Psychotherapy with Children and Adolescents in the Soviet Union

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Psychotherapy with Children and Adolescents In the Soviet Union Nancy Rollins, M.D.

The opportunity to study child and adolescent psychiatry in the Soviet Union led to several published reports, covering a number of topics, including diagnosis, organization of psychiatric services, training, research interests, and theoretical orientation (Rollins, 1971,1972,1974). Seven months of personal observation in the Soviet Union during the course of three visits between 1966 and 1972 were supplemented by a review of some of the recent Russian literature.' The present discussion focuses on milieu therapy and psychotherapeutic techniques used by Soviet child psychiatrists and educators with children and adolescents. In none of the fields of inquiry mentioned have the observations been as complete or systematic as I would have wished, for travel and free access to people and institutions in the Soviet Union were still limited and subject to restrictive controls during the time of my visits. The transcultural approach to psychiatry holds an increasing appeal as professional exchanges gradually become more available. The perspective gained may be useful in reevaluating our own practice. In the case of emotional problems of young people, I found it of particular interest to see how such difficulties are often quite similar in the Soviet and American societies, and yet are dealt with differently in the Soviet Union, within the framework of a tradition alien to our thinking. Russian and American psychiatry shared the historical influences of the eighteenth-century French enlightenment, and the nineteenth-century German preoccupation with nosology and brain pathology. The common heritage included Charcot's studies of hypnosis and hysteria. However, the Dr. Rollins is an Associate in Psychiatry. The Children's Hospital Medical Center, and Clinical Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts. Reprints may be requestedfrom the author, The Children's Hospital Medical Center, 300 Longwood Avenue, Boston, Mass. 02Jl5. I The trips were under the allspices of the Citizen's Exchange Corps in 1966, and the Medical Cultural Exchange between the US and the USSR in 1968-1969 and 1972.

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trails began to diverge toward the end of the nineteenth century, when Freud and Breuer published their studies of hysteria and rejected hypnosis as the treatment of choice. In the U.S., many psychiatrists and educators became interested in psychoanalysis in the decades of the 30s and 40s. Russian psychiatrists at first showed a mild interest, then definitely rejected it in the mid-30s, but remained receptive to hypnosis and other suggestive techniques. A detailed historical review of American and Soviet treatment methods used with children and adolescents is beyond the scope of this presentation. A brief summary of the development of Soviet child psychiatry, utilizing American and Soviet sources, appears in an earlier study (Rollins, 1972). Suffice it here to draw attention to the contrast between the strong interest on the American side in expressive techniques revealing subjective inner emotional experience, and the emphasis on the Soviet side on studying objectively observable phenomena and techniques of controlling and modifying outward behavior. These broad trends, as we shall see later, appear now to be undergoing an interesting reversal. In Soviet medical teaching, a distinction is made between psychotherapy in its general sense, and in its special sense. The first of these refers to a recognition of the importance of the doctor-patient relationship in all branches of medicine, perhaps especially in pediatrics. Soviet psychiatrists have been observed by many, including myself, to develop warm, personal relationships with their patients, in contrast to the stereotype held by some Americans of a cold, mechanical, impersonal doctor functioning as an agent of the communist state. Sometimes, under the pressure of overloaded clinics, this natural Russian warmth becomes overshadowed by perfunctoriness and superficiality, especially in outpatient practice, where as many as five or six patients might be seen in an hour in a psychoneurological clinic for children. Psychotherapy in its special sense is thought of as a group of psychological techniques used with individuals or groups. These skills are taught to psychiatrists, pediatricians, gynecologists, physicians specializing in sexual pathology, and others interested in developing the psychic dimension of medical practice. Psychological techniques, particularly in dealing with groups, are also part of the armamentarium of therapeutic pedagogy, a discipline in the field of education. THE REGIME AND THERAPEUTIC PEDAGOGY

I n the early Soviet era, a residential treatment center for children with neurological and psychiatric problems was established in Len-

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ingrad within the Psychoneurological Institute named for V. M. Bekhterev, a renowned psychiatrist and educator. This center, known in 1926 as the Educational Clinical Institute for Nervous Children, combined the services of psychoneurologists and educators to provide a milieu therapy which stressed the importance of a regime of regular work, recreation, and rest for disturbed children. The children's treatment centers I visited in the 60s and 70s were still guided by a belief in the importance of the regime in the treatment of the neuroses, character problems, psychopathy, and mild schizophrenia in the young. The regimes, under hospital or sanitorium conditions, were used to achieve a state of tranquillity through a disciplined schedule of schoolwork with shortened class periods deemed necessary because of the distractability of many disturbed children. Each class period was followed by a IO-minute rest. The children were taught in small groups, supplemented with individual instruction. Outdoor recreation and rest were stressed, and practically no free time was allowed in the schedule. The Young Pioneer Organization had a chapter in one sanitorium I visited, supplementing other recreational activities. Mealtimes and recreation were strictly supervised. When conflicts developed between children, the educator, assisted by nurses and child care workers intervened. The educator studied the needs of the individual child, including his assets and remedial requirements, with the help of the child psychiatrist. The influence of the collective was utilized by the educator to motivate the children to modify their habits and behavior. This was achieved by dividing the children into competing groups, encouraging the weaker to help the stronger, rewarding the winning group, praising individuals generously for small successes, and occasionally using group censure and public criticism for undesirable behavior. In short, Soviet educators and child psychiatrists have evolved a system of behavior modification, which they call regime therapy, through the application of therapeutic pedagogy and manipulation of the collective. The Russian tradition goes back to the 20s; in American psychiatry, behavior modification achieved prominence in the late 60s. To illustrate Soviet use of regime therapy and their increasing interest in social rehabilitation and readaptation, which they call social psychiatry, let us consider the 40-bed department of rehabilitation for boys 12 to 15 opened in 1969. 2 The facilities in the mod2 The Twentieth Department of the Moscow City Psychoneurological Dispensary for Children and Adolescents with Hospital. under the leadership in 1972 of Alexandr Sergeeich Emilyanov.

