In 1957 the eminent Czech poet František Hrubín, who had inspired the patriotic Czech public on the eve of World War II, as well as subsequent generations, wrote in the foreword to a textbook on alcoholism:

Hrubín had first-hand experience of treatment at an alcohol treatment facility. He was an alcoholic and was treated in Communist Czechoslovakia in the early 1950s. He described his frame of mind after the treatment: ‘A man who had doubts about himself, a man who had been doubted by the whole world, once again feels the desire of his entire being to live and to create his life again.’²

Rather than representing a typical description of psychiatric care in Stalinist Czechoslovakia, Hrubín’s observations highlight an important paradox. In spite of drastic political limitations imposed on socially and psychologically oriented approaches to health, and despite the marginalisation of psychiatric and psychological conditions in most socialist countries, the treatment of alcohol addiction experienced dynamic development within the field of socialist medical care from the late 1940s. Legislation targeted at alcohol addiction introduced compulsory treatment, addictology was established as a prominent medical sub-discipline, and extensive public resources were invested into a number of treatment centres and campaigns. These were spaces where shattered souls like Hrubín could be restored to health in a dignified way.

This chapter examines the generally conservative and repressive context of psychiatric care in Czechoslovakia and complicates this picture with examples of psychiatrists who managed to practise alternative approaches within the system of public healthcare. In this sense, it represents an important complement to Christian Werkmeister’s chapter on Soviet treatment in this book (see Chapter 12). It also explores the context within which different approaches to alcoholism emerged, and their theoretical backgrounds, political backing and actual practices. Emphasis is on the assessment of the therapeutic approach followed by Jaroslav Skála and colleagues. It will be argued that these psychiatrists employed particular strategies in order to channel public health resources into the kind of care they considered useful for clients, and which were, in some instances, subversive of the authoritarian Communist system of healthcare as well as Communist governance in general. The treatment of alcohol abuse will also be contextualised as an example of institutionalised expert environments that have recently been described as key to understanding the dynamics of communist rule and its dissolution.³

Hitherto research of psychiatry in communist countries has largely focused on the abuse of psychiatry by communist police and judiciary authorities.⁴ In contrast, this chapter presents the kinds of professional, intellectual and moral dilemmas medical staff were faced with in an authoritarian context. It directly links the medical with the political history of Czechoslovakia.

Pavlovism and ‘active therapy’

As in many other spheres, the treatment of mental illnesses in Czechoslovakia was subject to centralised policies endorsed by the Communist state since its foundation in 1948. The campaign against psychoanalysis was a key aspect of such policy. For example, the removal of the memorial plaque commemorating Sigmund Freud from the house of his birth in the northern Moravian town of Příbor shortly after Communist government was established in Czechoslovakia in 1948 was just one manifestation of the anti-psychoanalysis operations initiated by the Communist authorities.⁵ (Ironically, a first such plaque had been destroyed by the Nazis when Příbor became part of Germany in 1938.⁶) This anti-psychiatry campaign forced practitioners and prominent authors of psychoanalysis to either engage in other approaches or to practise illegally.⁷ The theoretical basis for building a new ‘socialist’ psychiatry included Pavlovism, an approach based on I.P. Pavlov’s reflex theory. It was based on an understanding of all social relations as external stimuli that created conditioned reflexes in people and influenced their behaviour. Since this approach held that Western psychotherapy individualised social problems, thereby concealing and sustaining their real causes such as economic inequality and class-specific exploitation, communism was believed to have erased these underlying causes. Pavlovism aimed to integrate the theories of physiology, biology, psychiatry, psychology and pedagogy. The earlier pre-communist psychological perspective was replaced with an exclusive focus on ‘higher nervous activity’.⁸

