Автор: А.М. Демьяненко​​​​​​​,
врач-психотерапевт, Санкт-Петербург

Why psychotherapy in Russia has no future

Демьяненко Алексей Михайлович
Демьяненко Алексей Михайлович

May my dear readers forgive me for the provocative and at the same time ambitious-expert title of the article. I hope that further narration will fully clarify my vision and explain this name. In order to talk about psychotherapy, let alone reason about whether it has a future or not, it is advisable to decide what is psychotherapy. In the book of B. D. Karvasarskii "Psychotherapy. Textbook for students of medical universities "contains the following definition and understanding of psychotherapy:" The domestic tradition is that psychotherapy is primarily defined as a method of treatment, that is, it is within the competence of medicine. Foreign definitions of psychotherapy emphasize its psychological aspects to a greater degree.

As an example of a medical approach to understanding psychotherapy, its following definitions, which necessarily include such concepts as therapeutic effects, sickness, health or illness, can be cited.

• "a system of therapeutic effects on the psyche and through the psyche - on the human body";

• "a specific effective form of influence on the human psyche in order to ensure and preserve its health";

• "the process of therapeutic impact on the psyche of a patient or a group of patients, combining treatment and education".

Thus, from this definition and understanding it clearly follows that psychotherapy in Russia is a medical specialty, the activity in the field of which is performed by a doctor-psychotherapist. In other words, from the legal point of view:

• psychotherapy is ALWAYS medicine;

• a specialist who practices psychotherapy is ALWAYS a psychotherapist, in addition, having basic training in the specialty "psychiatry";

• Medical activities in Russia are licensed, that is, engaging in any medical specialty involves a huge number of requirements, only a small part of which is directly related to professional competencies. First of all, the requirements concern the place (premises) in which the assistance is provided, and the availability of a huge number of necessary documents. In fact, if you want to obtain a license for ANY medical activity in the Russian Federation, you should clearly understand that, first of all, it is about licensing of the PREMISES and related papers (I especially recommend looking at licensing requirements for psychotherapeutic activities).

It seems to be with the notion that there is psychotherapy, and the subject matter of activity has been determined. Now, a little bit about myself, who I am, that I take the liberty of discussing whether the future of psychotherapy in Russia is or not. I am a doctor by training, I have completed an internship in psychiatry and residency in psychotherapy, in addition, I have completed long training in the Gestalt approach and I am a certified Gestalt practitioner, also received an additional education in the field of organizational development (Cleveland model), I am currently continuing Professional training in the GATLA program (Gestalt Association of Los Angeles trainers). The peculiarity of my professional activity is that for a long time I have managed to combine different roles in the field of psychotherapeutic and about psychotherapeutic activities. At present I am the head of the City Psychotherapeutic Center of St. Petersburg; This is a state center, one of the structural subdivisions of the Neuroses Clinic named after I.P. Pavlova (SPb GBZU GPB No. 7). My professional path in the field of public medicine is: a psychotherapist psychiatric department, head of the department, deputy chief medical officer, head of the center. But this is only one of the vectors of my activity, at the same time I am a lecturer at the Department of Psychotherapy and Sexology of the SZGMU named after. I.I. Mechnikova, a teacher at the East European Gestalt Institute (VEGI), co-author and co-host of the Gestalt Approach in Clinical Practice program (LL - hello!). In addition, like most colleagues, I have extensive private practice, within which I am engaged in individual work, working with couples and groups. In addition, I am the head of the regional branch of the Russian Psychotherapeutic Association (RPA) and the certified supervisor of the RPA. If you ask me about professional identification, then I’m primarily a psychotherapist and teacher in the field of psychotherapy and gestalt-approach. I listed the main areas of my activity not with a narcissistic goal (except a little), but first of all for a clear idea that if I’m not a very big specialist in psychotherapy, then at least , I am quite broad in its various fields, and I have an idea about psychotherapy within the framework of state medicine, and about private psychotherapeutic practice, as well as education in psychotherapy (state and non-state) and about the activities of public organizations in area of ​​psychotherapy.

So, the introductory part is over, I hope, my dear reader is not too tired. Let us pass to the essence of the question.

