The International Journal of Person Centered Medicine Vol 2 Issue 1 pp 104-108

FROM THE FOURTH GENEVA CONFERENCE ON PERSON CENTERED MEDICINE: CONTRIBUTIONS TO THE ADVANCEMENT OF PERSON-CENTERED CARE

Personality in Russian psychology and psychiatry

Valery N. Krasnov MD MSc

Director, Moscow Research Institute of Psychiatry, Moscow, Russian Federation

Abstract A review of historical developments in Russian psychiatry that support person-centered approaches is presented. A proper orientation to the patient’s personality and a correct use of the intact personality properties along with an understanding of patient’s values and societal context as the basis for individual treatment policy are rooted in Russian psychiatric tradition which evolved in close interaction with national psychological schools, specifically, the cultural-historical concept of mental development (Vygotsky) and activity theory (Leontyev et al.). Contemporary psychiatric practice is frequently based on other theories. However, there are exceptions, i.e. a naturalistic study that is used as an illustration of effective person- oriented treatment of organic brain damage. This article describes a cohort of patients with organic psychosyndrome (without pronounced dementia features) of predominantly cerebrovascular nature that developed in persons exposed to the Chernobyl nuclear disaster in 1986.

Keywords Chernobyl, doctor-patient relationship, humanistic context, multidisciplinary teamwork, person-centered psychiatry, personality as facilitating rehabilitation factor, Russian psychology and psychiatry,

Correspondence address Prof. Valery Krasnov, Director, Moscow Research Institute of Psychiatry, Poteshnaya 3, Moscow 107076, Russian Federation. E-mail: [email protected]

Accepted for publication: 14 March 2012

Introduction distant supervision for some therapeutic procedures increase the distance between doctor and patient and

reduce the time of face-to-face communication. However, Mezzich’s pioneering work focused on the development of many people, especially younger doctors, consider these person-centered psychiatry [1] has triggered a discussion technical intermediates in diagnosis and treatment as about person-oriented medicine within international perfectly normal and even preferable in dealing with medicine more generally. This initiative has reminded us medical and medico-psychological problems. Medicine about the dual nature of the medical profession that seems to be increasingly ‘estranged’ from the human combines in itself both humanist knowledge and the being, being transformed into a service, even a natural sciences. Nowadays, biological advances in ‘transaction’. Psychiatry is destined, perhaps, to remain medicine by far exceed developments in humanistic one of a few medical disciplines in which face-to-face disciplines. Indeed, because of new technologies and contact and conversation with the patient are modern updated equipment and the appearance of various indispensable, though one might anticipate that such technical, IT and organizational mediators in healthcare, communication will decrease as a function of new including diagnosis and treatment, the humanistic technologies. In this context, it makes sense to reflect on dimension of medicine is becoming lost. Under these the traditions of national psychiatric schools with the conditions, lack of adequate humanistic knowledge and purpose of distinguishing, preserving and developing the humanitarian norms (primarily rooted in psychology and person-oriented approach. ethics) would bring about de-individualization and de- humanization of medical care and convert medicine into a plain and technical procedure. New technologies in, for example, information Russian psychiatry processing on the one hand, facilitate the functioning of specialists. On the other hand, they create a range of Developments in Russian psychiatry should be viewed in obstacles to the doctor-patient relationship and the context of close cooperation between psychiatrists and communication. Indeed, on-line diagnostics, electronic psychologists, with a focus on personality, including the versions of psychometric tests, video interviews, patient’s personality. In Russian psychiatry and consultations by Internet and Internet-counseling and psychology, one can distinguish two principal directions

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associated with the ‘St. Petersburg’ and the ‘Moscow’ environment, and the individual’s adopting existing Schools. cultural patterns (Vygotsky’s ‘interiorisation’). In the activity theory, an individual transforms into a Vladimir Bekhterev and the St. Petersburg personality by means of adopting social values and their School further development using his own abilities and skills. Personality cannot be explained exclusively by