Within this guiding framework, the human mind was considered to be part of the biological organism. Any mental-health-related problems were framed as diseases, deviations and disorders. People suffering from mental illnesses were called ‘patients’ and had a right to treatment. This treatment was required to be scientific and measurable, and was meant to directly address the biological aspect of the mind. Psycho-pharmaceuticals, which had been invented and tested since the mid-twentieth century, were favoured over other treatments. The methods applied were often highly invasive and turned patients into passive objects of ‘active therapy’. This was particularly so when treatments were tested on people, and their effects were unknown or not well understood. One example was insulin coma therapy, which was widely applied across the Soviet Union and in other communist nations, as well as in Western and other countries around the globe.⁹ The number of active therapies provided in a given psychiatric facility was interpreted as a gauge of its excellence.¹⁰

Nevertheless, there was more ambiguity and heterogeneity than the general ideological guidelines and the rhetoric of a state-run healthcare service would suggest. This was especially true in the clinical sector, an area to which many resorted from the heavily surveilled sectors of medical education and academic research. Although de-Stalinisation in the Czechoslovak political sphere from the mid-1950s onwards was largely non-existent, this was also the period when psychology and psychiatry adopted, formulated and developed various unorthodox approaches. As Sarah Marks remarked in Psychiatry in Communist Europe,

Marks focused on the example of Oldřich Starý’s integrative human ecology, which considered the impact of working and urban environments of patients as important factors in the prevention of mental illness. Other examples of approaches that did not follow the official Party line include that of Ferdinand Knobloch and Jiřina Knoblochová, who experimented with group psychotherapy in a number of public facilities (namely the previously private estates that had been nationalised after World War II, such as a farm in Doksany, a country house in Lniště and the Lobeč chateau near Mšeno). They developed so-called ‘integrated psychotherapy’ for the treatment of neuroses and ran psychotherapy training courses for professionals.¹² Along with many other talented practitioners, the Knoblochs left Czechoslovakia after the military invasion in 1968. Before that, in the 1960s, they introduced ‘psycho-gymnastics’ at Lobeč, an original mime-based therapy method that was later developed further by the psychoanalytically trained social worker Hana Junová.¹³ Other alternative styles of therapy that contested official practices were explored by Eva Syřišťová, who introduced approaches based on mutual understanding and acceptance into treatment, along with respect for client imagination. Syřišťová summarised her understanding of schizophrenia in The Imaginary World, a book directed at the wider public.¹⁴ Similarly, Stanislav Kratochvíl developed a community-based method of treatment at the psychiatric hospital in Kroměříž, where he had worked since the late 1950s.¹⁵ Ondrej Kondáš formulated learning theory applications, and Petr Boš practised and taught family therapy at the Children’s Psychiatric Hospital in Dubí near Teplice.¹⁶ Clinical practice in institutions was usually accompanied by research, including unconventional experiments, such as those by Milan Hausner, who carried out research on the effects of LSD therapy in the treatment of psychiatric disorders at the clinic at Sadská from the early 1960s to the mid-1970s.¹⁷

While the focus on ‘positive deviations’ certainly tends to create a picture that does not fit in with common representations of communist countries as authoritarian and oppressive, the majority of hospitals did follow the official guidelines. Sarah Marks’s depiction therefore does not quite reflect the situation in regard to more widely accessible psychiatric treatments. Jaromír Rubeš, the manager of several large psychiatric clinics from the 1950s to 1968 and later one of the founding fathers of the first psychotherapy training programme, described his experience at official psychiatric meetings and committees in his memoirs in 1991:

Rubeš remarked that he had realised that ‘what essentially accounts for “biological” psychiatry, does not, in fact, fall under the heading of psychiatry at all. It should fall under internal medicine or somewhere else, but not psychiatry.’¹⁹

Rubeš’s memoirs also include numerous descriptions of the conditions in psychiatric hospitals, namely a lack of organisation, unethical attitudes to patients, the terror of electroshocks, erratic medication and so forth. For example, when he first entered the Dobřany Psychiatric Hospital near Pilsen as a young psychiatrist and as the new director, he noted ‘chaos and nineteenth-century conditions’, with patients tied up and an omnipotent rule of ‘cliques of nurses and Communist cadres’.²⁰ Rubeš became famous for having managed to successfully turn this neglected facility into a treatment centre run on the basis of modern concepts. He restructured Dobřany hospital and established specialist departments, as well as one dedicated to internal medicine. Patients with alcohol addictions were placed in a separate building; this was meant to facilitate their detoxification and longer abstention.

