Table of Contents
Chapter Seven
From The Margins of Globalization
Lexington Books, Oxford, 2004
Ruchama Marton
Introduction
The psychiatric establishment is an agent of social supervision, discipline, and control, due, inter alia, to the part it plays in determining societal norms. Society has turned psychiatry into an authority with quasi-judicial powers, which has the ability: (1) to determine a person’s fitness to stand trial; (2) to determine whether an individual’s behavior is dangerous or not; (3) to enforce confinement in mental health institutions; and (4) to set and evaluate various skills, including the intelligence of individuals. At the same time, psychiatry produces the rules informing its own position of power, a power that is both judicial and executive. These different social roles provide the psychiatric establishment—both as a whole, as well as individual psychiatrists—with extremely significant powers that extend well beyond the professional medical definition of diagnosis and treatment of mental illnesses and disease.
Importantly, human rights are historically connected with the advent of psychiatry. The French physician Philippe Pinel was responsible for the release of mentally ill inmates from French jails. The role of understanding mental illness, distinguishing it from criminal activity, and protecting the rights of the mentally ill, is today still part of psychiatry’s function. Society has compelled psychiatry to be the field that determines fitness to stand trial and fitness for imprisonment, and this responsibility gives rise to an additional duty: namely, upholding the rights of prisoners—the mentally ill in particular, and detainees in general. Human rights and their protection are therefore an integral and substantial component of psychiatry. The awareness or lack thereof of this function dictates, to a considerable extent, the use psychiatry makes of its own power.
The question of where psychiatry situates itself in relation to the state and the individual is a socio-political question that depends on the degree to which it is aware of its role as a protector of human rights. Simultaneously, though, psychiatry’s location in the social landscape also stems from and is subject to the theoretical position which it adopts. According to classical theory, which has informed psychiatry from its inception, the intrapersonal is the principle dimension of the therapeutic relationship. During the last few decades of the 20th century, however, theoretical developments have stressed the significance of the interpersonal dimension. From the perspective of classical psychiatry, which assumes that everything takes place within the personal field, the socio-political dimension—i.e., the super-personal—is considered outside the borders of psychiatry and therefore is not included within the boundaries of its discourse. Obviously, this theoretical position, which ignores the socio-political dimension, is, in itself, political. As we will see the inclusion of the super-personal dimension within the psychiatric discourse is crucial for both increasing awareness of and in providing the necessary theoretical tools for dealing with human rights.
The theoretical term used here to conceptualize the super-personal dimension is intersubjectivity. The intersubjective relationship between the patient and the psychiatrist provides room not only for the individual or personal dimension, but also for both parties’ socio-political background. It enables the psychiatrist to broaden his or her spectrum when looking-inward—allowing an in-depth examination of the system of motives, emotions, fears and prejudices informing the psychiatrist—as well as his or her rapport with the patient. This chapter will underscore some of the dangers resulting from the exclusion of the super-personal dimension from psychiatry, particularly those that entail the violation of human rights. I shall examine how psychiatry employs its immense force, asking whether it uses it in order to protect human rights, the rights of the mentally ill and of prisoners, or whether it uses its power perversely by toeing the establishment’s line, while disregarding the rights of the individual. Using Israel as a case study, in the following pages I explore some practical and theoretical aspects of these questions. I focus on the rights of prisoners, while analyzing decisions made by individual psychiatrists, the Israeli Psychiatric Association and the Israeli Medical Association (IMA) regarding three issues: 1) the mental illnesses of Palestinian prisoners; 2) the Israeli medical establishment’s ethical obligation regarding solitary and segregated confinement of prisoners; and 3), the IMA’s ethical obligations regarding the use of torture.
I. The Diagnostic Relationship in Prison—A Theoretical Perspective
In classical psychiatric language, the psychiatrist is the “subject.” The psychiatrist brings to the diagnostic or remedial relationship his own view of reality, whether consciously or not. This view of reality constitutes a large portion of the power and knowledge used in understanding the patient, the “object.” In far too many cases, this causes the personality of the object, the prisoner, to be reduced so as to accord to the needs of the psychiatrist; the object is reduced by the subject to just one aspect of all of his traits. The subject (the psychiatrist), in a blindness that serves parts of his subjectivity, sees only a part of the object (the patient), yet considers it to be the whole. The object is nothing more than a “criminal,” an “Arab,” a “terrorist,” a “woman,” a “mother.” This view eliminates the object’s individuality and transforms him into nothing more than the representative of a group with stereotypical characteristics, which stem from the psychiatrist’s prejudices.
When therapeutic theory and practice provide room for two subjects—one being the classical subject or psychiatrist, and the other the patient as subject (replacing the classical object)—this is much more than mere semantics. In such instances, the patient and psychiatrist are both treated as subjects, each of whom has his own view of reality, including his own personal, social, political, and cultural background. Relating to the patient as a subject, with all of the factors characterizing a subject, is the best antidote to the distorted view psychiatrists often have of their patients. In Jessica Benjamin’s words: “Most important, this [intersubjective] perspective observes that the other whom the self meets is also a self, a subject in his or her own right, as an other who is capable of sharing similar mental experience.” This intersubjectivity is supposed to exist in all types of relationships, according to Benjamin, including relationships between countries, between societies, within families, among spouses, and friends, as well as relations characterized by diagnosis and treatment.
Just as a surgeon works with a knife, a psychiatrist works with his personality. The psychiatrist-subject is required to be aware of his own subjectivity, to recognize that his own subjectivity is ever-present, and not to rely merely on classical theory which considers him to be an objective and neutral observer. Only then does the patient have a chance to stand alongside the psychiatrist, instead of opposite him. The prisoner-patient will no longer be an object, in the sense of a person standing opposite, or in opposition, which gives rise to feelings of enmity and a state of war. Transforming the classical view, which assumes that psychiatrist can be objective and neutral people, involves the introduction of a new and different concept of counter-transference. A “continual deconstruction and analysis of counter-transference,” according to Stephen Mitchell, “is a powerful, very influential form of announcing the psychiatrist’s values and concerns.” When the psychiatrist is not at all interested in developing self-awareness regarding the values and concerns he brings to the relationship, then Mitchell’s helpful advice will have no effect. The opposite is the case: Instead of looking inward, into his own personal, social, cultural and political world, or in Mitchell’s language, his concerns, the psychiatrist will make a critical decision, preferring, as it were, outsight to insight.
