- 9.2. THE PHENOMENOLOGY OF NEUROSES: MECHANISMS OF OCCURRENCE, FORMS,

Lecture

Это продолжение увлекательной статьи про нервозы профилактика диагностика и лечение.

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significant for the patient. In the associative experiment with
simultaneous recording of the galvanic skin response, there was a lengthening of the latency period of the verbal reaction and a pronounced galvanic skin response to verbal
stimuli emotionally significant for the patient: the words «audit», «work», «heart»,
«father». When the mobility of nervous processes was examined by the proofreading method, their inertness was revealed, which was expressed in the fact that after the instructions were changed, a large number of incorrect letter cross-outs were observed, made not in accordance with the changed instructions, but according to the original ones. Examination of motor
reflexes revealed a weakening of the inhibitory process – the conditioned reflex, although it formed quickly, was prone to irradiation (Lat. irradiare – to shine), or spreading.

E.K. Yakovleva (1958) posed the question: «Was the fainting episode that occurred the sole cause
of the morbid change in the patient's higher nervous activity?», to which she quite
correctly answered: «The answer to this question is given by clarifying all the circumstances preceding the fainting episode, clarifying the patient's personality features and the causes of the patient's emotional processing of the fainting episode that occurred». In connection with the working conditions that arose on the business trip, many difficulties arose, the main one of which was connected not with the heat and
frequent night work, but with the nature of the work itself, which did not correspond to his
personality features. For him, as a soft-hearted, somewhat insecure person, the responsibility of the assigned task and the need to make immediate decisions (removing some of those he was auditing from
their positions) proved a heavy burden, which, together with other
causes, brought on overstrain. In addition, the patient made an incorrect interpretation of the fainting episode that had occurred. A conversation with the patient made it possible to establish that, at the moment the fainting state set in, the thought of his father's death "sharply" flashed through his mind, his father having died two years earlier of «heart failure» (Yakovleva E.K., 1956, 1958). At the time, the patient had taken his
father's death calmly, since his father had died at an advanced age. Thus, at the
moment of a sharp disturbance of brain activity during the fainting episode, the patient developed
a temporary connection – between painful sensations in the heart and previously existing
impressions of his father's sudden death from «heart failure». A connection was formed which
became firmly fixed thanks to the disturbed state of nervous activity and a pronounced emotional reaction – fear of death – the same as his father's. From this
time on, any sensation arising in the region of the heart initiated the thought of death
(Yakovleva E.K., 1956, 1958). In the course of psychotherapy the patient was guided toward an understanding
of these causes of his illness, which determined his recovery.
We cannot fail to mention another case of obsession, described by E.K. Yakovleva (1958). This case is notable in that the obsession (cancerophobia) arose via the
mechanism of secondary gain! We should note that E.K. Yakovleva (1958), in describing this
case, does not mention the mechanism of secondary gain (that is, the hysterical nature of the symptom), but in essence describes precisely this mechanism. Cancerophobia appeared in the patient after a doctor's remark regarding some thickening in the area of the mammary gland. The doctor did not
consider it dangerous, although he did suggest surgical intervention. Two years earlier,
another doctor had suggested doing the same thing. At that time, having learned from an oncologist that this was not related to
oncology, the patient attached no significance to the suggestion. Now, however, despite repeated conclusions by specialists that there was no oncology, the patient could not be reassured. She began
going to doctors, crying a great deal, considering herself doomed, and stopped taking care of household matters,
of her son and husband.

On the electroencephalogram, when the word «husband» was pronounced, clear changes were noted
– there was an increase in the frequency of fast potentials with a rise in their amplitude, whereas when
the word «cancer» was pronounced, the reaction was significantly less pronounced! An increase in the galvanic skin response occurred upon pronunciation of the following words: «husband», «illness»,
«family», «cancer», «infidelity».
As the study of the case history showed, in the development of the latter the iatrogenic (doctor-induced)
factor was incidental, accidental, one to which the patient's attention switched only during a period of complex, hard-to-resolve conflictual family experiences for her. The distress began from the moment when she accidentally (upon her husband's return from a
rest home) discovered a photograph of a woman with a touching inscription belonging to him. The patient's
husband at first denied everything, but then confessed. The patient was shocked by the infidelity and the lying.
Despite having lived happily married for 16 years, her first thought was of divorce (being straightforward and not tolerating lies, she lost all trust in her husband). On the other
hand, she could not bring herself to break up the family, since for her, a graduate of an orphanage
who had never known her parents, her husband was the only close person she had, whom she loved very much and even somewhat idealized. The struggle of contradictory tendencies continued for 3 months. She could not bear to see her husband, constantly reproached him, which created a heavy atmosphere in the family. Her husband told her that if he was so unpleasant to her, it would be better for him to leave the family, to
which she said nothing. Later, however, she sent their son to him, so that he would persuade the father to stay.
This entire situation caused overstrain in the patient, disorganizing her nervous activity. It was precisely during this period, when her psyche was being torn apart by insoluble contradictions, that the doctor's
words about the thickening provoked the appearance of ideas about having cancer. From this moment the patient continued to suffer and cry, but now over the supposed
cancer of her mammary gland (Yakovleva E.K., 1958).
Thus, the cause of the neurosis was by no means the iatrogenic influence, but the contradictory tendencies connected with family circumstances. This is confirmed by many facts.
