of Soviet psychiatry in the fight against dissent (Bloch & Reddaway, 1977; Fireside, 2001; Luty, 2014), only in recent years began to study certain aspects of hospital and community-based treatment of mental illness in the USSR of the 1930s (Byford, 2018; Dufaud, 2014; Zajicek, 2009, 2014).

The research was performed on the basis of records (reports, inspection reports, certification materials) of psychiatric hospitals in Leningrad, stored in the St. Petersburg archives, as well as the memoirs of a psychiatrist at the 1^st City Psychiatric Hospital named after O. Forel – S. A. Sokolskaya. The analysis of archival sources and ego documents helps reconstruct the social history of Russian psychiatry in the 1930s.

Findings

Cultural impact on the mentally ill was used in psychiatric hospitals since the late nineteenth century Most physicians saw in the “entertainment” means of patient excitation of the interest to the world and normal activities. Vladimir Chekhov, the doctor at one of the best psychiatric clinics of St-Petersburg – hospital of All Who Sorrow, pointed out that there is an overall “tightening” of patients seeking to behave in such events as well: “I can still see one mentally disturbed patient, that is almost two completely different people in the hospital department and the evening. In the department, he goes about dressed in a haphazard way, with his socks on his hands, his blouse turned inside out, his boots torn off, completely incapable of a coherent conversation of any length-whereas at an evening party, he is a very decent gentleman, cleanly dressed, who obligingly offers the ladies chairs, picks up a handkerchief dropped by someone, speaks quietly, calmly... sometimes taking an animated part in a quadrille” (Chekhov, 1898, pp. 22-23). A typical list of “amusements” in hospitals in St. Petersburg looked like this: performances and musical and literary evenings, including with the participation of patients, Christmas trees, riding on “wakes”, walking in the park and in the city. By the beginning of the twentieth century, almost every psychiatric hospital in Russia had facilities for musical and literary evenings, dances, and performances and even the most financially troubled institutions invited visiting magicians or “organ-grinder with Petrushka” (Chekhov, 1898, p. 24).

At the centre of discussions in Russian pre-revolutionary science was the question: whether it is desirable to actively participate in the organization and conduct of cultural events, or whether they should be present only as spectators. The second point of view had a larger number of adherents; it is no coincidence that in hospital reports this activity was referred to as “entertainment” or “amusement”.

In the post-revolutionary era, the prevailing view was that it was possible to introduce elements of a “healthy” collective into the environment of psychiatric hospitals. Cultural and educational work was supposed to help instil new social skills in patients and maintain their communication links, the extinction of which inevitably led to the degradation of the individual, antisocial behaviour and, ultimately, the loss of a person to society. From this point of view, the significance of the mentally ill participation people in cultural events (of course, taking into account their diagnosis and condition) was no longer disputed. The fundamental question was whether it was appropriate to talk about cultural therapy or whether it was more correct to talk about cultural work with patients and their cult services.

Since such measures were carried out taking into account medical recommendations, were coordinated with the course of the treatment process, and were aimed at restoring health, many doctors considered it possible to talk about their therapeutic nature. If in the early 1930s the term “cultural work” was used mainly in hospital reports, then in the middle of the decade it was already about “cultural therapy”.

Since the early 1930s, in most hospitals, cultural work has been allocated to a separate sector headed by a psychiatrist. Thus, in the hospital named after P. P. Kashchenko, under the supervision of such a doctor, there were “culture-sisters” and social activists (as cited in Limankin, 2009). At the hospital. Since 1932, ten nurses and a projectionist were assigned to the cultural work sector daily for certain hours (CSASTD SPb, n.d. b).

Being non-specific (common to various forms of psychosis), cultural therapy assumed the recognition of mentally ill people not only as objects, but also as subjects of therapeutic influence. From this point of view, the forms of cultural therapy were divided into active and passive. The first ones that required active participation of patients was amateur activities/concerts (both within hospital departments and hospital in general), music and dance evenings, and theatrical performances. In the organization of walks and excursions, lectures, “loud” readings through, board games, the leading role belonged to the staff, and the application of creative efforts on the part of patients was not required.