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ern building where the department was housed in 1972 were impressive, including wards with 12-15 beds, an attractive recreation room, and workshops for wood and artistic objects. Children came here with severe adjustment difficulties, many with long psychiatric histories and previous hospitalizations. Common symptoms were running away, refusal to go to school, aggressive outbursts, unresponsiveness to discipline. Of 32 patients in the unit at the time, there were 3 with drug problems. One had taken a variety of drugs, including laudanum; a second, the doctors described as a hippy; a third was a juvenile alcoholic. Of their patients, 80 percent were diagnosed schizophrenic. The remainder of the diagnoses were psychopathy or pathocharacterological development of the personality due to unfavorable conditions of upbringing and family conflicts. The details of Soviet diagnosis in this area are a subject to be developed in a separate study. The school program was divided into four quarters of three months each. The average patient completed one or two quarters. Classes were limited to 12 students each since these youngsters were in need of special educational help. At regular school in classes of up to 40 students, they had lost all interest, had been criticized, punished, and labeled as "hooligans." The teachers here avoided criticism, worked hard to elicit interest, changing subject matter as frequently as every 20 minutes if necessary. Many patients required virtually individual teaching. Frequently, actionoriented children showed their best potential in the workshops. The regular regime of work, school, recreation, and rest was supplemented by cultural therapy, such as excursions to museums, movies, and the circus. Saturdays and Sundays, the children went home. They were frequently observed to return from these home visits in a poor mood. Work with the family was considered very important, but was only beginning, and such a program had not yet been conceptualized. Family work was carried out on an individual basis, partly by the educators. Occasionally, a nurse would make home visits. One of the children I shall call Pavel, a 12-year-old boy, was transferred from another department of the hospital where he had been admitted 4 months previously because of aggressive outbursts, suicidal threats, and refusal to attend school. Pavel was the only child of parents who had separated when he was 5. His father was in prison, with a childhood history of refusal to attend school, followed by disorderly conduct, drinking, and desertion. The paternal grandfather was alcoholic and did not work. The mother, too, had character problems and came from a disturbed back-

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ground. The maternal grandfather was aggressive and excitable, stole, ran away, and had been placed for a time in a colony. A maternal aunt was hospitalized at the time in a mental hospital. Pavel was born full-term into a chaotic family situation. Early feeding, walking, and speech development were not remarkable. By 3 years, Pavel was excitable and aggressive with other children in kindergarten and at home with his mother. He was stubborn and had tantrums, in which he would scream, stamp his feet, and pound his head. He would hit his mother and show no remorse. Pavel had developed tuberculosis by the age of 3, and for a time was placed in a sanitorium. In kindergarten, he learned with great difficulty because of his excitability and short attention span. He was always in conflict with other children and had to be the boss. In school, he showed poor self-control from the beginning. He would shout, throw down his notebook, walk out of class, and wander around in the streets seeking the companionship of other troubled children. In third class, transfer to another school resulted in repetition of the difficulties in all areas. In fourth class, Pavel was placed in a boarding school while his mother was hospitalized. Filled with defiance, he began to steal things at home, learned to smoke, hit his mother, stopping when she reacted visibly. By the sixth class, Pavel was spending much time in the streets. He began drinking vodka and would respond to his mother's attempts to discipline him with shouting, fist pounding, and suicidal threats. In the hospital, Pavel continued to be stubborn and uncooperative, doing the opposite of what was asked. He refused to carry out orders, disrupted the regime, blamed others for offending him, and complained about his mother and stepfather arguing. His mood was sullen, and he never showed pleasure. He also worried about his heart and had headaches. After transfer to the rehabilitation department, he bullied younger children, displayed much motor restlessness, but worked at his best in the workshop. He never apologized for any offensive behavior. When I saw Pavel, he wore a dour expression and exuded hostility. At first, he refused to sit down, and his answers were abrupt and clipped. He preferred this department to the other, knew he was here for illness, but denied believing he was ill. He also denied he never apologized. When we were discussing his attacks on other children, Pavel grew tense and began to play with his fingers. When I asked if he had any close relationships, Pavel became more upset, hung his head, and looked sad. He said he liked some kids, mostly those considered bad. He also said he loved his mother.

