Complex approach to the treatment of border neuropsychiatric disorders in the non-state scientific and practical center "Psychotherapy" The monthly reviewed scientific and practical journal "Psychotherapy" 2011 No. 12 (108) PAS .20-25 !!Sgibov Vladimir Nikolaevich - academician of the Russian Academy of Natural Sciences and the Russian Academy of Medical Sciences, Doctor of Medical Sciences, professor, chief psychotherapist of Penza, director of the Scientific and Practical Center "Psychotherapy", full member of the PPL, psychotherapist of the Unified Register of Professional Psychotherapists in Europe ( Penza)!! !!Kocherganov Pavel Nikolaevich - candidate of medical sciences, deputy director of the Scientific and Practical Center "Psychotherapy", full member of the PPL, (Penza) !! !!Ksenia Vladislavovna Bobro - medical psychologist of the highest category, head of the psychological service of the Scientific and Practical Center "Psychotherapy", full member of the PPL, (Penza) !! The structure of the organization of integrative psychotherapy in the non-state Scientific and Practical Center “Psychotherapy” is revealed. The principle of a differentiated, step-by-step, integrated approach to the treatment of patients with borderline neuropsychiatric disorders, carried out with the help of a multiprofessional team, is proposed, allowing for the implementation of outpatient psychotherapeutic programs of any complexity using a whole range of evidence-based methods, forms and types of psychotherapy. Key words: Scientific and Practical Center "Psychotherapy", multiprofessional team method of treatment, the principle of a differentiated, step-by-step, integrated approach to the treatment of patients with border-line neuropsychic disorders Team approach to the treatment of the border-line neuropsychic disorders in the non-state Research and Practical Center “Psychotherapy”. Sgibov VN — Academician of Russian Academy of Medico-Technical Science and Natural Science, Doctor of Medical Science, Professor, Head psychotherapist of Penza, Director of the Research and Practical Center “Psychotherapy”, Full Member of the Professional Psychotherapeutic League, psychotherapist of the Unified Register for Professional Psychotherapists of Europe, (Penza) Kocherganov PN— Ph.D. in medical science, Deputy Director of the Research and Practical Center “Psychotherapy”, Full Member of the Professional Psychotherapeutic League, (Penza) Bobro KV— medical psychologist, leader of the psychological service of the Research and Practical Center “Psychotherapy”, Full Member of the Professional Psychotherapeutic League, (Penza) The structure of the integrative psychotherapy in the non-state Research and Practical Center “Psychotherapy” has been cleared up. The principle of the differential staged complex approach to the treatment of the patients with the border-line neuropsychic dissociations has been proposed. This principle is performed with the help of the multiprofessional team, allowing to realize ambulant psychotherapeutic programs on different levels of complexity using the whole spectrum of scientifically grounded methods, forms and types of psychotherapy. Key words: Research and Practical Center “Psychotherapy”, poliprofessional team method of treatment, principle of the differential staged complex approach to the treatment of the patients with the border-line neuropsychic dissociations Dedicated to the tenth anniversary of the Penza Scientific and Practical Center “Psychotherapy” Modern pathomorphosis of neuroses with the complication of their clinical picture, the increase in the proportion of protracted and chronic forms, the ever-increasing number of patients with neuroses determines the modern strategy and tactics of providing assistance to such patients. [1] According to the chief psychotherapist of Russia B.D. Karvasarsky (2001), “it is absolutely obvious that today it is impossible to provide full psychotherapeutic assistance in the conditions of medical institutions. Only large psychotherapeutic centers can significantly change the level of provision of this assistance and improve the training of the personnel necessary for this.non-state forms of ownership.” In order to fulfill this task, the Penza Scientific and Practical Center “Psychotherapy” was opened in December 2001. Employees of the Federal Scientific and Methodological Center for Psychotherapy and Medical Psychology, the Russian Psychotherapeutic Association and the Professional Psychotherapeutic League took part in its organization and preparation of scientific and methodological programs. [3]Currently, the Scientific and Practical Center “Psychotherapy” is a multidisciplinary treatment and preventive institution that carries out scientific, medical and educational activities. The center employs medical psychologists, psychotherapists, psychiatrists, a psychiatrist-narcologist, a neurologist, a speech