The recognition of the therapeutic value of cultural events made it possible to reach bigger amount of the mentally ill. As noted in the report of the I. I. Skvortsov-Stepanov Hospital, the main task of the medical staff was to bring cultural work closer to the departments themselves (especially for the restless and semi-restless). In 1931, the hospital choir held 62 classes and 59 performances, a drama club was created, and a library was opened (670 books were issued, 16,156 newspapers, and 3,756 magazines were issued during the year). In addition, there were 16 hospital-wide concerts (7 of them were organized by patients and staff), 65 concerts inside the departments, 25 movie shows, 9 parties, 13 excursions to museums and exhibitions, 11 trips to the theatre and circus, 86 “loud” readings through, 18 sanitary and educational conversations. Patients were particularly enthusiastic about participating in ski trips. It is appropriate to point out that by the beginning of 1932, there were 1,136 patients undergoing treatment in the I. I. Skvortsov-Stepanov Hospital, on average, each of them spent 226.4 days in the hospital. Such more or less stable contingent allowed to involve the bulk of patients in the work. However, according to the doctors, most of them did not participate much in the implementation of active forms of culture therapy (CSASTD SPb, n.d. a).

Despite the recognition of the therapeutic effect of such cultural "procedures", the actual scientific study of their impact on patients was carried out on a very limited scale. For example, in the hospital. According to S. A. Sokolskaya, this work began almost accidentally. As the doctor on duty, she saw the patients gathered in the living room of the quiet women's department at the piano: “It was played by an old paranoid, good-looking, always friendly, once pretty woman. More sang romances, sang solo and chorus, recited. It was so cozy, good” (as cited in MMM MD RF, n.d., p. 86). The positive experience of such “home” evenings was recognized as useful, and with the permission of the chief doctor, concerts were held for all patients, including the restless. In such cases, the concert hall, which could accommodate about two hundred people, was divided into sectors, where each of the departments had a permanent place. Quiet patients were located near the stage, restless and suffering from epileptic seizures-closer to the door (for quick evacuation). Each doctor was assigned a special role: “sometimes to conduct an epileptic, then a rampant hysterical woman, then a distressed lady” (MMM MD RF, n.d., p. 86).

Without clear instructions, doctors followed trial and error when choosing specific elements of culture therapy. Concert programs were usually approved by the chief medical officer. The repertoire was established experimentally, as a result of observing the reaction of patients. It is common practice to interview patients the morning after the event. And it often happened that in the ward of special supervision of the restless department, “a heavy old aggressive epileptic” told with emotion that he liked most of all how “Galya Bolshakova danced polka under a pink umbrella” (MMM MD RF, n.d., p. 87). A mandatory number in every concert program of the Forel Hospital was a romance “Silence” (music by S. A. Kashevarov, words by N. B. Khvostov). And, on the contrary, was forever rejected “Aria of Dubrovsky” before the portrait of his mother “Oh, give me oblivion, my dear” (from the opera by E. F. Napravnik), as already half of the aria in the audience began to worry, and then followed by crying, hysterics, and doctors had to take the audience out by the hand. An attempt to study in detail the effects of music on various groups of patients failed: the participants of the experiment were happy to have fun, but did not show a specific reaction to a particular tune: “all the depressive fell asleep” at the sound of Kamarinskaya, and “manic danced” and to the funeral march of Chopin. After a month of almost fruitless efforts, targeted “music therapy” was abandoned (MMM MD RF, n.d., p. 88).

Doctors of the 2^nd Psychiatric Hospital “experimentally” found out that for a “mentally ill person” it is desirable to select not very long plays (up to 5-10 minutes), excluding music “erotic”, “pathological” (for example, “Last things” by Schumann) and “music of the last decades”. The basis of concert programs began to be the works of classics, taking into account their division into “sunny and shadow, exciting and soothing, sad and funny” (Svistun, 2012, p. 420).

Amateur concerts, which were considered active forms of cultural therapy, helped the mentally ill to show their creativity, forced them to actively communicate with each other in the process of preparing musical and dance numbers, singing choruses. According to the records of hospitals, almost every Department (with the exception of those intended for" acute", restless patients) had musical instruments: occasionally – a Grand piano, more often – strings (guitar, balalaika, and mandolin). Also, gramophones with records were often placed in the wards (although they were considered a luxury item).

Dramatic productions contributed even more to the involvement of patients in the cultural life of the hospital. The choice of the play, the distribution of roles, the design of the stage-all this evoked emotions, forced Amateur artists to show their individuality and sometimes gave remarkable results. Patients from the 2nd psychiatric hospital, with the participation of doctors and nurses, put on stage dramas by A. N. Ostrovsky, with whom they went on tour to other hospitals and even to a sponsored collective farm.