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In the discussion of the case, I noted this boy's avoidance of showing any warm or positive feelings, and suggested that his aggressive delinquent behavior could mask a depression due to his deprivation. This was a concept the doctors treating Pavel had not entertained. Their diagnosis was epileptoid psychopathy on a constitutional basis with physical and psychic infantilism. I agree that Pavel was a case of severe, internalized personality disturbance which might be called psychopathy, but I would stress the environmental factors, while my Soviet colleagues stressed the constitutional predisposition. It is worth noting that in spite of the pessimistic sound of such a diagnosis as epileptoid psychopathy, the attitude of the psychiatrists and educators I met in this department conveyed warmth and positive expectations for improved behavior. Much of the therapeutic interaction is provided by special educators trained in "therapeutic pedagogy." In addition to managing the collective for therapeutic purposes, they are in a position to take up with an individual child on the spot aspects of his disturbed behavior. While the emphasis on the collective and group conformity is real, there is also an appreciation of the children as individuals, with special needs. The remainder of this article deals with two quite divergent special psychotherapeutic methods as they are applied to children and adolescents in the early 70s. SUGGESTION AND AUTOSUGGESTION

Professor V. E. Rozhnov in Moscow has developed a variety of suggestive techniques, including individual and group hypnosis and autogenic training, a suggestive technique held in Soviet psychiatry to be related to, yet distinct from, hypnosis. Autogenic training, little known in the United States, was originated by J. H. Schultz in Germany and became widely accepted in Soviet psychiatry. Schultz observed that under hypnosis, spontaneous psychophysiological phenomena occur: vasodilation and muscular relaxation with accompanying subjective sensations. Reasoning that suggestion works best when it anticipates a natural physiological tendency, Schultz developed a standard series of exercises which train the subject to achieve a relaxed, tranquil state of mind, and to gain control over certain autonomic functions. Rozhnov's pupil, B. Z. Drapkin, and Drapkin's associate, N. E. Polyakova, were the first to apply these techniques to adolescents in a hospital program. Originally, they worked with stutterers (Drapkin, 1969), later with

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children with a variety of neurotic disturbances and mild schizophrenia. Drapkin's recently reorganized department in 1972:l had a full hospital where the patients first stayed all the time, later going home Saturdays and Sundays. Some patients would spend nights at the hospital, attending school or working outside the hospital during the daytime. Drapkin invited me on several occasions to observe his autogenic training sessions with his whole patient group, half of whom were boys and half girls, ages 12-16. Sometimes the sessions would be conducted in a school classroom; at other times, a less schoollike atmosphere was created by seating the patients in a large circle in a room without desks. Drapkin began one session with an educational talk. Sensitive people, he said, are subject to neurotic types of disturbance. A poor mood can make everything seem negative. In treatment, the word becomes a powerful tool, as in life. Words can kill or give life. In autogenic training, words are used to influence blood How. After creating a subdued atmosphere, and gaining the full attention of the young people, Drapkin would give a series of suggestions, as in the following translation of a taped session: There is not a thought in my head. My head is light, separate, apart. I will be at peace. I will be relaxed in all the muscles of my body. The muscles of my right hand are relaxed. I am at peace. My right hand is relaxed and is becoming heavy. I am at peace. My right hand feels all heavy. My right hand has become completely, completely heavy. I am at peace. The heaviness is going from my right hand into my left hand. I am at peace. My hands are very heavy. I am at peace. The heaviness is going Into my legs. My right leg is relaxed and has become heavy. I am at peace. My legs and hands are becoming weak and are becoming heavier. I am beginning to feel a sense of fullness in my right hand. I am at peace. My right hand feels full and swollen. My right hand feels as if it has been in hot water. I am at peace. My right hand feels full. I am at peace. [Rollins, 1972, p. 154]. Such a series of instructions would be given to a group who had been working several weeks, gradually increasing the areas of the body involved, and working from muscular relaxation to influencing blood How. One way of testing the effectiveness of the suggestions was to demonstrate a difference in temperature between two extremities. The suggestions might then progress to specific body 3 The Fifteenth Department of the Moscow City Psychoneurological Dispensary for Children and Adolescents with Hospital.