From the mid-1950s onwards, psychiatric care in Communist Czechoslovakia was organised in secluded establishments. Despite the obvious flaws of what were, in the context of Western countries, described as impermeable institutions, their closed doors provided at the same time an opportunity for several leading open-minded psychiatrists to practise a surprising variety of approaches and methods. Nevertheless, as in Western countries, the closed-door system meant that patients were isolated from the outside world and rarely had a chance to influence their own treatment, and the segregation of patients from wider society encouraged the tabooisation of psychiatric conditions. Notwithstanding some notable exceptions, in the majority of state-run institutions the treatment prescribed by medical specialists was subject to political and ideological intrusion.

Alcohol abuse in a communist state

The approach to alcohol consumption and addiction adopted by the Czechoslovak Communist government contained a fundamental contradiction. It was argued that alcoholism was an issue inherent to capitalism and caused by its exploitative nature. At the same time heavy alcohol consumption was a common phenomenon not only among the former bourgeois elites and the Party leadership but also among the working class – a social group on which the rhetoric of the state relied for its legitimacy. When the psychiatrist Skála published the first book specialising on alcoholism in Communist Czechoslovakia in 1957, he concluded:

Although the government introduced extensive legislation, starting with the Law on Elimination of Alcoholism of 1948,²² the consumption of alcoholic beverages kept rising dramatically throughout the Communist era: from 2.9 litres of pure alcohol per capita in 1949 to 9.2 litres in 1984.²³ To conceal the contradiction, cultural aspects of drinking and the fact that it was part of local tradition were downplayed, while the economic effects on collective prosperity were emphasised. Skála argued that alcohol consumption ‘particularly stains a socialist society where one relies on the productive contribution of individuals and where reduced work performance or loss of work on the part of any citizen involved in the productive process must be made up by others’.²⁴ Furthermore, in Skála’s view, alcohol consumption was responsible for the rising rates of crime, car accidents, divorce and other social problems, and hence it had to be combated.

Official discourse was hesitant to accept any cultural or sociological interpretations of the increased rate of alcohol consumption. Even as late as the period of perestroika (political and economic restructuring) in the late 1980s, the Slovak sociologist Martin Bútora struggled to have his book It Can Never Happen to Me: On the Sociology of Alcoholism published.²⁵ It summarised his professional experience, which he had acquired in counselling centres for alcohol addictions. Bútora offered a sociological interpretation and pointed out regional differences in the pattern of alcohol abuse, namely the high rates of alcohol addiction in Slovakia in contrast to the Czech region. As the book touched on a number of communist taboos, the authorities repeatedly rejected and delayed its publication.

It could be argued that the continued medicalisation of over-consumption of alcohol across the globe after World War II provided a convenient rationale for communist states because alcoholism became projected as an issue that had to be addressed medically rather than as a problem woven into the social fabric of a state. The framing of alcoholism as a disorder that required medical rather than social treatment and intervention was not new in post-war Czechoslovakia, for experiments with apomorphine therapy had been undertaken from the mid-1920s.²⁶ Apomorphine induced vomiting and other side-effects among some patients if taken together with alcohol. Although clinics practising this treatment were closed down by the Nazis in 1939, a similar type of treatment was re-introduced in Prague in 1947 and involved thousands of patients.²⁷ From the outset it was connected with Jaroslav Skála.