Outsight is a system of ideas including points of view that come from the outside. In the aggressive, political game that the Israeli state is playing to silence and oppress the other, there is a constant danger that the psychiatrist will maintain a blind spot regarding his complicity in this process. This blind spot enables the psychiatrist to ignore his professional-ethical obligation as a physician whose role is to protect the rights of the patient, the prisoner, the “other”—any person whom the social order knowingly silences. As a result of his blind spots, the psychiatrist acts as an agent for the authorities, the powers that psychiatrist his blind spots do not enable him even to see that he is uncritically accepting the government’s worldview and system of ideas. This specific blindness allows him, in turn, to consider himself apolitical, while any person who does not identify with the government’s worldview, or who objects to it, is considered to be acting according to “political motives,” which counter the purity of the psychiatric profession.
As is well known, psychiatrists have identified with government power throughout history. In Nazi Germany, the Soviet Union, Argentina, Chile as well as other countries, psychiatry was employed as a tool by the authorities. It is both theoretically and practically important that the Israeli psychiatrist recognize the fact that he is positioned on the aggressive side within a concrete socio-cultural-political reality: healthy versus ill, Israeli versus Palestinian, free versus imprisoned, white collar versus convicted criminal—and frequently, wealthy and educated versus poor and uneducated—and (although changes have taken place over time and there has been progress) man versus woman.
II. Psychiatry as Determiner of Fitness to Stand Trial
In Israel, psychiatrists are responsible for diagnosing and assessing people who are about to be tried, in order to determine their ability to stand trial. This responsibility raises important questions, since psychiatry’s boundaries are not always clear. There are the questions concerning the prisoner’s responsibility, will, and ability to understand the difference between right and wrong, as well as whether he is dangerous to the public and/or to himself and what the motives or reasons for his actions were. The motivations for the act ascribed to the patients, not only derive from the mental-personal field and therefore cannot be accounted for by simply invoking mental theory. Motivations are always informed by the socio-political and cultural spheres, and the borders between them are neither sharp nor clear. In this respect, as with other issues, the psychiatrist’s counter-transference is of considerable significance.
One should bear in mind that mentally ill prisoners are a minority within a minority, and they often suffer from very severe violations of human rights. When mentally ill prisoners are members of a different cultural and national group than that of their psychiatrist, the difference becomes a decisive factor in the diagnosis and treatment. Which raises the question concerning the psychiatrist’s personal stance when his patient is from a different culture or nationality? What is the psychiatrist’s position when the patient is a Palestinian—not only a foreigner, but the enemy? Is the psychiatrist aware of his subjective position, which perceives his patient as a “terrorist,” i.e., as a real threat to society’s security? Such a view might be so encompassing as to conceal all other parts of the patient’s humanity. The specific role ascribed to Israeli psychiatry, to protect “public security,” can obscure the boundaries between the psychiatrist’s professional judgment and his political beliefs, and this may occur without sufficient self-awareness.
After all, a Palestinian patient, who is considered by the psychiatrist to be a terrorist, most certainly constitutes a threat to public security. Palestinian mental illness can therefore fall within the blind spot of the Jewish-Israeli psychiatrist—unseen and undiagnosed. The patient’s (potential) threat to the public is visible, but as opposed to other cases—in which non-Palestinian prisoners are diagnosed—the origin of the threat is political, not mental illness. The crucial question here is the extent to which the Jewish-Israeli psychiatrist is at all aware of his own blindness. In psychiatric language one might say that insofar as the psychiatrist’s counter-transference does not undergo processing and is not raised to the level of consciousness, he is unaware of his motivations.
III. Disregarding the Super-Personal Dimension: A Case Study
The youth Ali Shaban, a resident of the village of Yamoun in the West Bank, was arrested on February 7, 1990, and was incarcerated at Farah prison near Nablus. Information about him reached Physicians for Human Rights (PHR) at the beginning of May 1990. The three months that elapsed from his arrest until a relative contacted PHR reflect the harsh conditions of Palestinian life at the time, and the obstacles that they had to overcome in order to exercise basic rights. Very often the military would not inform the family that one of its members had been arrested or where he was being held. Many Palestinians, and Palestinian villagers in particular, did not have the financial resources to obtain legal assistance, and did not know how to contact human rights organizations in order to help them exercise their rights. On a practical level, many of the villages did not even have telephone services not to mention cellular phones. At best, there was a telephone in the home of the Mukhtar—the village head. For this reason, PHR had no idea when, in the course of his incarceration, Ali suffered a severe psychotic attack. In an activity report from that year, PHR wrote:
…[T]he rights group has the impression that the youth has suffered from a severe psychotic attack and from initial symptoms of schizophrenia. The youth has not spoken for a few weeks; he uses his own private sign language, laughs for no apparent reason and then makes desolate-looking faces. It seemed as if he is in his own psychotic world which he expresses by drawing animals and giving them men’s and women’s names, treating them as if they were alive. He kisses his drawings and protects them so that nothing bad would happen to them. Drawings such as these are characteristic of persons suffering from schizophrenia.
In the first months following his incarceration, Shaban did not undergo any kind of psychiatric treatment. The person who finally noticed his dire mental state was a military judge who presided over a hearing regarding the extension of Shaban’s detention. Before granting an extension, the military judge ordered a psychiatric examination to determine whether Shaban was fit to stand trial. It is important to note that it is very unusual for a military judge to request that a Palestinian prisoner be given a psychiatric examination of his own initiative. Following the judge’s referral, a psychiatric opinion was provided by Dr. Yakov Avni, a senior Jewish-Israeli psychiatrist, and director of the psychiatric ward at Hadassah Hospital, Jerusalem. What follows is an analysis of Avni’s psychiatric diagnosis.
“The above, 17 years old, born in Israel” –
Avni employed Israeli medical jargon, transferring it, as it were, to a completely different society and culture. In doing so he effectively colonized Palestinian society. Where was this Palestinian villager born? And what did the doctor mean when he wrote “Israel,” when referring to a person born in the West Bank?
“A resident of the village of Yamoun. Occupation unclear.”—
The youth was a high-school student until the day he was arrested. But why didn’t Avni check whether Ali was a student in his village? It would have been very easy to find out. The vagueness or lack of clarity regarding his “occupation” contains a certain hint about a defect in the patient’s character or behavior.
