Psychosomatic medicine and practical resource psychotherapy
Prof. Kovalenko – Madzhuga N. P. – PhD, Ds, GD
Psychosomatic model of modern medicine is gradually entering the doctors’ understanding and is developing in conjunction with such fields of knowledge as prenatal psychology, clinical psychology, resource psychotherapy and others. The concept of psychosomatic relations is based on the acceptance of initial importance of personal-medium factors in the genesis of somatic diseases, in their resistance to treatment and on secondary prevention. The patient is justly seen not only as “carrier” of sick organ or function, but as a personality, which functions in one or the other, usually pathogenic medium (environment). The relationship of the sick to their sickness, formation in them of adequate model of expected results of treatment have significant value for diagnostics of disease and level of re-socialization .
Psychosomatic experiences of the sick with the one and the same disease can significantly differ depending on the personality’s specifics and includes different levels of reflection by the sick of his own condition: sensitivity, emotional, intellectual, and motivational. Apart from that there are people tended to organize a typical lifestyle, under which they put themselves under conditions, which increase the probability of occurrence of stress events, which result in occurrence or enhancement of somatic disease .
The term “psychosomatic disorder” has significantly changed in the last few years [1, 5, 16], but the essence of the problem remains the same. The very psychosomatic model, which takes in to account mainly the psychogenetic factors, is being replaced by bio-psychosocial model (Drozdova M. S. 2003).
There has been a noticeable distancing from the interpretation of the term “psychosomatic”, which combines in a very crunched together, simply saying the “holy seven”: duodenum ulcer, colitise ulcerosa, essential hypertension, rheumatic arthritis, hyperthyroid, neuro-dermatitis and bronchial asthma . Clinical signs of psychosomatic disorders differ by significant polymorphism and can be shown in different sections of psychiatric disorders as per ICD-10, but they are “identified by a common symptom: the overlapping of diseases of somatic and psychiatric nature” . The modern concept of psychosomatics due to the works by such researchers as W. Brutigam, G. Engel, Th. Uexkull, A. Jores highlights the need for integrated approach to understanding aetiology, pathogenesis and possibilities of therapy of different diseases keeping in mind the psychological specifics of the patient .
“The sickness itself is not only somatic, but also psychiatric experience, not only biological but also social occurrence as per origin as well as its result. The modern doctor should take into account with the psyche of the patient, take into account the patient’s relation to the sickness. It is also no less important for practicing doctor to imagine the inside picture of the sickness in any given person” .
“Due to inability and often unwillingness of the doctors to engage in the patient’s psychology, the latter go away from them and to the miracle-runners (witchdoctors)” wrote D. D. Pletnev: “The doctors unknowingly encourage quackery” . Unfortunately this note is still valid even for our contemporaries, who are looking for relief at the hands of “psychics” and “Clairvoyants”. The level of medical culture, medical up-bringing of the people clearly show the real condition of practical medicine, which forms stereotypes about patient behaviour.
The famous neurologist K. F. Kanaraikin wrote that the integral aspect of psychosomatic medicine is “not psychiatrics in medicine”, since “each doctor comes across one or the other psychosomatic problems of his patient and must consider them working out treatment strategy” (quote as per ). According to him the psychosomatic orientation in modern understanding of human pathologies must become mandatory for any practicing doctor.
Changes in healthcare have been long overdue, which could be meant to reorganize doctor training teaching them a lot of psychology and psychotherapy . Currently we are gathering experience, related to the attempts at bringing closer professional interests of the internists, psychiatrists, psychotherapists, medicinal psychologists into a wider field of medical practice. Such collaboration will help increase knowledge of mixed specialities, formation of the most detailed image of the disease (its psychiatric and somatic components, “In such cases we are talking about the integration, but not about simple addition or replacement of specialists’ knowledge” .
The pathogenesis of psychosomatic disorders, described by D. N. Isaev , is distinguishable due to the combination and interaction of the following basic factors:
- Non-specific inherited and burdened by-birth by somatic disorders and defects;
- Inherited susceptibility to psychosomatic disorders;
- Due to neuro-dynamic shifts (CNS disorders);
- Personal specifics;
- Psychiatric and physical condition at the time of occurrence of psycho-traumatic events;
- Backdrop to unpleasant family and other social factors;
- Specifics of the psycho-traumatic events.