Skála’s innovations and the role of the Apolinář

When Skála joined the psychiatric clinic of Prague University Hospital as a young psychiatrist in the late 1940s, his first contact with alcoholics was during experiments with emetine in the so-called blinkačky (vomit) cycles. Injecting the substance and allowing the client to consume alcohol created a psychological connection between the nausea and vomiting triggered by emetine and drinking. The therapy perfectly fitted the Pavlovian orthodoxy, as it built aversive reflex to alcohol: its smell and taste. In 1950 Antabuse therapy was introduced. Its major advantage was that the medication could be administered in the form of pills.²⁸ And yet when Skála had the first ever substantial monograph, Alkoholismus (Alcoholism), published by the State Healthcare Publishing House in 1957, he presented a much more complex picture. The foreword (quoted at the beginning of this chapter) was written by one of his patients, the well-known poet František Hrubín, who publicly revealed his own alcohol problem therein. What is more, the book proposed a system of treatment that evidently involved psychotherapy and the role of a therapeutic community. Neither psychotherapy nor therapeutic communities were meant to exist in public institutions, as they contradicted the state’s healthcare ideology. Skála explained his shift away from the pure pharmacotherapy of addictions he was expected to perform at the clinic: ‘I felt there was something missing in what I was doing.’²⁹

Although state policy suggested that alcoholism was a medical, physiological problem, in reality many classical psychiatrists tended to rely on psychotherapy-oriented approaches in their practical work with alcoholics. Commenting on his career in the above-mentioned ‘nineteenth-century-style’ Dobřany hospital, Jaromír Rubeš said: ‘I didn’t have a clue about psychotherapy then, yet the place made me realise the extent of the issue of alcohol. When emetine therapy appeared, I immediately had the feeling that the problem was too complicated to be simply cured by emetine.’³⁰ Václav Hyrman, a follower of Ferdinand Knobloch’s integrated psychotherapy, worked in the alcohol clinic in the North Bohemian city of Liberec until 1968 before he left for Canada. He recalled his first years in Liberec: ‘Indoctrination and triggering the vomit reflexes to alcohol were the main treatments at the time. Yet psychotherapy and organised work could prove far more effective.’³¹

As early as 1948, Jaroslav Skála was promoted to head of the Alcoholism Treatment Centre in a detached building within the hospital compound. A building next to St Apollinaris Church, the so-called Apolinář, became home to a new system of alcoholism treatment and to Jaroslav Skála. The system of treatment he introduced to the centre combined the previous approaches of detailed medical examination, regular checks and pharmacotherapy with a characteristic strict ‘regime’ and a number of highly progressive psychotherapeutic methods.³² Under the regime schedule, every hour of the day, starting at 5.45 a.m. and ending at 10 p.m., was used for an activity, be it therapy, exercise, work, jogging, relaxation, reading newspapers, cleaning, writing progress reports or walking in the garden. The treatment was the same for everyone, and patients had no say in it. Points were assigned or deducted on a behaviour chart that mapped patients’ efforts. In popular understanding, Skála – whose name means ‘rock’ in Czech – became a synonym for a kind of boot-camp discipline and asceticism.

At the same time, the strict regime was complemented by a wide range of psychotherapeutic methods, including group therapy, diary keeping and reflections on the previous week in open discussions as well as art therapy, composition of motivational songs and theatre plays. There were lectures for the patients (‘didacto-therapy’) and two-week sports camps in the countryside. Skála did not leave the Apolinář centre, where he lived in a small studio in the same building. In fact, he joined in all the patients’ activities. This led him to the idea that only abstainers can help alcoholics overcome addiction, and that therapists should share the treatment process with their patients. This was a revolutionary idea in the paternalistic medical and educational system that was characteristic of the country. Success rates were impressive, with 60 per cent of patients remaining abstinent for at least one year after treatment.³³

In Skála’s view, leaving the programme after a successful four-month treatment in hospital was only the beginning of a possible long abstention. He set up a follow-up club for abstinent ex-patients at the Apolinář, where they benefited from a supportive peer community as well as expert advice.³⁴