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regions: in the case of stutterers, relaxation of the musculature of the face and neck, and regular, deep respiration. The stuttering patients were shown they could speak normally if they could achieve and maintain a state of relaxation. However, the more impOl"tant use of the technique was to achieve a happy, confident state of mind. This is worth comment, since one American objection to the use of suggestive techniques is that they are devoted only to symptom removal, with no concern for the patient's state as a whole. The sessions were always ended with the suggestion that after a certain count, the patients would waken in an alert, refreshed state of mind. The patients were trained to continue the technique independently at home on a regular basis. Hypnosis in small groups of five or six boys and girls was also used, to achieve a general state of well-being and at times to modify specific symptoms. In the case of stuttering, the intervention was directed to the neurotic overlay of fear, self-consciousness, and progressive social withdrawal. The adolescent stutterer, in Drapkin's view, becomes more and more imprisoned as he gives up using the telephone, answering in class, going to stores, communicating with friends. Suggestions were never given beyond a patient's capacity. I never heard Drapkin suggest that a psychiatric symptom vanish. In handling enuretics, he might give the suggestion that the urge to urinate will be consciously experienced and will awaken the patient if he is sleeping. The general atmosphere of the department must surely contribute to the success of these therapies. Drapkin and Polyakova showed a warm interest in their patients, and an appreciation of their adolescent needs and creative potential. Drapkin showed me a collection of his patients' drawings and paintings which revealed extraordinary creative ability. There were studies of old women with shawls over their heads, bathers on a pebbly beach, and many others which caught the spirit of Russia in a remarkable way. One 16-year-old boy had done a skillful woodcut of trees in a forest. When I admired it, Drapkin asked the boy if he would give it to me. The youngster came in and presented it to me with a polite bow, inscribing it on the back with his name, in memory of the American doctor. He had been diagnosed schizophrenic. His main symptoms were fears of death and supernatural preoccupations bordering on the religious. These he expressed in paintings of spiritual figures with wings and much use of blue tones. When he did the woodcut, he had been thinking of Cleopatra's death and the composer Berlioz. His treatment included autogenic training and a combination of Stelazine 10-30 mg. and Librium 30 mg.

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daily. In the autogenic training session I observed. he asked to leave the room, was granted permission, and later returned voluntarily. It is noteworthy that the hypnotic and autosuggestive techniques I observed were not used to encourage expression of affect, fantasy, or hidden conflict. But other aspects of the program did include an expressive element. In addition to art and crafts, the children were asked to keep notebooks in which they wrote on their values, what they wanted From treatment . what they liked and disliked about the program . Creative expression was also encouraged in the social events on the ward where the young people gained social experience and developed their abilities in dance, song, and musical instruments. One of the stutterers in Drapkin's program was a l-l-year-old girl I shall call Zoya, who had additional symptoms in the form of fear of loud noises and insomnia. For American psychiatrists, accustomed to psychodynamic investigations of their patients' life histories, this and other Soviet case studies may seem less than adequate. Although information about her fears and their sources was lacking. Zoya was chosen to illustrate a common problem treated by suggestive techniques in Soviet practice, and to show the Soviet emphasis on neurophysiological components of ps ychiatric disorders. The available famil y history revealed that the mother, a scientific worker, had begun to stutter at around 4 years of age and later improved. while the father, an engineer. was a quiet, withdrawn man who had also stuttered mildly. There was one sister. 9 years old. The mother had had seven subsequent abortive pregnancies, about which Zoya supposedly knew nothing. As an infant Zoya was weak , with poor weight gain for the first 3 months and frequent crying for the first half year. At around 7 months, she experienced two episodes of loss of consciousness and clonic movements, with no recurrences after anticonvulsive therapy was started. When she was 2, Zoya suddenly started talking clearly in complete sentences. Before this, she gave evidence of understanding what others said. Her stuttering began suddenly at 5 years after a fearful incident which caused her to cry and scream. When Zoya was 8, she began to have compulsive movements of her arms and legs, sometimes episodic, and at other times prolonged, accompanied by tension . She played with other children, answered in class, but began to refuse to answer the telephone . By 14, she preferred younger children and was still playing with dolls. She was slow in her schoolwork, frequentl y absent , and in school was observed to daydream a lot.

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Physical examination revealed signs of residual neurological deficit with no clear-cut localization. The skull X-ray showed signs of minimal hydrocephalus. On the ward, Zoya was passive, interacting little with other children except when playing a favorite game. She had a habit of repeating a sentence three times, shifting the word order around. This was taken to be organic perseveration, rather than compulsive repetition. Little stuttering was observed. Zoya would demand that other children be quiet, even when there was little noise. She said she needed no friends; at home, she was content to play with her sister. At times, she reported a visionary experience, always with the same content. She was treated with Gamalon, a Japanese preparation to improve brain metabolism, Librium, glutamic acid, vitamins, and Medocal. She also received physiotherapy and dehydrating agents. These measures were directed toward the nutritional deficiency and the minimal hydrocephalus. She was also in the autogenic training program. Her parents and her doctors found her improved. Her speech was better, and the compulsive movements disappeared, except when she watched scary movies at home on TV. When Zoya came in to talk with us, she was a slender child, short in stature, looking more like a 9- or IO-year-old, with no adolescent development. Her bright red hair was done in pigtails, and she wore a brown dress which looked like a uniform, although the children in the department dressed as they chose. She sat stiffly in her chair, her body full of tension, hands folded behind her back, as if to inhibit their movements. She spoke in a high nasal voice with a babyish quality. The stuttering became obvious while she was discussing a frightening film and when I asked about nightmares. She denied specific fears, except of dogs. Drapkin thought Zoya was free of fears and that her stuttering was on an organic basis. I thought the history of onset of stuttering after a fearful incident, the insomnia, the exacerbation of stuttering while watching frightening movies, her failure to deal with adolescent issues, and the high degree of tension she showed with us were all signs of being quite fearful. She was still a child, emotionally and physically, nowhere near her adolescent agernates. The history of seizurelike episodes and evidence of mild neurological residue point to some minimal central nervous system dysfunction, but in my view it would be difficult to determine how this was related to the speech problem. I felt this little wisp of a girl would have a miserable time in a big regular school, surrounded by robust, sexually developing adolescents. I felt she would react with further efforts to retreat into childhood.