“Did not respond before the Judge, on March 6, 1990, giving the latter the impression that he was mentally unsound. In the request for issuing an arrest warrant are detailed hostile activities during demonstrations, writing PLO slogans and placing road blockades throughout the past year. Was arrested on February 7, 1990, and according to the Police, ‘confessed, his investigation is not yet complete.’ Sentenced on March 6, 1990 to 47 days imprisonment.”
Parenthetically, it is important to pay attention—even though this only indirectly pertains to our discussion—to the charges for which Shaban was arrested and the way the security forces apprehended him. My experience suggests that in many cases security forces turn up at a Palestinian home late at night with a list of names in hand. This list is obtained from a Palestinian youth in the village, who had been arrested previously, interrogated and tortured; the youth simply gives the interrogators whatever name comes to his head. The interrogators use the list as clear proof of the guilt of other youths. And indeed, the charges are usually general; they do not note the place and time of the event for which the person was arrested, and lack specific and detailed descriptions.
“…hostile activities during demonstrations, writing PLO slogans and placing road blockades during the past year.”
The doctor erases the youth’s subjectivity. Whenever a civilian population is fighting against occupation, youths participate in non-violent forms of resistance such as those that Shaban was charged with. During the period of the British mandate, Jewish-Israeli youths participated in activities almost identical to the actions described. When the psychiatrist and the patient are part of the same group, the youth’s subjectivity will frequently be observed and taken into account by the psychiatrist, but when the psychiatrist and patient each come from hostile groups the language of object/subject is employed.
“…the youth confessed,” according to Avni.
What is the meaning here of “confessed”? Did Shaban confess to the charges brought against him before suffering the psychotic attack? Did he confess to them while he was psychotic, while he was unable to understand what was being said to him? Was his psychotic state a result of the interrogation? I would like to remind the readers that the word “interrogation,” in the language of the General Security Services and the Israeli military is often, far too often, a euphemism for the word “torture.” Did Avni check what Shaban’s mental state was at the time of his “confession”? No, he did not.
“Past history: Unknown. In his records it is written that there are no medical problems. The patient is not providing any information. Upon examination: Theatrical effect… he is of clear consciousness. There is no evidence of disturbance in his perceptions. He does not disclose his thoughts. He supposedly is not aware of time, place or of himself. In summary … based on this examination, it seems to me that Ali Shaban is an imposter, and is not mentally ill. In my opinion, he is fit to stand trial.”
“In his records it is written that there are no medical problems.” –
Did Shaban go to a doctor? Which Palestinian village boy has medical records stating that the boy has “no medical problems”? Why did Avni bother writing that there were “no medical problems”? Might Avni be laying the grounds for the diagnosis which comes later, where he states that, in his opinion, Shaban is an imposter? Since, after all, it is a “fact” that Shaban was healthy beforehand… one of those “healthy” village boys who have papers stating that they have “no medical problems.”
“The patient is not providing any information” –
That is to say, the patient is not talking. Why isn’t he talking? Might it be because he refuses to talk? Or perhaps he was so deeply entrenched in his own internal psychotic world that he had lost all contact with reality and was unable to answer? I wonder why details of Shaban’s behavior during his period in prison don’t appear in the psychiatrist’s report. He was, after all, in prison some two months before the medical examination. The doctor did not bring forth even one piece of information regarding the youth’s past and the state he was in while in prison.
“Upon examination” –
From the short diagnosis one is led to believe that there was some kind of theatrical show; at least that is how Avni understood it. There is an “entrance,” the show begins, the show ends, and afterwards the youth goes back to sit in the corridor in complete silence. And indeed, the following sentence says: “When he enters, he begins to act very theatrically. He tries to pour water into a pocket where he has stuck flowers, to eat toothpaste, etc.” I wonder how Shaban obtained toothpaste in a psychiatrist’s examination room. Could he really have brought toothpaste and flowers from prison as theatrical accessories for the examination? What state were the flowers in, having traveled all the way from Farah Prison near Nablus to Hadassah Hospital in Jerusalem? And what did the psychiatrist mean when he said “etc.”? The psychiatrist would have done better to detail what Shaban was actually doing in the examination room, and whether the eating of the toothpaste and the watering of the flowers actually took place during the examination, or whether those were stories that he heard from Shaban’s wardens, acts which he did not see with his own eyes in the examination room.
“Does not say a word, but sometimes answers with “I don’t know” gestures … Does not know where he is, what day it is, how old he is” –
These are standard questions at the beginning of every psychiatric examination. It is strange, then, that Avni writes, later on, “clear consciousness. No evidence of disturbance in his perceptions.” I am wondering how it is possible to bear witness to clarity of consciousness and lack of disturbance in perception when the patient does not say a word. To readers who are not psychiatrists, I’ll add that it is impossible to discuss a state of consciousness or disturbances of thought when the patient does not speak.
“He does not disclose his thoughts” –
When a person doesn’t speak, it should not be surprising that he does not disclose his thoughts. But there is nothing innocent about this sentence when one takes into account that it was written by a psychiatrist. This sentence is not as straightforward as it may appear. In psychiatric language, this sentence—that a person who does not speak, doesn’t disclose his thoughts—suggests that the patient is willfully refusing to disclose his thoughts, whether because he is an imposter, or because he is paranoid. In other words, it is an “incriminating” sentence.
And the examination ends with a clearly biased sentence. He supposedly is unaware of time, place or of himself. In summary: I don’t have any evidence before me of past mental illness or mental treatment” –
Is this true, Dr. Avni? Was there really no “evidence”? The head of Shaban’s village council claimed that the patient suffers from mental illness and that his situation is serious. The military judge sent him off to a psychiatric examination, which in itself is rare. But Avni saw no mental illness before him.
“…based on this examination, it seems to me that Ali Shaban is an imposter, and is not mentally ill. In my opinion, he is fit to stand trial.”
A clear-cut conclusion, which leaves no room for a second diagnosis, although a second opinion is actually common practice in psychiatric examinations. It seems that there was no doubt in Avni’s mind that he was facing an imposter, who was, most likely, a “terrorist” who had, for the last year, been involved in a variety of hostile acts. The person in front of him was not a young psychotic patient, undergoing his first psychotic attack, perhaps a forewarning of schizophrenia.
