From the author: As in other cycles of advanced training, programs of additional professional education of the Institute of Psychotherapy and Medical Psychology named after. B.D. Karvasarsky, at the 1st cycle of the professional retraining program in clinical (medical) psychology “Current issues in clinical and medical psychology. Clinical psychodiagnostics”, on September 21, 2016, the next briefing “Academician’s Answers-3” took place. Future clinical psychologists have prepared their questions. Here are the questions this time, and how Genrikh Vladislavovich Zalevsky, Doctor of Medical Sciences, Professor, Member, answered them. correspondent RAO... Reference: Genrikh Vladislavovich Zalevsky Doctor of Psychological Sciences, Honored Scientist of the Russian Federation, corresponding member. RAO, full member of the International Academy of Psychological Sciences, member of the World Federation of Mental Health, Russian Psychotherapeutic Association, Cognitive-Behavioral Psychotherapist, Supervisor. Author of over 300 publications on the problems of medical (clinical) psychology, including the monograph “Personality and fixed forms of behavior” (2007), textbooks: “Introduction to clinical psychology” (2010, 2012, 2013), “Fundamentals of behavioral-cognitive psychotherapy and counseling" (2002, 2006, 2013), "History of clinical psychology" (2012), "Introduction to the profession. Clinical Psychology" (2012). “Psychological supervision” (“2008, 2010, 2013”).1. What is the “norm” in clinical psychology? Answering, Genrikh Vladislavovich noted that this topic has tormented philosophers, sociologists, psychologists and doctors throughout the history of medicine. In the coming decades, it is unlikely that it will be possible to find an exact answer (without objections). The concept of norm is an extremely complex phenomenon. There are many variables involved. In the history of psychiatry, Emil Kraepelin tried to find the answer to this question by compiling a taxonomy of mental disorders. Modern psychiatry, and together with it medical psychology, consider the concept of norm in the context of the international taxonomy of diseases (currently the 10th revision of such taxonomy is in force - ICD-10 and the American DSM-V, and ICD-11 will appear in the near future). Despite such attempts to distinguish the norm from the “not normal”, difficulties remain even in determining the diagnosis, since conditions that are considered “pre-morbid” are included in modern diagnostics. The academician emphasized that a significant contribution to the development of the concept of pre-illness was made by the St. Petersburg resident, famous psychiatrist and psychopathologist Sergei Borisovich Semechev. Currently, there is a tendency to abandon the idea of ​​the so-called. “absolute” norm (ideals are not achievable!), and then in practical activity and science, we can talk about a more pragmatic approach - understanding the norm from an average position - a “statistical” norm. The statistical norm is understood today as the level of psychosocial development of a person, which corresponds to the average qualitative and quantitative indicators of people of the same age, gender, culture, etc. Concepts about other types of norms are also being developed. In clinical psychology, the statistical norm is more often used. This is due to the fact that a number of psychodiagnostic methods are based on statistical validation. Such an example could be the norms for assessing MMPI schools or subtests in the study of intelligence (IQ), etc. A statistical norm is when, based on a huge number of studies, ideas about the “average” person have been revealed, but there is a danger of “averaging” our patient, seeing it does not contain an individual person, but a representative of a statistical series. So, when they talk about an ideal norm, it is not achievable, and the application of social norms hides the danger of controlling a person. In the history of psychiatry, there have been cases when people were wrongfully hospitalized in psychiatric clinics and not only for ideological and politicized reasons, but also because of rigid ideas about normssocial behavior. Another very important aspect of understanding the norm today is cultural differences. In this regard, there is a lot of subjectiveness in the concept of cultural norm. For example, bisexual relationships are considered the norm in some countries, but not in others; the use of alcohol or drugs in some countries is an honor of tradition, while in others it is a criminal offense. Therefore, if we talk about norms in clinical psychology, the statistical norm is most often used , but there is a desire to move to a more advanced form of defining the norm - to the so-called. "individual" norm. An individual norm is when a person is compared not with anyone, but with himself. Therefore, it is preferable to focus on such a dynamic, personalized understanding of the norm, if possible. What psychological sign reflects the state of the norm? The main and total sign from the point of view of Genrikh Vladislavovich is when the state of the body and psyche does not limit the freedom of life. A norm is a life that is not limited in its freedom, but “not a norm” - limited. And freedom, of course, needs to be revealed, perhaps through the characteristics of intelligence, emotions, creativity, motivation, etc. Commentary by Nazyrov R.K.: An example of such an approach to understanding the norm can be a diagnostic sign that is used today in borderline psychiatry to delimit