Skála managed to acquire a number of other state-owned buildings, mostly rural estates, which the Communist government had repossessed from nobility and religious orders after the Communist coup in 1948. For example, a new alcoholism treatment facility was set up at the Chateau Lojovice in 1958.³⁵ In 1971 Skála founded here the first department for women alcoholics and a rehabilitation centre for patients who had completed their programme at the Apolinář. Staff even invited the relatives of alcoholics to stay on the premises, and experimented with including patients, their partners and their children in the therapeutic process.³⁶ In a sports and recreation centre in Dobronice, South Bohemia, the Apolinář organised a summer camp each year, in which previous patients were joined by therapists from other facilities to experience the unusual mix of clients and staff and learn from the core team.

The original Apolinář programme became the blueprint for alcohol treatment departments set up at most psychiatric hospitals. Riesel suggests that contemporary authors who wrote about alcoholism treatment considered Skála’s system to be the foundational model for inpatient treatment in Czechoslovakia.³⁷ Self-help publications and instruction booklets for teachers, healthcare staff and social workers, which were published by local administrations (the so-called National Committees), also relied on Skála’s system.³⁸

Skála’s system also had a wider impact on the public administration of provision for alcoholics. A procedure for locating alcohol addicts within the population had been set up by the Law on Elimination of Alcoholism in 1948 and further developed by the Law on the Fight against Alcoholism in 1962.³⁹ Both laws required police or local National Committees to refer addicts they had identified or were informed about to local anti-alcohol counselling centres or, in the case of more serious ‘anti-social behaviour’, to compulsory inpatient treatment facilities. A network of specialised counselling and advice centres emerged from the 1950s and by the late 1970s reached about 200, in which over 130,000 patients had been officially registered.⁴⁰

Jaroslav Skála provided the impetus for another innovation in the public system, a development that was subsequently established worldwide. These were the renowned detoxification units or medically supervised sobering-up cells. They were called protialkoholní záchytné stanice (anti-alcohol detention stations) in Czech and were designed for people in a state of acute alcohol intoxication who needed to be hospitalised compulsorily for their own protection or that of the people surrounding them. The first unit with twelve beds was set up at the Apolinář in Prague in 1951, and seventeen more detoxification facilities were established in various parts of the country by 1955. Over fifty remained in place by the 1980s.⁴¹ Patients were required to stay for at least eight hours and were forced to pay a fee for the time spent in the centre, and their local anti-alcohol advice bureau had to be informed.⁴² As the leading Czech psychiatrist J. Dobiáš pointed out in 1986, after its foundation, the network of detoxification centres became an inspiration for many other countries.⁴³

A cradle of psychotherapy

Last but not least, the Apolinář also became a semi-official centre for the dissemination of ideas on addiction treatment, psychiatry and medicine in general. Skála obtained permission to use the Prague Faculty Hospital’s cyclostyle printer to produce a number of semi-samizdat publications under the hospital’s auspices.⁴⁴ Zápisy z Apolináře (Apollinaris Records) was launched in 1951, and its several annual issues included working material to be used by patients and therapists alike: excerpts from patients’ diaries, discussion minutes, short stories and poems, historical overviews, but also Skála’s reports and impressions about conference visits abroad and translations of short texts by foreign specialists.⁴⁵ From 1979, the more academically and clinically focused Psychoterapeutické sešity (Psychotherapeutic Dossiers) were produced under the auspices of the Prague Faculty Hospital’s psychiatric clinic.⁴⁶ They mostly offered translations of noteworthy international texts on psychotherapy, which could not be published officially at the time; this issue will be explored further in the final section of this chapter.

