COMMUNICATION WITH DIFFICULT PATIENTS
Interview with Dmitrii Kovpak
Dmitrii Kovpak is Associate Professor of the Department of General and Medical Psychology and Pedagogy of North-Western State Medical University n. a. I. I. Mechnikov (Saint-Petersburg). He is the author of more than hundred scientific articles and twelve scientific monographs and popular science books about psychotherapy, and a founder and the organizer of 3 countrywide conferences: «Clinical Pavlovian readings» (since 2000); «Actual aspects of psychosomatics in general medical practice» (since 2003); and round tables in the framework of the program «Modern practice in psychiatry» (since 2002).
We are very interested in learning about the role of psychologists in your country. What is the current situation of Clinical Psychology in Russia? Are clinical psychologists fully integrated in the Russian health system? How is the relation with other mental health professionals? Could you describe the main tasks they carry out within the Health system?
DK: In this country there is a clear trend of growth in the number of psychologists, primarily clinical psychologists. This is due to both the interest of specialists in the field of psychology to clinical phenomena that help to study actively the specific mechanisms of the human psyche. On the other hand the need of the population of this country for qualified non-pharmacological care and nonbiological therapies in the field of mental health is very high.
Clinical psychology in this country has a long history of development and is based on the fundamental national scientific school of psychology and its traditions. At the same time, due to its active integration into the world of scientific environment and practical psychological assistance, the modern model of clinical psychology becomes more functional, flexible and multifaceted.
Unfortunately, the integration of clinical psychologists in the treatment process in the field of mental health, despite their broad representation in public health, is much more active in private forms of psychological assistance to the population. The number of private practitioners in the field of clinical psychology exceeds those who work for public organizations both in absolute number and in the volume of their assistance to the population.
In public clinics and outpatient clinics, the integration of clinical psychologists is often declarative and formalized. It is reduced to the implementation of routine narrow-profile tasks, without the full implementation of a wide arsenal of possibilities of a modern competent specialist in the field of clinical psychology. Private organizations involving clinical psychologists who assist the population in mental health are often more flexible and innovative, more fully and adequately meeting patients’ demand.
Clinical psychology in Russia has long been a "Cinderella" in the shadow of large psychiatry. And the attitude of the colleagues among psychiatrists was sometimes leniently guardian. The successes of modern psychotherapy has helped clinical psychologists to become equal partners, who equally provide assistance to the population and support the development of modern psychiatry through the second and third words in the title of the biopsychosocial model. This allows psychiatry to become a more modern, innovative, socially integrated and holistic discipline.
The Ministry of Health of the Russian Federation has officially declared brigade form of assistance in the field of mental health. In this form, both in public and private institutions, psychiatrists, clinical psychologists, speech therapists, social workers, physical therapists, and even specialists in internal medicine can be combined in the form of functional teams. Depending on the profile of the teams may vary in composition and size. For example, in the case of neurorehabilitation of stroke patients, they are treated by a large team, including a neurologist, a psychiatrist, a psychotherapist, a physiotherapist, a clinical psychologist, a speech therapist, a specialist in social work, an instructor for the development of motor skills trainer. In the case of patients with psychosomatic disorders, psychiatrists, psychotherapists and clinical psychologists form a similar multiprofessional team. It also includes neurologists (pain neuralgic syndrome, hypertonicity of the muscular system, pseudo-paralysis and pseudoparesis, etc.), gastroenterologists (for example, in the case of Irritable Bowels Syndrome - IBS, functional biliary dyskinesia, functional enteritis and colitis, etc.), cardiologists (anxiety disorders with dysfunction of the cardiovascular system), dermatologists (dermatitis, psoriasis, neurodermatitis), pulmonologists (functional disorders of the respiratory system) and other specialists (physical therapy instructors, kinesiologists, massage therapists, physiotherapists, yoga instructors, specialists in meditation and mindfulness practices, stretching trainers, Tai Chi (T'ai chi ch'üan) and Wushu instructors.
Clinical psychologists perform a wide range of tasks - such as psychological diagnostics and testing, individual and group psychotherapy, psychoeducation, psychological support and prevention.
As the president of the Association for Cognitive and Behavioral Psychotherapy, could you specify what is the distinctive role of cognitive-behavioral psychologists compared to the clinical psychologists that are part of the Russian professional net?
