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PRESENT CONDITION AND PERSPECTIVES OF PSYCHOTHERAPY AND MEDICAL PSYCHOLOGY IN UKRAINE

S. I. Tabachnikov, B. V. Mikhailov, N. O. Maruta

* Originally in Ukrainian:
Tabachnikov, S. I., Mikhailov, B. V., Maruta, N. O. (2004). Present condition and perspectives of psychotherapy and medical psychology in Ukraine. Forum of Psychiatry and Psychotherapy (Lviv), 5, suppl., 34–40.

The high dynamics of sociotechnocratic development of modern society, improvement of the information technologies, scientific and technical achievements along with the improvement of the quality of life bring about the elevation of psychological and emotional tension, complication of an individual’s behavioral patterns, and, finally, put forward harsh requirements to the integrative activities of all mental processes as a whole.

The following system-creating factors require a basic revision of the role and function of psychotherapy in modern medicine:

  1. Psychological causes of diseases and factors of neurotization.
  2. Changes in the morbidity structure.
  3. Rigidity of professional doctrines and organizational ways of providing healthcare for the population.
  4. Evolution of concepts of psychosomatic and somatopsychic correlates.
  5. “Internal” tendencies in development of psychotherapy itself.
  6. Resocialization of patients as an ultimate aim of the treatment process.

Psychological causes of diseases and factors of neurotization of Ukrainian population have a number of peculiarities:

Changes in the morbidity structure take place in the following directions:

Table 1

Structure of prevalence of mental and behavioral disorders among the population of Ukraine

  1990 1995 2000 2001
absolute number index absolute numbers index absolute numbers index absolute numbers index
Total 1,178,465 2271.0 1,168,846 2268.0 1,202,227 2430.0 1,201,024 2449.2
Psychotic mental disorders 341,237* 658.0 348,940 677.0 320,135 647.3 316,910 646.27
Non-psychotic mental disorders 429,813* 828.0 564,607 1096.0 603,861 1221.0 601,710 1227.07
Mental retardation (all degrees) 234,848* 453.0 255,299 495.0 278,253 562.6 282,404 575.91

* out-patient group only.

Table 2

Structure of morbidity of mental and behavioral disorders among the population of Ukraine

  1990 1995 2000 2001
absolute numbers index absolute numbers index absolute numbers index absolute numbers index
Total 128,915 248.0 135,586 255.0 128,974 260.7 124,032 252.9
Psychotic mental disorders 19,935 38.0 21,861 39.0 21,388 43.2 20,684 42.18
Non-psychotic mental disorders 94,402 182.0 99,274 189.0 90,488 183 87,392 178.22
Mental retardation (all degrees) 14,578 28.0 14,451 27.0 1778 34.5 15,956 32.54

The changes in morbidity structure testify that a considerable increase in psychologically caused, somatization, psychosomatic and neurosomatic diseases with chronic course, and in borderline states is seen in Ukraine over the last years. These illnesses, regardless of their cause, are characterized by a wide psychoemotional range of symptoms with appropriate neurological, vegetative and somatic correlates, which most frequently leads to their unjustified treatment by neurologists and internists. The tendencies of solving personal problems by “going deep into illness” also play a significant part in their formation.

Formation of “aim at disease” as a variety of a “social style”, when it is prestigious to have chronic illnesses and constantly undergo treatment, also plays a part.

Rigidity of professional doctrines and organizational ways of providing healthcare for the population

A psychotherapy consulting room is a substantial organizational unit of psychotherapeutic healthcare. The total number of psychotherapy consulting rooms amounted to 218 by January 1, 2003; out of those, 133 (60 percent) located in psychiatric healthcare, and 85 (40 percent) in general medical practice.

The most developed psychotherapeutic networks are those in Dnipropetrovsk, Donetsk, Kharkiv regions, Crimea, Kyiv; they possess 91 consulting rooms, which is 41.7 percent of the total.

Unfortunately, the psychotherapeutic network has a tendency to decrease: compared to January 1, 2002 the number of psychotherapeutic rooms decreased from 221 to 218.

By January 1, 2003 the number of physicians psychotherapists in Ukraine amounted to 480 persons.

The organizational structural peculiarities of healthcare system and social protection of people in Ukraine for many years have led to some formation of aggravation and secondary gain goals.