psychological regularities and, therefore, it cannot be The psychiatrist and neurologist Vladimir Bekhterev (St. described only in terms of psychological characteristics. Petersburg School), started his professional career by Personality development is associated with certain setting up a psychological laboratory in a psychiatric hereditary biological predisposition, but, principally, it is clinic. His ideas about the biosocial nature of the human culture and social relations that play a decisive role. being [2] emerged much earlier than George Engel’s Continuous interaction between biological predisposition concept of the biopsychosocial unity of the human being and social influences (including cultural tradition, ethical [3]. Bekhterev’s colleague and disciple Dr. Alexander and behavior norms, requirements for professionals, the Lazursky distinguished the ‘endopsyche’ as an inborn basis communication range, etc.) occur in the course of specific of the individual that included temperament, character and activities. Adoption of social and cultural traditions is at a number of other psychophysiological characteristics and least as important as hereditary predisposition. The latter the ‘exopsyche’ that was understood as a system of plays a key role in some natural talents (such as in music, relations between the personality and the surrounding mathematics, motor activities, etc.) and in temperament. world [4]. These concepts formed the foundation for his However, the character is shaped in interaction with the personality classification. In Soviet times, these ideas were environment, though partially it also depends on genetics further developed by Vladimir Myasishchev in his and heredity. Certainly, development of personality as the ‘psychology of relations’. Myasischev was a psychologist pinnacle of mental organization invariably occurs in and for many years he was the head of the Bekhterev interaction with the social environment, in confrontation Psychoneurological Research Institute in St.Petersburg. In with it, in yielding to its demand or in resisting its his ‘psychology of relations’, personality was considered pressures – all during the activities aimed at changing as a system of interrelations between an individual and his external circumstances and self-evolvement. social environment, with specific attachments, preferences Naturally, all the personality definitions in Russian and values. In clinical practice, ‘psychology of relations’ psychology would encompass, in addition to general was applied mainly in diagnosis and treatment of neurotic outlook, also cultural and social values, social range and disorders [5]. In contrast with many psychodynamic motivation and the development of self-awareness. A approaches, it did not view the personality as something mature personality should have a differentiated self- defective and burdened with various hidden complexes, awareness and realize the unity of self and the but as the pinnacle of mental functioning, as a highly environment. organized psychological system, with self-awareness and the ability to control manifestations of disease. This system can be effectively used if properly supported by the therapist and accompanied by correction of relations with Ideas in Russian psychology immediate environment. The ideas in Russian psychology resemble to a certain Sergey Korsakov, Fyodor Rybakov and the extent the theories of American psychologists Gordon Moscow School Allport and Abraham Maslow. Allport also considered the personality as a complicated and developing hierarchical

system, which is more influenced by social and cultural The Moscow psychiatric School, due to the contributions motives than by biological determinants [10]. Maslow’s of psychiatrists Sergey Korsakov [6], Fyodor Rybakov [7] th concept was also based on recognition of importance of and others, had developed by the beginning of the 20 social influences and personal values and proposed an Century the ‘principles of clinicism’, which accentuated hierarchical motivation model, the so-called ‘hierarchy of the patient’s personality, his cultural, moral and spiritual needs’ [11]. According to Maslow, higher needs, including values and his relations with the environment. Also, the tradition of clinicism implied multilevel dynamic clinical the need for self-actualization, can be fulfilled only after analysis that combined a phenomenological approach with the lower basic needs are met. Obviously, many people never become self-actualized, but it is self-actualization searching for global regularities of the morbid process. that constitutes the essence of an individual’s personality. Personality and microsocial environment could also act as In many respects, the ideas of Russian psychologists a potential defense against disease. To a certain degree, these principles are noticeable in the ‘cultural-historical were close to Maslow’s self-actualization concept. concept of mental development’ (Vygotsky) [8] and the However, there are some axiological differences. Russian activity theory or “psychology of activity” (Leontyev) [9] psychologists, especially those who worked during the Soviet era, considered social values as a principal that evolved in Russian psychology in the past one hundred personality component. Individual achievements, creative years. Personality was viewed as a hierarchical system of activities and moral characteristics obtained special interconnected properties that developed in the course of interaction between the individual and his social significance in the light of their usefulness for Society. In