First, the first suggestion to remove the thickening caused the patient no anxiety, whereas
a similar suggestion, made during a period of complicated family circumstances, entailed the appearance of obsessive thoughts. This is explained not only by the exhaustion of the nervous system due to emotional tension, but also by the impossibility of
resolving the contradiction between the wish to preserve the marriage and the wish to destroy it. The patient could in no way resolve this contradiction, and the doctor's words about the necessity of surgical intervention showed a «way out» of the contradiction that had arisen: «How can I leave my husband now, when I am ill?». Second, a more pronounced bioelectric reaction was observed not upon pronouncing the word «cancer», which related to the morbid symptom, but upon pronouncing the word «husband», which related to her conflictual experiences and was emotionally more significant for her. Psychotherapeutic work aimed at clarifying for the patient the causes of her ailment made it possible to eliminate the
symptomatology. Follow-up (observation after the illness) showed that this woman's fears
did not recur.
In her work, E.K. Yakovleva (1958) divided neuroses in which one obsessive phenomenon or another manifests into such types as obsessive-compulsive neurosis (in a developmental form and in a reactive form) and psychasthenia. Obsessive-compulsive neurosis was singled out by the author as an independent clinical entity on the grounds that the obsessive symptom essentially exhausts the entire clinical picture and that it is precisely the obsessive symptom
that in such cases is the source of decompensation. The author distinguishes between the developmental form and the reactive form
of obsessive-compulsive neurosis based on whether the neurosis developed acutely or gradually: the reactive form arises acutely, while the developmental form arises gradually, with the obsessive symptom complex being more complex in the latter. In the developmental form the situational factor is less clearly expressed, but the features of the patients' personalities and the attitudes toward various aspects of reality that formed in the course of their lives acquire greater importance: «traces of the past leave their imprint on personality traits and attitudes».
As E.K. Yakovleva (1958) notes, patients with psychasthenia constituted, with regard to the clinical
picture, a more homogeneous group than patients with obsessive-compulsive neurosis. In patients with psychasthenia, their distinctive characterological features came to the fore: indecisiveness, insecurity, a tendency toward constant doubt, timidity, shyness, difficulty communicating with people, a tendency toward solitude. In
the life histories of these patients, low activity was noted, along with a fear of any changes, of anything new, new people, new work. Outwardly these patients are usually reserved and, owing to a constant tendency to delay the direct expression of their feelings, appear to be individuals with reduced sensitivity. In actual fact, such patients are marked by heightened impressionability, but their sensitivity, because of their suppression and inhibition, does not find external expression. In the opinion of E.K. Yakovleva (1958), the usual description of
psychasthenia, owing to the seemingly homogeneous nature of the psychasthenic's personality traits, suffers from a certain excessive typification. Obsessive phenomena in these patients are already secondary
formations. Traits of a psychasthenic character are not yet in themselves an illness. Psychasthenia as an illness begins when the noted characterological features become more pronounced
and obsessive phenomena develop, which in essence flow from the features of character,
being their consequence: for example, obsessive ruminations, deliberations, doubts.

The psychopathological structure of the obsessive syndrome, according to N.K. Lipgart (1978), consists
of the phenomenon of obsession, the background against which it manifests (the scope of consciousness), and secondary
elements – a conscious critical attitude, struggle against the obsession, and a lowered
mood.
The phenomenon of obsession includes suddenness of occurrence, alienness to the content
of consciousness at a given moment, and a sense of being imposed, while at the same time the obsession is experienced
as a mental phenomenon belonging to the patient themselves – not imposed from outside (Tatarenko N.P., 1956; Lipgart N.K., 1978). Obsessive phenomena proceed against a background of clear consciousness, but the scope of the latter can vary. A dependence has been established between the scope of consciousness
and the form and strength of the obsession: the scope of consciousness changed least of all in obsessive
thoughts, rituals, and drives, and most of all in phobias, where the emotional component was
especially pronounced. A greater degree of change in the scope of consciousness was found in hysteria than in obsessive-compulsive neurosis. In all patients a critical
attitude toward the obsessions was noted. The critical attitude was more pronounced in obsessive thoughts and drives and least pronounced in phobias; in obsessions with hypochondriacal content it was often absent. In a calm state, when the strength of the obsessive phenomena was not very pronounced, the critical attitude was clear. During periods of intensification
of the obsession, and especially during attacks, many patients lost the sense of the alienness, absurdity, and morbidity of this phenomenon. For the same type of obsession, the critical attitude was more clearly expressed in patients with obsessive-compulsive neurosis than in
patients with hysteria (Lipgart N.K., 1978).
N.K. Lipgart (1978) identified two main forms of struggling with the morbid state –
active and passive. In the active form the patient actively directed all their attention and
all their strength toward eliminating the obsessive symptom complex: for example, in an obsessive
urge to throw themselves under the wheels of a passing train, they would stand close to it and watch it
rush past. The passive form was divided, by degree of activity, into three types:
1) patients tried to switch their attention to any other kind of activity:
physical work, conversations, memories;
2) patients tried to avoid all those situations that caused the obsession: for example, hiding sharp objects in the case of an obsessive fear or desire to kill a child, or
not leaving the house in the case of a fear of open spaces;
3) patients developed a series of movements, actions, and words, the performance of which relieved
or even removed the obsession: for example, spitting on their hand in the case of a fear of contamination.
It is characteristic that in obsessions, especially in phobias, patients as a rule show unpleasant sensations in one part of the body or organ or another, which in turn
influence the course of the obsessive phenomena, intensifying them or causing a repeat
attack of the conditioned-reflex type. Since a conditioned reflex is developed not only to a single main conditioned stimulus, but to the entire sum of extero- and interoceptive stimuli that coincided in time with the main one, it is far from always possible for the patient themselves to establish which stimuli repeatedly evoke the obsession (Tatarenko N.P.,
1956). Even one of the stimuli (for example, stimulation of the receptors of internal organs,
or interoreceptors) that forms part of the complex may, under certain conditions, evoke the entire
range of conditioned-reflex phenomena developed for the whole complex of stimuli. In
the opinion of N.P. Tatarenko (1956), it is precisely this that can explain the extraordinary «tenacity»
that distinguishes obsessive phenomena.