Evolution of concepts of psychosomatic and somatopsychic correlates

Tight connections and mutual influence of mental and somatic disorders allows distinguishing five types of conditions within this pathological frame, reflecting different structure of psychosomatic correlations:

  1. Somatization mental reactions — somatoform disorders forming within the neurotic or personality-constitutional levels (neurotic disorders, neuropathies, and personality developments).
  2. Psychologically caused and personality reactions (nosogenous), appearing in connection to general medical condition (the latter presents itself as a traumatic event, as a subjectively involuntary factor, considerably influencing the patient’s quality of life) — secondary neurotic disorders of acute and prolonged type.
  3. Organ or systemic somatic failures of psychosomatic character, appearing in response to a constellation of socially psychologically caused, personality and bioconstitutional factors (in the form of the “response” of the organ or the target system — locus minoris resistentiae).
  4. Exogenous type reactions (somatogenies), developing as a result of the neurotoxic effect of the general medical condition, in the form of neurotic like or psychotic organic symptoms.
  5. Somatopsychic comorbidity — a relatively independent parallel course of general medical condition and mental disturbances.

Particular difficulties in diagnostic, and correspondingly, therapeutic practice are caused by existence in professional circles of such diagnostic formulae as “vegeto-vascular dystonia” and “neurocirculatory dystonia”.

As it is known, vegeto-vascular dystonia is defined as a condition characterized by disturbance of the normal activity of the autonomous nervous system due to the change in the tone of its sympathetic and parasympathetic parts, and prevalence of the ton of one of those.

In ICD-9, vegeto-vascular dystonia was coded ³n Chapter VI — Diseases of the Nervous System and Sense Organs, and also in Chapter VII — Diseases of the Circulatory System.

Neurocirculatory dystonia is a disease caused by the changes in vascular tone and reactivity due to dystonia (dysfunction) of vasomotor centers (both central and peripheral) of congenital constitution or acquired character, caused by endogenous an exogenous risk factors.

According to ICD-9, neurocirculatory dystonia was distinguished as a separate form of disease — neurocirculatory asthenia, code 305.3, which used to be part of Chapter V — Mental Disorders.

Presently, there is a tendency among internists and neurologists to code vegeto-vascular and neurocirculatory dystonia according to ICD-10, in Chapter VI — Diseases of the Nervous System as G90.8 and G99 respectively.

“Internal” tendencies in development of psychotherapy itself:

Rigidity of professional doctrines and organizational ways of providing healthcare continues modeling psychotherapy as a rather narrow specialty, concentrated in psychiatric field.

The fundamental and applied research concerning the psychosocially induced mechanisms of morbid conditions development and the psychotherapeutic methods of their treatment and prevention are clearly insufficient. This leads to the insufficiency of the mass methodical provision of psychotherapy application in treatment process and the unjustified uncontrolled invasion of people without medical education into psychotherapy.

The “internal” tendencies in development of psychotherapy are in its extensive character leading to existence of a large number of psychotherapy forms and modalities, which disorientates the professional community and creates a comfortably safe situation for non-professional and clearly charlatan directions in educational and treatment activities.

In Ukraine, psychotherapy is defined as a system of curing influence on a patient through his or her mental sphere. Respectively, the medical specialty “Psychotherapy” No. 88 is listed in the “Nomenclature of Medical Specialties” approved by the Ministry of Health of Ukraine Directive No. 359 of December 19, 1997. Training of psychotherapists is carried out by a specialization course in Psychotherapy for individuals allowed to practice medicine according to the Ministry of Health of Ukraine Directive No. 195 of December 25, 1992. The basic education is a higher medical one according to a 6-year program consisting of 30,000 hours. Specialization is accomplished in four months (624 hours) according to the academic curriculum and the program elaborated according to the Ministry of Health of Ukraine Directive No. 513 of March 11, 1999. After the specialization course completion, the students are to take a certification exam, after which they are awarded certificates of physicians-psychotherapists (Ministry of Health of Ukraine Directive No. 359 of December 19, 1997). Some foreign associations adhere to an opposite viewpoint. Thus, according to the “Declaration in Psychotherapy” adopted by the EAP on October 21, 1990 in Strasbourg, psychotherapy is a peculiar humanitarian field of science, practicing of which is a freelance and independent profession… education in one of the psychotherapeutic modalities… include: theory, personal therapeutic experience and practicing under supervision… obtaining of this kind of education is possible on condition of the former training in the field of humanitarian and social sciences.