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Would suggestive therapy benefit such a patient? Would she have responded better to some form of expressive play therapy to help her to verbalize the fears I thoug-ht I detected? Did she need the protective atmosphere and emotional support of a controlled milieu so that she could relax, speak more freely, and approach adolescent issues? In Boston, she would have been offered individual expressive therapy. There would have been no medication, autogenic training, or residential treatment. Perhaps the reader will have still other ideas about how to treat Zoya. THE THERAPIES EVOLVING IN LENINGRAD

A different therapeutic tradition has evolved in Leningrad at the Institute named for Bekhterev under the leadership of V. N. Myasishchev (Rollins, 1972). For him, personality is a "system of social attitudes reHecting external reality, especially relationships with other people" (p, 17). But the person also acts and changes reality. Myasishchev stressed the historical dimension and the element of conHict in the dynamic process of development of the individual into a socialized being with a hierarchy of values. He acknowledged the importance of the early childhood years and the child-rearing practices in the family. However, the inHuence of other collectives on the growing child is important, too, in Myasishchev's thought; earlier developmental trends are molded and modified by later experience. It is this flexibility we count on when we apply psychotherapeutic techniques to correct earlier adverse influences. Myasishchev viewed neurosis as a result of conHict between individual development and the social-historical process in the surrounding environment where such tension is generated that there is no outlet or possibility of resolution. While acknowledging social determinants, he also considered constitutional neuropathy and residuals of early central nervous system damage important, particularly in children. Myasishchev's "neurosis of development" is a gradual internalization of faulty reaction patterns, ending up in a personality distortion, with poor attitudes, tension in interpersonal relationships, and disorganizing reactions of hostility, fear, and deceit. Myasishchev developed a therapeutic approach to the adult neurotic patient called pathogenetic therapy. He believed the two effective factors in psychotherapy were suggestion and persuasion. Suggestion is a nonverbal process, while persuasion is a "rational" process, depending on the power of the word, mediated through the second signal system. The therapeutic task is to make contact

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with the "pathogenetic point," a term borrowed from Pavlovian thought meaning a "point of pathological sensitivity and excessive irritability, leading to neurotic predisposition" (Rollins, 1972, p. 21). This is done in exploratory interviews with the patient, designed to expose the connections between the patient's symptoms and his life situation with its inherent conflict. The first aim is to make the patient aware of these connections. This is a tacit recognition of the importance of unconscious determinants both in producing neurosis and in the therapeutic resolution of neurotic conflict, but the unconscious is not explicitly dealt with in Myasishchev's thought. The second task is to help the patient achieve a shift in his attitude toward his life situation. The past is considered only insofar as it is dynamically connected with the present conflict. Myasishchev believed character distortions are particularly amenable to treatment with pathogenetic therapy, while other types of illness, e.g., psychosomatic disorders, responded better to suggestive therapies. The opportunity to talk personally with Myasishchev was granted in 1972, although by this time he had retired from fulltime work at the Bekhterev Institute. It was a welcome chance to explore further several questions stimulated by the earlier visits and a review of his written works which had given me a sense of the importance of his thinking in Soviet psychiatry. Soviet psychiatrists, referring to Myasishchev's type of psychotherapy, frequently called it rational psychotherapy, since persuasion and the word are considered the effective therapeutic factors. This concept turns out to be not quite accurate. Myasishchev explained to me that rational psychotherapy originated with Dubois as an attempt to persuade the patient of the irrationality of his fears. But then, according to Myasishchev, the patient replies, "That's all very well, doctor, but I'm still afraid." With a twinkle in his eye, he added, "Psychoanalysis was the first attempt to apply pathogenetic therapy." He reiterated the need to bring the patient to the awareness that his symptoms were connected with his situation. Jung, Adler, and the post-Freudians, he said, understood how feelings of inadequacy and inferiority were related to symptoms, but at the basis of it all are "unfavorable conditions of upbringing." He added, Dubois did not correctly understand the role of history in symptom formation. Since the term "rational psychotherapy" had implied to me an intellectual exercise to get the patient to see the absurdity of his fears, I attempted to find out whether Myasishchev was claiming psychotherapy to be an intellectual process. "Psychotherapy," I said, "we understand to be an emotional process, not purely an in-

