The psychosocial approach as a multifaceted scientific and practical direction in extreme psychology and psychological assistance. Information model of PTSD

• Dontsov Alexander Ivanovich, Doctor of Science, Professor, other position
• Moscow State University named after M.V. Lomonosov
• Dontsov Dmitry Alexandrovich, Candidate of Sciences, Associate Professor
• State Classical Academy named after. Maimonides
• Dontsova Margarita Valerievna, Candidate of Sciences, Associate Professor
• Moscow Psychological and Social University

• PSYCHOLOGICAL HELP
• PSYCHOSOCIAL WORK
• POST-TRAUMATIC STRESS DISORDER
• PSYCHOSOCIAL APPROACH
• PTSD SUFFERERS
• PSYCHOLOGICAL TRAUMA
• EXTREME PSYCHOLOGY

The article presents the main provisions of the psychosocial approach to the study of post-traumatic stress disorder (PTSD), to psychosocial work with people suffering from PTSD and to psychological assistance for PTSD.

• History and trends in the development of psychological counseling on the Internet information network
• System of concepts and general content of orientation in the world of professions
• Professional orientation of the individual as a component of human social development
• Socio-psychological and pedagogical support for the professional and personal development of psychology students

Brief Description of PTSD

When it is said that a person suffers from PTSD, first of all, it means that he has experienced something terrible and has some of the specific symptoms, there are post-stress consequences. PTSD (post-traumatic stress disorder) occurs due to traumatic situations. Traumatic situations are extreme critical events that have a powerful negative impact on individuals and groups of people. These are situations of clear and strong threat that require extraordinary efforts from a person to cope with the consequences of a sharply negative impact on him and/or the people around him. Traumatic situations take the form of events that go beyond everyday experience and are fundamentally different from typical classes of situations of social and professional interaction between people. In a traumatic situation, a person (a group of people) is exposed to an extreme, intense, extraordinary impact, which is expressed in a threat to the life or health of both the person himself and people close to him (meaningful to him). Traumatic situations are extremely powerful negative stressors for people.

According to ICD-10 (adopted in 1995, the tenth edition of the International Classification of Diseases, the main diagnostic standard in European countries, including RF), post-traumatic stress disorder (PTSD) may develop following traumatic events that are beyond the scope of normal human experience. “Ordinary” human experience refers to events such as: loss loved one, which occurred due to natural reasons, severe chronic illness, loss of work, family conflicts, etc. Stressors that go beyond ordinary human experience include those events that can traumatize the psyche of almost any healthy person: natural disasters, man-made disasters, as well as events that are the result of purposeful, often criminal activities (sabotage, terrorist acts, torture, mass violence, fighting, getting into a “hostage situation”, destroying your own home, etc.).

PTSD is a complex of human psychophysiological reactions to physical and/or psychological trauma, where trauma is defined as an experience, a shock, which in most people causes fear, horror, and a feeling of helplessness. These are, first of all, situations where a person himself has experienced a threat to his own life, the death or injury of another person (especially a loved one), which occurred in emergency circumstances. It is assumed that PTSD can manifest itself in a person immediately after being in a traumatic situation, or it can arise several months or even years later - this is the special tricky aspect of PTSD (I.G. Malkina-Pykh, 2008).

Theoretical models of PTSD

The intensity of the traumatic situation is the primary risk factor for the development of PTSD. Other risk factors include: low level of education, low social status, chronic stress, psychiatric problems preceding the traumatic event, the presence of close relatives suffering from psychiatric disorders, etc.

Other important risk factors for PTSD include such personal characteristics of a person as accentuation of character, sociopathic disorder, low level of intellectual development, as well as the presence of alcohol or drug addiction.

If a person is prone to externalizing (“externalizing”) stress, then he is less susceptible to PTSD.

Genetic predisposition (history of mental disorders) may increase the risk of developing PTSD following trauma.

A risk factor for the development of PTSD is previous traumatic experiences (for example, due to physical abuse in childhood, parental divorce, past accidents). The age factor is important: overcoming extreme situations is more difficult for very young and very old people.

The risk of developing PTSD also increases in cases of isolation of a person during a period of experiencing trauma, loss of family and close circle. The overall psychobehavioral reaction of family members is of great importance, and the role of timely professional psychological assistance is great.

IN Lately more and more importance is being attached psychological aspects stress, in particular, the vital significance of a tragic event, including the individual’s attitude to a threatening situation, taking into account moral values, religious values ​​and ideology.

Currently, there is no single generally accepted theoretical concept that explains the etiology (“origin”) and mechanisms of the emergence and development of PTSD. There are several theoretical models, among which are the psychodynamic (psychoanalytical) approach, the cognitive approach, the psychosocial approach, the psychobiological (psychophysiological) approach, and the multifactorial theory of PTSD, which has been developed in recent years. Psychodynamic (psychoanalytic) models, cognitive models and psychosocial models refer to psychological models. These models were developed during the analysis of the basic patterns of the process of adaptation of victims of traumatic events to normal life.