The psychosomatic orientation of medicine, supposing a significant role of biological, psychiatric and social factors in their occurrence, passage and result of pathological conditions in humans, show the need for complex approaches to integrated diagnostics, therapy, prevention and rehabilitation based on combined knowledge . For the patients, who suffer from psychosomatic pathologies, greater influence of disorders of this or that type at the given stage of the disease is the determinant for the selection of form and method of correction, as well as the level of participation and accent on the role of the therapist or psychiatrist. The most tolerant model, which fulfils all the above mentioned requirements is the model of resource psychotherapy (Kovalenko-Madzhuga N. N.) [11, 12].
The use of the methods of resource psychotherapy, which are preventive and therapeutic in nature, can become an important support for the doctor-internist. This is the direction, in which research of psychosomatic cause layer is going on and the problem of targeted adjustment of the internal image of the disease is being solved. The resource psychotherapy has joined together such fields of medicine as obstetrics, paediatrics, as well as reflex therapy and study of neurosis. In the broad sense resource psychotherapy is part of psychology and humanistic medicine, which is based on the supposition of uniqueness of human personality and which makes real the application of the idea of unification of psychiatric and physical in medical and consultation practice (Drozdova M. S. 2008) . This way the most important place among the problems, related to the practice of psychotherapeutic approach is the problem of interrelation between the doctor and his patient (with the psychologist and client). In the prenatal psychology there are descriptions of actual connections in the system of relations between mother and the obstetrician, pregnant woman and the doctor and the resultants identified are either heterogenic or positive developing effects. Everything in this system depends on the quality of communication. Not every specialist, even the experts with the highest level of professionalism, is capable of supporting his patient and to become for him more of a spiritual healer, a psychologist than just a doctor. This is also to be noted that too much of psychotherapeutic activity by the doctor can cause heterogenic psychiatric reactions, disorders. This is what for example happens in case of wrong declaration of oncological diagnosis. Unsolicited acceptance of all complaints and inability to identify the real cause of disease is not only dangerous due to uncertainty of actions and intensions of the patient, but also in the decrease in the doctor’s professional authority in front of the colleagues and patients.
Using the resource psychotherapeutic approach in case of the presence of effective contact of the doctor or psychologist with the patient we can speed-up the solution of a number of important tasks. We can achieve the optimum fulfilment of the general plan of diagnostic, therapeutic and rehabilitative actions. The initial course of resource psychotherapy has psycho-preventive and psycho-adjustment value and while using resource psychotherapy in cases of psychogenic somatic disorders the personal therapeutic aspect is brought forward.
The sensitivity component of reaction of the personality to the disease nearly always includes the effect of discomfort, anxiety, fear and sometimes depression or apathy. In any disease the expectation of its results, worries about how it would reflect on work, family life, fear of the upcoming tests, procedures or operations make-up the emotional backdrop, which might make hard the flow of the sickness and can negatively affect the results of the on-going treatment. Therefore the decrease in effect of such experiences, relief of emotional tension is in some cases the most important task for the psychotherapeutic approach . Pathogenesis of anxieties during pregnancy have been well studied by prenatal psychologists and the need to prepare the woman for the regulation of emotional and behavioural reactions in case of stress during pregnancy and after delivery has been proven (Kovalenk-Majuga N.P.., Shkuratenko O.S.).
Dominance of depressive or apathic effect can also become the cause or one of the resultants of forced hypo kinesis; therefore the second most important task is to increase the patient’s activity. It is necessary to mobilize all the internal resources to fight the disease. During the course of talks with the patient it is important to specifically remind him that the process of getting healing can be slowed down or sped-up by his relation to the disease and treatment. To help resolve this problem there have been programs designed for resource psychotherapy called “Resource potential”, “resource art-therapy” etc. The use of these methods for pregnant women who show signs of premature delivery with pregnancy related pathologies showed their effectiveness and correctness.