A Friday seminar series at the Apolinář was originally designed for healthcare professionals who worked at other institutions. The seminars were characterised by an open-minded and politically liberal atmosphere, and became an attraction for intellectuals from various backgrounds. In the mid-2010s, Jitka Vodňanská, a psychologist working in Skála’s team at the Apolinář, recollected that she invited her husband-to-be, the musician Jan Vodňanský, to one of the seminars in 1974. The psychologist Ivan Douda, who later specialised in non-alcoholic addictions, gave a lecture on Arthur Janov’s The Primal Scream, which had been inaccessible at the time in Czechoslovakia.

All of these activities are key to the Czech context for a simple reason. Psychotherapy as an institutionalised autonomous discipline did not officially exist. In psychiatry, it was accepted as ‘one of the techniques’ that could be applied to patients. Yet the official discourse always considered it only a supplementary method – an accessory to more invasive biological treatment. Moreover, psychiatrists and psychologists were expected to somehow acquire the technique on their own initiative, since no training was provided within the medicine and psychology syllabuses. Skála’s alcoholism treatment model and his training and outreach initiatives at the Apolinář became the cradle of psychotherapy in Czechoslovakia.

Without systematic psychotherapeutic training and supervision well into the 1980s, Skála and his two colleagues – the psychologist Eduard Urban and the aforementioned Jaromír Rubeš – decided to establish a semi-formal scheme of psychotherapy training courses: the so-called SUR, an acronym created from the first letters of the founders’ surnames. It started in 1969, after Skála had returned from the 1967 Lindauer Psychotherapiewoche (Lindau Psychotherapy Week) in West Germany, an annual event of workshops and lectures on the latest approaches in the field. He organised a similar event for doctors and social workers in Czechoslovakia, initiating a four-year training course. SUR remained unofficial and unsubsidised; nonetheless, the courses and meetings moved between state-run psychiatric facilities. In his own words, Skála ‘offered his institutions at Lojovice, Červený Dvůr and Dobronice as venues’.⁴⁸ The training combined educational lectures on psychotherapy with practical group therapy sessions based on self-experience. The small groups, each led by its own therapist, provided a space in which individuals exchanged difficult-to-access literature with others and experienced a special atmosphere of trust, or even conspiracy. The combination of small-group therapy and reflection on this experience within a larger community was admired even among Western colleagues.⁴⁹ The lack of commercial interest and of business-oriented efficiency, typical of a communist economy, contributed to a setting in which the trainees could profit from enhanced educational opportunities as well as being allowed enough time for their slow personal growth and continuing professional development at no cost – something a democratic state based on a competitive market economy could hardly offer.

SUR was an extraordinary undertaking, especially during the two decades following the Prague Spring in 1968, when the Soviet Union suppressed reforms with the invasion of Czechoslovakia by 600,000 Warsaw Pact troops. According to Antonín Šimek, SUR trained over two thousand very loyal and devoted graduates, who became the main source of the belated psychotherapeutic boom in the 1990s.⁵⁰ Participants remembered the training as ‘a veil under which you could meet and talk freely, engage in uncensored discussions’.⁵¹ Šimek suggests that official academic publications mentioned the training only reluctantly in the late 1980s in order to downplay any semblance of a potential political threat.⁵² In an interview in 2000, Skála contrasted the SUR circle with the psychoanalysts, who, he contended, ‘were holed up, all scared, while we weren’t’.⁵³ He used controversial rhetoric in relation to the 1970s and 1980s. While these decades were referred to as the period of ‘Normalisation’ by the Communist Party, they were characterised by political purges and intellectual oppression. Skála noted in 2001 that he and his colleagues ‘did not really mind the Normalisation. On the contrary, we were able to benefit from it, I suppose.’⁵⁴ Skála’s initiatives attracted many talented people from the medical and care professions precisely because, after the military invasion put an end to the Prague Spring of 1968, they were disillusioned with the prospect of unreformed state socialism and some were even unable to work in their chosen professional field.