When obsessive phenomena exist for a prolonged period, they affect character traits: there occurs an addition of traits not previously characteristic, or a sharp exacerbation of a number of traits previously little pronounced. Only in patients with a short duration of illness (up to 2 years) did no secondary changes of character occur. Patients complained that they had become extremely
suspicious, impressionable, anxious, insecure, indecisive,
timid, shy, and fearful. In patients with neuroses involving obsessive phenomena of
long duration, secondary changes of character occur, and, regardless of
the form of neurosis and premorbid personality features, in all patients these proved to be of the same type and manifested in anxious-suspicious or even pronounced psychasthenic
character traits (Lipgart N.K., 1978).
Earlier we presented data on the personality traits predisposing to the occurrence of neurasthenia, hysteria, and obsessive-compulsive neurosis. Each of the three groups of
personality traits determines not only the form of neurosis a person will develop, but also their normal behavior, in particular – in the workplace. In this connection, extremely interesting data
are presented by B.D. Karvasarsky (1990). As the author points out, satisfaction with the chosen
profession is high in the groups of patients with neurasthenia (84%) and obsessive-compulsive neurosis (82%), whereas among patients with hysteria this figure is noticeably lower (65%). Patients
with neurasthenia and obsessive-compulsive neurosis are characterized by a greater frequency of high
work performance ratings (52 and 55% respectively) compared with patients with hysteria
(35%). A positive attitude toward one's own work was most often noted in the group of patients
with neurasthenia (92%) and least often – with hysteria (69%). Promotion in service was found in 51%
of neurasthenics, 37% of hysterics, and 32% of psychasthenics.
Indeed, the trends indicated by B.D. Karvasarsky are exactly these, and this is why an employer should pay special attention to candidates with hysteroid personality
traits – as a rule, not only not the best employees, but also particularly dangerous should
they gain leadership positions.
Thus, the following conditions are necessary for the formation of neuroses.
1. The presence of a psychotrauma with the affect and amnesia occurring at the moment of its action,
owing to which the resulting symptoms cannot be eliminated. One of the most severe psychotraumas is an unresolved contradiction between one and another important human need (an intrapersonal conflict).
2. Asthenization of the nervous system, lowering the sensitivity threshold to the blocking of
important needs (that is, the sensitivity threshold to psychotraumas) and naturally increasing the traumatic potential of information.
3. Certain personality traits, which will determine the inability to process the psychotraumatizing situation (each form of neurosis having its own personality traits).
4. The additional action of new psychotraumas, which intensify the neurotic
symptomatology and further confuse the search for the root cause.
Since neuroses are informational disorders, one can be rid of them exclusively by means of informational influence – various types of psychotherapy.
Psychotherapy (Gr. psyche – soul + therapeia – treatment) is an informational influence on a person with the aim of eliminating negative emotions in them and freeing them from psychogenic disorders caused by psychotraumatizing information reflecting the blocking of one significant need or another for the person.
One of the outstanding European psychotherapists of the late 19th – early 20th centuries, P. Dubois (1911), spoke extremely precisely and succinctly about the role of psychotherapy in medical practice: «In present-day medicine a certain metamorphosis is definitely becoming noticeable. Whereas previously
the word psychotherapy evoked only a compassionate smile, nowadays it is heard almost daily from the lips of internists, even surgeons and gynecologists. At first this was
laughed at, then it was agreed that there was, after all, something to it, and now everyone has zealously taken up psychotherapy and even claims to have always practiced it. Excellent –
that is all I wished for; once again the human head has been found, if only it is not forgotten again».
The most effective types of psychotherapeutic influence are causal, pathogenetic, and psychoanalytic psychotherapy. On the whole all three methods of psychotherapeutic work represent one and the same approach to treating neuroses. The differences between these
types of psychotherapy lie in individual elements.
In the first chapter of this textbook we mentioned that it is precisely with the names of Josef Breuer and Sigmund Freud that the onset of a new stage in the development of psychology is connected. Thanks to
the discoveries of these two scholars, an understanding of the nature of neuroses and their treatment became possible.

The discoveries they made have no equal in scale to this day.
It was precisely psychoanalysis, as a method of psychotherapy, that became the starting point for the emergence of the overwhelming majority of methods of psychotherapeutic work.
In his scientific works, S. Freud repeatedly emphasized that the credit for the birth of the method of psychoanalysis belongs to the Viennese physician Josef Breuer, who applied this
method to treat a patient with hysteria (1880–1882). During the illness the patient showed extremely severe symptomatology: paralysis of both right limbs with an absence of sensitivity, disturbances of eye movement, a severe nervous cough, an aversion to taking
food and water, loss of the ability to speak, and states of confused consciousness. Despite the
quite formidable symptomatology, all the organs, including the brain, showed no organic pathology whatsoever, and in this situation, as S. Freud notes, in understanding the origin of the symptoms the physician can be helped by neither their anatomical-physiological nor their pathological training. Distinguishing hysteria from severe organic pathology can be quite
difficult. As S. Freud notes, physicians, having no notion of the genesis of hysterical symptoms, quite naturally did not understand the causes of the illness and accused hysterical patients of simulation and exaggeration, punishing them with their inattention.