I wrote a letter to the civil administration officer in charge of health in the West Bank, asking that he urgently approve a second psychiatric examination by a psychiatrist who does not work in a governmental institute. I attached a copy of a picture that Shaban had drawn—a picture of a couple, a rooster and a hen, that he had drawn on a small piece of paper. He would kiss them, feed them and he called them by male and female names. On July 18, 1990, I received a reply from Dr. Itshak Sever, the officer in charge of health. He permitted a second examination by a psychiatrist from Afula Hospital; an examination by a psychiatrist from PHR was not permitted.
In order to present a more complete picture of the socio-political situation at the time, it is important to note that this was right after an Israeli Jew named Ami Popper murdered seven Palestinian workers. Popper was examined by five psychiatrists and later demanded to be examined by three more psychiatrists, doctors that “he trusted.” His request was granted. Shaban’s case was not treated in a similar fashion. PHR published the case in the newspaper. The journalist contacted Avni, who, when referring to me, said: “Her request is political. As opposed to her, I am not a political personality, but rather a specialist in legal psychiatry and an Arabic speaker.”
One can answer Avni simply by quoting Stephen Mitchell: “Is not the posture of not taking sides itself a partisan position, a side one is taking?” The problem is not whether one takes sides, since everyone takes sides all the time. The problem is when a person does not see that he is taking sides. The question is only to what extent are we aware of the fact that we, psychiatrists, like everyone else, are subjective and political. We must view, as J. Greenberg says, “the psychiatrist’s participation as inevitably subjective.” Yet, when one takes the side of the establishment, there is a tendency to blindness.
The patient’s political “crimes” as spelled out by the prosecution—and not his mental state—often determine the psychiatric diagnosis. Rather than diagnosing the prisoner, the psychiatrist, willingly or unwillingly, tries him. As O. Renik argues, the psychiatrist’s understanding of the patient is a result, if but a partial result, of the totality of the psychiatrist’s subjectivity. The prisoner is regarded as a terrorist, an enemy, a person endangering the state of Israel, its citizens and its soldiers, rather than as a person who has lost his sanity. While the psychiatrist cannot escape his or her subjectivity, as Renik points out, in my opinion psychiatrists do not need to flee from such subjectivity—they need to be aware of it as much as possible.
One should keep in mind that the term illness itself—not only one’s political persuasion—is more than a mere description of fact. Illness is subjective and emotionally charged. As K.W.M. Fulford has stated, illness is a fact plus an added value. Our own judgment will always accompany us when dealing with disease or illness. For instance, “influenza” is not as charged as AIDS is. This is also true, of course, when confronted with schizophrenia, which is charged with negative values and judgments. This helps explain why members of higher classes are less likely to be diagnosed as schizophrenic than those of lower classes. The psychiatric community has known for several years, following the publication of various articles and studies carried out in the Western world, that people who belong to the low end of the social scale for reasons of race, color, gender, economy, or education are more likely to be diagnosed as having mental illnesses such as schizophrenia than people who are higher up on the social scale.
According to these findings Avni should have diagnosed Ali Shaban as mentally ill, not only because of his illness, but also because of his low standing on the social hierarchy: he was a poor villager, from a national and religious minority. Yet, in Shaban’s case, the diagnosis was in stark contrast to the common trend shown in the studies: Shaban, a mentally ill youth, was transformed into an imposter, for political-social-cultural reasons. In this case, which is just one of many, the psychiatrist’s tribalism (racism, vengeance, and fear) leads him to introduce a level of sophistication: a mentally ill Palestinian terrorist will be diagnosed as an imposter, so that his illness will not protect him from being incarcerated. The objective is clear: the patient/prisoner will not be freed from a military prison and admitted to a psychiatric hospital, and he will continue to be considered a national threat.
Before continuing, I would like to briefly recount what happened to Shaban. The psychiatrist at Afula Hospital did not wish to diagnose the psychotic youth, and asked that the diagnosis be done at a psychiatric hospital. Since no Israeli hospital agreed to examine him, he was released, following pressure from PHR. More than a decade after his arrest, Shaban spends most of his days in the streets as the village fool. He is not a student; he does not work. Shaban has become a chronic, untreated psychotic. That is Avni’s “imposter.”
I have described Shaban’s case in some detail not because it is exceptional. On the contrary, I know of several similar cases, and, I presume, there are many more that I am unaware of. This was simply the first of a series of cases that I dealt with. Avni’s claim about who is political and who is not is certainly not unique. Many people work, think, and speak like this, including members of the medical establishment. If you don’t question the government, if you agree with the establishment, you are seen as being objective, as being apolitical. But if you object to crimes perpetrated by the government, you are taking a political stance. Making the blind spot visible is accordingly considered one-sided, extremist, and un-collegial.
The knowledge that all humans are “tainted” with political views will enable us to begin engaging in an intra-psychiatric discussion and will increase our self-awareness while carrying out our work. Advancement in this direction will enable psychiatry to support human rights, and will enhance a more pluralistic and conscious discourse. Lack of openness, on the other hand, will necessarily lead to the violation of human rights and to the perverse use of psychiatric power.
IV. The IMA’s Ethics Committee and Prisoner’s Rights
An article, published in the Israeli daily newspaper Hadashot on March 5, 1993, which was based almost entirely on an interview with me, presented the cases of three Palestinian prisoners who were undoubtedly chronic schizophrenics. The article cited bizarre diagnoses attributed to these patients by Israeli psychiatrists like “anxiety as a result of conditions of incarceration” and “an imposter.”
“Anxiety due to conditions of incarceration” seems to mean anxiety as a result of conditions of imprisonment. This apparently logical combination of words requires an explanation, particularly since there is no such diagnosis in psychiatric textbooks. Ostensibly, anxiety due to conditions of incarceration is a normal phenomenon experienced by every prisoner. However, when written by Israeli psychiatrists about Palestinian prisoners who are mentally ill, it eliminates these prisoners’ right to madness; they are subsequently sent, as if completely sane, directly to a military court and frequently to prison for lengthy periods of time.