Arousing in the patient the feeling or hunger for life, active desire of self-development, change of opportunities, learning of skills, which could be used beyond the limits of the hospital, is a difficult task, which requires time. Usually in case of hyper-nozogenosis during the first stage of psycho-treatment indicated are the methods “supportive” of psychotherapy, meant for reduction of sense of fear, despair and helplessness. This type of technique is effective for patients with clear “avoidance of danger”, traits of dependence, infantilism, anxiety, and orientation towards the doctor’s authority. Psychotherapy at this stage is predominantly symptomatic in character and helps solve the task of reduction in the level of anxiety, distraction from the hypochondriac experiences, and understanding of the treatment process . But this type of approach is less effective and short lived. The job of the resource psychotherapy is the formation in the patients of active and independent thought about the possibility of cure and for active “participation” in the treatment process, readiness for training and experiments, ability to actively participate in the analysis of test results and to accept (share) the responsibility for the results of the treatment.
In case of introduction of hypnosis at the first stage of treatment, it is reasonable to use “rational” psycho-correction with directive-suggestive elements, meant to explain to the patient the necessity of treatment, dangers of non-compliance with regimen and attempts at self-treatment. Some of the authors note the effectiveness of such psychotherapy mainly for patients with clear signs of “search for the new”, low anxiety level, high activeness level and self-control, underestimation of existing dangers . For them it is important to arouse their resource potential, creative activity, which is provided for by resource psychotherapy.
At later stages of psychotherapy of such patients there are methods indicated, which are meant to adjust the hypertrophic imagination of the patient regarding his/her own competence in situations of sickness, development of his/her altruistic emotional strategies, co-existence, ability to collaborate and to respect others. For such patients it is useful to apply resource art-therapy to activate their artistic potential through self-reflexes.
Modern medicine is first of all evidence based science, based on protocols and standards of diagnostics, treatment and prevention of certain diseases. But on the one hand standards are a great achievement to avoid doctor’s mistakes (errors) but from the other hand these are instructions, which do not yet cover psychosomatic relations. Due to this we think it is time to develop clear, standardized programs for the diagnosis of psychiatric disorders in general medical practice. So in our opinion considering the resource approach in psychotherapy it is necessary to enhance preventive programs, which could develop the resource potential of the patients and the one which adjusts actions at the time of initial deviations, not allowing the pathology to be somatised.
Already for many years at Saint-Petersburg in the Russian Association of Prenatal Psychology Medicine (RAPPM) there has been an on-going process for the training and enhancement of psychologists and doctors in the field of resource and prenatal psychotherapy, with the conduct of conferences held with the support of SPbSU, D.O.Otta SRI AG. IN the last few years the RAPPM experts found common grounds with doctors of the clinic of traditional medicine “Amrita”, where methods of reflex therapy and resource psychotherapy are applied successfully in combination and there is a department of resource therapy headed by the author.
To work with pregnant women to prepare them for delivery we have introduced the “Gloria” program (Kovalenko N.P. 1998). To offer preventive and therapeutic help for women in their climacteric period (in combination with pathologies) we have introduced the “Camellia” program, which has clear therapeutic effect for women with psychosomatic problems. We have also developed diagnostic methods to work with patient’s family resource and to identify the causes of occurrence of psychosomatic disorders due to emotional traumas, incurred in the family.
The detailed study of the question of causes of psychosomatic disorders has given us the right to suppose that personal-environmental factors take up the leading place in the nest of somatic diseases . The results of scientific-research and therapeutic work for 10 years are discussed at the science conferences held by RAPPM and makes us suppose the following:
1. It is necessary to start teaching medical students the basics of psychosomatic medicine and resource psychotherapy at the earliest (along with the teaching of general patient handling in the second year or with teaching of internal diseases in the third year).
2. For doctors of general somatic hospitals, maternity homes, paediatric medical centers and polyclinics – Improve their knowledge of medical psychology and resource psychotherapy.
3. It is necessary to establish state funded resource centers in each city, which would handle problems like resource potential of individuals, families, groups, organizations, as well as would conduct preventive programs, which would increase citizen information level about the direct relation of psychiatry and somatic (spiritual and psychiatric) and one’s own responsibility for one’s health.
The questions about health are handled in preventive discussions: this reality is known to all. Human resources – these are the results of the human’s specific actions and attempts. This very thesis is the basis for the tactics of resource psychotherapy.
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