1. The model of relations. A common model of relations in general medical practice is paternalistic relations, where there is a doctor - the main expert on the change, and the patient, who is inherently a passive recipient of care. Interactions in this dyad, in the framework of professional activity, subject-object. If we talk about relationships in the psychotherapeutic model of relations, then it is necessary to clarify the limits of competence and effectiveness of the method. In fact, psychotherapy is effective where something that happens to a person (people) - a symptom (situation, etc.), somehow appears with the participation of the person himself. It can be said that the task of any "good" psychotherapy is to help learn how a person participates in creating their own problem areas. In this case, the position of the therapist is not a directive, the only true, expert nature. The client of the psychotherapist is an equal participant in the therapeutic work, the relations in psychotherapy are subject-subjective. But back to the definition of psychotherapy, which is given at the beginning of the article: "The domestic tradition is that psychotherapy is primarily determined as a method of treatment, that is, it is within the competence of medicine", and the usual way of building relations in medical practice is paternalistic, and according to legislation, the psychotherapist Is a doctor, and the doctor treats patients, and patients must comply with the doctor’s prescriptions, etc. There arises a paradox in which specialists practicing psychotherapy are located within the medical model: on the one hand, To be able to "technologically" carry out psychotherapy, equal, dialogical relations are necessary, and on the other hand, the medical model of relations does not imply them. In fact, the psychotherapist becomes a hostage of his white coat.

2. Conditions of psychotherapeutic practice. If we talk about psychotherapy as a medical kind of activity, it becomes clear that it should be carried out within the walls of a medical institution (let us recall about licensing). In real practice, psychotherapy is carried out both outpatiently and permanently. It is especially difficult to carry out psychotherapeutic work in stationary conditions. As you well know, if we talk about the medical application of psychotherapy (about whether there is a medical model of psychotherapy or not, a little lower), then first of all the field of practical application is the "treatment" of neurotic disorders. Why is the treatment in quotes? At least because the symptoms of a neurotic disorder are just markers of a disturbed system of relationships with internal and external objects. The symptom is a part (consequence) of adaptive reactions in the context of the situation. The task of "good" psychotherapy is not the removal of the symptom, but the disclosure of those internal mechanisms and their relationship to the present context of the situation that lead to the onset of symptoms. In this case, the symptom is just the point of entry into the psychotherapeutic work. In real practice in the state-run medical facility, this becomes not possible for a number of reasons: a nosocenter approach to any mental disorders, including the neurotic level, when the main task is to get rid of symptoms in the shortest possible time; insufficient time for psychotherapeutic work for pathogenetic rather than symptom-centered psychotherapy; the presence of primary and secondary benefits in neurotic disorders, the absence of a real payment for psychotherapy, which leads to low motivation and a high level of resistance in the recipient of psychotherapy; parallel, not always necessary pharmacotherapy, which largely depreciates the process of psychotherapeutic work; habitual model of changes for general medical practice, where the main source of change is a doctor; the often occurring situation when the doctor-psychotherapist is in medical practice in the role of a helping specialist, and the main is a psychiatrist whose role presupposes a pharmacological response to any presentation of symptoms.

3. Education. The only and basic document that confirms the right of a specialist doctor to engage in psychotherapy is a certificate in the specialty "psychotherapy". Currently, the certificate can be obtained as follows: either passing clinical residency within two years, or primary specialization lasting from four to six months. Yes, a history of a doctor-psychiatrist certificate is required. My experience of studying within the clinical residency and the experience of teaching at the Department of Psychotherapy suggests that these terms are not sufficient for the implementation of quality, independent practice. In the framework of state programs of training and certification, the cadets are not required to have their own therapy, and they are extremely necessary, since the therapist is himself a kind of basic "tool" of work.

4. Medical model of psychotherapy. Let’s return to the domestic tradition of defining psychotherapy as a sphere of medicine and a method of treatment. As far as I understand, psychotherapy is inherently a collective concept that unites various psychotherapeutic directions and approaches. To date, there are three main psychotherapeutic directions: psychodynamic, cognitive-behavioral, existential-humanistic. But all these approaches are psychological, not medical models. It turns out that the medical model of psychotherapy - this is what is not, it is correct to speak only about the clinical application of psychotherapy, about the implementation of psychotherapeutic practice in the field of medicine. Thus, the term "medical psychotherapy" is untenable, and the domestic tradition, in which only a doctor can be called a psychotherapist and only he exercises psychotherapy, is extremely doubtful. The paradox is that, for example, there is a doctor-psychotherapist practicing, for example, in the cognitive-behavioral model of therapy, next to him at the department is a psychologist who is also a follower of the cognitive-behavioral approach. Both go in white coats, from the point of view of real practice they do identical things; if you do not know which one of them who is watching their work, then do not distinguish! BUT - the legislator clearly defines: the psychologist carries out psychocorrection, and the psychotherapist - psychotherapy, and nothing else! Paradox!!!