therapist, a sexologist , as well as representatives of traditional medicine: reflexologist, specialists in medical massage and exercise therapy. There are 15 employees in total, of which 1 is a Doctor of Medical Sciences, 4 are a Candidate of Medical Sciences, 1 is a Candidate of Pedagogical Sciences. All employees of the center have the highest or first qualification category. The Psychotherapy Center is the only non-state specialized psychotherapeutic institution in Penza and the Volga region of the country, which implements outpatient psychotherapeutic programs of any complexity using a whole range of evidence-based methods, forms and types of psychotherapy .The leading approach in the diagnosis and treatment of the Center is clinical psychotherapy, which is carried out in out-of-hospital conditions, where it is possible to satisfy almost any request of a person seeking help. All this provides, in full, qualified diagnosis and comprehensive treatment of neurotic and neurosis-like disorders. At the center “Psychotherapy” uses a multiprofessional team method of treating patients with borderline neuropsychiatric diseases. The team of specialists is headed by an experienced psychotherapist who draws up individual treatment and rehabilitation programs for each patient and coordinates the work of the team. [4] The principle of a differentiated, step-by-step, integrated approach to the treatment of patients with borderline neuropsychiatric disorders has been proposed (Sgibov V.N., Nikolaev V.M., 2002). [5] This approach is carried out using modern equipment and effective treatment methods, collected in one place: psychotherapy and psychological correction, psychopharmacotherapy, reflexology, bioresonance therapy, herbal medicine, aromatherapy, medical massage and exercise therapy. All treatment is based on an accurate and comprehensive diagnosis: psychological diagnostics, clinical diagnostics, bioresonance diagnostics, electropuncture diagnostics. The latest achievements and experience-tested knowledge in the field of psychiatry, psychotherapy, psychology, sexology, neurology and traditional medicine are collected in a single complex. In the etiopathogenesis of neuroses and neurosis-like conditions, biological, psychological and social mechanisms are combined. Naturally, the therapeutic effect should be aimed at all these factors. This principle consists in a careful assessment of the specific gravity and specificity of the action of each factor in a given particular case. Depending on those or other mechanisms in the genesis of a neurotic state, much attention is paid to psychological, social and biological methods of treatment. Treatment combines differentiation and complexity with a focus on individual cases of diseases, represented by a combination of three therapeutic methods - biological, psychological and social. [6] The fundamental basis of the concept of this approach to the treatment of borderline neuropsychiatric disorders is that treatment is aimed at restoring and maintaining a harmonious state of the internal environment of the body in interaction with the external environment. The implementation of the therapeutic program is carried out differentiated for each specific patient, which makes it possible to implement the basic tenet of healing: “Treat is notdisease, but the patient.” This differentiation allows you to build a complex therapeutic effect individually and reasonably, combining causal (individual and group pathogenetic psychotherapy) and symptomatic (individual and group hypnosis, auto-training) treatment with the most studied methods of traditional medicine: herbal medicine, reflexology, aromatherapy, medical massage and exercise therapy. At the same time, the psychotherapist’s main attention is paid to the study and restructuring of the patient’s personality, his value system, relationships with the outside world, restoration of the fullness of his social functioning, while other elements of complex treatment serve to intensify and deepen this main task. Development of individual therapeutic rehabilitation programs allow us to carry out the complexity of therapeutic effects and their stages already at the patient’s initial treatment. Collaboration of doctors of related specialties significantly increases the effectiveness of treatment and reduces its time. Individual use of psychotherapeutic techniques (gestalt therapy, spiritually-oriented therapy, body-oriented therapy, etc.) in combination with reflexology, accompanied by music therapy and aromatherapy leads to the activation of the body’s sanogenic resources, a decrease in emotional stress, and to the patient’s conscious construction of an individual plan for overcoming his painful illness. condition, building confidence in recovery and discovering new opportunities to manage your body. The main method in the general therapeutic complex is psychotherapy, represented