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tellectual one." Myasishchev agreed he, too, regarded therapy as an emotional process, adding, for some reason not clear to me, that this point of view was good Marxist thinking. The emotional nature of the therapeutic process led into Myasishchev's understanding of transference. "What," I asked, "is your concept of transference of attitudes, for example, from the father to the doctor?" His reply indicated his recognition of the importance of the positive father-child relationship, especially the child's trust, and his faith in the father's ability to protect him from harm. He stressed the positive transference to the doctor as an essential condition for an effective therapeutic relationship, just as a similar father-child relationship is a requirement for healthy child development. For this reason, he added, it is better for the patient if he does not have to pay the doctor. The doctor-patient relationship, he said, should be based on something other than economics. Soviet psychiatrists are trained to an awareness of a political dimension in all aspects of their practice, although it was not extensively discussed in my presence (Rollins, 1973). Myasishchev's remark left: me wondering whether he was being inconsistent. Did not Marx claim all human relationships are based on man's economic relationship to man? Furthermore, I asked myself, if the doctor-patient relationship is to be on some other basis, does this not increase the danger of irrational, not always benign motivation to treat patients? Application of Myasishchev's ideas in the Adult Clinic for the Neurosis at the Bekhterev Institute has led to increasing interest in studying the family, and an attempt to relate specific faulty childrearing practices to particular types of neurosis and neurotic personality development. The lack of penetration of Myasishchev's ideas into the field of child psychiatry had puzzled me in 1969, since his thought was so relevant to the understanding of child development and the psychopathology of childhood; so I asked Myasishchev in 1972 why the children's department of his own institution was so exclusively preoccupied with epilepsy, in view of his ideas on neurotic development from the earliest years of childhood. His influence, it seemed, was felt more in the adult department than in the child department. He replied that for his ideas to be assimilated, a restructuring of the theory of personality had to occur, and a functionalist point of view had to prevail over formalism. I think he meant the decisive factor to study is functional change, both physiological and psychological, instead of change in morphological structure. The interest of the staff of the adult clinic in family rela-

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tionships influenced a young child psychiatrist, A. I. Zakharov, to develop play therapy techniques with children and an approach to the family of the child patient. As far as I know, he was the first Soviet child psychiatrist to develop such techniques. Zakharov said he had been influenced by Myasishchev's ideas concerning childhood upbringing, the neurosis of development, and pathogenetic therapy. He had also read the Russian edition of Freud's works, published by Ermikov in the 20s, and was aware of the concept of mechanisms of defense developed by Anna Freud. While receptive to much in psychoanalytic thought, he remained critical of attempts to explain neurosis solely on the basis of libidinal conflict. Zakharov was working in a new interdisciplinary clinic in Leningrad for the study of the neuroses of childhood from several points of view." The collaborators were a psychoneurologist, a psychotherapist, a neurophysiologist, two medical psychologists, and one speech therapist. The neurophysiologist was using EEG, EKG, psychogalvanic skin responses, and other variables to explore the organic base they believed to exist in some neuroticlike syndromes. A special interest was the investigation of sleep disturbances, using the EEG. The medical psychologists studied both the patient and the parcn ts with psychological tests, incl uding projcctivc methods, They had little, if any, ideological objection to the use of such instruments as the TAT, Draw-A-Person, Wechsler-Bellevue, and Stanford-Binet, with corrected norms for their population. Zakharov, the psychotherapist, had equipped his office with play materials, especially puppets, masks, and drawing materials. His procedure was first to hold individual diagnostic interviews with the parents to assess the conflicts in the family. Next, he would see the child alone for a free-play interview to reveal the child's perception of family conflicts and the child's role in the family. The third step was to work out with the family a "scenario" of the child's difficulties. Zakharov would then see the child and act out with him the scenario, using role reversal. For example, if the child feared his father, the child would be asked to play the father role. The fifth step was to bring the child and family together and replay the scenario, with the child playing parental roles, and the parents taking the part of the children. The final stage was another family session in which everyone returned to his own role. U nfortunately, there was no time to hear case illustrations of this technique. Another outgrowth of the Leningrad school was the work of A. E. Lichko with adolescents. He had been studying the incidence 'City Specialized Department for the Treatment of Neuroses of Childhood. Children's Polyclinic No. 26. Leningrad.

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of various character types in a normal population of adolescents, and comparing them with the incidence of the same types in a patient population in a psychoneurological hospital who had a mixture of psychiatric disorders." One of Lichko's major ideas emerging from this study was that adolescent conflict with parents stems from discrepancies between their self-evaluations and their evaluations of each other with respect to basic character and needs. He remarked that he found adolescents better judges of their parents' character than vice versa. His therapeutic technique was to bring the patient and his family to an awareness of the patient's real character, and to foster a better understanding of the patient's underlying needs. However, Lichko observed that many adolescents are at war with their families, although the official Soviet view is that adolescence need not necessarily be a period of turmoil. In his cases in which conflict with the parents had made the patient impervious to parental control, he noted how susceptible such teen-agers are to peer-group influence. He began to invite close friends of these patients to come and talk with him at the hospital, appealing to them for help, and soliciting their opinions as to what measures would be useful. He found them strongly impressed to see their friend in a psychiatric hospital, and willing to be helpful. After listening to their ideas, he would interpret to the friends his concept of the patient's illness, basic character, and needs for support and reassurance. One of Lichko's patients was a boy hospitalized for pathological sensitivity to alcohol, which Lichko took to be based on "diencephalic insufficiency." The boy's basic character type was conformist, the commonest type in Lichko's classification. While he rebelled strongly against his mother, he conformed consistently with the values and expectations of his peer group. Lichko invited the leaders of the group to the hospital, elicited their cooperation, and explained their friend was ill and could not tolerate alcohol. By this intervention, Lichko succeeded in obtaining environmental support to stop the patient's self-destructive drinking. The second example he gave was of a boy, also of the conformist type, with many traits of emotional lability. Basically, Lichko saw him as dependent, "in need of constant psychotherapy" from his peers, who, unaware of his deeper needs, were constantly criticizing him. Lichko invited the captain of the patient's basketball team to come , Lichko's research is described in another paper (Rollins, 1974). The commonest character type Lichko found in a normal population of adolescents in Leningrad was the conformist. His method was to compare self- and parent-evaluations of the adolescent on a series of items pertaining to personality and attitudes.