The patient mentioned above fell ill during the period of caring for her sick father, who
died, but only after she had, because of her own illness, given up caring for him. J. Breuer
at first did not know what line to follow in her treatment. Observing the patient for a long time, J. Breuer noticed that during states of confused consciousness the patient
would mutter certain words that gave the impression of relating to certain thoughts occupying the patient's mind. He asked the patient to remember these words, after which he put
her into a state of hypnosis (Gr. hypnos – sleep) and spoke them, in order to prompt her
to say something more on this topic. As a result of this procedure the patient voiced the content of her psyche corresponding to the state of confused consciousness. These were deeply sorrowful fantasies on the theme of her being at her sick father's bedside. Following
her reproducing these fantasies, she would return to a normal state of mind. This good state persisted for many hours and was replaced the next day by a new attack of confusion of consciousness. The patient figuratively called this method of
treatment chimney sweeping or the talking cure.
Subsequently it emerged that, with the help of the aforementioned method (the method of catharsis),
one could achieve not only short-term improvements, but also complete recovery. If
the patient, with an expression of affect, recalled under hypnosis the connection with which one symptom or another first arose, it was possible to eliminate these symptoms entirely. During a summer period that was
very hot, the patient suddenly, without any apparent reason, stopped drinking water, quenching
her thirst instead with fruit and vegetables. About 6 weeks after the appearance of this symptom, the patient, while in a state of hypnosis, spoke of a friend of hers whom she disliked. She spoke of her with obvious disgust. Once she had witnessed the little dog belonging to her disliked friend drinking water from a glass, but, not wishing to seem impolite, had not commented on it at all. After
expressing her disgust regarding this situation, the patient demanded to drink: she drank, and
woke up with a glass of water at her mouth. The symptom disappeared after this. As S. Freud points out, before
this case no one had ever eliminated hysterical symptoms in this way. Subsequent immersion in the problems of the illness revealed that almost all of the patient's symptoms had formed as residues of affective experiences. From this time on the causes of neuroses ceased to be a mystery. The patient had almost always been forced to suppress strong excitation
– instead of ridding herself of this excitation through the corresponding expressions
(manifestations) of affect – words, actions (she suppressed her disgust toward her friend, suppressed her tears at her father's bedside, her grief).
The patient exhibited various states of mind: states of confusion alternating with a normal state. In the normal state she knew nothing of the pathogenic scenes or of their connection with the symptoms. Thanks to the study of hypnotic phenomena, it
came to be understood that within one and the same person there exist different mental groupings, which alternately take hold of consciousness.
J. Breuer suggested that hysterical symptoms arise in a special (hypnoid)
mental state. A symptom that arises in a hypnoid state passes over into the normal
state and exists in it as something alien. Consciousness, therefore, knows nothing about
the pathogenic experiences of the hypnoid state. Where a symptom exists, there also exists amnesia, and filling the resulting gap in memory coincides with the destruction of the conditions for
the symptom's occurrence. Nowadays it is understood that the hypnoid mental state
of which J. Breuer spoke is nothing other than a state of affect.
As discovered by S. Freud, needs that contradict one another give rise to an intrapersonal conflict, and in order not to feel mental pain in connection with this conflict,
the representation relating to one of the conflicting needs was repressed from consciousness and forgotten. The study of patients with hysteria and other forms of neurosis led
S. Freud to the notion that they had not succeeded in repressing the idea with which the
contradicting needs were connected. They had, it is true, removed it from consciousness and from memory,
and had thereby seemingly rid themselves of unpleasant sensations, but in the unconscious the repressed wish continues to exist and waits for the opportunity to become active and to send from
itself into consciousness a distorted, unrecognizable substitute. The representation (symptom) substituting for the repressed
thought is spared further attacks from the defending «I», and instead of a short-term conflict, endless suffering ensues.
In the symptom, alongside features of distortion, a remnant of resemblance to the repressed
idea is present. The paths by which the substitution took place can be uncovered during psychoanalytic treatment, and for recovery it is necessary for the symptom to be traced back to the repressed idea by these same paths.
S. Freud and J. Breuer directed the patient's attention directly to the psychotraumatizing situation during which the symptom arose, trying to uncover within it the psychic
conflict and to free the suppressed affect. The patient's associations went from the psychotraumatizing situation that it was desirable to explain, back to earlier experiences. This «regression» led ever further back – into childhood. It emerged that psychoanalysis
cannot explain anything in the patient's present state without tracing it back to the past
(Freud S., 1923)!
If what has been repressed is once again transferred into the sphere of consciousness, the psychic conflict that the patient wished to avoid finds, under the guidance of the psychoanalyst, a better outlet
than it found by means of repression. S. Freud identified three ways of working with thoughts
extracted from the unconscious.
1. The patient becomes convinced that they unjustly rejected the repressed wish and
accepts it (perceives it as a new acquisition, a new need, once undeservedly suppressed and rejected).
2. The repressed wish is brought to awareness, and the energy released as a result of this awareness is directed toward a different need (one that raises no doubt as to its purity),
which constitutes the essence of sublimation (Lat. sublimare – to raise up) – the process of redirecting the energy generated by the primary repressed need toward secondary needs,
the realization of which will not give rise to an intrapersonal conflict – a conflict arising as a result of one need contradicting another.
3. The rejection of a once-repressed wish is recognized as just at present as well and is condemned.
By these methods, conscious control of repressed wishes is achieved: if a repressed thought remains unconscious, it controls the person, whereas in
the case of its becoming conscious it loses its former charge, and it is now the person who controls this thought,
in connection with which it can no longer do harm!
J. Breuer's method of catharsis (Gr. katharsis – purification) involved putting the patient into
a hypnotic state – in order to obtain information about pathogenic material that the patient in a normal state does not know about. S. Freud set himself the goal of
using the method of catharsis without putting the person into a state of hypnosis. He succeeded in this by obtaining information through such methods as the method of association, the method of dream analysis, and the method of analyzing erroneous, accidental actions.