the fear of flying on airplanes (who isn’t afraid of flying today?), from aerophobia – a sign of a neurotic disorder. To make a diagnosis of erophobia, you need at least one confirmed case of refusing to fly and returning a ticket precisely because of fear of flying. Then it becomes clear that a “healthy” fear of flying does not limit a person’s movement, but pathological fear does. 2. How do you see the future of clinical psychology in the scientific space? Genrikh Vladislavovich believes in the good prospects of clinical psychology, since from his point of view the problem of norm and pathology will never be “removed” from the agenda. This problem is getting worse and requires the attention of science. It is known about the mutual influence of the psyche and human biology. In medicine, ideas about the high importance of psychology and clinical psychology in the first place are increasingly crystallized. Clinical psychologists who should be at the forefront of “interception” of diseases - contact with primary patients. In America, 60% of psychologists are clinical, and if clinical psychologists are in demand, clinical psychology will also be in demand. This is a frontier area – it contributes to more efficient delivery of health care. But the importance of clinical psychology will increase due to the fact that clinical psychology will gradually extend its influence to areas of normal human functioning in life. And over time, clinical psychology will transform into health psychology and will include all existing aspects of clinical psychology and psychological issues of normal human functioning. Commentary by Nazyrov R.K.: In our country, there is a known positive experience of such “interception” of mental illnesses. A clinical (medical) psychologist becomes a “primary reception” specialist and carries out the functions of managing the flow of patients. In this model, a clinical (medical) psychologist with good clinical training refers the patient or even the family to other specialists - an internist (general practitioner), psychiatrist, psychotherapist, narcologist, neurologist, sexologist. This model of organizing assistance existed, for example, in Tyumen at the Mental Health Center and children's clinics and worked very well. In the future, after the completion of the medical care reform in our country, such approaches to organizing care for children and adults will be used more widely. True, this requires a high-quality trained clinical (medical) psychologist. 3. Three main, in your opinion, competencies of a successful clinicalpsychologist. There are, of course, many competencies in clinical psychology; theoretical knowledge, practical skills and abilities with high-quality training are transformed into reproducible professional techniques that reflect all aspects of the work of a clinical psychologist. There are many of them and they are focused on practical tasks. “If you single out three core competencies, the rest will be offended,” Genrikh Vladislavovich joked. There are no core or secondary competencies in our work; all are important and can be indispensable in a particular situation. Then he adds: “I would generalize and highlight four meta-competencies.” The first is excellent mastery of the object and subject of one’s science. In fact, a clinical psychologist must understand the psychology of a healthy person like a practical psychologist, and in mental disorders just like a good psychiatrist or even better, because he must understand all the features of the psychological functioning of a person suffering from a mental disorder. The second is a practical knowledge of the history of his science and practices. Genrikh Vladislavovich notes that he wrote an article for the journal “Medical Psychology in Russia” *, and will speak at a conference in Yaroslavl (III International Scientific and Practical Conference “Medical (Clinical) Psychology: Historical Traditions and Modern Practice”, 13-15 October, Yaroslavl), focusing on the fact that modern psychologists, alas, are “ahistorical.” The modern clinical psychologist is very poorly versed in the history of world psychology. And practice should be based on the full power of the world history of psychology, because all practical tools are based on the history of psychological thought. And possession of only the “final” results of psychological achievements leads to simplification and reduction in quality. The third competence is methodological. A clinical psychologist must be able to investigate the subject of his activity and only on this basis provide professional assistance. “Intervention - after diagnosis, and not vice versa!” As the fourth meta-competence, Academician G.V. Zalewski highlights the ethical one. The ethical component of the activity of a clinical (medical) psychologist is extremely important. It is still extremely important today, but has its own historical background. In the history of medicine and psychology, ethics was regulated by various value imperatives. For Hippocrates, the basis of ethics was the value of non-harm “Do no harm!”, for Paracelsus - “Do good!”, in the deontology of the 20th century “Observe duty!”, and the current stage, the so-called. “Bioethics” is based on the value of “Respect for the rights and dignity of the patient”, and incorporates all these ethical achievements of medicine. Today all this should be present in the activities of a clinical psychologist. G.V. Zalewski noted that other generalizations of professional and personal competencies are possible and desirable. 