The politics behind expert success

The success of an idea and of a professional career usually comes with a degree of power. This particularly applies to a discipline such as the treatment of alcoholism, where success is often dependent on conformity with prevailing social and political agendas, and hence backing from the powers that be is often required. The need for acquiescence to political requirements was much stronger, if not crucial, in the case of communist dictatorships in Eastern and Central Europe.⁵⁵ Therefore historical examination of the innovative niches within an otherwise blinkered Czechoslovak psychiatry requires an excursion into the country’s political history. Public archives and the official press do not contain any first-hand records that could offer a direct insight into what was essentially to remain concealed. Research is therefore limited to other sources, such as academic journals and reports drawn up by the State Security, as well as memoirs and other, largely unreliable, material. Even if their interpretation is inevitably often intuitive, these sources are indispensable in any attempt to present the full picture.

Official academic journals, which were controlled centrally, offer the most immediate tool with which to approach the theme. Československá psychiatrie (Czechoslovak Psychiatry) and Československá psychologie (Czechoslovak Psychology) were the most respected, albeit carefully censored, journals of the two disciplines. Occasionally, they published articles that contained carefully worded and tactical references to unorthodox approaches and procedures common in Western countries. At the same time, they fully conformed to the requirement to publish contributions celebrating such anniversaries as ‘the triumphant February 1948’ (the date of the Communist coup in Czechoslovakia) or ‘Thirty years of socialist psychiatry’.⁵⁶ Many of the authors were even prepared to celebrate the prevailing isolation of and restrictions in psychiatry as welcome measures. Such obsequiousness may have been intended to earn a permit to travel to congresses abroad. The psychiatrist Petr Příhoda tellingly commented on colleagues who managed to go abroad: ‘They had to be such ace experts, or such bastards.’⁵⁷ Jaroslav Skála, too, was accomplished in balancing routine political tributes and elaborate challenges of the authorities. In his publications, he usually added a few paragraphs in each chapter about how a given method or tool was practised – successfully – in the Soviet Union.⁵⁸ In addition to the multitude of ground-breaking innovations in the treatment of alcoholism, his authority helped raise self-confidence among his colleagues vis-à-vis the Communist government. When the petition Několik vět (A Few Sentences) was circulated and signed at the Apolinář in 1989, Skála refused to report the petitioners.⁵⁹

The balancing of kowtowing and resistance was a tool that people in Communist Czechoslovakia widely exploited in order to arrange or secure whatever they were striving for, be it a travel permit, scarce goods or officially unavailable services. People assumed different identities depending on the requirements of the context. The identities they adopted were manifold and intricately interwoven, with plural loyalties. Skála and his colleagues frequently utilised public resources, buildings, material and staff for professional and social, albeit non-official, purposes. A liberal-minded therapist might be a member of the Communist Party, participate in the management of a large healthcare facility and serve on an editorial board of an academic journal in order to protect other spheres of her or his professional activity.

This sophisticated exploitation of the complex combination of multiple and fluid identities and loyalties enabled leading psychiatrists to maximise the political chances of their professional survival, to secure funding for their projects and to shape their specialist fields, as was the case in the treatment of alcoholism. The experienced hospital manager Jaromír Rubeš once described the careful preparations for the first psychiatric congress in Czechoslovakia, which was planned to include international participants. It was held in the mid-1950s in Jeseník, a remote northern Moravian spa town. Rubeš, as the head of the psychiatric ward, invited an official who was responsible for authorising the event. In the evening, he plied his guest with drinks until he was completely inebriated and the next day obligingly arranged the necessary massage and wellness procedures. The congress was duly authorised once the official had recovered from his hangover.⁶⁰ Such strategies may also have been at play in regard to the acquisition of badly needed treatment premises or recreation facilities for anti-addiction projects.