Research has revealed that there is a close connection between ways to overcome a crisis situation, i.e. ways to overcome PTSD (elimination and every possible avoidance of any reminders of the trauma, absorption in work, alcohol, drugs, desire to join a mutual help group, etc.) and the success of subsequent adaptation. It was found that the most effective (positively productive) are two cumulative (used comprehensively) strategies to combat PTSD:

1. purposeful return to memories of a traumatic event (carried out by the person himself with the help of professional psychologists) in order to analyze it and fully understand all the circumstances of the trauma that occurred;
2. awareness by the bearer of the traumatic experience of the reversible significance of the traumatic event for subsequent life, readaptation of the victim and the development of self-help skills, which is also carried out with the help of professional psychologists (I.G. Malkina-Pykh, 2008).

Information model of PTSD

The information model of PTSD was developed by the American psychologist M. Horowitz (Horowitz, 1998), who coined the term “post-traumatic stress disorder (PTSD)” in scientific use in 1980. The information model of PTSD is an attempt at a scientific and empirical synthesis of three models of PTSD: cognitive, psychodynamic (psychoanalytic) and psychobiological (psychophysiological) models. According to the information model of PTSD, stress is a mass of internal and external information, the main part of which cannot be consistent with the cognitive (intellectual) schemes (ideas) of the subject. In this regard, information overload occurs. Raw information is transferred from consciousness to unconsciousness, but is stored in an active form. Subject to the universal principle of avoiding pain, a person strives to store information in an unconscious form. But, in accordance with the tendency toward completion (the unfinished image effect), at times traumatic information becomes conscious as part of the information processing process. When information processing is completed, the experience becomes integrated into the structure of the personality, the trauma is no longer “stored in an active state.” The biological factor, as well as the psychological one, is included in this dynamic. This kind of reaction phenomenon is a normal reaction to shocking information. Extremely intense reactions that are not adaptive and block the processing of information (in a negative way, integrating it into the subject’s cognitive schemes) are abnormal. Horowitz's information model of PTSD, for all its successful typology, is not sufficiently scientifically and empirically differentiated, as a result of which it does not allow to fully take into account individual differences in traumatic disorders (I.G. Malkina-Pykh, 2008).

A psychosocial approach to the study of PTSD and to psychological assistance for PTSD

The enormous importance of social conditions, in particular, the factor of social support from others, for the successful overcoming of PTSD is reflected in models called “psychosocial”.

According to the psychosocial approach, the trauma response model is multifactorial and the weight of each factor in the development of the stress response must be considered. The psychosocial model of PTSD is based on Horowitz's information model of PTSD. Along with this, developers and supporters of the psychosocial approach also emphasize the exceptional need to take into account environmental factors (Creen, 1990; Wilson, 1993). The authors mean such factors as: social support factors, religious beliefs, demographic factors, cultural characteristics, the presence or absence of additional stress, etc.

A number of other conditions can be identified that influence the intensification of PTSD:

1. the extent to which the situation was subjectively perceived as threatening;
2. how objectively real was the threat to life;
3. how close the subject was to the scene of the tragic events (he might not have been physically harmed, but could have seen the consequences of the disaster, the corpses of the victims, etc.);
4. to what extent people close to the person were involved in the tragic event, whether they suffered, what was their reaction. This is especially significant for children. When parents perceive events that have occurred that are not irreversible very painfully and react in panic, the child will doubly not feel psychologically safe.

The psychosocial model of PTSD has the limitations of an information model, but the introduction of environmental factors allows for the identification of individual differences. The main social factors influencing the successful adaptation of victims of mental trauma were identified. These are factors such as: absence/presence of physical consequences of injury, durable/fragile financial position, preservation/non-preservation of the previous social status, presence/absence of social support from society (people around) and, especially, a group of close people.

At the same time, the social support factor is the most significant. Regarding people who fought, the following stressful situations associated with the social environment were identified: a person with military experience is not needed by society; the war and its participants are unpopular; there is no mutual understanding between those who were in the war and those who were not; society forms a guilt complex among veterans, etc.

Colliding with such stressors, which are secondary in relation to the extreme experience, for example, gained in war (the so-called secondary disadaptation), quite often led to a deterioration in the condition of war veterans (for example, veterans of the Great Patriotic War (WWII), veterans of the Vietnam War, veterans of the war in Afghanistan)).

This all indicates an objectively very significant role social factors both in the course of assistance in experiencing traumatic stress conditions, and in the formation of PTSD in cases where there is no support and understanding from society and surrounding people.