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to the hospital, and explained that the boy needed encouragement and support, not criticism. DISCUSSION

The techniques of autogenic training and hypnosis may be particularly applicable to symptoms under mixed autonomic and voluntary central nervous system control. Common examples in children are enuresis, soiling, asthma, and cyclic vomiting. While hypnotic techniques have been developed in the United States, they have not become widely accepted in psychiatry, and there is even more reluctance to use them with the young. It may be time we overcome the prejudice against using and teaching suggestive techniques. Asthmatic patients who benefit by breathing exercises might be greatly assisted in achieving a state of calm and relaxation by the use of autogenic training. The addition of suggestive techniques to our therapeutic armamentarium in child and adolescent psychiatry need not mean an abandonment of psychodynamic insight. A comprehensive theoretical framework is needed in psychiatry to recognize the multiple levels of organization of living matter involved in the formation of psychopathological syndromes. The law of qualitative change in the thought of Engels and Marx states that with increasing complexity in the organization of matter, a point is reached at which there is a qualitative shift, and a new set of laws begins to operate. If this principle can be said to apply to normal human functioning, it must also apply to abnormality. To illustrate these ideas about a common childhood symptom, hyperactivity, we would begin with an attempt to determine which level of integration was primarily responsible for producing the disturbance. If early minimal brain damage has left residuals, or if there has been a developmental lag in the maturation of the central nervous system, it might be said the child is overactive because of a disturbance originating at the neurophysiological level. If the nervous system is intact, and free-play interviews show evidence of much aggressive fantasy and fear of bodily injury, perhaps the child is overactive to ward off castration anxiety and feared passivity. This would be an intrapsychic conHict. Or far too commonly, the diagnostic investigation uncovers globally disturbed family functioning, and the child's hyperactivity reHects emotional deprivations and a chaotic lack of order and discipline. Since nothing in medicine is clear-cut, we often find children who are hyperactive because of disturbances at all three levels. At which level would intervention be appropriate?

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The levels most relevant for child psychiatry are in the neurophysiological plane at which psychopharmacological agents operate; the psychophysiological plane at which exercises, regIme therapy, and suggestive techniques operate; the intrapsychic plane, represented by various individual expressive therapies; the microsocial plane at which family therapy operates; and finally, the plane of larger groups, the social system in which the patient lives. At this level. correct ive in terven tion takes on a sociopolitical aspect. The current controversy in American psychiatry over the degree to which political action is the proper business of psychiatry is beyond the scope of this discussion. In a comprehensive psychiatric orientation of this kind, some troublesome dichotomies disappear, and we may find there is room for a variety of therapies, such as the Soviet techniques described (regime therapy, autogenic training), as well as our American techniques (psychodynamically oriented psychotherapy, family thera py, behavior modification). The relevant questions are: At which level will intervention be effective- Are multiple levels of intervention necessary to move the situation? Another dichotomy which becomes untenable is the one which opposes individual psychotherapy and therapy devoted to the family as a small social system. In some cases, the intrapsychic approach will be the most important intervention. I believe this is true especially in articulate children who are aware of suffering and wish to change. In others, when the conflict is largely between the child and his environment, as it was in Pavel. a family approach may be more fruitful. In still another group, a combination of individual and family treatment, either concurrently, or one technique superseding the other, may be indicated. In the case of Pavel, should a family approach improve his environment to a point at which the boy could give up his defensive hostility, he might come to feel his loneliness and sadness. At this point, he might respond to individual. psychoanalytically oriented psychotherapy. Finally, there need not be a dichotomy between suggestive techniques and psychoanalytically oriented techniques. To use the example of asthma, breathing exercises could be incorporated in an autogenic training sequence to promote relaxation and to diminish anxiety. Expressive play therapy could be conducted concomitantly to explore frightening suffocation fantasies and their dynamic connection with both the wheezing and the child's significant emotional experiences, such as situations of separation or competition. If American psychiatry were to include suggestive techniques and regime therapy in the therapeutic armamentarium, as I believe