This combination of words—anxiety due to conditions of incarceration—derides psychiatry, the prisoner, and schizophrenia. Almost every person experiences anxiety—actually fear—when subjected to incarceration. But it is a mistake to call such fear anxiety. The physical and mental conditions that are at times called “fear” and at times “anxiety” are not identical. According to classical psychiatric terminology, the difference between fear and anxiety is that fear has a cause that is visible, while anxiety, including all of the physical aspects of it which are identical to fear, lacks any visible cause.
Could the term “anxiety due to conditions of incarceration” have been written innocently? I do not think so. In classical psychiatry, “anxiety” is a phenomenon that belongs to the world of neuroses and not to mental illnesses—psychoses. So a prisoner suffering from “anxiety due to conditions of incarceration” is most likely neurotic and surely not psychotic. If he is not psychotic, he is fit to stand trial, because only the psychotic is considered to be unfit. Accordingly, the diagnosis “anxiety due to conditions of incarceration,” is employed to prevent a mentally ill person from not being tried or sent to prison. The mentally ill prisoner’s basic right is thus violated. Ironically, many of these prisoners, despite being diagnosed as non-psychotic, are usually given anti-psychotic drugs in prison.
Since “suffers from anxiety as a result of conditions of incarceration” is not a diagnosis, I consider it to be a description of a condition. The problem is that this description is offered as a diagnosis. But what is worse is that this description, disguised to look like a diagnosis, was given to a psychotic person, who was consequently not diagnosed as psychotic.
What does the doctor mean when he says “imposter”? “Imposter” is a well-known psychiatric diagnosis. This diagnosis, when correct, is appropriate in cases where the patient reveals signs of clear consciousness, sophistication, design, awareness of location, time, and reality. None of these signs appear when the patient is in a psychotic state. Therefore, when a psychotic person is misdiagnosed as an imposter, there is a reversal of roles: most imposters act or play a part when they wish to receive compensation or improve their living conditions in some other way. In this case, it is the psychiatrist who wishes to gain something. What does he wish to gain? He wants to make the authorities happy by not letting a “dangerous” Palestinian “terrorist” evade prison. Another possibility is that the psychiatrist wants to remain true to his blind spot, and not to bother himself with difficult questions. The rhetorical question asked by the journalist at Hadashot hit the nail on the head: “What is a psychiatrist supposed to do when asked to treat a terrorist who is also mentally ill? In the case of Mahsan Mahlal, he was found to be sane, incarcerated for eight years, but given anti-schizophrenia drugs. Psychiatrists also take security into consideration.”
Following the publication of my interview in Hadashot, two of the seven psychiatrists mentioned in the article filed a suit with the IMA’s Ethics Committee. After two years of hearings, the disciplinary court, appointed by the IMA’s Ethics Committee, decided that I should apologize in writing for mentioning the doctors’ names in the article. My apology was to appear in the IMA’s official newsletter. The IMA’s Ethics Committee refused to deal with the moral issues that I raised, which were the basis of the newspaper article, namely, that Jewish-Israeli psychiatrists who examined Palestinian prisoners were providing improper diagnoses time and time again, and therefore, in my opinion, this was not simply an error on their part—it was intentional.
In my “apology,” I discussed the principle and moral significance of the way Jewish-Israeli psychiatrists have systematically related to Palestinians who are mentally ill as imposters and manipulative. As a result, I argued, mentally ill Palestinians are incarcerated in solitary confinement. While serving their full sentence, which is imposed upon them by a military court, this kind of confinement frequently leads them to wipe the cell walls with their own excrement and to hit their heads against the walls. Adding insult to injury, they are not only incarcerated despite their mental illness, they are also forced to suffer the torments of solitary confinement. The apology letter I wrote contained a request that the IMA’s Ethics Committee act to remedy this situation. The letter was never published, and the IMA’s Ethics Committee never convened to discuss my request.
The fact that Israel’s supreme medical authority (IMA) has never discussed these issues is a reflection of the socio-political needs of many individual psychiatrists as well as of the organization that unites them. That is, the Israeli-Zionist socio-political need to see Palestinians as the enemy, as terrorists, and as dangerous, may be considered to be part of the hegemonic worldview. This worldview is so powerful that it does not permit a mentally ill Palestinian any means of deviating from this preordained image, not even deviation by way of insanity, of madness. Both junior and senior psychiatrists have diagnosed mentally ill Palestinians as imposters, as prisoners suffering from anxiety due to conditions of incarceration, as manipulative, as not mentally ill; the psychiatrist can be a director of a hospital ward or a district physician, a new immigrant or a Sabras, from northern Israel, the center or the south. They are integral members of their community. Surely, not all of these psychiatrists have had bad intentions or were professionally ignorant. Indeed, they do not intend to violate human rights, particularly not the rights of patients. Rather, their objective is to ensure that Palestinians, as a unified body, remain the enemy, which helps keep Zionist Israeli society glued together as a group with a common ideology and goal. The presence of the enemy is essential for maintaining the link and the interconnection between the patriotic Zionist discourse and the action deriving from this discourse—occupation, oppression, arrests and torture.
If these claims seem at first glance to be unconnected to psychiatry, it would behoove us to look again. The Zionist/Palestinian binary opposition is an integral part of the subjective individual experience of Jewish Israelis, and in many ways helps shape their identity. Jewish Israelis also derive their identity from the social group to which they belong and choose to belong, and the social group, in turn, derives its identity through, among other things, its opposition to other groups. The individual identity determines, inter alia, the way in which psychiatrists encounter their patient. As W. W. Meissner suggests, “It becomes for all practical purposes impossible for the psychiatrist’s values not to impinge on the analytic process, and this would include both technical and personal values…[V]alue judgments seem to seep into the therapeutic process throughout every available pore.”
V. Collaboration of the Israeli Medical Establishment in Solitary Confinement and Segregation
For years the Israeli prison system (including prisons under the control of the police, prison services, military and secret services) have used solitary confinement and segregation as a common way of dealing with “problematic prisoners.” The official reasons for holding a prisoner in solitary confinement or segregation include state security, protection of the prisoner, protection from the prisoner, and punishment. However, the prison authorities use solitary confinement and segregation not only for these “protective” purposes, but also as a policing and disciplinary mechanism. This latter use is absolutely prohibited according to Israeli law.