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our contemporary times, this statement has lost its human being as a protective factor has not been properly ideological meaning, but it is preserved as a cultural norm. studied and used in everyday psychiatric and therapeutic practice so far though it can play a role in counteracting the Application of ideas in clinical practice disease and its relapses or in overcoming the difficulties of social adjustment in remission. However, addressing the Doctor Dmitry Melekhov, who was a noteworthy personality happens to be the core of cognitive behavioral representative of the Moscow Psychiatric School, therapy and the accent on strong sides of the personality consequently applied Vygotsky’s cultural-historical allowed Melekhov in the past to develop a productive concept and Leontyev’s activity theory to clinical practice. direction in treatment and so called labor rehabilitation of He saw in the activity theory a powerful potential for mental patients. Finally, addressing the personality and rehabilitation of patients with severe and disabling even a community of personalities, forms the basis for diseases, for example, schizophrenia [12]. His psychosocial rehabilitation in contemporary psychiatry. rehabilitation model was based on making use of the strong and healthier facets of the personality that could counteract the deterioration and it proved productive even in the pre- Person-centered psychology and pharmacological era in psychiatry. Recent developments concerning psychosocial intervention and rehabilitation in the example of Chernobyl combination with long-term medication are based in Russia on the above mentioned appeal to the personality. The importance of person-oriented approaches in In addition, Russian psychiatric care uses psychoeducation psychiatric and general medical practice can be illustrated and involves the patient’s social net in his treatment and by the following naturalistic study. The clinic of the rehabilitation. Moscow Research Institute of Psychiatry for longer than 20 years has been providing examination, investigations and, if necessary, in-patient treatment for a cohort of persons who had been involved in the elimination of the Multidisciplinary teamwork and role consequences of the nuclear Chernobyl disaster in 1986. harmonization By 2011, this cohort consisted of 658 persons. Those were the persons who kept in contact with the clinic for at least However, the theory and the practice of multidisciplinary ten years. Besides, more than 1100 persons at least once teamwork in psychiatry have brought about some were investigated or treated as in-patients and more than difficulties in ‘harmonization’ of the roles of those 7,000 of the Chernobyl rescue workers were examined in participating in the treatment process. In many cases, there the clinic of the Institute. are consistency problems when the function of the The history of this study is interesting because of the therapist goes from the psychiatrist to the clinical person- and personality-centered approach. The majority of psychologist or from the clinical psychologist to the social the rescue workers at the Chernobyl Nuclear Power Plant worker, generating problems in sharing the responsibility were not professional rescue staff. They were urgently and development of a true partnership between the called upon for the carrying out of various professionals, the patients and their family members. The decontamination measures on the contaminated territory close and trustful doctor-patient relationship of the past is and for the erection of a ‘sarcophagus’ in order to contain being replaced more recently by a preferential the radiation. One of the potentially dangerous tasks was concentration on the patient’s personality and respect for digging a tunnel below the destroyed reactor and making a his cultural values and identity, though this is not always cooling slab in order to protect the underground water and observed in everyday practice. So, despite the humanistic soil from contamination. This work was done by Russian context of the personality concept described, sometimes in and Ukrainian coal miners who had arrived from different psychiatric literature and even more frequently in routine regions of the country. In addition, there were drivers, psychiatric practice, the personality is given a negative dosimetrists, construction workers and engineers, etc. This connotation while discussing individual cases of a mental urgent work had to be completed immediately following disorder or mental health problem. Usually, such facts are the disaster, with background occasional radiation leaks associated with treatment and rehabilitation difficulties, in that continued for several months. Shift work (i.e. which a patient’s personality traits (accentuations) or his circadian dysrhythmia), physical and psychological personal circumstances are announced to blame. Among tension, polluted air, toxic effects of the decontamination the accentuations that cause adjustment problems after an substances, lack of information – all these factors had to be episode of disease, psychiatrists mention rigid attitudes, taken into account while looking for an explanation in egocentrism, proneness to conflicts and a tendency to cases of immediate abnormal reactions or delayed in time conversion reactions. Actually, they rather mean psychosomatic and non-psychotic mental disorders that abnormalities of the character than those of the personality. occurred in significant number of these rescue workers. In this respect, psychiatry has a long way to go in direction Normally, small doses of radiation do not cause of differential evaluation of the character and the radiation disease, but in combination with other negative personality and their abnormalities and accentuations, not effects they can play the role of a synergetic pathogenic to mention using these differences for treatment and factor and produce ultimately a variety of symptoms. The rehabilitation purposes. The personality potential of a onset of disease – soon after returning from the Chernobyl