Speaking of the method of free association, S. Freud pointed out that a chance thought should
relate to the repressed thought as a hint. He proposed calling a group of representations connected by one affect a complex. Proceeding, in the search for the repressed complex, from
the last thought expressed by the patient, as S. Freud points out, we can hope to find the sought-after complex if the patient provides us with a sufficient quantity of thoughts that come freely to mind. In carrying out this task, one is hindered
by the fact that the patient falls silent, stumbles, and begins to claim that they do not know what to say.
This is explained by the fact that the patient holds back (eliminates) the thought that has come into their head
owing to the presence of a force which S. Freud called resistance, which disguises itself under various critical judgments about the significance of the thought. The patient must say absolutely everything that comes into their head, even if they consider it incorrect, senseless, irrelevant to the matter, and especially in cases where it is unpleasant for them to occupy their
mind with such a thought.
The second technique by which one can investigate the unconscious is dream analysis. Regarding this method, S. Freud said that we look condescendingly upon our
dreams – almost as the patient looks upon their chance thoughts, which are needed by the psychoanalyst. The low estimation of dreams depends on the strange character even of those dreams that are not senseless or confused, as well as on the absurdity and senselessness of the rest. The dreams of small children (from 1.5 years of age) lend themselves simply and easily to explanation
– the child dreams of the fulfillment of wishes that arose the day before and did not find
satisfaction. The dreams of adults, however, have undergone distortion. In the formation of dreams the same struggle of mental forces takes place as in the formation of symptoms. The manifest content of a dream is a distorted substitute for unconscious thoughts (the handiwork of the defensive forces of the «I»), that is, of the resistance which, in the waking state, does not admit repressed unconscious wishes into the sphere of consciousness at all. With the weakening of consciousness in the state of sleep, this resistance is nevertheless still strong enough to bring about a disguising of unconscious thoughts. One must set aside the seeming connection of elements in the manifest dream and gather together the chance thoughts that arise upon free association to each of the elements of the dream. The manifest content of the dream, which
is remembered upon waking, is a disguised fulfillment of repressed wishes.
Dream-work is the process leading to the distortion of unconscious hidden thoughts in the manifest content. Dream-work is a particular case of the influence of various
mental groupings upon one another (a particular case of the splitting of the psyche). Dream-work
is identical to the work of distortion which turns repressed complexes, in the event of
failed repression, into symptoms.
Causal (Lat. causa – cause) psychotherapy presupposes an exchange of information between the patient and the psychologist, leading to the patient's becoming aware of and abreacting psychotraumatizing experiences (Svyadoshch A.M., 1971, 1982). In order to be rid of certain pathogenic symptoms, one must identify them and become aware of the cause that gave rise to them. After
the unconscious causes of the illness have been discovered, and the existing conditioned-reflex connections identified, one proceeds to «explaining» them to the patient. One strives to have the person
arrive at the conclusion of their existence on their own (which is why psychotherapy is defined first and foremost as a system of questions to the client, rather than a system of answers from the psychotherapist). It must
be said that this is a common error in understanding psychotherapeutic work: it is believed that in working with a psychotherapist, the latter will give advice and teach how and what
needs to be done. If this occurs, psychotherapy becomes ineffective (Evstigneev D.A., Kopysov V.Kh., 2007). There is a well-known regularity – conclusions formulated by another person tend to be received worse than those a person has drawn themselves, even though the conclusions are identical! Psychotherapeutic work is a very delicate instrument, requiring extremely careful handling.
Causal (cause-and-effect) psychotherapy is an influence through which
cause-and-effect connections are established between neurotic symptoms and
psychotraumatizing situations that took place. Psychotherapy is applied in two variants, both of which are used in psychological counseling. The first variant of psychotherapy is a system of questions to the person, in the process of answering which an understanding occurs of thoughts previously unconscious, and an abreaction of previously suppressed and
repressed emotions occurs. In the second variant of psychotherapy, the psychotherapist
does not enter into direct interaction with the person, does not ask them any questions, but in the process of the case history of neurotic patients being disclosed, the person is given the opportunity
to see something similar in their own behavior, which gives them the opportunity, even without entering into a dialogue with the
psychotherapist, to solve their own problem – just as in the first variant, to become aware of previously unconscious thoughts and to abreact suppressed emotions.
It should be noted that telling the patient about the case histories of other neurotic
patients with bodily ailments they had was used as a psychotherapeutic technique as early as P. Dubois (1911).
Causal psychotherapy is very close to pathogenetic (Myasishchev V.N., 1939, 1956,
1958, 1960; Yakovleva E.K., 1956, 1958; Karvasarsky B.D., 1985) and analytical (psychoanalytic)
psychotherapy (Freud S., 1997; Horney K., 2002). All three types of psychotherapy postulate
the importance of identifying cause-and-effect dependencies between the features of the system of needs (that is, the significance of information, and consequently – its traumatic potential) and neurotic symptoms.
In the course of psychotherapy, upon penetrating to the «sore» point, a person sometimes
experiences a violent emotional reaction, often with a number of expressive movements (Svyadoshch A.M., 1971, 1982), which should be treated as an ordinary phenomenon when thoughts oppressive to the person are transferred from the
unconscious into the sphere of consciousness. The unconscious of any person can be defined as a «storehouse of pain» – one of the functions of the unconscious consists
in removing from the sphere of consciousness experiences that are agonizing for the person. It would seem that if
psychotraumatizing information is removed into the unconscious, subjected to active amnesia, then the person is freed from suffering. Indeed, part of the information is in this way «frozen», and thanks to this the person can preserve their capacity for work,
reacting to various situations in a manner typical for themselves. But another part of the information repressed into the unconscious, though it seems forgotten to the person, continues its life in
the sphere of the unconscious, is transformed within it, and, as was discovered by S. Freud, passes over into consciousness in the form of one symptom or another. In order to be freed of a symptom, one must retrieve from the unconscious the repressed information, abreact it, relive once again the situation of the affect that once occurred, and recall the information that was repressed, not accepted, and understand the reasons for the repression.