People usually do not die from solitary confinement—they simply become insane. In the last decade, extensive studies have examined the psychopathological effects of solitary confinement. The findings of the different studies are uniform: solitary confinement creates profound psychotic reactions, such as hallucinations, body-image distortions, feelings of suffocation, thought disorder, loss of memory, difficulty in concentrating, acute confusional states and subsequent partial amnesia, obsessions, disorientation as to time and space, fear, panic, paranoid states, fear of impending death, depression, hopelessness, apathy, and self-inflicted injuries. People who have been held in solitary confinement have reported continuing symptoms after their release from this form of confinement. They often suffer from dependence, impaired memory and concentration, and confusion. Research has shown that these long-term effects generally do not subside over time as one would expect, but are actually intensified if they are not exteriorized and treated.
Solitary confinement undermines the equilibrium a human being seeks between the needs and demands that stem from both outer and inner worlds. Some of us need more stimuli, some less. The stimuli might be positive or negative, but it is an absolute need. In a state of sensory deprivation, there is no equilibrium between the internal and the external worlds. In short, humans need information via their senses to keep sane. And one of the most elemental stimuli humans require—in fact it is essential to our existence—is the sense of solidarity, the sense of being accepted by others, the need to hear, talk and touch another human being. Yet, all these essential needs are withheld from solitary detainees. As a consequence, one very dominant sensation that inevitably develops is the loss of any ability to feel. Losing this possibility to feel ultimately risks as psychological death. In my opinion, solitary confinement is comparable to lobotomy; only here the process is longer and crueler.
In a petition filed to the High Court of Justice in November 1997, PHR and HaMoked (The Center for Protection of the Individual), sought to cancel the unlimited use of solitary confinement. Following the appeal, the Minister of Internal Security appointed a five member committee, including the prison authority’s legal adviser, to examine the issue. In their report the committee members wrote:
“The findings of researchers in this area are unequivocal and show that segregated incarceration leads to deep psychotic responses such as: Hallucinations (visual and acoustic), distorted bodily views, a choking sensation and a sense of confusion of thought, loss of memory, difficulty in concentrating, obsession, paranoid states, etc. This is in addition to the [unhealthy] physical condition that follows anxiety brought on by segregated incarceration. Clearly, the length of time a prisoner is held in solitary confinement has direct implications on the side effects of being held in isolation, since a person held in a cell for one day cannot be compared to a person held for a period of ten weeks, months or years. There can be no doubt that there is a limit beyond which most people will feel that their isolation has become impossible to bear and will suffer from long-term side effects as a result.”
Following the report’s publication, the Mental Health Division of the Ministry of Health refused to provide psychiatrists who would examine prisoners being held in segregation in order to determine whether their mental capacity had changed as a result of such confinement. The psychiatrists at the Ministry of Health refused to cooperate with prison authorities and to assume responsibility of regularly examining prisoners in solitary confinement. The psychiatric examination could be seen as a form of consent to such a method, and in fact, could amount to collaboration with human rights violations. They were not prepared to become a fig leaf, covering up unacceptable methods of imprisonment. In other words, the Ministry of Health’s psychiatrists refused to become part of a disciplinarian apparatus, because they knew they would have no influence over the apparatus itself.
It is important to underscore just how significant and principled this decision was. When an individual psychiatrist, who is employed by the Ministry of Health, understands that unlimited solitary confinement is an egregious violation of human rights and recognizes the severe damage that might be caused to the prisoner as a result of segregation, frequently it is very difficult for him to fight as an individual against the conditions of imprisonment. But if his professional association backs him up, and if the association remains a full partner in such struggle, the psychiatrist can struggle against the violation.
Frequently, the medical associations have not backed physicians regarding the treatment of Palestinian patients. Consider the case of a female Palestinian political prisoner who was suffering from a severe mental illness. In November 1998, attorney Allegra Pacheco asked PHR to intervene on behalf of the young prisoner who prior to her arrest had been abused by her husband whom she was forced to marry. Before her incarceration she had tried to kill herself. In prison she suffered greatly due to the separation from her three children. She did not adapt to prison life and fought with other political prisoners. As a result of her mental condition and other problems, she was placed in solitary confinement for months on end, sometimes without permission to go out.
Dr. Ze’ev Weiner, a psychiatrist, examined the prisoner on behalf of PHR on November 16, 1999 at the Neve Tirtsa Prison, and diagnosed her as suffering from border-line personality disorder with slips into psychosis, which is different from an outright psychotic disorder. Weiner recommended medical treatment and psychotherapy and stated that isolation should not be resorted to as an alternative to treatment.
Dr. Moshe Birger, Director of the Israeli prisons’ Mental Health Department, agreed with the diagnosis and recommendations. Nonetheless, in his response to PHR he stated that the prison system does not provide psychotherapy for Arabic speakers. Despite his opinion that solitary confinement was both wrong and harmful, he added that the prisoner would continue to be held in solitary confinement since the ultimate decision rested in the hands of the prison authorities. This response underscores that even when a senior physician knows and understands the therapeutic needs of a prisoner, he is forced to accept the dictates of the prison system.
The clear role of the Israeli Psychiatric Association in such cases would have been to support the physician in his dealings with the prison authorities, to provide assistance when he or she demands to put an end to harmful solitary confinement. The Psychiatric Association ought to examine the conditions of mentally ill prisoners and to protect them when their rights are violated. Mentally ill prisoners should be released from solitary or segregated confinement and be sent to psychiatric wards. The only way the Psychiatric Association can meet its obligation to ensure that the mentally ill in prison are treated is by stripping the prison authorities of its power to make what are essentially psychiatric decisions. Decisions regarding the nature of treatment, psychiatric hospitalization, etc., should be subject to medical calculations alone and determined by medical authorities.
Birger did the best he could as a doctor and as a private person. Had the Psychiatric Association given him organizational-medical support, he might have released the prisoner so that she could be treated within her community. Alternatively, he could have admitted her to a mental hospital. The doctor, as an individual, needs the support of his professional association when facing such institutions like the prison authorities, because he cannot succeed in fulfilling his professional duty to treat and take care of patients without the association’s assistance. The Israeli Psychiatric Association must become a serious and efficient address for matters of this kind, and I can only hope that raising these issues and discussing them will bring about an increase in awareness of the infringement of the rights of prisoners who are suffering from mental problems, and that such awareness will, in turn, also give rise to remedial action.
