Arash Javanbakht, MD
Chief resident of Psychiatry, Ibn E Sina Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
Mohammad Sanati, MD, F.R.C. Psych
Associate Professor of Psychiatry, Head, Unit for Dynamic Psychotherapy and Human Studies, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
The American Academy of Psychoanalysis and Dynamic Psychiatry has always had a cosmopolitan perspective and has welcomed articles and scholars from different nationalities. It serves as a forum that is not limited only to the borders of the United States, but embraces psychoan- alytic minds and writings from other parts of the world. In this Frontline, the authors present an overview of psychiatry and psychol- ogy (especially psychoanalysis) in Iran.
The Islamic Republic of Iran is located in the Middle East between the Caspian Sea and the Persian Gulf. Iran’s total land area is 1.6 million square kilometers. Its total population in 2003 was about 70 million (UNICEF, 2003). The annual population growth rate is 1.41%. Of the to- tal population, 60% are urban and 40% live in rural areas (Yasamy et al 2001).
PSYCHIATRY IN IRAN
As in the West, the history of psychiatry in Iran is as old as the history of medicine. Some early sources refer to the Islamic era. For example, there is a story about the Prophet Mohammad, who tells his followers that an epileptic person is diseased rather than possessed by spirits. There is no history of aggressive or neglectful behavior toward the men- tally ill, and in the poetry, only children might stone a psychotic. Such hurtful behavior was viewed as childish. The mentally ill were per- ceived as patients and there is evidence of treating these people in spe- cial hospitals or wards. In Iranian mystic literature there is no prominent negative attitude toward the mentally ill and, unlike in the West, they were not assumed to be possessed by devils or evil spirits. Occasionally there are even positive stories about the mentally ill in literature (Davidian, 1995).
Great Iranian physicians have presented distinctive ideas about mental illness. The physician Ali Ibn Tabari (800–860 C.E.) had a seven volume compendium on medicine with one volume on mental illnesses discussing mind, psyche, the senses, wake–sleep cycles, emotions epilepsy, and Parkinson’s disease among others. Rhazes (Muhammadibn Zakariya al–Razi, 865–925 C.E.) and Avicenna (Abu Ali Ibn E Sina 980–1037 C.E.), two great Iranian physicians and philosophers, wrote of melancholia, mania, and delirious states. They also prescribed psychotherapy for their patients and described the effects of emotions on the cardiovascular system (Moharrari, 1994–1995).
In his book, Qanun, Ibn E Sina described the phenomenology and classification of mental illness in detail and suggested treatments for them. He described hallucinations of mentally ill patients and noted that in severe illness, when the patient tries to grasp things in the air that do not exist (as is frequently observed in delirium), it is a sign of poor prognosis. He also noted that aggression should not be used against the mentally ill, and indicated that only when patients are harmful to themselves or to the healing of their wounds physical restriction should be administered. There is evidence of a mental hospital in the city of Yazd a hundred years b efore I bn E S ina. In the Zakhireh Kharazmshahi (Kharazmshahi’s Treasure), Seyyed Esmail Jorjani describes “Vahm,” a synonym for delusion. He reports case examples of delusions of poisoning, poverty, kingship (grandeur), persecution, nihilism, somatic, and other delusions. He also reports successful behavioral, cognitive, and dynamic–like therapies for these delusions. Interestingly, he indicates that delusions might form based on the knowledge or job of the individual when sane Modern psychiatry in Iran begins with the foundation of Tehran University in 1934. Three years later the department of psychiatry at the medical school began teaching students. The first teachers at the department were mainly French–educated, among them the late Professor Abdolhossein Mirsepassi and Professor Hossein Rezai, who were pioneers of psychiatry in Iran. There had been some asylums for psychiatric patients since the 19th century in Tehran and other major cities of Iran but these were mainly managed by the municipalities and suffered unfavorable conditions. Roozbeh Hospital was founded in 1946 as the first modern psychiatric teaching hospital in Iran. A few years later, Ahmad Nezam played a significant role in developing Razi Hospital, Iran’s biggest psychiatric hospital. These founders of Iranian psychiatry were French–trained neuropsychiatrists with a biological orientation. The second generation of psychiatrists was English–trained, with an organic orientation and began their work in Iran during the 50s. This group also founded the National Board of Psychiatry. During the 60s and 70s, a third group of American–trained psychiatrists based their work at Teh- ran Psychiatric Institute. This center was founded by Iraj Siasi and trained residents with a psychoanalytic orientation. The first textbook of psychiatry written in the Persian language was a two volume, 600 page work written by Abdolhossein Mirsepassi in 1953. Tehran University also saw the founding of the first program in child psychiatry during the 1970s, and training of subspecialty residents was begun by Vali Sahami in the 1990s with an orientation in family therapy. There are currently 8,950 psychiatric beds distributed among 23 psy- chiatric and general hospitals, and about 1,000 psychiatrists practicing throughout the country, of whom 30 are child psychiatrists (Ministry of Health and Medical Education, 2003; National Research Centre of Medical Sciences, 2003).