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would be desirable, would this mean we can move toward a comprehensive psychiatry, a blend of east and west? Before we venture to answer this question, let us reconsider one conclusion I reached in the study of 1972: Treatment in the USSR acts to desensitize or perhaps to insulate the patient from a frustrating environment . . . there is little or no attempt to change the environment. The forms of treatment growing out of the psychoanalytic movement in the United States have acted to sensitize the patient and his family to the interpersonal environment, to experience and to work through conflict, and in some instances to modify the environment. The stress on sensitivity seems to me to be related to a paradox in our society: severe communication difficulties in the land of free speech [Rollins, 1972, p. 240]. There was, I concluded, need in the United States for a higher degree of ability and sophistication in communication because of the melting-pot features of our society. Americans, to achieve an adequate social adaptation, need to transcend cultural and ethnic differences and to tolerate diverse points of view. I now must report that these trends appear to be reversing themselves. In the United States, the child work of the early 70s showed a trend away from catharsis and expression toward behavior modification, manipulation of the family system, and psychopharmacology. In contrast, expressive play therapy was just beginning in Leningrad. In one sense, American techniques were becoming more like Soviet techniques of the recent past, while Soviet therapies were becoming more like psychodynamically oriented psychotherapies evolved in the United States. Both Soviet and American psychiatrists were recognizing the importance of work with families. Perhaps this simply means the world is becoming smaller, and influences are spreading more easily. I doubt this, since there was still a great chasm between Soviet and American society in the early 70s, and little professional dialogue had developed. The observed trends should rather be taken to reflect the historical and social evolution within two cultures, each at a different point in a great spiraling movement: destruction of existing forms, social dislocations, and revolutionary foment; organization, ossification, and reactionary conservatism; growing maladaptation and discontent complete the spiral, and a new loop of the spiral begins with revolutionary movements." 6 While the reactionary phase tends to revert to a position resembling an older form. the movement is not only circular. as the new form is never identical with the older one. Therefore, the analogy of a spiral is more correct than that of a circle.

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Seen in this light. the United States of the early 70s was entering a reactionary phase. Excesses of expression and permissiveness had led to chaos. The broad social need of the time was for organization, stability. and new form. The movement away from expressive therapies reflected this need. Soviet society of the same era had become ossified into rigid forms, and the intellectuals were rumbling in discontent, demanding freedom of expression. Leningrad has traditionally in prerevolutionary and Soviet times played a leadership role in initiating intellectual movements. It was Leningrad which developed the expressive therapies and recently expanded their application to the young. So the psychiatry of each society reflects the culture, and to some degree corrects for cultural deficits. What impresses me most now is the dynamic quality of this process of continual change and its spiral movement. In conclusion, a comprehensive psychiatry remains an ideal to be striven for. The positions of American and Soviet society on the revolutionary spiral in 1972 were not identical. So the divergent points of view in their respective psychiatries can be expected to persist. This does not mean we cannot learn from each other. It does mean the question of who is ahead of whom is an absurdity. Furthermore, the methods of one cultural setting may not be directly applicable to another culture without modification. Again, I conclude, to each his own, with some understanding of the other. REFERENCES DRAPKIl';. B. Z. (1969). Untitled paper on psychotherapy of stuttering in adolescence, MS. Moscow. LICIIKO. A. E. (1971). 0 razrabotke kharakterologicheskogo diagnosticheskogo oprosnika dlya issledovaniya v podrostkovoi psikhiatrii [On the construction of a characterological diagnostic questionnaire for research in adolescent psychiatry]. In: Klinilw-psikhologicheslcie issledouaniva lichnosti [Clinical-Psychological Studies of Personality1 ed. V. N. Myasishchev, B. D. Karvasarskii, L M. Tonkanogii. Leningrad: Leningradskii Psikhonevrologicheskii Institut im V. 1\1. Bekhtereva [Leningrad Psychoneurological Institute named for Bekhtercv], pp. 165-170. MYASISIILIIEV. V. N. (1!160). Prrsonnlit» and Neuroses (joint Publications Research Service). Washington. D.C.: U.S. Department of Commerce. t963. Otchet 0 deyatelnosti vospitatelno-khnicheskogo instituta dlya nervnykh detei imeni Akademika V. M. Bekhtereva Psikho-nevrologicheskoi Akademii [Account of the Activity of the Educational Clinical Institute for Nervous Children Named for Academician V. M. Bekhterev, of the Psychoneurological Academy] (1926), Vaposy izucheniya i vospitaniya lichnosti [Questions in the Study and Training of Personality]. 2/3:231-234. ROLLINS, 1'\. (1971), Is Soviet psvchiatri« training relevant in America? A mer. J. Psychiat., 12H:622-1i27. - - (1972), Child Psychiatry in the Soviet Union. Cambridge, Mass.: Harvard University

Press. - - (1974), Soviet and American youth in a changing world. Austral. NI!W Zeal. J. Psychiat., H: 149-15:t SClflIt.TZ. .J. H. & LPTlIE. W. (1932).AlItogmic Training. New York: Grune & Stratton, 1959.