One of the forms of psychotherapeutic work with patients with neuroses is pathogenetic psychotherapy (Myasishchev V.N., 1939, 1956, 1958, 1960; Karvasarsky B.D., 1985). The aim of pathogenetic (Gr. pathos – suffering + genos – kind, that which gives birth) psychotherapy is to change the patient's disturbed system of relationships, to correct inadequate emotional reactions and forms of behavior, a necessary precondition for which is the patient's achieving an understanding of the cause-and-effect dependencies between the features of
their system of relationships and their illness. As V.N. Myasishchev (1939, 1955, 1956, 1960) notes,
in each case the concrete picture of the illness can be constructed only on the basis of an analysis of the case history, the history of the personality under the specific social conditions of its development.
Knowledge of this history, knowledge of the qualities of the personality and the conditions of its experiences, makes it possible to decipher an often incredibly tangled complex of morbid manifestations and to outline, on the basis of
such a structural-genetic understanding, a rational treatment plan.
Psychotherapy gives the best results provided the patient actively participates in
becoming aware of the causes of their illness, of their inadequate reactions. Awareness presupposes
that the patient themselves establishes the connection between the conditions of life, their experiences, and the morbid
state. Having clarified the connection between the conditions and the occurrence of the symptoms of the illness, the patient masters their condition and is freed from it. They eliminate the morbid focus
of stagnant excitation, destroy the isolation of this focus, setting themselves new, real,
life tasks (Myasishchev V.N., 1956). The process of becoming aware (making sense) of the pathogenesis of the illness is a process of establishing or restoring associative connections of a focus of pathological dominance or pathological automatism that has become
isolated and stagnant (Myasishchev V.N., 1958).
According to the pathogenetic conception, the inner conflictuality of the patient with neurosis and
their unresolved emotional problems find their expression in a disturbance of relations with their immediate social environment. Owing to distortions in the sphere of social perception (arising as a result of the conflictuality of self-esteem), the neurotic misinterprets the motivation of communication partners, reacts inadequately to arising interpersonal situations, and all their attention is concentrated not on resolving real problems, but on preserving the notion of the significance of their «I», both in their own
eyes and in the eyes of others (Karvasarsky B.D., 1985; Karvasarsky B.D., Prostomolotov V.F., 1988).
Pathogenetic psychotherapy presupposes both individual and group forms of work. Because the primary mechanisms (contributing to the occurrence of neurosis) are
to a greater degree connected with the intrapersonal conflict and the patient's life history, while
the secondary mechanisms (contributing to the maintenance of the neurosis) are connected with difficulties in their interpersonal relationships and their current life situation, it is natural for individual psychotherapy to concentrate attention on the problems of the primary mechanisms, and for group psychotherapy to concentrate on the secondary mechanisms of neurotic symptomatology (Karvasarsky B.D.,
1985; Karvasarsky B.D., Prostomolotov V.F., 1988). Within the framework of the group form of psychotherapeutic work, V.N. Myasishchev (1958) identified three variants of the method: – discussion with patients of the forms and origins of various psychogenic illnesses; – discussion of real
cases of illness; – analysis of a patient and the history of their illness in the presence of other patients.
According to B.D. Karvasarsky (1985), a psychotherapeutic group should, to a certain degree, be a model of the patient's «natural» groups (family, work) and should contribute to the manifestation of as wide a range as possible of behavioral stereotypes and emotional experiences characteristic of the patient; it is essential that the relationships forming
among the group's participants be able to undergo constant change in the course of its work. The reconstruction of the patient's disturbed relationships is facilitated by the fact that the behavior of the group's members toward the patient differs from the behavior of the members of their «natural» groups.

The goals and objectives of pathogenetic psychotherapy, applied in individual and
group form, include (Karvasarsky B.D., 1985; Karvasarsky B.D., Prostomolotov
V.F., 1988):
1) a deep and comprehensive study of the patient's personality, the features of their emotional responses, their motivation, and the specifics of the formation, structure, and functioning
of their system of relationships;
2) identifying and studying the etiopathogenetic mechanisms contributing both to the occurrence and to the maintenance of the neurotic state and symptomatology;
3) achieving in the patient an awareness and understanding of the cause-and-effect connection between
the features of their system of relationships and their illness;
4) helping the patient to reasonably resolve the psychotraumatizing situation, changing,
where necessary, their objective position and the attitude of those around them toward them;
5) changing the patient's relationships, correcting inadequate reactions and forms of behavior,
which is the main task of psychotherapy and leads to an improvement in the patient's well-being and
the restoration of the full value of their social functioning.
At the root of neuroses, according to V.N. Myasishchev (1934, 1939, 1960), lie contradictions between the individual and the aspects of reality significant for them that are unsuccessfully, irrationally, and
unproductively resolved by the individual. An inability to find a rational and productive way out entails
mental and physiological disorganization of the personality. Neurosis arises when
the conflict between the individual and reality cannot be processed in such a way that
the pathogenic tension disappears, that a rational way out of the resulting situation is found.