The Iranian Psychiatric Association was founded in 1966 and is a member of the World Psychiatric Association (WPA), and currently has about 500 members. The Child and Adolescent Psychiatric Association was founded in 2001. There is also an association for clinical psycholo- gists and one for counselors. There are other nongovernmental organi- zations (NGOs) active in mental heath, including the Association for the Support of Schizophrenic Patients and Narcotic Anonymous (NA; Sadeghi & Mirsepassi, 2005). Research institutes include the Addiction Research Center, Tehran Psychiatric Institute, Cognitive Sciences Re- search Center, Center for Psychiatric and Psychological Research, and Center for Family Studies among others. Psychiatric and psychological periodicals are also published in Iran.
MEDICAL AND PSYCHIATRIC EDUCATION IN IRAN
Entry to medical school requires passing a highly competitive yearly national exam leading to a seven-year program of general medicine. This includes a two-unit course on general psychology, a two-unit theo- retical course on psychiatry, a one-month externship in psychiatry, and a one-month internship. Interestingly, most of the scientific references for medical education are American. For residency, general practitio- ners must pass a highly competitive national entrance examination. Based on their score, they choose a field of specialty. Surprisingly, there is no oral interview even for psychiatry.
Residency in psychiatry in Iran is three consecutive years, and there are plans to extend it to four years. Most of this experience is in psychiat- ric hospitals. Presently there are 12 psychiatric training departments in the country. Educational activities include classes, morning rounds case reports, patient interviews, and daily inpatient and day clinic con- sultations. Residents have night call, a three-month neurology rotation, and a rotation in child psychiatry. They also receive training in cognitive behavioral psychotherapy with an emphasis on biological therapies. Each resident has to conduct a supervised research project during his/her training as a prerequisite for participation in written and oral board certification examinations set by the National Board Examiners Committee. Despite this, residents’ experience in research is deficient, and it is hoped that the recent introduction of courses on research meth- odology will improve the situation. The only sub–specialty training is a two-year child and adolescent psychiatry course. The main references used for training as well as for the National Board Exam are Kaplan and Sadock’s Synopsis of Psychiatry, Comprehensive Textbook of Psychiatry, and Oxford Core Textbook of Psychiatry. The first two are emphasized, and complement the American and British Journals of Psychiatry and several Iranian psychiatric journals in the Persian language. Most psychiatrists in Iran use the DSM–IV–TR classification and it is the classification used in educational hospitals.
One great opportunity for Iranian residents is the availability of many patients due to the limited number of inpatient and outpatient facilities. For example, the hospital where the first author studies (Ibn E Sina Edu- cational Psychiatric Hospital of the Mashhad University of Medical Sci- ences) in the second biggest city of the country has 790 hospital beds that are almost always occupied. Although most of the patients are not in the educational system, the residents have an opportunity to learn much from this large population. It is not unusual for a resident to see 10 to 20 emergency patients during his/her shift.