5. Private practice. It s no secret that specialization in the field of psychotherapy determines a very large degree of freedom in real practice. The psychotherapist is almost completely free from the instruments of production, since he himself is a kind of basic instrument of activity. I always joke (and in every joke, as is known, there is a joke) that in fact for individual work in psychotherapy you need a client, a therapist and two hemp, in principle, you can even without hemp. In fact, you can carry out real work anywhere and anytime. Moreover, in the practice of psychotherapy, the following situation is often observed: a sensible specialist, having come to work in a state institution, forms his client base and goes into private practice as he develops and receives additional education. In reality, it is enough to remove the office in any office center, and sometimes practitioners do without it, taking, let s say, at home. Will this be in terms of legislation the implementation of psychotherapeutic activities? Never! As you remember, psychotherapy in Russia is a medical activity, there is a list of licensing requirements that have little relevance to the implementation of real practice. For example, first of all, for legal practice, it is necessary to create a legal entity. At once I will say that I do not know of any precedent in St. Petersburg, that someone received a medical license for a legal entity in the form of IP. Usually, in order to pass the licensing procedure, it is necessary at least to create an LLC, which is extremely burdensome and it is not necessary from the point of view of the essence and meaning of real psychotherapeutic practice. As a result of all legislative difficulties, the following situation arises: according to the law, an overwhelming minority of psychotherapists are engaged legally with psychotherapy outside the walls of the state institution. If it is performed by a doctor-psychotherapist without legal entity registration, then this is illegal medical activities and illegal business; if psychotherapy is conducted by a psychologist, then this is by definition not psychotherapy. Among the ways colleagues go are getting additional education in the field of psychology, the discovery of IP, the statement of activity as psychological counseling, that is, in effect, a complete refusal to use the term "psychotherapy", which involves a huge number of problems . In reality, it is still simpler: specialists prefer to practice, most often not formulating their relations with the state. Given the specifics of practical activities, we can say that this is the simplest and most burdensome situation, since it is almost impossible to prove the illegal conduct of psychotherapy - we sit and talk. The line between psychotherapy and ugly, in my opinion, the word "psychocorrection" in general seems invisible (and whether it is ???), in terms of the essence of the work. As a result, in private psychotherapeutic practice, the following situation arises: according to the legislative understanding of psychotherapeutic activities, practically no one is engaged in psychotherapy, this is either psychocorrection, or psychological counseling, or simply counseling, for example, in the Gestalt approach to quality of life.

Let’s return to the title of the article. If we take into account the phenomena that I described, then a paradox arises: what is understood as psychotherapy and implemented within the walls of public medical institutions is largely doomed to failure based on the above-described processes. The creation of legal private practice in the field of psychotherapy is extremely difficult and burdensome. The state system of education in the field of psychotherapy is imperfect and does not ensure the formation of a specialist. Non-state forms of education in the field of psychotherapy, which are now many (and among them there are very worthy!), From the point of view of the law can not assign any qualifications in the field of psychotherapy. Let me remind you that the only (!!!) document that gives the right to call yourself a psychotherapist according to the Russian legislation is the state certificate for the specialty "psychotherapy", everything else is not valid, and only the doctor can get this certificate, having a diploma and a certificate for the beginning specialty "psychiatry". Public professional associations, such as, for example, the Russian Psychotherapeutic Association, also do not have rights in the field of certification and accreditation of specialists. The following conclusion arises: what is understood by psychotherapy from the point of view of the law is often not psychotherapy in its essence, but what is essentially psychotherapy is not considered a psychotherapy from the point of view of the law. Misty is not only the future of psychotherapy in Russia, but also its present.

Is there a future for psychotherapy in Russia? It seems to me that there is, but only if the legislative understanding of what psychotherapy is, will correspond to the essence of the activity.

The following are the most optimal ways for me to solve this problem:

1. rejection of the term "medical psychotherapy" as insolvent;

2. understanding of the term "psychotherapist" as a specialist with a special training in the field of psychological counseling and some generally accepted in the world psychotherapeutic approaches;

3. the allocation of individual additional specializations in the field of psychotherapy, for example, a psychotherapist in the field of clinical (medical) practice. In this case, a reasonable requirement may be the requirement for additional education in the field of psychiatry and clinical psychology;

4. changes in the licensing of psychotherapeutic practices aimed at simplifying or completely abandoning licensing requirements, for example, if it is not psychotherapy in clinical practice;

5. expansion of the powers of professional associations and non-state educational institutions in the field of training, certification and accreditation of specialists.

I hope, in this case, psychotherapy in Russia is expected a new stage of development and prosperity!

P.S. I express my great gratitude to my elder comrade, friend, colleague and teacher, professor, doctor of medical sciences, President of the Republican Party of Armenia Babin S.M. for creative support, idea, discussion and preview of this opus.

Source: Russian Psychotherapeutic Journal No.1, 2017, pages 103 - 107; is published by the Russian Psychotherapeutic Association

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