in modern practice by many forms and techniques, which is based on the principle of stages. We have developed a program of an integrated approach to the treatment of patients with borderline neurological disorders. mental disorders. The program consists of five stages: diagnostic, activating, reconstructive, training and supporting. [7] Pathogenetic biological therapy included: pharmacotherapy, reflexology, physiotherapy, medical massage and exercise therapy. Various types of individual, family and group psychotherapy were used. At the first, diagnostic stage, contact is established with the patient, his experiences, features of the social environment, family relationships, personal characteristics that contribute to the occurrence of a mental disorder and are a reserve for the patient’s adaptation are clarified and clarified. The main psychotherapeutic The methods of the first stage are explanatory psychotherapy and hypnosuggestive psychotherapy. We used explanatory psychotherapy in combination with rational psychotherapy in cases where the patient had already formed incorrect ideas about the occurrence and course of the disease. In the process of conversations with the patient, a correct logical understanding of the cause-and-effect relationships of the occurrence and course of his illness was built, which makes it possible to directly influence the world of the patient’s ideas through persuasion and is considered as treatment with information on the basis of which new attitudes for the future can arise. As a result of psychotherapy, disappears “lack of information”, and the patient gains an understanding of the origin of the disease, the patient’s hidden resources are mobilized to overcome his illness, the level of stress decreases, which allows him to make his life plans more rationally, and faith in the doctor is strengthened. The “internal picture of the disease” is optimized, especially its emotional and intellectual parts. Hypnosuggestive psychotherapy at this stage is carried out with the aim of inducing a mitigation of affective experiences (anxiety, fear), improvement of the general condition and mood. Great importance was given to indirect psychotherapy in relation to a strictly individualized motor mode and drug therapy, including psychopharmacotherapy. The use of psychotropic drugs at this stage is necessary for general strengthening therapy, reducingemotional stress, normalization of sleep. For this purpose, drugs that have minimal side effects are used: tranquilizers, mild antidepressants, nootropics. The drugs are used in small therapeutic doses, usually in short courses. In addition, phyto- and homeopathic drugs of various types were used (sedatives, restoratives, stimulants). At the diagnostic stage, a therapeutic team of specialists carries out an initial examination of the patient, each specialist in his or her own profile. A psychotherapist collects anamnesis, clinical examination (psychopathological, neurological, somatic and, if necessary, paraclinical). A medical psychologist conducts experimental psychological and pathopsychological research (study of personality structure, type of accentuation, features of personal response, specific mechanisms of psychological defense and adaptation, features of psychological mechanisms of the occurrence and development of the disease, symptom formation, features of the realization of personal capabilities, the presence and nature of motivation to participate in treatment and rehabilitation activities, the possibility of compensatory mechanisms, etc.). The data obtained are jointly discussed by a team of specialists in order to establish a “multi-axial diagnosis”. Data that is essential for establishing a diagnosis and for developing a program of treatment and rehabilitation measures is entered into the patient’s personal medical documentation - a unified card for the study and recording of patients with borderline mental disorders in the “multi-axis diagnosis” section. At the second, activating stage, treatment was aimed at elimination of the main manifestations of borderline mental disorder. A large share here was occupied by methods of mental self-regulation with the aim of developing basic techniques for responding to painful symptoms and the traumatic situation associated with it. In addition, the following methods of psychotherapeutic assistance were widely used: body-oriented psychotherapy, spiritually-oriented psychotherapy, gestalt therapy, art therapy, etc. Reflexology, bioresonance therapy, medical massage and exercise therapy were used. The main task of the third, reconstructive stage is the resolution of intrapersonal conflicts, correction of levels of aspirations the patient and changing the painfully established system of relationships within the framework of personality-oriented (reconstructive) psychotherapy by Karvasarsky, Isurina, Tashlykov, which arose