One should also note that a doctor will find it very difficult to act in accordance with the Hippocratic ethical code so long as he or she has dual loyalties: on the one hand, to the totalitarian system of police, prison services, military and general security services, and, on the other hand, to the patient. Therefore, PHR recommends that doctors working for the security forces be employed directly by the Ministry of Health. Simultaneously, there should be clear ethical guidelines regarding the doctor’s role, as well as a support network for doctors who have to confront the system.
VI. The IMA’s Failure to fulfill its Ethical Duty against the use of Torture
In 1993, six years before the High Court of Justice prohibited the use of moderate or severe physical pressure in Israel, or, in other words, torture, PHR asked the IMA to confront the problem of physicians participating in torture. PHR’s demand was based on the United Nations Convention against Torture (1984) and the Declaration of Tokyo (1975). Both documents indicate that the methods of interrogation employed by the Israeli General Security Services (GSS) constitute torture, and the latter contends that a medical examination conducted before, during or after such interrogations constitutes participation in torture.
Following the logic of these and other international documents, PHR does not accept the claim that doctor participation in torture—i.e., by performing examinations before and during interrogations—is in any way justifiable and rejects the argument that doctors are able to prevent suffering and irreparable damage in such examinations. PHR is of the opinion that a doctor’s recommendation to interrogators not to use a particular method of torture clearly implies permission to use other methods. Through his cooperation, the doctor becomes a safety net for the General Security Services, which can then torture without fear that “on site accidents”—i.e. the death of the tortured person—will occur. In addition, a treatment that is nothing more than merely providing remedies for pain (which is what is done in examinations and treatment during interrogations) and is in essence a stamp of approval for sending the patient back to the place where he was subjected to pain—i.e., the interrogation room—amounts to complicity with torture.
The IMA did not rise to PHR’s challenge, which demanded that it insert the following clauses dealing with human rights into its medical code of ethics:
- A prohibition against the participation of doctors in torture by way of medical examinations before and during torture in GSS interrogations.
- Prohibition against writing false doctor’s letters constituting a cover for the GSS after harm was inflicted on the body or mind.
- The obligation of every doctor who sees a man or a woman who has suffered from abuse, beating, torture, etc., to file a report, similar to the law already existing in Israel regarding the duty to report cases of child abuse.
- Prohibition against active participation of doctors, such as examination and treatment of prisoners in solitary confinement or segregated confinement.
- An examination of the professional-ethical problem concerning the way in which Israeli psychiatrists relate to mentally ill prisoners, drawing conclusions and preparing ethical and professional guidelines.
By failing to accept the challenge, the IMA acted in a manner similar to the Medical Association of South Africa, which during the years of apartheid failed to condemn those who allowed the torture and killing of political prisoners, like Steve Biko. According to PHR, the work of doctors in GSS prisons amounts to complicity in torture and is no more than an ethical rubber stamp, which says torture can be carried out in a “humane” manner, which does not harm the torture victim’s body or mind. Only an absolute prohibition of any participation with the GSS will ensure that doctors do not slide down the slippery slope ultimately leading them to participation in torture.
PHR presented a number of cases where Israeli doctors participated in torture and provided its recommendations to the IMA, but the rights group did not receive a germane response from the IMA until the Israel High Court banned the use of torture in September 1999. For six years, the IMA used manipulative tactics to evade PHR’s demands—to introduce new ethical regulations as well as offering a series of seminars on the topic—to prohibit doctor participation in torture. The IMA imposed an impossible and unfair demand: “Bring us the names of the doctors working with the General Security Services who participate in torture, and we will deal with them.” This demand was impractical, because PHR has no way of knowing all the names of doctors who work for the GSS, and it is unfair because it would punish the messengers, but leave the method intact. Therefore, PHR refused to give the IMA the names of two doctors whose signatures appeared on “fitness for torture” medical forms, which it had obtained. The forms themselves provided evidence that doctors regularly examined prisoners before they were tortured.
VII. Conclusion
As a field, psychiatry has considerable influence in determining social norms. The definition of norms and “the normal” are interconnected, and psychiatry is conceived as both having expertise about the two and as an authority regarding their definition. Thus, psychiatry is at the same time the body that determines society’s norms, and the guardian of those norms. Psychiatry can use its powers to determine norms that respect and accentuate the human rights of all people, patients and prisoners, or it can use its powers in a perverse manner, establishing and maintaining unethical and amoral norms.
Tragically, in Israel physiatrists have frequently chosen to use their power in a perverse way. In order to do so, they have violated an unwritten rule of western psychiatry—the rule which calls upon them to remove the mentally ill from the social sphere. The lunatic, as Michel Foucault described him, is the “other” and society treats him accordingly. He is positioned outside the social order, alone, and marked. Ironically, when the mad person is a mentally ill Palestinian prisoner, this rule does not apply. A mentally ill Palestinian will be pushed by force—of power/knowledge—into the middle of the Israeli social order. He is not removed from the social terrain to a psychiatric hospital, as one would expect, but rather kept in an Israeli prison. A mad Palestinian prisoner is not expelled from the boundaries set by the Israeli systems of power/knowledge, since these systems stipulate that every Palestinian is an enemy. And the enemy is part and parcel of the system, one of its constituting elements; accordingly, mentally ill Palestinians are not expelled from the system as mad people are. Therefore, no Palestinian, not even a madman or an insane person, will be allowed to deviate from the identity that has been attributed to him—i.e., the enemy—for the simple reason that any deviation can threaten the hegemonic worldview. Palestinian village fools are consequently killed by security forces and mentally ill Palestinians are tried and imprisoned as if they were aware of or responsible for their actions or, more accurately, the actions that they have been accused of committing.
Within the power game managed by the state to silence the voices of the “other,” the psychiatrist becomes complicit so long as he or she does not actively resist the prevailing mood. The discussion concerning human rights is, I hope, the beginning of a necessary dialectic process which will open the way for critical thinking. This kind of critical think has to be carried out by the doctors themselves, and by the organizations that represent them, not least the Psychiatric Association and the IMA. By way of conclusion, I will briefly discuss the way each group relates to human rights and the rights of patients.