DK: The distinctive features of clinical psychologists specializing in cognitive behavioral therapy in this country include high structure of their work, methodological transparency and clarity of the model of therapy for both professionals and their patients, a high degree of compliance and quality of therapeutic relationships. All this allows to actively motivate and involve patients in therapy, consistently delegating them a number of techniques and technologies for independent use, at the same time forming an active involvement in the therapeutic process and responsibility for its results.
Given the high levels of psychosomatic disorders, depression and anxiety related problems detected in primary care, as well as the difficulty in accessing psychological treatments in this level in Spain, we are currently working on the integration and recognition of clinical psychologists in all different levels of the health system, and specifically in primary care. We wonder if your health system may be facing the same challenges and, in any case, what is the response that is being given (or is being planned to offer) to people with these kinds of problems? Do you consider that patients are being offered the appropriate and optimum help in terms of resources, access to psychological treatment, etc.?
DK: We face exactly the same problems as our Spanish colleagues. These include the same leading disorders in a large part of the population, such as anxiety, depression and psychosomatic disorders. What is more, we encounter similar difficulties in the optimization and integration of resources to provide affordable, competent and high-quality psychological assistance. Today, the improvement of such assistance is mainly due to the flexibility and innovation of non-state forms of its provision. In addition to face-to-face reception of patients in the form of individual consultations, family therapy, group psychotherapy, skills training, coaching and other modern models, new technologies of remote assistance via the Internet (via Skype, ZOOM and other programs) in the form of individual reception, group psychotherapy, online workshops and webinars for clients, including even such unusual options as "marathons" in Instagram with a series of various surveys and assignments, - all these options are used increasingly. Specialists seek to expand their audience, including the young part of it, attracting specific communication channels used by them. Mental health specialists try to attract the attention of potential customers not only by popular articles published in specialized psychological web resources, but also illustrated posts in social networks and videos. This form of reporting has a dual purpose: both the dissemination of elements of psychoeducation and promotion of clinical psychology, as well as advertising of their private services and the formation of personal brands for each specialist.
As we have previously mentioned, psychosomatic disorders are one of the main consultations in primary care. You have organized various conferences related to psychosomatic disorders. What are the demands and needs of Russian psychologists (and any given psychologist) in order to approach these problems? In your opinion, what is the role of Psychology in this specific field?
DK: For the past twenty years, I have been organizing various conferences in the field of mental health, including those dedicated to psychosomatics. I am convinced that the role of psychotherapy and clinical psychology in this area is the leading one. Psychotherapists and clinical psychologists consider a person not as a set of tissues and organs, but systemically and holistically. Many reports and theses over the years have been devoted to the role of psychology in understanding the mechanisms of the central genesis of psychosomatic disorders. Higher neurological activity in the context of Ivan Pavlov's works is considered to be the integrator of all organs and systems of one organism. Both internal and external conflicts of the person, his mental overstrain and distress have the most important value for understanding etiology and pathogenesis of these difficult disorders. Psychotherapy should not serve as crutches or a replacement, as medications and treatments might, but rather it is seen as causal assistance to such patients. We have numerous randomized controlled trials that confirm the clinical efficacy of psychotherapy in general and cognitive behavioral therapy in particular to address this type of disorder and population problems.
You also organize periodic conferences oriented to the modern practice of Psychiatry. In this regard, what practices/tendencies in mental health are currently focusing on Russian professionals and researchers?
DK: As a general trend in recent years in Russia we see the increasing role of clinical psychology in the field of mental health and the potential of psychological and social component of the biopsychosocial model in contemporary psychiatry and psychotherapy. In this country the ideas of modern brain sciences (neuroscience) and methods of cognitive behavioral direction are becoming more and more popular.
From a global point of view, we are witnessing the crisis of the mental disorders classification/diagnose systems as well as a downturn of the biological models applied to mental health. How is this crisis/ debate impacting Psychology in your country?
DK: A revision of the classification and diagnostic models is unavoidable. We cannot effectively operate only with a mechanical sum of clinical phenomena, turning them into lifeless labels of formal diagnoses emasculating complex mechanisms of genesis and maintenance of dysfunction and pathology of the mind and body. The current DSM and ICD models haven’t been criticized only by a lazy specialist. And this is largely justified. Modern classifications are more convenient for health care providers and insurance companies than for clinicians and practitioners. They are convenient for reporting, but rather create the illusion of understanding disorders than revealing their basic mechanisms for treating causes rather than consequences, eliminating pathogenesis rather than symptoms.