In the professional sense part of their work, physicians-psychotherapists are to observe the postulates of the “Bases of Legislature of Ukraine on Healthcare” of November 19, 1992 No. 2801-XII. Special attention is to be paid to:

Article 32. “… In order to prevent harming the population’s health, carrying out of group therapeutic sessions or similar procedures utilizing hypnosis and other techniques of psychic or bioenergetic influence without a special license issued by the Ministry of Health of Ukraine is prohibited”.

Physicians-psychotherapists also must observe the Law of Ukraine "On Psychiatric Help" No. 1489-III adopted on February 22, 2000.

Article 6. “… Medical professionals… providing psychiatric healthcare… who… have learned of a person having a mental disorder, of turning for psychiatric help and treatment in a psychiatric hospital, or admission to psychoneurological institutions… or other information on the mental health condition, or the person’s private life, cannot divulge this information…”.

Article 7. “… The methods of diagnostics and treatment and medications allowed by the Ministry of Health of Ukraine are used only for diagnostic and therapeutic purpose according to the type of mental disorders…”.

Thus, realization of the psychotherapy concept under modern conditions requires creation of a new professional paradigm, reorganization of the system of psychotherapeutic help to people, and elaboration of the differentiated system of physicians’ preparation in the field of psychotherapy.

Resocialization of patients as the ultimate aim of the treatment process

For establishing of this new direction, the Ministry of Health of Ukraine has taken measures towards essential improvement of the organizational structures and the forms of psychotherapeutic care.

In order to develop psychotherapy and adequately establish it in the modern system of medical care for the people, the following issues should be solved.

  1. Creating of the conceptual professionally concise model of the psychotherapy development. An integrative model of psychotherapy should be created, containing the necessary attributes of the completed medical act: diagnosis of the pathological state of a patient; identifying the individually typological traits of the patient; constitution and realization of the psychotherapeutic directives; achievement of medical results in the form of maximal possible reduction of the morbid symptoms; patient’s rehabilitation with the maximal recovery of the patient’s social status and quality of life.
  2. Development of the traditional psychotherapeutic methods that were used in Ukraine. Optimization of various forms of suggestive psychotherapy, and their differential application depending on the leading pathological symptoms.
  3. Adaptation, development of the techniques of usage and introduction of the methods that had not been used in Ukrainian psychotherapy before: psychoanalytical techniques: existential modality — Gestalttherapy, non-directive psychotherapy, etc.; behavioral therapy — and systematic desensitization, immersion, paradoxical intention, etc. Improvement and differentiation of using the methods of operant confirmation, and bioadaptive regulation.
  4. Integration of the system of psychotherapeutic care into general medical institutions. Broadening the use of psychotherapy techniques in somatic medicine. It is important to increase the number of psychotherapeutic consultancy rooms in the general medical practice according to Appendix 26 and Appendix 2 to the Directive No. 33 of the Ministry of Health of Ukraine, and also to precipitate establishing of psychosomatic units in the structure of regional general hospitals, which is envisaged by Appendix 1 of the Directive No. 33 of the Ministry of Health of Ukraine.
  5. Psychotherapeutic care in the structure of specialized stages of medical assistance needs immediate organizational and personnel strengthening: the obstetric and gynecological units, pediatric and gerontologic networks, dispensaries of the radiation protection of the people, subunits of catastrophe medical care, etc.
    Medical specialty of child psychotherapist should be introduced.
  6. The development of psychological counseling and direction in psychic correction. Elaboration of a concept of a psychological model of psychotherapy and determining the range of psychotherapeutic and psychocorrectional measures for medical psychologists.
  7. A research expansion is necessary in psychotherapy. The code of the academic specialty “Psychotherapy” in the appropriate list of the Higher Certification Committee of Ukraine.
    Psychotherapy should be introduced into the curricula of the institutions of higher medical education as a major, not a minor course.
  8. The further elaboration of the departmental normative and legislative base in psychotherapeutic care provided for the people.

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