PSYCHIATRIC TREATMENTS
Therapeuti c i nterve ntions are u sually bi ological and most psychotropic drugs are available in Iran. For example, risperidone, olanzapine, and clozapine are widely available and quetiapine can be obtained at high prices. The first three drugs are available in Iranian brands with affordable prices; however, the imported brands are expen- sive and cannot be afforded by patients from the middle or lower eco- nomic classes. Insurance does not cover the cost of imported medications that are available in Iranian formulations. Routine labora- tory tests, neurological examinations by specialists, CT scans and MR imaging are available and EEG is widely used. All psychiatric hospitals are also equipped with ECT instruments. Although there are social workers and clinical psychologists employed in hospitals, their main function is solving admission and discharge problems. Clinical psychologists do psychological tests requested by physicians or psychiatric hos- pitals, and are in short supply. There are no half–way houses and most of the burden of the outpatient mentally ill falls on their families unless they are severely ill and need chronic hospitalization. However, recent pilot studies are providing home–visit and family education to some outpatients. A few private hospitals are located in the big cities. Occupational therapies and brief rehabilitation programs for chronic patients are also available.
Substance abuse, particularly opioids, is a major issue in Iran. There are detoxification facilities and methadone maintenance treatment has recently become available for those who cannot withdraw from opioids permanently.
The National Program of Mental Health, which seeks to integrate mental healthcare within primary healthcare, was started in 1989 as a pi- lot study in two rural areas (Yasamy & Bagheri Yazdi, 2004). In 1995 it was jointly evaluated by the World Health Organization and the Tehran Psychiatric Institute. The program was recognized as one the most suc- cessful in the region (Murthy, 2002). The aim is to establish a hierarchi- cal, pyramid–like referral system. At the base of the pyramid there are health workers known as Behvarz, who are mainly local residents in each primary healthcare area. They are trained to recognize, refer and follow psychiatric cases to the higher level, the rural health centers (Fenton, 1998). Currently, 21.7% of the urban population and 82.8% of the rural population is covered by the National Program of Mental Health (Yasamy et al, 2001). Under this plan, in rural areas the Behvarz drops by the home of the chronically ill in regular intervals to check their health and monitor their medication (Sadeghi & Mirsepassi, 2005).
Until recently there was a negative attitude toward psychiatric ill- nesses and treatment. Highly educated people would refuse to see a psy- chiatrist, and most preferred to see a neurologist for their mental ill- nesses. The common answer to any suggestion about visiting a psychiatrist was (and still is), “I am not a psycho!”
There was a major stigma associated with taking psychiatric medica- tions. However, in recent years this trend is moderating, and some go voluntarily to psychiatrists for their neuroses, marital problems, and consultations. In one study of 924 randomly selected patients living in urban and rural medical settings, 86% of the patients visited a physician or a psychiatrist as the first person for their mental problem and only 14% went to traditional healers to seek help (Shahmohammadi, Bayanzadeh, & Ehsanmanesh, 1998). Increasingly, people are more trusting of psychiatrists, and more comfortable consulting them. The reputation of psychiatry among the people seems to be ascending. Psy- chiatrists are admired among common people and other medical specialists who are ready to consult them. Almost every day that one author of this paper goes to study in the general hospital library, medical stu- dents and residents share their secrets and consult him about their prob- lems. Most of them also accept medications easily whenever it is needed in sharp contrast to the previous decade!
PSYCHOANALYSIS IN IRAN
The Zoroastrian literature refers to three types of physicians: herbal therapists, surgeons, and divine word healers who may be thought of as the first psychotherapists in Iran. However, most data about dynamic approaches to psychiatry are from the Islamic era, and are a mixture of Greek and Islamic thought. Physicians and philosophers like Galen, Hippocrates, and Aristotle had prominent impact.
Partially derived from Aristotle’s concept of Anima, Elmol Nafs, or Is- lamic psychology, focuses on Nafs. This complicated concept differs from spirit, and at times refers to psyche or soul or to their components. It was believed that one of the drives within Nafs was the Showghie fac- ulty. From the psychoanalytic point of view the Showghie faculty con- sists of two main drives. One of these is the Shahvie faculty. It is for plea- sure and lust, and is similar to Freud’s concept of Eros. The other, which is aggressive, predatory, and violent is called Ghazabie, and is similar to Freud’s concept of destructiveness. The relation between instincts and drives is also noted in Islamic psychology. The term Nafs, apart from re- ferring to the psyche, also refers to its components. During the eighth century, Iranian thinkers believed in various kinds of Nafs from which three are most important and are similar to Freud’s structural model of the mind. The first kind of Nafs was Nafs e Ammare which drives man to- ward basic instincts (roughly similar to Id). The second component, Nafs e Lavvame, contained conscience and would criticize man on his immoral and instinctual behavior (reminiscent of super ego). Third, Nafs e Motmaenne is a transcendental, or perfect, human ego.