It must be emphasized that quite often subjects with PTSD experience secondary traumatization, which usually arises as a result of negative reactions of relatives, surrounding people, medical personnel and social workers to the problems faced by people who have suffered trauma.

Negative reactions of people to a mentally traumatized person are manifested in denial of the very fact of trauma, in denial of the connection between the trauma and the person’s suffering, in a negative attitude towards the victim and blaming her (“it’s his own fault”), and in refusal to provide help.

In other cases, secondary traumatization may arise as a result of overprotection (excessive care) shown by others towards victims, around whom relatives create a “disabled environment” that isolates them from the outside world and impedes rehabilitation and readaptation.

So, the so-called are extremely important for the development and course of PTSD. secondary factors, among which a complex of social (socio-psychological) factors, of course, occupies a leading place, since often what happens to a person after an injury affects him even more than the injury itself. It is possible to identify factors (conditions) that help prevent the development of PTSD and mitigate its course. These include: psychosocial therapy immediately started with the victim, giving him the opportunity to actively share his experiences; early and long-term social support; socio-professional restoration of the victim’s belonging to society (rehabilitation and readaptation) and resuscitation of the sense of psychological safety; participation of the victim in psychotherapeutic work together with psychologically traumatized people like him; absence of re-traumatization, etc. (I.G. Malkina-Pykh, 2008).

In overcoming the significant majority of the negative consequences of psychological trauma listed above, the most effective (productive) is the psychosocial approach.

Bibliography

1. Malkina-Pykh I.G. Extreme situations: a reference book for a practical psychologist. - M.: Eksmo, 2005.
2. Malkina-Pykh I.G. Psychological assistance in crisis situations / I.G. Malkina-Pykh. - M.: Eksmo, 2008. - 928 p. - (The newest psychologist's reference book).
3. Malkina-Pykh I.G. Psychological assistance in crisis situations. - M.: Eksmo, 2010.

In its theoretical foundations it goes back to the concept of mental trauma 3. Freud, which is presented in his relatively later works. According to this concept, in addition to unbearable traumatic external influences, unacceptable and unbearably intense impulses and desires, i.e. internal traumatic factors, should be distinguished. In this case, the trauma becomes inevitable integral part life history as the history of the development of motivations and life goals. Freud proposed to distinguish between two cases: a traumatic situation is a provoking factor that reveals the neurotic structure that existed in the premorbid; trauma determines the occurrence and content of the symptom. At the same time, repetition of traumatic experiences, constantly recurring nightmares, sleep disorders, etc. can be understood as attempts to “bind” the trauma, to respond to it.

In subsequent decades psychoanalytic concept injury undergoes a number of changes. Thus, in the works of A. Freud (1989,1995), D. Winnicott (1998) and others, the role of the relationship between mother and child is emphasized and the nature and meaning of the concept of mental trauma is radically revised. These views received their greatest development in the works of the English psychoanalyst M. Khan (1974), who proposed the concept of “cumulative trauma.” He considered the mother's role in the child's mental development from the point of view of her protective function - the “shield” - and argued that cumulative trauma arises from minor injuries as a result of the mother’s failures in the implementation of this function. This statement, he believes, is true throughout the entire development of a child - from his birth to adolescence in those areas of life where he needs this “shield” to support his still unstable and immature “I”. Such minor injuries at the time of their occurrence may not yet have a traumatic nature, however, accumulating, they turn into mental trauma. Optimally, the mother's inevitable failures are corrected or overcome through the complex process of maturation and development; if they occur too often, then a gradual formation of a psychosomatic disorder in the child is possible, which then becomes the core of subsequent pathogenic behavior.

Thus, in line with the psychodynamic understanding of trauma, three different interpretations of the term itself can be distinguished:

1) mental trauma as an extreme event, limited in time (i.e., having a beginning and an end), which had an adverse effect on the subject’s psyche;

2) “cumulative trauma” that arises in ontogenesis from many minor psychotraumatic events;

3) mental trauma of development as a result of inevitable frustrations of the subject’s needs and drives. Within the framework of this work, we will keep in mind the first meaning of the term and refer only to those works that operate with the concept of trauma in this meaning.

Currently, the “energetic” ideas about trauma once proposed by Freud are receiving a new interpretation in line with the psychodynamic approach: modern authors propose replacing the concept of “energy” with the concept of “information”. The latter refers to both cognitive and emotional experiences and perceptions that have an external and/or internal nature (Horowitz M. J., 1998; Lazarus R. S., 1966). Thanks to this, there is a convergence of cognitive-informational and psychodynamic views on trauma. This approach assumes that information overload plunges a person into a state of constant stress until this information undergoes appropriate processing. Information, being influenced by psychological defense mechanisms, obsessively reproduced in memory (flashbacks); emotions, which play an important role in post-stress syndrome, are essentially a reaction to cognitive conflict and at the same time motives for protective, controlling and coping behavior.