Hence, in constructing pathogenetic psychotherapy, V.N. Myasishchev (1956, 1960) recommends striving not only to help the patient become aware of the connection between the psychotraumatizing events
and the system of relationships especially significant to them, but also to change this system as a whole – to restructure the patient's attitude toward their surroundings, to correct their life positions and attitudes. Thanks to this a stable elimination of the morbid symptom is achieved.
From what has been described above, it is clear that causal and pathogenetic psychotherapy are identical to one another and should be regarded as synonymous. B.D. Karvasarsky (1990) also calls pathogenetic (causal) psychotherapy personality-oriented (reconstructive) psychotherapy.
Thus, in conducting psychotherapeutic work one should be guided by
the following rules and regularities.
1. In the presence of neurotic symptomatology (expressed either in changes in the sphere of the psyche or in the sphere of somatic health), the time of onset of the
symptoms should be established – most often it corresponds to the moment when the psychotraumatizing information acted (less often the symptoms appear some time after the psychotrauma).
2. After establishing the order in which the symptoms arose (from the most recent back to the very first symptoms), one should, as S. Freud suggests, return step by step to all the psychotraumatizing situations, relive them anew – abreacting all suppressed emotions. Remember
that the focus of excitation in the brain connected with a suppressed negative emotion persists for as long as it takes, and it will not disappear until it is discharged as a result of the suppressed emotion being abreacted!
3. During and after abreacting emotions that had previously been suppressed, it is necessary to understand the causes of all (without exception) emotional reactions: any negative emotion is a reaction
to the blocking of important needs, in connection with which it is necessary to answer the question – the blocking of precisely which need caused the negative emotion that created a pathological focus of excitation in the brain. We have already repeatedly noted that suppressing negative emotions is dangerous – psychosomatic illnesses arise, and it is precisely the abreaction of once-suppressed, once-restrained emotions that allows one to free oneself from distressing
sensations (the focus of excitation connected with an affect that once arose, and giving rise to organ damage, persists until it is discharged).
4. After understanding the blocking of which particular needs led to the occurrence of negative emotions, a person gains the ability to manage themselves: the needs underlying negative emotions that once arose are either eliminated (more often as a result of understanding the «foolishness» of one's former needs – by the time psychotherapy is conducted, a person's needs may have already changed, and it is precisely thanks to new needs that the person will assess their past behavior quite differently –
behavior whose traces are often found only in the unconscious, and here an encounter between the needs of consciousness and the unconscious is unavoidable), or are replaced with others, which
is achieved by means of the psychotherapist explaining the regularities that exist in
the world (within the framework of interpersonal relationships in particular), giving rise in the person seeking help to the formation of new, adaptive (incapable of forming a neurosis) needs (more on this in the chapter on psychotherapeutic rules and their implementation in the process of communication).
The essence of psychotherapeutic rules comes down to explaining the true cause-and-effect connections that determine mental phenomena.
To emphasize once more the importance of correctly expressing emotions at the moment they arise, let us give one more example. A young man, after a conflict situation
with his girlfriend, in which he was undeservedly attacked by her and restrained his anger at
the moment the situation developed, began to experience tremor at subsequent meetings with her, which
he found very difficult to cope with. This is a vivid illustration of the rule – any suppressed
emotion strives for expression and will ultimately be expressed! However much one might wish otherwise,
it cannot be any other way. On the level of consciousness the young man was entirely convinced that restraining his anger in the conflict situation was the only correct and noble decision, but his organism, through the tremor arising in his girlfriend's presence, was signaling something quite different.
Thus, the expression (abreaction) of negative emotions connected with one
psychotraumatizing event or another is a mandatory component of psychotherapy, thanks to which the pathological focus of excitation that arose in the brain during the psychotrauma is discharged and frees the person both from agonizing experiences (if the person is aware of the existence of the focus of excitation and suffers from it) and from bodily ailments. In certain states, pathological foci of excitation and the negative emotions connected with them become more accessible for awareness and abreaction. One such state is alcohol intoxication. Alcohol contributes to the «exposure» of foci, making them more accessible for awareness and discharge. This occurs because alcohol suppresses the activity of consciousness – the grouping of the psyche that stands on
guard so that what contradicts its needs and is unpleasant to it remains in the unconscious – the grouping of the psyche performing the function of a «storehouse of pain»,
the function of «freezing» unpleasant sensations. The disinhibition, in a state of alcohol
intoxication, of pathological foci of excitation previously hidden in the unconscious can
lead either to their complete elimination (the energy released as a result of the emotions being abreacted goes toward rewriting the previously existing pathological conditioned
reflex into a new, now normal, reflex, which is possible on condition that the need whose blocking once caused the psychotrauma disappears, or on condition that the aforementioned need is replaced by a new one), or to aggressive actions (in this case the released energy is directed at those people from the past connected with the blocking of an
important need, that is, with the psychotrauma). In the latter case no new need is formed in the person
that could destroy the one whose blocking, in the past, formed a pathological focus of excitation. The danger of this kind of reaction
lies not only in the fact that aggressive actions may cause some harm or other to those people connected with the blocking of the need (the psychotrauma), but also in the fact that aggression
may be directed not at people from the past, but at those whose behavior resembles the behavior of people from the past. It was precisely such a situation that occurred with a young man who,
while in a state of intoxication, nearly committed a crime. As the psychotherapy conducted after this episode showed, the aggression directed at another person was
connected with people from the past. Being modest and losing his composure in conflict situations,
he had been unable to express his aggression (anger) at the moment it arose, and this suppressed anger, quite naturally, formed a pathological focus of excitation. In
a state of alcohol intoxication his interlocutor showed him disrespect, which, via the mechanism of the conditioned reflex, became associated with past situations of disrespect and, owing to
the greater accessibility of the pathological focus of excitation, caused a most powerful discharge of it. It should be fully understood that the aggression directed by the young man at his interlocutor was directed at all those with whom unpleasant (psychotraumatizing) situations had been connected in the past. It should be noted that it was only in the course of psychotherapy that the young man understood why he had nearly committed a crime. In the period between the act and the psychotherapy, it had been completely unclear to him what such disproportionate aggression was connected with. In
the foreword to this textbook we pointed out that cause and effect can be significantly separated from one another. In the case under consideration we observe that the cause
(the suppression of negative emotions) is quite significantly removed from the effect (the disproportionality of the aggression). Other causes of the disproportionality of aggression are examined in
the chapter devoted to psychotherapeutic rules and their implementation in the process of communication.