Iranian mystics also had interesting ideas regarding the psychic ap- paratus and growth. Apart from man’s apparent behavior, they believed in man’s inner world, which was called Baaten. This concept described the individual and collective unconscious. Only an inquiring individual who follows a master (Pir = old wise man) that mirrors the seeker can gain insight to the mysteries of Batten. In fact, this master is a kind of ana- lyst, who, apart from being a mirror, should be believed by the seeker to be a masterful medium between himself and god. The master does not have the passive manner of an analyst. Rather, he is supposed to know all that is needed and, through identification with him, the seeker can find insight to the inner world and the mysteries of divinity. Through following the master, Sufi rituals, religious prayers, and asceticism, the seeker gives up and denies his identity (ego) and dissolves into the other: “man na manam, na man manam” (I am not I, not–I am I). This process will end in a state of self–transcendence and unity with god, an ecstatic peak experience. For the union with god, the seeker should give up mun- dane reality and earthly living, and prepare to leave the prison of body for the eternal life after death. These ideas are prominent in the works of universally known Iranian mystics including Attar, Mowlana, and Hafez. These mystical ideas still influence common thought, and may be the basis for the popularity of Jungian ideas in Iran.
The first example of the word-association method was practiced by Ibn E Sina (980– 1037). A prince was in severe fever and no doctor seemed able to help. Ibn E Sina understood that the prince was in love with a girl and diagnosed “love fever.” Ashamed, the prince denied his love and would not express the name of the girl. While taking his pa- tient’s pulse Ibn E Sina named neighboring counties, and one caused a rise in the pulse rate. He then began to name the streets of that county, and one caused the pulse to rise again. Finally, he named the girls on that same street and the pulse rate revealed the name of the girl. He advised the prince’s parents to let the marriage happen and the prince was cured! (Moin, 1962).
Following the Second World War, Iranian socio–political life was di- vided between traditional religion and secular, Marxist ideology. Psy- choanalysis was introduced in this context. Freudianism, the first book on Freud’s ideas in the Persian language, was written by Amirhossein Arianpour, a Marxist sociologist at Tehran University in 1951. This was followed by a series of poor and distorted translations of Freud’s abridged texts made by common translators. At the same time the first U.K.–trained Iranian psychoanalyst, Mahmoud Sanaie (1918–1983) was a professor and the head of the department of psychology at the same university.
Sanaie made some interesting contributions to the understanding of Iranian culture by analyzing mythological figures in Ferdowsi’s Shahnama (the most important Persian epic). These stories told of filicide and fratricide in Iranian culture as compared to patricide in western cul- tures. His most important theoretical contribution was to introduce the Rostam (as opposed to the Oedipus) complex, comparing son–killing and brother–killing in Iranian culture with patricide in western culture. (Rostam, an Iranian epic hero, unknowingly kills his own son. He also kills Prince Esfanidar, whose downfall was ordered by his father, King Goshtasb.) Sanaie’s second important academic contribution was to found a library for psychological and psychoanalytic literature in Tehran University.
Roozbeh Hospital was the first university psychiatric hospital at- tached to the medical school of Tehran University. This hospital re- mained the main training center until the early 1970s when a group of U.S.–trained psychiatrists and psychoanalysts returned to Iran with a different orientation from the mainly organic and descriptive approach of that time. Since these people could not influence the Roozbeh orienta- tion, they worked in private practice or in psychiatric departments in other provinces like Isfahan or Shiraz Universities.