As a result of a traumatic experience, a conflict between the old and new images of “I” is actualized in a person, which gives rise to strong negative emotions; in order to get rid of them, he tries not to think about the trauma and its real and possible consequences; as a result, traumatic perceptions turn out to be insufficiently processed. Nevertheless, all information is stored in memory, and in a fairly active state, causing involuntary memories. However, as soon as the processing of this information is completed, ideas about the traumatic event are erased from active memory (Horowitz M. J., 1986).

This theory focuses on symptoms of PTSD such as alienation and a feeling of a “shortened” future. In addition, this approach offers an explanation for flashbacks and avoidance symptoms. Cognitive schema here refers to a pattern of information stored in memory that regulates and organizes perception and behavior. In clinical psychology, such a pattern is designated by the term “I-schema”, which breaks down into various components (schemas, images of “I”, roles); This also includes schemas of a significant other/significant others and the world as a whole (worldview). Altered cognitive schemas are associated with so-called dysfunctional cognitions, i.e., altered attitudes or “thinking errors” leading to distorted processing of information. Under the influence of trauma, these schemes can change, first of all, the “I” schemes and the role schemes (Horowitz M. J., 1986;).

After trauma, the image of “I” and the images of significant others change; these altered schemas remain in memory until the perception and processing of further information leads to the integration of the altered schemas into the old ones that remained unaffected by the trauma. For example, a previously confident, active person suddenly feels weak and helpless as a result of injury. His idea of ​​himself after the injury can be formulated as follows: “I am weak and vulnerable.” This idea conflicts with his previous self-image: “I am competent and stable.” Traumatically altered circuits will remain active until the person is able to accept the fact that he may also be weak and vulnerable at times. Until the activated altered schemas are integrated into the self-image, they generate flashbacks and intense emotional stress. To reduce it, according to Horowitz, the processes of defense and cognitive control are activated, for example in the form of avoidance, denial or emotional deafness. Whenever cognitive control fails, the trauma is re-experienced as an intrusion (flashback), which in turn leads to emotional stress and further avoidance or denial. Recovery from trauma, according to Horowitz, occurs only as a result of intensive processing of traumatically altered cognitive schemes.

Empirical research provides quite convincing evidence in favor of M. Horowitz's theory. Thus, using the method of content analysis of the categories found in the statements of patients - victims of road accidents and criminal acts - the most frequent themes were identified: frustration about one’s own vulnerability, self-blame, fear of a future loss of control over feelings (Krupnick J. L., Horowitz M. J., 1981). A group of women who had been raped was examined - their statements were grouped as follows: a changed image of the other; altered self-image; changed close relationships; changed sense of confidence; self-blame (Resick R. A., Schnicke M. K., 1991).

The intensity of post-stress syndrome, according to Horowitz, is determined by how strong, firstly, the tendency towards the invasion of involuntary memories is, and secondly, the tendency towards avoidance and denial. The main goal of psychotherapy is to reduce the excessive intensity of both of these processes. First, it is necessary to bring under control the extreme mental state that arose after traumatization, and then the task arises of integrating the traumatic experience into an integral system of ideas about oneself and the world, thereby reducing the severity of the conflict between old and new ideas. The overall goal of therapy is not to implement a comprehensive change in the personality of a patient with PTSD, but to achieve cognitive and emotional integration of images of “self” and the world, allowing to reduce the post-stressful state.

The practical steps of psychodynamic short-term psychotherapy for PTSD are traced according to the data in Table. 7.1 (Horowitz M. J., 1998).

Features of psychotherapy for PTSD

Psychotherapy for post-traumatic disorder, regardless of the specifically chosen treatment method, is characterized by a number of features. First of all, one should keep in mind the high rates of “breakage” of therapy with victims of road accidents, robberies and other attacks (50% of cases). Patients who have interrupted therapy are characterized by intense manifestations of flashbacks; No significant differences were found in relation to other symptoms.

This dynamic is explained by severe trauma that shook the patient’s foundations of trust. He feels unable to trust anyone again for fear of being hurt again (Janoff-Bulman R., 1995). This is especially true for those who have been traumatized by others. Mistrust can be expressed in an openly skeptical attitude towards treatment. Feelings of alienation from people who have not experienced similar trauma often come to the fore and make it difficult for the therapist to reach the patient. Patients with PTSD are unable to believe that they will be cured, and the slightest misunderstanding on the part of the therapist reinforces their sense of alienation. Patients with PTSD also experience certain difficulties

associated with their acceptance of the role of recipient of psychotherapeutic assistance. Let us list the reasons causing these difficulties:

Patients often believe that they must, on their own, “get the experience out of their heads.” This desire is also stimulated by the expectations of others, who believe that patients should finally stop thinking about what happened. However, this assumption of patients, naturally, is not justified.