The list of cultural events was about the same for all psychiatric institutions, the differences were due to personal preferences and capabilities of medical staff, and sometimes the connections of patients in the clinic. For example, in the department of the Forel Hospital., which was headed by S. A. Sokolskaya, was a ballet artist on the recovery, whose comrades constantly participated in hospital concerts. Sometimes the posters listed up to forty names of artists of the Kirov theatre. The invitation of professional performers was aimed at overcoming the wary attitude to the “abnormal” that existed in the 1930s in Soviet society. This case is very significant in this regard. During the concert, the lights in the hall suddenly went out. The artist on the stage continued to read his text after a moment of confusion, while his companion wrapped himself in the curtain of the stage in fear. They said they were both terrified that the patients would attack them in the dark. When the incident was successfully resolved, they declared that “madmen are noble people” (MMM MD RF, n.d., p. 87).

An innovation in comparison with the pre-revolutionary period was the holding of hospital film and radio sessions. At the hospital. Forel had a separate cinema room that could accommodate up to 300 people. A special success among patients was the film “Silent friend”, where the main role was given to a large dog. The I. M. Balinsky hospital, the first of the psychiatric hospitals, purchased a sound film installation. At the P. P. Kashchenko hospital, which was radioed in 1933, music and popular science lectures were broadcast daily while patients were eating. Such activities did not require any effort on the part of those who were recovering, while at the same time helping to maintain their social skills.

Table games were also considered a passive form of cultural therapy. Their therapeutic significance consisted in developing the ability of the mentally ill to make decisions (but within precisely defined rules), in getting rid of inferiority complexes, and in social interaction. It was assumed that games should not be of a gambling nature and could not distract patients from work. Therefore, chess, draughts, and Lotto tournaments were held exclusively in the evening, free from medical procedures and work in hospital workshops.

The medical staffs also had to support and develop the patients “political consciousness” so that they could more easily integrate into the Soviet society after their recovery. Therefore, regular classes on the problems of the “current moment” were an integral part of the cultural work in each psychiatric hospital. For example, at the I. M. Balinsky hospital in 1936, there were 8 conversations on political topics (covering 220 people), 2 reports on the international situation (for 90 people), the following year – 10 political conversations and the same number of reports on the international situation (CSASTD SPb, n.d., c; CSASTD SPb, n.d. d).

The program for the elimination of illiteracy in the USSR gave special importance to the reading of political and artistic literature and in the walls of psychiatric clinics. Hospitals were provided with a standard set of Newspapers and magazines. For example, “Leningradskaya Pravda”, “Krasnaya Gazeta” (including the evening edition), “Izvestia”, “Trud”, “Krestyanskaya Pravda”, “Komsomolskaya Pravda”, “Leninskie Iskry”, as well as popular science publications (“Self-education”, “Hygiene and health”, “Science and technology”, “Around the world”) were issued for the psychiatric hospital named after P. P. Kashchenko. The selection of periodicals suggests that reading should have contributed to the formation of the patients '"correct" reaction to the phenomena of social life. “Loud” reading through of classical literature, as well as humorous stories and feuilletons, followed by a discussion of the actions and characters of the characters helped to restore the understanding of the social norm in patients, contributed to the emancipation of patients, the manifestation of sincere emotions in them.

By the end of the pre-war decade, after the “exposure” of perversions in pedology and psychohygiene, research in the field of psychiatry was focused on medical and biological tasks as the main ones for the social and labour recovery of mentally ill people. Cultural work began to play a subsidiary role.

Conclusion

Among Soviet psychiatrists in the 1930s, there was a widespread view that cultural events could not be limited to the purpose of entertaining patients, but should reflect the forms of a “socialist community” of a healthy collective. Purposeful cultural and educational work, including active participation in it by the patients themselves, acquired a therapeutic character, became an important factor in the overall complex of therapeutic effects (along with physiotherapy, medication and surgical treatment). Cultural therapy helped to restore and preserve the communication skills of psychiatric hospital patients, and to integrate people with mental disorders into Soviet society. At the same time, it depended on the discretion of the medical staff of the clinic and remained in the 1930s the most poorly developed system of influence on the mentally ill.

Acknowledgments

The study was prepared with the financial support of the Russian Foundation for Fundamental Research (RFFR), project № 19-09-00404 «S.A. Sokolskaya. Ordinary life. Memoirs».