In terms of the individual psychiatrist, the violation of human rights and the rights of a patient frequently takes place when the humanity of the Palestinian prisoner is reduced in such a way that the patient is identified as a “dangerous terrorist.” Accordingly, the Palestinian is not diagnosed as mentally ill and as such he is responsible for his acts; he is not considered unfit to stand trial or unfit for incarceration, but rather he is diagnosed as a manipulative imposter or one who suffers anxiety as a result of his imprisonment. The psychiatrist’s worldview is so entrenched that the Palestinian cannot deviate from this reduction to enemy, even when he is psychotic and mentally ill.
Not unlike the majority of Israeli society, psychiatrists often forget their professional obligations when these appear to be in conflict or in contradiction with its obligations towards the state of Israel. Professionalism is undermined due to a type of patriotism, the psychiatrist’s embodiment of a vague ideology known as “Zionism.” The Israeli socio-political need to make all Palestinians identical cannot permit any deviation. Therefore, an insane Palestinian is denied his right to madness. The very same madness that is supposed to eject him from the discourse that describes him as a “dangerous enemy.” To cite once again the words of the journalist from Hadashot: “What is a psychiatrist supposed to do when asked to treat a terrorist who is also mentally ill?” I believe the answer is obvious: one should treat him as a mentally ill patient. Conversely, one should not treat him as the representative of a boundary beyond which there is nothing but fear and hate and therefore as someone who needs to be distanced and punished—one should not disregard his humanity, that is, the fact that he is an individual in and of himself.
The psychiatrist must be conscious of the interests he is serving: the patient’s interests or those of the institution and system for which he works. The psychiatrist must first be aware of his own social, political and cultural background. If these components are part of his blind spot, he will be unconscious of his identification with the authorities even while this identification dictates the way in which he relates, professionally to a Palestinian patient. It will not allow him to see that he is violating human rights or being disloyal to basic medical values. In the complex reality in which the Jewish-Israeli psychiatrist operates, he needs an ethical support system no less than a professional support system. Without external ethical support, a psychiatrist who makes the ethical decision might find himself in an extremely difficult position, acting as if he were a Don Quixote and paying a great price for it, with a high chance that his struggle will not bear fruit.
An important and crucial role which the Psychiatric Association should take on involves the provision of courses on human rights and, more specifically, on the rights of the patient. A discussion of human rights’ relation to psychiatry is, in my view, a crucial step in altering the prevailing theoretical worldview which holds that psychiatrists are supposed to be objective and neutral as well as apolitical. It may lead to a broader understanding of ourselves as psychiatrists and as humans. This understanding includes the social, political, cultural relations that help constitute our own personal identities.
The Israel Psychiatric Association can and must be the body that leads the transition from a worldview whose time has passed, both theoretically and socio-politically; that is, it must lead psychiatry from a view that conceives the psychiatrist to be a neutral subject and the patient as an object, to a self-awareness amongst psychiatrists that their own subjectivity is constituted by the political, cultural and social power relations circulating in society and that their patients are also subjects who are constituted in a similar fashion. This view will enable psychiatrists to become aware of human rights in general as well as the specific rights of prisoners and the mentally ill.
The Psychiatric Association is part of the third group, the Israeli Medical Association, which is located at the top of the pyramid. What is the IMA’s position regarding human rights? At a political-government level, human rights are frequently infringed upon in the name of upholding the state’s security, and the IMA does not use its power to remedy this situation. The IMA has a tendency to toe the line drawn by the Israeli government when health and medicine related human rights are violated, particularly when the person abused is a Palestinian. The ways in which the security forces act towards the mentally ill help create the position which, unfortunately, the medical establishment adopts.
One final example may prove revealing. A chronically mentally ill Palestinian, named Rejwan was held in administrative detention for two years. When he was brought before a military judge in order to extend his detention, the judge sensed that his mental state justified a psychiatric examination. Rejwan was accordingly taken to Be’er Yakov Hospital and examined by a psychiatrist who found that he was schizophrenic and thus unfit to stand trial. The military judge decided, therefore, not to try him. At this stage, the Major General of the Southern Command of the Israel Defense Forces, Matan Vilnai, intervened and overturned the previous decisions—both medical and judicial—and ruled, by virtue of his power (in January 1992) that Rejwan would be sentenced to a further six months of administrative detention.
This case exemplifies how the higher echelons of the Israeli security forces demarcate the borders of professional fairness and medical ethics for many psychiatrists. Within totalitarian systems there is the common phenomenon of “obeying orders.” Namely, members of the higher echelons dictate the way things ought to be (not always in writing), and their subordinates obey their orders. If the general in charge puts a mentally ill Palestinian in administrative detention (after he had already been imprisoned for two years without trial), and ignores a judicial decision and a psychiatric diagnosis which say that this person should not be incarcerated, then most psychiatrists who are “obeying orders” will ignore their own professional obligations and abdicate their ethical responsibility.
As an individual, the psychiatrist usually cannot fight such blatant violations of human and patient’s rights. The individual psychiatrist needs the assistance of his professional association—i.e. the Israel Psychiatric Association—and of the umbrella organization, the IMA. The IMA must use its powers, both professional and ethical, in order to remedy the situation and protect the patient’s rights. If it does not do so, then it is using its immense powers in a perverse manner. If the government’s rights-abusive policies are not challenged at the individual level and/or at the organizational level, the rights-abusive worldview will ultimately determine the society’s social practices, and thus cause psychiatrists to “forget” their professional knowledge and obligations.
The medical establishment, including the IMA’s Ethics Committee, is unwilling to challenge in any way whatsoever the security forces. Moreover, the IMA identifies with the security forces’ values, which overshadows professional and ethical questions. I do not know what the positions of individual doctors are; however, I can say that most doctors do not have the opportunity to participate in earnest and in-depth discussions about human rights, at least not in an organized fashion. No courses on human rights are offered at any of the Israeli medical schools. The IMA, which has the power to initiate such courses and hold discussions of this type as well as to introduce regulations that would assist doctors who undergo difficult experiences, does not rise to the occasion even when rights groups challenge it to do just that.
The IMA’s obligation is, inter alia, to protect doctors from committing war crimes and violating international law. If it does not introduce ethical regulations as well as training and education courses, it fails to fulfill its obligations towards doctors. In the absence of any real discussion about these issues and the constant provision of ethical and professional support for all doctors who provide medical services to the security forces, then how can we expect individual doctors to challenge the existing system?
From the Margins of Globalization, Critical Perspectives on Human Rights
Edited by Neve Gordon, Lexington Books, USA, 2004:195-221