Their own suffering is, at least partially, externalized: patients remain convinced that there is an external cause of the trauma (the rapist, the culprit of the accident, etc.), and the subsequent mental disorders are also beyond their control.

Post-traumatic symptoms (nightmares, phobias, fears) cause enough suffering, but the patient does not know that they constitute a picture of a treatable illness (like depression or anxiety).

Some patients struggle to obtain legal and/or financial compensation and see a doctor or psychologist only to confirm their right to it. Based on this, the psychotherapist, even at the very first contact with a patient suffering from PTSD, should strive to achieve the following goals: creating a trusting and reliable contact; informing the patient about the nature of his disorder and the possibilities of therapeutic intervention; preparing the patient for further therapeutic experience, in particular the need to return again to painful traumatic experiences.

D. Hammond (Hammond D. C, 1990) suggests using the metaphor of “straightening the fracture” or “disinfecting the wound” to prepare the patient for a painful encounter with a traumatic experience. Here's what he says: "The work we have to do in the next sessions is similar to what happens when

a child breaks a leg or an adult gets a painful infected wound requiring antiseptic treatment. The doctor does not want to cause pain to the patient. However, he knows that if he doesn't straighten the fracture or disinfect the wound, the patient will end up in pain longer, become disabled, and never be able to walk normally again. The doctor also experiences pain, causing suffering to the patient when he repairs a broken bone or cleans a wound. But these necessary actions of the doctor are a manifestation of care for the patient, without which cure is impossible. Likewise, replaying a trauma experience can be very painful, like disinfecting a wound. But after this, the pain will become less and recovery may come” (Maercker A., ​​1998).

The main prerequisites for successful work with patients suffering from PTSD can be formulated as follows. The patient's ability to talk about trauma is directly proportional to the therapist's ability to listen empathetically to the story. Any sign of rejection or devaluation is perceived by the patient as a failure of the therapist to help him and can lead to the cessation of efforts on the part of the patient to fight for his recovery. An empathic therapist encourages the patient to talk about the terrible events without being distracted or slipping into unrelated topics, without looking at the patient with surprise or fear, and without showing the patient his own shock reaction. The therapist does not downplay spontaneously emerging topics or divert the conversation into areas that are not directly related to the traumatic fear. Otherwise, the patient will have the feeling that the existential weight of the experience is unbearable for the therapist, and he will feel misunderstood.

The therapeutic relationship with a patient who has PTSD has characteristic features, which can be formulated as follows:

Gradually gaining the patient's trust, taking into account the fact that he has a pronounced loss of trust in the world.

Increased sensitivity to the “formalities” of therapy” (refusal of standard diagnostic procedures before talking about traumatic events).

Creating a safe environment for the patient during therapy.

Adequate implementation of rituals that help satisfy the patient's need for safety.

Before starting therapy, reduce the dose drug treatment or its cancellation to demonstrate the success of psychotherapeutic effects.

Discussion and elimination of possible sources of danger in real life patient.

The fundamental rule of PTSD therapy is to accept the pace of work and self-disclosure of the patient that he himself proposes. Sometimes it is necessary to educate family members about why work on remembering and reproducing traumatic experiences is necessary, since they are often the ones who support the avoidant behavior strategies of patients with PTSD.

The most damaged trust is among victims of violence or abuse (child abuse, rape, torture). These patients exhibit “testing behavior” at the beginning of therapy, assessing how adequately and proportionately the therapist responds to their account of traumatic events. For the gradual development of trust, statements from the therapist that acknowledge the difficulties experienced by the patient are useful; The therapist must first earn the patient's trust in any case. Severely traumatized patients often resort to various rituals to channel their fears (for example, doors and windows must always be open). The therapist should respond to this with respect and understanding. Reducing the dosage of medications or completely stopping them before starting therapy is necessary because otherwise an improvement in the condition that is reliably associated with new experiences of understanding what happened and new opportunities to cope with traumatic experiences will not be achieved.

Another noteworthy aspect of therapeutic work with patients suffering from PTSD is the psychological difficulties that the psychotherapist experiences in the process of his work. First of all, he must be intellectually and emotionally prepared to face the evil and tragedy of the world. Here we can distinguish two negative behavioral strategies of psychotherapists - avoidance (devaluation) and overidentification (see Table 7.2).

The first extreme reaction on the part of the therapist is avoidance or devaluation; “No, I can’t stand such a patient!” The therapist’s own feelings (fear, disgust) interfere with his ability to perceive the patient’s story, and distrust of individual details may arise. This attitude leads to the therapist not asking any questions about details and specific experiences. Thus, his defensive behavior is a fundamental mistake in the treatment of traumatized patients. The therapist’s reluctance to touch upon the repulsive (from the point of view of generally accepted morality) biographical facts of the patient’s life only strengthens the “conspiracy of silence” around the latter, which can ultimately lead to the development of a chronic form of PTSD.