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area – was characterized by extreme physical and mental neurometabolic, vasotropic and vegetotropic therapy in fatigue, sleep problems, dizziness, persistent headaches, combination with small doses of mood stabilizers emotional and vegetative-vascular instability and (carbamazepine) and occasional symptomatic use of proneness to increased blood pressure. These conditions anxiolytics, in the majority of cases brought positive did not fit any clinical category and seemed unexplainable results and prevented subsequent development of for the majority of physicians. dementia. Asthenic, psychovegetative, anxious and For a few years after the nuclear disaster, the depressive manifestations of this complex syndrome government was reluctant to introduce a special status for responded well to the medication. It is noteworthy that the participants of the Chernobyl rescue operation, i.e. depression diminished without use of antidepressants or people involved in the elimination of the consequences of when a small dose of antidepressant, specifically a SSRI, this disaster, the construction of a protective cover and the was added to neurometabolic and vasotropic medication. radiation containment. That was an obstacle in obtaining Cognitive problems, as expected, least responded to access to adequate and timely healthcare and also created treatment. However, the therapeutic interventions problems for staying in their profession, so some of these described, including a healthy lifestyle with abstaining workers later lost their jobs and divorced their partners. from smoking and alcohol, resulted in a slowing down of Further deterioration of health in those relatively young negative processes in the cognitive sphere. Existing people resembled very much an ‘early vascular process’, memory and attention problems and impairment of i.e. a combination of abnormally early atherosclerosis and intellectual functioning remained moderate for a long time arterial hypertension. Different investigation techniques, and did not interfere with the patients’ adjustment. The specifically, dopplerography, single-photon emission above described personality characteristics compensated computed tomography (SPECT) and magnetic resonance for the impairments of intellectual functioning and in many imaging (MRI) confirmed vascular regulation problems. cases helped to reunite the families and avoid conflicts Central symptoms of this polymorphic clinical condition within the immediate environment. The patients were were moderate, but persistent, problems with memory, willing to work and in some cases they were able to attention and decreased intellectual functioning [13]. These resume their professional activities, at least on a part-time manifestations were more pronounced than in so-called basis. Repeated in-patient treatment, also involving mild cognitive disorder, but they also did not fit the criteria additional somatic investigations, psychological training, of dementia. However, these symptoms very well fit the sometimes with family counseling, has proved helpful in description of the ‘organic psychosyndrome’ [14], achieving a more or less stable remission. especially its moderate forms free from dementia. Thus the intact personality characteristics of the Physicians had difficulties with the understanding and former rescue workers enabled the avoidance in the interpretation of the symptoms described and the patients’ majority of cases of a destructive course of disease and repeated attempts to seek professional help were frequently facilitated treatment and rehabilitation processes. labeled as ‘hypochondria’, ‘psychopathy’ or even malingering. Psychiatrists happened to be the only medical specialists equipped to look for an explanation for these Conclusion polymorphic disorders and meticulously and carefully seek access to adequate treatment. In doing this, psychiatrists Long-term clinical work with former members of the had to arrange psychoeducation for the persons affected rescue team which took part in the elimination of the and their family members and to deal with prejudice Chernobyl nuclear disaster consequences (1986) reveals a against psychiatry and the stigma of mental disorders. In very important role of personality resources in the course of the development of the therapeutic maintenance treatment and in the formation of therapeutic partnership, the personality characteristics that had adherence. It meets a strong tradition of cooperation emerged and were reinforced in the patients during the between Russian psychiatrists and representatives of rescue operation proved useful. These were features such general and clinical psychology, as well as of as responsibility for oneself and others, mutual support, neuropsychology. This is an example of person-centered willpower, ability to ignore prejudice and follow the psychiatry as a successful secondary prophylaxis and agreed recommendations. The intact personality of the rehabilitation strategy in spite of a more or less persons who had been exposed to the massive and multiple unsuccessful prognosis. noxious effects from their work at Chernobyl confirms the fundamental statement of the activity theory that participation in constructive activities and coordinated interaction with others reveal and reinforce social and Acknowledgements humanistic values of an individual. Organic psycho-syndrome, also of vascular nature, has I am grateful to my colleagues for joint efforts in in general a negative prognosis. It tends to develop into searching for the best way of long-term cooperation with dementia, with pronounced memory problems, orientation patients. difficulties, impoverished speech and a combination of apathy with outbursts of anger that finish in tears (affective incontinence). But in the Chernobyl cohort, long-term systematic treatment with repeated courses of

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References

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