Yes, we still face a number of mysteries about what consciousness is, how the leading mental processes actually function (take, for example, only human memory, the models of which are obviously not exhaustive today). Therefore, in Russia there is a long-lasting tradition of expression which states that we treat the patient and the individual, not the diagnosis and disease. Human is an open complex system. It's a lot harder than labels which are applied to it. We have no way of telling how broad the person’s interconnections are within the widest neural network with 87 billion neurons and hundreds of trillions of their connections, just as wide on its basis. These internal relationships result from learning not only a simple conditioned reflexes, but also speech and thinking, symbolic system or the second signal system by Ivan Pavlov and external social relations from the microsocial system called family, to macro-social level of state, ethno-cultural, gender, professional, religious, political or other value systems. Ignoring these factors and connections critically reduces medical and psychological care to the level of professionals who specialize in left little fingers, as we call it here, who might consider a person regardless of the universe within the framework of a model of a spherical horse in vacuum.
Regarding the conference you will be giving during the XI Congreso Internacional de Psicología Clínica in Granada on communicating with difficult people, could you further explain what a difficult person is? Why is so important that clinical psychologists are aware of these difficulties and what are the core competencies they should develop in order to approach this situations?
DK: A difficult person for us is someone whom we don't understand, whose motives are not clear to us, and whose behavior does not fit into our patterns of perception and information processing. These are the ones with whom communication is most difficult or ineffective. A difficult person is not a problem, but he or she is a challenge not only for professionals, but also for general population.
After all, a new experience lies beyond the borders of our patterns of thinking and behavior. By going beyond these limiting beliefs, we can gain not only greater knowledge about others, but also about ourselves. After all, in the French philosophical tradition, the Other with a capital letter is a mirror of our soul, including an important step in development. The skills and competencies of psychologists in building effective communication go far beyond the clinical model. They also relate to interpersonal relationships, working with families, groups and organizations.
One of the aspects you will be focusing on in your conference is interpsychic and intrapsychic conflicts in communication. How do these conflicts manifest in a psychotherapeutic context and how can they affect the patient-psychotherapist relationship?
DK: Intra-psychic and inter-psychic conflicts are not just closely related. They are an integral continuum. The whole person is a holistic phenomenon as well. Being mere observers, we notice only parts of it, but as researchers we split it into components. After dissecting into parts, we can look inside this "machine", but we cannot see the spirit connecting its elements – the psyche. Conflicts expose this spirit at the peak of contradiction, demonstrating how it works in life. Experiments on dissected mice may provide unsatisfactory models and obviously incomplete analogies. The map is not a territory. The examples of overcoming the problems of modern classification in Cognitive Behavioral Therapy are David Barlow's UP-transdiagnostic protocols and currently formed process-oriented PB CBT by Steven C. Hayes and Stefan G. Hofmann.
In most types of psychotherapy therapeutic relationships are considered today as one of the leading factors of its effectiveness. It's neither just compliance and cooperation, nor mere adherence to therapy. It's really specific (and not non-specific as earlier believed) factor of therapy. Therapeutic relationships can help a client (and sometimes a therapist as well) to form new experiences and new patterns of thinking and behavior. Professional development of high-quality complementary relationships enables the fullest use of therapeutic relationships in many aspects of therapy. Conflicts often lead to difficulties in therapy for both participants and even raises the likelihood of patients’ withdrawal from therapy.
As it appears from your abstract, you seem to understand cognitive-behavioral therapy is an adequate technique to approach theses communication problems. Would you mind deepening in this idea? What are the main tools that cognitive-behavioral therapy can offer in order to solve these communication problems?
DK: Cognitive behavioral therapy provides a wide arsenal of techniques and a well-developed and scientifically based methodology for solving problems caused by interpersonal conflicts and miscommunication as individuals, groups and organizations. I’m not afraid to say that global conflicts between countries and political blocs could be solved much more effectively by relying on clinical psychology and psychotherapy, overcoming cognitive distortions, biased thinking, intrapersonal problems of politicians and decision makers, which affect their uncritical preferences and choices. A lot more things unite us than divide. Russians and Spaniards, Asians and Europeans, residents of Granada and Madrid, or even residents of Barcelona and Bilbao. What separates us is often the result of cognitive distortion rather than irreconcilable contradictions. The leading diagnostic tool of CBT is the analysis that allows to identify both external manifestations and internal processes that contribute to the formation and development of miscommunication and conflicts. CBT is based on the theory of learning and clarifies the models built by a person on the basis of their experience.