Overidentification is another extreme position of the therapist, associated with fantasies of salvation or revenge and caused by an “excess” of empathy. As a result of this excessive empathy, the therapist may go beyond professional communication with the patient. By taking on the role of a comrade in misfortune or struggle, he significantly limits his ability to stimulate a corrective emotional experience in the patient. The danger of such “overexertion” is that any disillusionment that is inevitable in therapy can have a destructive effect on the therapeutic relationship when the goals and rules of the therapeutic contract are violated.

The therapist's reactions of uncertainty are due to his embarrassment or fear of increasing traumatization, fear of causing decompensation of the patient when questioning about the content and details of the experienced trauma. In cases of sexual trauma, the therapist's reaction to this is due to his shyness, so when the patient reports that it is difficult for him to talk about this topic, the therapist is inclined to follow his lead. The patient's story about the trauma can cause the therapist to lose control over emotions: he is unable to collect his thoughts, and tears come to his eyes from what he hears. The patient begins to doubt the therapist's actions because the latter cannot bear his story. However, most patients can tolerate the therapist's momentary breakthrough, provided that he then returns to his role as a comforter; a therapist's emotional response that is too strong is just as harmful as one that is too weak.

Working with traumatized patients requires a large emotional investment from the therapist, up to the development of a similar disorder - secondary PTSD (Y. Danieli, 1994) as a result of the fact that he is constantly a witness to all these accidents, disasters, etc. Secondary PTSD manifests itself in the form of flashbacks, depression, feelings of helplessness, alienation, regression, and cynicism. There is also a high risk of psychosomatic disorders, fatigue, sleep disorders, hyperarousal and uncontrollable breakthroughs of feelings. The general rule for therapists working with PTSD is to be kind to yourself. Permission to experience joy and pleasure is a necessary condition for working in this field, without which it is impossible to perform professional duties.

Factors for overcoming secondary traumatization of therapists according to Y. Danieli (Y. Danieli, 1994):

Identifying your own reactions: paying attention to bodily signals: insomnia, headaches, sweating, etc.

Attempts to find verbal expression for one’s own feelings and experiences.

Limiting your own reactions.

Finding the optimal level of comfort, within which openness, tolerance, and willingness to listen to the patient are possible.

Knowing that every feeling has a beginning, middle and end.

The ability to soften the overwhelming feeling without slipping into a defensive state, openness to one’s own maturation process.

Accepting the fact that everything changes and you can’t go back to the way it was.

In the case where one’s own feelings are strongly hurt, the ability to take a “timeout” to perceive them, calm them and heal them before continuing to work.

Using existing contacts with colleagues.

Creating a professional community of therapists working with trauma.

Using and developing your own relaxation and relaxation capabilities

Conclusion

A general analysis of PTSD research shows that the development of PTSD and its manifestations in people vary significantly, depending on the semantic content of traumatic events and the context in which these events occur. Definitive answers to any questions that still exist will be provided by future studies aimed at examining the interaction between the effects of traumatic events and other factors, such as vulnerability, on the onset and course of psychiatric disorders in other settings. The importance of the problem is also emphasized by the fact that both types of consequences and their duration vary widely. It is also important to answer the question of how personality traits drive symptom reduction after prolonged exposure to trauma. The priority is the problem of demonstrating the effectiveness of preventive measures, since the chronic impact of injury is of great importance for the health of the nation.

Bibliography

1. Winnicott D.V. Small children and their mothers. - M.: Class, 1998.

2. Freud 3. Introduction to psychoanalysis. Lectures. - M.: Nauka, 1989.

3. Freud A. Introduction to child psychoanalysis. - St. Petersburg: East European Institute of Psychoanalysis, 1995.

4. Shapiro F. Psychotherapy of emotional trauma using eye movements: basic principles, protocols and procedures / Transl. from English - M.: Independent company “Class”, 1998.

5. Acierno R., Hersen M., Van Hasselt V.V., Tremont G., MeuserK. T. Review of the validation and dissemination of eye movement desensitization and reprocessing: A scientific and ethical dilemma // Clinical Psychological Review. - 1994. - No. 14. - P. 287-299.

6. Allen A., Bloom S. L. Group and family treatment of post-traumatic stress disorder // The Psychiatric Clinics of North America / Ed. D. A. Tomb. - 1994. - V. 8. - P. 425-438.

7. Blake D. D., AbwegF. R., WoodwardS. H., Keane T. M. Treatment efficacy in post-traumatic stress disorder // Handbook of effective psychotherapy / Ed. T. R. Giles. - N.Y.: Plenum Press, 1993.