Until just before the revolution, the impact of these US–trained people on the general psychiatric orientation was very limited. Iraj Siasi, a psy- chiatrist with psychoanalytic orientation, was a notable exception. Siasi and his group worked at the Institute of Psychiatry, and were attached to the Ministry of Health outside the influence of the medical schools that were related to the Ministry of Sciences and Higher Education. Opposed to the unshakable organic–descriptive orientation at Roozbeh, Siasi managed to take some psychiatric residents and run a training program with a psychoanalytic approach. This program was halted by the revolu- tion of 1979, when most U.S.–trained specialists immigrated to the United States. Before the revolution, there was also a series of psychoan- alytic discussions for ordinary people on a popular radio program run by nonanalysts. This program began in the 1950s and continued for some 20 years. In parallel with the Iranian socio–cultural division be- tween mysticism and Marxism the 1950s and 1970s psychoanalytic liter- ature translated into Persian focused on Jung, and the post–Freudians, Eric Fromm and Karen Horney. These three have become the most popular in Iran.
After the 1979 revolution there was a common change in intellectual attitude which turned eastward, and rejected the westernization of Ira- nian culture which was called “Gharbzadegi” (western malady, western bites). This reflected a renewed emphasis on the native Iranian identity, and a quest for its past religious and traditional perspectives.
Following the 1979 revolution there was a widespread negative atti- tude toward psychoanalysis, particularly the sexual emphasis in Freud’s ideas. Another important factor was the engagement of Iran in the war with Iraq. This conflict demanded enormous healthcare re- sources, and saw a return to biological therapies. During the first few years of war, there was no place for psychoanalysis in universities and academic settings. Therefore, psychoanalytic practice was done outside the academic system in the private sector by only a few practitioners. Some clinical psychologists with a behavioral approach continued working in the psychiatric system at that time.
Since there was no academic education in psychoanalysis, one author of this paper (Mohammad Sanati, a U.K.–trained psychoanalytic psychotherapist), who had begun his academic work in Tehran University in 1985 as a general psychiatrist, gave a series of lectures about psycho- analysis in the Iran University of Medical Sciences and Tehran Institute of Psychiatry. In 1986 he also developed a private sector psychoanalytic training program for young psychiatrists. This was a new beginning for psychoanalytic education for psychiatric residents that continued for about 10 years. He also had a series of television and radio programs to complement academic lectures aimed at educating the general popula- tion. To interest the sophisticated, he focused on the psychoanalytic criti- cism of art and literature. These efforts had a good effect on the govern- ment and academic attitude toward psychoanalysis. However, as in the United States, during the 1990s psychoanalytic thought seemed to lose recognition in Iran.
Sanati also began a method of “single–sex group therapy” which was consonant with Iranian society, and which was welcomed and grew rap- idly. There are now 20 groups with 10 to 12 members run by him or co–therapists trained by him. These groups are slow–open and run by one or two (from the two sexes) therapists that are more active than clas- sic psychoanalytic group therapists. Beginning in 1996, Sanati returned psychoanalytic education to psychiatric training, after approval by a special committee for revision of psychiatric programs. Another mile- stone was the establishment of academic psychoanalytic training in Roozbeh hospital. During the same period, brief psychotherapy was also introduced to the Iranian academic system by U.S.–trained psychia- trists. Since then, lectures, seminars, and therapies are given in academic settings and psychoanalytic education is now represented in the pro- posed four–year training curriculum to complement cognitive–behav- ioral approaches. Academic psychoanalysts are, however, primarily limited to the universities of the capital city of Tehran. Official recogni- tion of the Dynamic Psychotherapy and Human Studies Unit in Tehran University coincides with the publication of this “Frontline” essay.
Currently analytic psychotherapeutic approaches include a mixture of object relations and ego psychology, sex therapy, group therapy, fam- ily therapy, brief psychotherapy, and transactional analysis. While the books of Jung, Fromm and Horney are still popular, their therapeutic methods are not widely practiced. It is hoped that the recent academic acceptance of dynamic psychotherapy in psychiatric education por- tends a promising future for psychoanalytic thought in Iran’s near future.
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Aknowledgement
With thanks to Dr. Seyyed Ahmad Jalili, President, Iranian Psychiatric Association, and Dr. Gholamreza Mirsepassi, Secretary, Iranian National Board Examiners Committee.
And with special thanks and regards to Clay C. Whitehead, M.D., for his generous help.
Journal of The American Academy of Psychoanalysis and Dynamic Psychiatry, 34(3) 405-414, 2006.
© 2006 The American Academy of Psychoanalysis and Dynamic Psychiatry