From the point of view of CBT, a person learns patterns of processing incoming information and its interpretation, which then forms the basis for further requirements. Some of these models become dysfunctional due to several different reasons. These reasons include, for example, specific parent-child relationships. A child may receive insufficient attention, emotional support, love and care. Any child is largely trained by reinforcements from significant adults. An emotionally cold mother (for example, a depressed one or one suffering from a personality disorder) or her absence can lead to deficiencies in the formation of effective communication skills, self-regulation and social competencies. A person’s belief system may include various dysfunctional schemas, beliefs of different levels that have arisen as a result of traumatic experiences. They significantly affect a child’s perception, thinking and behavior. The realization of his or her own needs, from basic to social ones, will be difficult for such a person. Deep beliefs of non-acceptance or helplessness will force them to build a system of rules, walls of defenses and compensatory strategies designed to protect them from new pain, disappointments and failures. But this entire arsenal turns into a suffocating cocoon. Instead of protecting, it leads to distancing a person from others and the world, reliably preventing the realization of his or her need for contact. As Somerset Maugham wrote, “Each one of us is alone in the world… We seek pitifully to convey to others the treasures of our heart, but they have not the power to accept them, and so we go lonely, side by side but not together, unable to know our fellows and unknown by them. We are like people living in a country whose language they know so little that, with all manner of beautiful and profound things to say, they are condemned to the banalities of the conversation manual. Their brain is seething with ideas, and they can only tell you that the umbrella of the gardener's aunt is in the house.”
Awareness of such limitations and dysfunctions is possible both through cognitive analysis and conceptualization with the introduction of alternatives through therapeutic debates, and through the influence of new behaviors.
We do not wish you to spoil the whole content of your conference. However, would you mind to let us know about some of the best and essential practices to efficiently communicate with difficult people?
DK: Naturally, there is no one magic move of hands, no wands or manipulative tricks which would simultaneously resolve all the accumulated human communication problems and help us manage people like they do it in the movies. However, mindfulness and acceptance practices, skills trainings will help us realize the necessary tasks and form useful competencies. Psychological flexibility, based on the elaboration of our cognitive distortions, the formation of useful skills (e.g. concentration, active listening, self-regulation, assertive behavior, etc.) can significantly expand the range of communication and the possibility of constructive contact with a wider range of people.
Overgeneralizing and labeling, emotional reasoning and mental filtering, magnifying negatives and minimizing positives, personalizing and catastrophizing, polarization splitting (all-or-nothing thinking, black-or-white thinking, dichotomous reasoning), making "must" or "should" statements and frustration intolerance are examples of cognitive distortions and dysfunctional rules of thinking formed on their basis. These are limiting beliefs.
They significantly influence the possibilities of communication, narrowing the range of choice and subordinating narrow and rigid dysfunctional patterns of thinking and behavior. Not everyone can fit in this hard Procrustean bed. And then it will inevitably become difficult for us. Accepting ourselves (selfacceptance) and accepting others as they are is not only an encouraging slogan, but also a systemic practice that contributes to a significant change in the system of relations with ourselves and others. CBT clarifies the algorithms of these practices, making them understandable and implementable for both clients and patients. Overcoming the learned helplessness and development of the competencies described above also significantly expands the behavioral repertoire of choice and communicative flexibility. As a specific exercise, I can give an example of working with acceptance. Try to observe what you don't like about other people. Write down 10 of the most annoying or frightening things that you can recall. See how you feel about such things about yourself, if you find them in your own personality. Do you condemn them, are you afraid to show them, do you try not to notice them? During the next week try to set yourself a challenge for a complete non-judgmental acceptance of these qualities in yourself and other people. Watch how it affects your communication.
We hope you will enjoy your participation in the Congress that will be held in Granada. Is there anything you would like to add before finishing with this interview?
DK: I would like to thank the organizers of the Congress for the invitation. It is a great honor for me. I am very grateful for the opportunity to speak to an international audience of colleagues. I would also like to thank the entire large team for their great and very important work in preparing for the Congress.