8. Boudewyns P. A., Stwertka S. A., Hyer L. A. et al. Eye movement desensitization for PTSD of combat: A treatment outcome pilot study // The Behavior Therapist. - 1993. - V. 16. - P. 29-33.

9. Danieli Y. As survivors age: PartH // NCP Clinical Quarterly. - 1994. - V. 4. - P. 20-24.

10. Horowitz M.J. Personlichkeitsstile und Belastungsfolgen. Integrative psychodynamisch-kognitive Psychotherapy // Therapie der posttraumatischen Belastungstoerung / Hrsg. A. Maercker. - Heidelberg, 1998.

11.Horowitz M.J. Stress response syndromes. 2nd ed. - North Vale, NJ: Aronson, 1986.

12. Hammond D. S. Handbook of hypnotic suggestion and metaphors. -N. Y.: W. W. Norton, 1990.

13. Horowitz M.J., Becker S.S. Cognitive response to stress: Experimental studies of a compulsion to repeat trauma // Psychoanalysis and contemporary science / Eds. R. Holt, E. Peterfreund. - N. Y.: Macmillan, 1972. - V.

14. Janoff-Bulman R. -Victims of violence // Psychotraumatology / Eds. G. S. Kr. Everly, J. M. bating. - N.Y.: Plenum Press, 1995.

15.JensenJ. A. An investigation of Eye Movement Desensitization and Reprocessing (EMDR) as a treatment of posttraumatic stress disorder (PTSD) symptoms of Vietnam combat veterans // Behavior Therapy. - 1994. - V. 25. - P. 311-325.

16. Khan M. M. R. The concept of cumulative trauma // The privacy of self / Ed. Khan M. M. R. - Hogarth, 1974.

17. KrupnickJ. L., Horowitz M.J. Stress response syndromes // Arch, of Gen. Psychiatry. - 1981. - V. 38. - P. 428-435.

18. Lazarus R. S. Psychological stress and the coping process. - N.Y.: McGraw-Hill, 1966.

19. Litz V. T., Blake D. D., Gerardi R. G., Keane T. M. Decision making guidelines for the use of direct therapeutic exposure in the treatment of post-traumatic stress disorder //Th e Behavior Therapist. - 1990. - V. 13.-P . 91-93.

20. Lohr J. M., Kleinknecht R.A., Conley A.T. et. al. A methodological critique of the current status of eye movement desensitization (EMD) //J. of Behavior Therapy and Experimental Psychiatry. - 1993. - V. 23. - P. 159-167.

21. Macklin M. L., Metzger L. J., Lasko N. B. et. al. Five-year follow-up of EMDR treatment for combat-related PTSD // XIY Annual Meeting ISSTS. - Washington, 1998.

22. Maercker A. Therapie der posttraumatischen Belastungstoerung. - Heidelberg, 1998.

23. Pitman R. K., Altman V., Greenwald et al. Psychiatric complications during flooding therapy for posttraumatic stress disorder // J. of Clinical Psychiatry. - 1991. - V. 52. - P. 17-20.

24. Resick P. A., Schnicke M. K. Cognitive processing therapy for sexual assault victims //J. of Consulting and Clinical Psychology. - 1991. - V. 60. - P. 748-756.

25. Solomon S. D., Gerrity E. T., & Muff A. M. Efficacy of stress for posttraumatic stress disorder: An empirical review //J. of the American Medical Association. - 1992. - V. 268. - P. 633-638.

26. Van derKolk B. A., Ducey C. P. The psychological processing of traumatic experience: Rorschach patterns in PTSD //J. of Traumatic Stress. - 1989. - V. 2. - P. 259-274.

1. THEORETICAL BASIS FOR STUDYING STRESS DISORDERS IN FIREFIGHTERS. 12 History of the formation of the concept of stress disorders 12 Diagnostic criteria for stress disorders 21 Stressful conditions and stress disorders in firefighters

2. EMPIRICAL STUDY OF THE REPRESENTATION OF STRESS DISORDERS IN FIREFIGHTERS 36 Sociodemographic characteristics of the sample 36 Research methods 37 Development of a methodology for assessing traumatic professional experiences (questionnaire for stressful situations) of firefighters

Other methods used in the work

Primary results 54 Symptoms of stress disorders in firefighters and representatives of other professions 56 Analysis of connections between professional experience and manifestations of PTSD and other mental disorders

Chapter Summary

3. DEVELOPMENT OF CRITERIA AND ALGORITHM FOR IDENTIFYING GROUPS AT RISK OF STRESS DISORDERS AMONG FIREFIGHTERS 67 Development of basic decisive rules for identifying risk groups 67

Assessing the risk of stress disorders using indirect signs

Brief summary of Chapter 3.