Specialists such as Rubeš and Skála were able to channel substantial public resources to finance projects that steered clear of official control and offered innovative approaches to treatment. The medical and counselling institutions also provided a cover for people and for semi-official activities, such as the production of semi-samizdat publications. Institutions related to psychiatry served as shelters for reform-minded specialists who had openly endorsed the Prague Spring reforms. During the post-1968 political purges in the public sector, these professionals found it virtually impossible to find highly qualified jobs elsewhere. In the 1970s, the state built a vast network of counselling centres. Once expelled from the university in Brno, leading clinical psychologists and psychiatrists such as Stanislav Kratochvíl found refuge in these centres.⁶¹ Those involved in the treatment of addictions describe their field as yet another realm where the scrutiny of political loyalty was much less consistent than in academia and in the education sector.⁶²

The preserved secret service files kept on some of the alcohol therapists indicate merely cursory interest on the part of the Communist regime in their creative projects and innovative activities. The files show that the State Security was almost solely concerned about contacts with former Prague Spring activists, Western nationals and emigrants, and about international travels to conferences, hiring new staff in hospitals and possible intakes of patients – individuals seeking refuge from police persecution. There seems to be no trace of attempts by State Security to infiltrate the SUR weekend courses or the alcoholics’ summer camps in different facilities.⁶³ Yet one can only offer a hypothesis drawing from the preserved fragments of files, as their current state prevents a more comprehensive analysis.⁶⁴

The patchy and inconsistent interest coming from the security apparatus is even more surprising given that Skála’s innovative approach to the treatment of alcoholism was based on both strict regimes and self-experience therapy, and implicitly challenged some of the key hierarchies of Communist dictatorship. A system of treatment where space and time were shared by medical personnel, patients and even their relatives greatly undermined the doctor–patient hierarchy and domination by specialists. Skála and his colleagues described their method as intuitive learning from experience.⁶⁵ Although there is no evidence to show that they were supportive of the Western anti-psychiatry movement, their approach was implicitly subversive of the Communist system in general. Despite the ubiquitous equality rhetoric, social hierarchies prevailed widely, including those between specialist disciplines, and between experts and their patients.⁶⁶

Conclusion

Jaroslav Skála was a central figure within the field of psychiatry who pioneered ground-breaking treatment of alcoholism. Despite finding himself in an ideologically conservative arena, he eagerly explored unconventional ideas from the start of his career. He succeeded in integrating non-Pavlovian and non-biological approaches into the officially endorsed system of alcoholism treatment. Skála led a number of addiction treatment facilities and introduced detoxification units. The long-term treatment that he introduced at the Apolinář rapidly spread to other psychiatric hospitals in Czechoslovakia. He and his colleagues reflected on their work in semi-official publications. They established a formal, though unofficial, system of psychotherapy training courses at a time when psychotherapeutic training and practice were non-existent.

Reflection on how Skála and his colleagues balanced the compulsory Communist rhetoric with medical reasoning, and on how they engaged in political bargaining using the charismatic if not authoritarian leadership style of Skála, offers insights into daily life and medical practice under Communist rule. Their methods and approaches emerged through a combination of transfer of Western ideas and expertise, independent local reflection and internal debates. In some cases, local innovations were even of interest to Western experts.

The psychiatrists dedicated to the treatment of alcoholism were no direct stakeholders of power in state socialism. Despite this, they were able to profit amply from the state resources. However, this eventually became their weak spot. After the collapse of Communism in 1989, psychiatry and psychotherapy experienced a boom in private training and counselling. Nonetheless, some of the founding fathers of the treatment of alcoholism and of Czechoslovak psychotherapy never quite accepted the principle of fee-based psychotherapy treatment.⁶⁷ They were hardly able to conceal their disillusion. Skála, who had once admitted that his circle had benefited from the politically depressing decades of the 1970s and 1980s, was much more modest in the mid-1990s: ‘We can only hope that the women’s anti-addiction facility at the Chateau Lojovice survives the restitution of assets.’⁶⁸ The chateau now serves as a private stud farm. A number of other progressive facilities which had been founded under, or in spite of, the Communist state met similar fates or were closed down.