on the basis of Myasishchev’s pathogenetic psychotherapy. Numerous works of his students and followers are devoted to this issue (Liebikh S.S., 1974; Myager V.K., 1976; Isurina G.L., 1983; Tashlykov V.A., 1984; Karvasarsky B.D., 1985; Aleksandrov A. A., 1992; Ababkov V. A., 1993; Tupitsyn Yu. Ya., 1993, etc.). Reconstruction of personality relationships is the main and distinctive goal of reconstructive psychotherapy. Achieving this goal leads not only to the elimination of neurotic symptoms, but also to the development of new, mature forms of perception, experiences and behavior of the patient. During the reconstruction of the patient’s disturbed relationships, two processes occur: correction of non-adaptive positions and development of new, more realistic ones, which are tested first in the therapeutic environment, and then in non-therapeutic situations in the patient’s real life. At the third stage of treatment, the integration processes of the individual and social adaptation are activated. in the fourth, training stage, a system of physical therapy exercises with mediated psychotherapy was selected for patients, and functional training was used. Behavioral methods included in the system of person-oriented psychotherapy are very effective in the treatment of primarily obsessive-phobic disorders (Yakubzon A. M., 1989), in Features of isolated neurotic monophobias. Methods of extinguishing fear in a pathogenic situation using a specially developed system of functional training (DanceM. D., 1956; Asatiani N.M., 1979) turn out to be effective in a complex of therapeutic and restorative effects in patients with obsessive-compulsive neurosis, even with its protracted, unfavorable course. Patients with neuroses were recommended to overcome the regime of self-restraint, expand the range of activities and interests and more effectively engage in an active motor mode. Patients mastered the skills of autogenic training, used relaxation and visualization techniques, progressive muscle relaxation according to Jacobson and other stress reduction techniques, i.e. actively participated in overcoming their painful condition. We used the autogenic training method more often for neurasthenia, neurovegetative and neurosomatic syndromes, sleep disorders, especially falling asleep, etc. And finally, at the fifth, supporting stage of treatment, patients independently engaged in methods of mental self-regulation, compiled a self-report, followed recommendations for rational nutrition, adequate motor mode, met with a doctor once a month, then once every three months, six months, a year. In a team form of work, a psychotherapist, a clinical psychologist, and, if necessary, other specialists, consider issues of the clinic, diagnosis, prognosis, treatment and rehabilitation of neuropsychiatric disorders from different angles: from the perspective of their specialties, mutually complementing each other. This makes it possible to develop an individual treatment plan for each patient, including the entire necessary range of medical, psychological and rehabilitation measures (individual, family, group psychotherapy , environmental therapy, etc.). In this case, the syndromic, nosological diagnosis and individual therapeutic program are determined by the psychotherapist. The psychosocial aspect of the treatment and rehabilitation program is developed jointly by a medical psychologist, taking into account clinical data provided by the attending physician, who is responsible for the treatment of the patient as a whole. At subsequent stages of treatment and rehabilitation (activating, reconstructive, training and supporting), a psychotherapist and a clinical psychologist jointly implement the activities of individual psychotherapeutic programs. Collaboration between specialists at these stages involves: 1) holding clinical meetings at which the progress of the implementation of individual therapeutic programs is analyzed; 2) carrying out activities for the implementation of individual therapeutic programs by specialists independently; 3) maintenance and analysis of personal documentation; 4) analysis of the effectiveness of therapeutic and rehabilitation measures. The content of the ongoing psychotherapeutic, psychocorrectional and developmental activities (specific methodological elements of the individual psychotherapeutic program) is determined by the specifics of the patient’s clinical condition, as well as mechanisms (pathogenetic, psychological, etc. ), which determine the occurrence and development of the disease, the characteristics of the patient’s social adaptation and his social functioning. [2] It should be taken into account that the content of the therapeutic program reflects the nature, level and specificity of the professional training of a multidisciplinary team of specialists, the individual style of the therapy they provide. The methodological basis