It should be remembered that the unconscious is a «storehouse of pain» (a storehouse of unpleasant, morbid information repressed from the sphere of consciousness, giving rise to neurotic symptoms), and
in order to be rid of it, the pain must be relived once again, the thoughts that were once repressed must be brought to the sphere of consciousness,
and now, with the participation of consciousness, their existence must be acknowledged, after which they must be processed (as S. Freud (1997) suggests, by accepting these thoughts,
condemning them, or acknowledging the impossibility of their realization, directing the energy released
as a result of this awareness toward some other goals – goals not connected with the primary
need).
It is interesting that, upon becoming aware of thoughts previously repressed, a person's consciousness, which had once
not permitted the understanding of certain thoughts and had for this reason repressed them into the unconscious, differs from the consciousness at the time psychotherapy is conducted – and the more so, the more
time has passed since the psychotrauma: during this time the understanding of the significance of one piece of information or another changes, and consequently – needs change, and, as a consequence, so does the degree of traumatic potential of the information (Evstigneev D.A., 2008). Thus, in such a state, what is retrieved from the unconscious will be assessed by a consciousness that is no longer quite the same one that existed at the time of the psychotrauma and that could not accept the existence of certain
thoughts. Past behavior and thoughts will now be assessed (to a greater or lesser degree) as if «from the outside», «through different eyes». One should not, however, think that this mechanism alone allows a person to perceive differently the
psychotraumatizing information that occurred in the past and, in connection with this, to be cured. Even if psychotherapy
were conducted immediately after the psychotrauma (when the person's consciousness had not yet had time to change),
this would not complicate the psychotherapeutic work, but in a number of cases, on the contrary, would facilitate
it. Immediately after a psychotrauma (or even at the moment it is occurring), memories and experiences are «fresh» and not all the information has been repressed or subjected to amnesia, and in this connection a minimum of effort will be required to reveal the dialogue between consciousness and the unconscious, in the disruption of which lies the cause of neurotic disorders (Evstigneev D.A., 2008). However, not everyone can conduct psychotherapy immediately after a psychotrauma – it is most difficult in
this situation to conduct psychotherapy with the person connected with the psychotraumatizing situation, and
in such cases psychotherapy should be conducted after some time has passed – time sufficient for the traumatized person to no longer perceive the information so acutely and in such a distorted way. It is well known that most attempts to enter into dialogue with a person while psychotraumatizing information is acting on them (during the affect) end
in the situation being aggravated – with growing irritation, hostility, and, crowning it all, extreme inadequacy of behavior.
Thus, neuroses form in the course of ontogenesis (during a person's lifetime) and only under the influence of information signaling the blocking of needs (psychotraumatizing information), and, this being so, they can be defined as pathogenic conditioned reflexes formed under the influence of
psychic traumatization. Owing to the fact that the origin of neuroses is conditioned-reflex in nature, in order to understand exactly how a neurosis (in other words
– a pathogenic conditioned reflex) formed, we will need to precisely establish the time of its appearance (that
is, return to the moment the psychic trauma acted) – in order not only to determine the type of need that was blocked in the person (that is, to name the psychotrauma), but also exactly how this conditioned connection was subsequently reinforced, owing to which the extinction of the pathogenic conditioned-reflex connection does not occur – it becomes ever more durable. Those situations that reinforce the pathogenic conditioned connection (subsequent secondary psychotraumas) often mask the primary psychotrauma that laid the foundation for the neurosis,
sometimes giving a false picture of the understanding of the true (primary) psychic trauma. It is precisely because the primary and subsequent psychotraumas are sometimes extremely similar that additional difficulty arises in recalling information that has already been repressed and subjected to amnesia. The whole point is that the symptomatology of a neurosis may appear
not at the moment the primary psychotrauma acts, but precisely during subsequent, similar traumas, illusorily giving the picture that the neurosis formed later than it actually did. The conditioned reflex that formed during the primary psychotrauma, against a background of
very strong negative emotions, may manifest itself in a situation where a subsequent psychotrauma acted, one not at all resembling the primary one, and the very fact of the occurrence of
powerful neurotic symptomatology will correspond precisely to the moment of the second psychotrauma. This is how the true moment of the neurosis's occurrence comes to be masked.
Thus, the fundamental proposition from which one must proceed in order to
understand the formation of neuroses and their treatment is that the overwhelming part of the psyche
consists of conditioned reflexes formed in the course of ontogenesis, in connection with which neuroses must be regarded as a pathogenic conditioned connection formed under the influence of psychic traumatization.
Proceeding from this proposition, it is obligatory to precisely establish the time of appearance of this pathogenic conditioned reflex and to work with the thoughts and emotional reactions of the person corresponding to this moment of the psychotrauma.
Practice shows that it is precisely various kinds of neurotic disorders, engendered by a disrupted dialogue between consciousness and the unconscious, that often form the basis of disagreements and conflicts,