References

1. Bloch, S., & Reddaway, P. (1977). Russia’s political hospitals. The abuse of psychiatry in the Soviet Union. Gollancz.
2. Byford, A. (2018). Lechebnaia pedagogika: The Concept and Practice of Therapy in Russian Defectology, 1880–1936. Medical History, 62(1), 67-90.
3. Chekhov, V. V. (1898). K voprosu ob ustrojstve uveselenij dlja dushevnobol'nyh (stranichka iz byta domov dlja umalishennyh) [To the question of the arrangement of entertainment for the mentally ill (a page from the household of houses for the mentally ill)]. Arhiv psihiatrii, nejrologii i sudebnoj psihopatologii [Archive of Psychiatry, Neurology and Forensic Psychopathology], 31(2), 20-42.
4. CSASTD. (n.d. a). Central State Archive of Scientific and Technical Documentation of St. Petersburg. F. 313 (V.M.Bechterev Psychoneurological Institute). Inventory 11. Dos. 40.
5. CSASTD. (n.d. b). Central State Archive of Scientific and Technical Documentation of St. Petersburg. F. 313 (V.M.Bechterev Psychoneurological Institute). Inventory 11. Dos. 52.
6. CSASTD. (n.d. c). Central State Archive of Scientific and Technical Documentation of St. Petersburg. F. 313 (V.M.Bechterev Psychoneurological Institute). Inventory 11. Dos. 99.
7. CSASTD. (n.d. d). Central State Archive of Scientific and Technical Documentation of St. Petersburg. F. 313 (V.M.Bechterev Psychoneurological Institute). Inventory 11. Dos. 162.
8. CSASTD. (n.d. e). Central State Archive of Scientific and Technical Documentation of St. Petersburg. F. 313 (V.M.Bechterev Psychoneurological Institute). Inventory 11. Dos. 256.
9. CSASTD. (n.d. f). Central State Archive of Scientific and Technical Documentation of St. Petersburg. F. 313 (V.M.Bechterev Psychoneurological Institute). Inventory 11. Dos. 291.
10. Dufaud, G. (2014). The Challenge of Physiology: Soviet Psychiatry in the 1930s. Ab Imperio, 4, 136-166.
11. Fireside, H. (2001). Psychiatry and censorship in the USSR, 1950s–1980s. Index on Censorship, 30(4), 211-212. DOI:
12. Limankin, O. V. (2009). Sankt-Peterburgskaja psihiatricheskaja bol'nica im. P.P. Kashhenkoju Stranicy stoletnej istorii [St. Petersburg Psychiatric Hospital named after P.P. Kaschenko. Pages of centenary history]. Kovcheg.
13. Luty, J. (2014). Psychiatry and the dark side: Eugenics, Nazi and Soviet psychiatry. Advances in Psychiatric Treatment, 20(1), 52-60. DOI:
14. MMM MD RF. (n.d.). Military Medical Museum of the Ministry of Defense of the Russian Federation, F. 76940. S.A. Sokolskaya's memoris
15. Naumov, F. A. (1929). K voprosu o reorganizacii psihiatricheskoj pomoshhi v Leningrade i Leningradskoj oblasti [To the issue of reorganization of psychiatric care in Leningrad and Leningrad region]. Zdravoohranenie [Healthcare], 2, 19-33.
16. Semashko, N. A. (1926). Sovetskaja medicina v bor'be za sovetskie nervy [Soviet medicine in the fight for Soviet nerves]. Ulyanovsk.
17. Svistun, S. J. (2012). Sankt-Peterburgskaja bol'nica sv. Nikolaja Chudotvorca: k 140-letiju. T. 1 [St. Petersburg Psychiatric Hospital of St. Nicholas the Miracle Worker: to the 140th Anniversary. Vol. 1]. KOSTA.
18. Yampolsky, E. Z. (1931). Nervno-psihicheskie zabolevanija i social'naja sreda [Nervous-mental diseases and social environment]. Aleksandrov.
19. Zajicek, B. (2014). Soviet madness nervousness, mild schizophrenia, and the jurisdiction of psychiatry in the USSR, 1918–1936. Ab Imperio, 4, 167-194. DOI:
20. Zajicek, B. (2009). Scientific Psychiatry in Stalin’s Soviet Union: The Politics of Modern Medicine and the Struggle to Define “Pavlovian Psychiatry”, 1939–1953. University of Chicago.