for the interaction of specialists from the multiprofessional team of the Scientific and Practical Center “Psychotherapy”, which provides comprehensive treatment and rehabilitation of patients with borderline mental disorders, presented in the table.!! Table !!!!Methodological characteristics of cooperation in a multidisciplinary team of specialists when conducting therapy and rehabilitation of patients with borderline mental disorders!! Aspects of interaction Specialists involved in psychotherapy and rehabilitation psychotherapist clinical (medical) psychologist 123 Typepsychotherapeutic and rehabilitation influence Clinical, aimed at recovery Psychological, aimed at restoring full individual functioning Basic elements of diagnostics and treatment and rehabilitation tactics1. History2. Clinical diagnosis (clinical aspect of multiaxial diagnosis)3. Forecast4. Treatment5. Recovery6..Secondary prevention1. Psychological interview2. Features of disruption of optimal personality functioning3. Choosing a method of psychological correction 4. Application of a psychotherapeutic method 5. Assessing the results of the method used Strategic orientation of the psychotherapy and rehabilitation carried out Personality in illness (personal and psychological aspects of the etiopathogenesis of a mental disorder) Healthy personality (personal and psychological mechanisms for the realization of personal capabilities) Nosological and pathogenetic orientation of therapeutic and rehabilitation effects etiological and pathogenetic therapy (psychopharmacotherapy, psychotherapy, physical treatment, etc.) correction of psychological phenomena of personality dysfunction Psychotherapy and rehabilitation are carried out taking into account the clinical condition of the patient, personality characteristics Targets of psychotherapy and rehabilitation are syndromic and pathogenetic psychological The purpose of psychotherapy and rehabilitation is recovery (improvement) harmonization of the personality, improving the possibilities of self-realization, improving the quality of life Assessing the effectiveness of treatment of psychotherapy and rehabilitation, recovery, level of improvement (degree of reduction of clinical manifestations) level of personality harmonization (degree of self-realization) Creation of a psychotherapeutic environment in the Scientific and Practical Center "Psychotherapy", a combination of individual and group work, employment therapy, environment, creative self-expression - this is not a complete list of tasks that must be solved multiprofessional teams focused on psychotherapy. At the same time, constant contact between the team’s specialists, their professionalism, awareness of the methods of research, treatment and rehabilitation, and understanding of the meaning of what another member of the team is doing are of great importance. Thus, when treating neuroses at the Scientific and Practical Center “Psychotherapy”, the following is created for the patient called the “psychotherapeutic field”, in the presence of which it is included in a wide network of systemic-organizational, interconnected activities implemented in a team interaction of psychotherapists, medical psychologists and traditional medicine specialists. In 2003, the Scientific and Practical Center “Psychotherapy” was awarded the Diploma of the All-Russian Exhibition Center ( VDNKh) “For the development of integrative medical technologies in the Penza region”, and 2004. Director of the Center Professor V.N. Sgibov awarded the gold medal “Laureate of the All-Russian Exhibition Center” “For the development of an integrated approach to the treatment and prevention of neuroses and somatoform disorders.” Today, psychotherapy carried out by private practitioners and psychotherapeutic centers organized outside the state health care system is of great importance. It is these doctors who work outside the state health care system who care about increasing the profitability and cost-effectiveness of psychotherapeutic care, and actively introduce the achievements of modern science into practice. The achievements of the Center are the scientific development of comprehensive programs for the treatment and rehabilitation of patients with neuroses and somatoform disorders and the scientific development of a spiritually oriented approach to psychotherapy of patients with borderline neuropsychiatric disorders and pathological addictions. [7,8] Today we can say with complete confidence that the Scientific and Practical Center “Psychotherapy” is an important and competitive link in the infrastructure of psychotherapeutic care in the region, which improves the quality of treatment and recreational activities and improves the indicators of somatic and mental health of the population of the Penza region . References1. Karvasarsky B.D. Neuroses. Guide for doctors. – M.: Medicine, 1990. - 573: [email protected]