4. Please tell us about the most difficult patient in your actual practice? Genrikh Vladislavovich recalled his significant clinical experience. In particular, he worked for 10 years at the Tomsk Research Institute of Mental Health, which was based on the clinical base of a large psychiatric clinic and took part in providing psychiatric and psychotherapeutic assistance to patients with mental disorders. Later he worked in other clinics and “after that I began to meet with patients less often, more often with clients.” Notes that “all patients are difficult!” If this is a disease, then it is difficult to identify who is more difficult. It is clear that one patient is more interesting, one less, in human and research terms. Patients with depressive disorder are the most difficult to work with. It is important how to look at the patient and see him. As Hippocrates bequeathed “to treat not the disease, but the patient,” to see in a person a person with resources, and not just a diagnosis, this is what a clinical psychologist should notice. That is why a patient needs both a doctor and a psychologist. The most difficult case for Genrikh Vladislavovich is the case of working with a patient suffering from a deep schizophrenic defect, the so-called. patient with"ultimate" state in schizophrenia. He was a man of more than 50 years old, he practically did not make contact and outwardly was completely devoid of meaningfulness, interest and spontaneity in communication. Genrikh Vladislavovich asked the patient to do a tapping test in a simplified form, tapping a pencil on paper. The patient knocked mechanically. The psychologist asked me to knock faster. The patient looked indifferently at the experimenter and knocked faster. The psychologist asked to knock even faster. The patient tried to do it faster, but couldn’t, and suddenly looked at his psychologist meaningfully with regret because he couldn’t fulfill the request. This was the first meaningful view of this patient with the “end state” of schizophrenia during the entire treatment. He tried, he couldn’t, and he regretted that he couldn’t speed it up. Summarizing this case, he emphasizes that in every patient there is humanity and hope for recovery. Academician G.V. In this regard, Zalevsky cites the words of the great Georgian psychologist Dmitry Nikolaevich Uznadze: “look at the patient, there is a spark of God in him.” And addressing the listeners of the series, he urged them: “... look for a spark in the patient, try to find it and rely on it in your work!” 5. What do you rely on and what is important for you in the initial appointment with a patient? In the initial appointment, communication skills are important, of course, but if we are talking about the initial appointment of the patient, the first meeting, it is necessary to clarify in which institution the psychologist carries out the initial appointment. In any case, it’s not just about getting to know each other, but the form of contact is determined by ethical competence, and the rest follows. The first meeting is 50% of success or failure in the future. Addressing the group of listeners G.V. Zalewski emphasizes that “... if after the first appointment the patient does not feel at least a little better, think about whether you are in the right place!” The first meeting should be favorable, since sometimes patients go to Golgotha ​​to see a specialist. And creating a favorable situation is very important. To quote Carl Rogers, creating a positive emotional climate is crucial. And first of all, everything possible must be done to make the patient feel that he is not under interrogation, but that he is interesting as a person. And then it’s clear - we clarify the complaints, conduct a psychological interview, if necessary, invite a doctor for consultation, and conclude a contract. A psychologist must clearly understand who you are dealing with in terms of diagnosis, and after this comes everything else... 6. Who are your authorities in science, and what teachers do you rely on or have relied on? Academician G.V. Zalevsky notes that his main teacher was Mikhail Semenovich Rogovin (famous Russian psychologist, psychological methodologist and cognitive psychologist, Doctor of Psychology, professor). Rogovin M.S. was the leader of G.V. Zalevsky for his candidate's dissertation and consultant for his doctoral dissertation. Remembering M.S. Rogovina, G.V. Zalevsky notes that he was a very “practice-oriented psychologist” in matters of psychopathology, and was friends with the famous Russian psychiatrist A.V. Snezhnevsky. In this regard, the first publications by G.V. Zalewski appeared in the Journal of Neurology and Psychiatry named after. S.S. Korsakov”, and not in psychological journals. As authoritative scientists G.V. Zalevsky also notes Andrei Vladimirovich Snezhnevsky as an outstanding specialist in the field of psychiatry and Boris Dmitrievich Karvasarsky, whom he considers an outstanding domestic psychologist and psychotherapist. Other famous psychologists A.N. also had a great influence on his professional development. Leontyev and A.R. Luria, D.B. Elkonin and B.F. Zeigarnik. 7. Who is the patient for you, and who is the client? Answering this question, Genrikh Vladislavovich notes that for Z. Freud, everyone who sought help was patients, and for K. Rogers, they were clients. He himself adheres to the latter view, “even if the person who comes to the appointment has a diagnosis.” Although the easiest criteria to differentiate is diagnosis, but even if