PTSD RISK ASSESSMENT CRITERIA.

Approbation of a shortened version of the methodological complex 91 Connection of psychodiagnostic data and observation of department heads 97 Approbation of the decisive rule for indirect assessment of the risk of stress disorders

Brief summary of Chapter 4.

Introduction of the dissertation in psychology, on the topic "Methods for identifying the risk of stress disorders in firefighters"

Relevance of the problem.

The work of firefighters refers to those types of activities whose distinctive feature is constant exposure to danger. Emergency circumstances and extreme operating conditions are an integral part of the professional experience of firefighters. For workers in hazardous professions, stress as a state of mental tension that occurs when a subject encounters professionally specific events and situations is caused, on the one hand, by everyday intense activity, leading to professional exhaustion, and on the other hand, so-called “critical incidents”, during which they have to witness the death or serious injury of people, or events in general take on a catastrophic nature. In addition, there are secondary stress factors that are determined by the nature of social relationships in departments and that enhance the effect of primary factors. Such secondary factors include insufficient material and moral encouragement, denial of necessary medical, psychological and social assistance, unfair accusations, rudeness and tactlessness of others - in particular, superiors.

For practical psychologists, an important task is the timely identification of persons who may find themselves in a severe neuropsychic state as a result of the extreme situations they have experienced. Such people need special attention from department management, effective moral support, and in many cases, professional help from psychologists and doctors. States of mental maladjustment that develop after experiencing extreme situations can manifest themselves in the form of specific mental disorders - acute and post-traumatic stress disorder (OSD and PTSD). Research in recent decades has led to the understanding that these disorders are not mental illness, because represent a natural protective mental reaction, which can exceed the normal level and lead to disruption of adaptation, depending on its intensity and duration /13, 53, 61, 76, 82, 84, 99, etc./. In developed countries, PTSD and OSD occur in 3% of the population, and in representatives of dangerous professions - 15-16%. According to foreign studies, among firefighters operating in large-scale disasters, these forms of mental disorders are no less common than among combatants /91, 97/.

The concept of PTSD, recently officially approved /63, 64/, affirms a humanistic approach to the problem psychological consequences extreme situations, because is based on the idea of ​​the non-pathological and reversible nature of these mental disorders. This distinguishes it from the concept of psychogenics, in which maladaptive states in extreme conditions are described exclusively within the framework of traditional psychiatric concepts /2, 3/. This also leads to differences in practical measures to overcome states of mental maladjustment: in the prevention and correction of PTSD, much more attention is paid to informational and educational work, psychotherapy, and various forms of non-drug treatment /14, 45, 61, 62/.

At the same time, until now there have been no domestic comprehensive studies of stress disorders in firefighters in accordance with internationally recognized theoretical concepts and diagnostic criteria for these disorders. The practice of diagnosing PTSD among police officers in departmental medical institutions is rare, and among firefighters it is practically non-existent; The number of specialists who are proficient in the clinical interview method for diagnosing PTSD is negligible.

Thus, there is a need: - development of scientific ideas about the nature of the psychological consequences of the activities of fire department employees in difficult and dangerous conditions; - timely determination of the presence and specificity of psychological problems of firefighters; - scientifically based improvement of the system of medical and psychological support for firefighters exposed to extreme situations.

For such a branch of psychological knowledge as occupational psychology, when studying PTSD, especially important are questions about the relationship between the specifics of the professional activities of the subjects and the phenomena of delayed mental reactions to events, as well as about the characteristics of the psychological consequences of extreme situations in different professional populations. Despite the fact that modern psychological science has accumulated rich material for the study and classification of “stressors” that can cause mental trauma, the issue of obtaining indicators that quantitatively characterize the traumatic experience of individuals remains insufficiently developed. Therefore, primary attention in the work is paid to studying the experience of workers encountering professionally specific situations that can cause mental trauma (we call it professional traumatic experience), and analyzing the connection of this experience with indicators of the severity of PTSD symptoms. In addition, the results obtained are compared with the results of studies that studied the symptoms of PTSD in workers of other professions (police, rescuers), whose activities are associated with increased risk.

Specialists involved in the diagnosis and correction of PTSD sometimes encounter the fact that people suffering from these disorders do not want to talk about the events they have experienced and discuss their psychological problems with anyone, and are reluctant to make contact in communication, although they need it /16 , 61/. In this regard, it is often necessary to assess the risk of PTSD not only by direct signs (using verbal or written questions about symptoms), but also indirectly (questions not related to symptoms as such) or external ones (changes in behavior observed from the side). Therefore, part of our work is devoted to the possibility of studying indirect and external signs in identifying the risk of stress disorders.

The object of the study is employees of the territorial fire departments of Moscow, Irkutsk and the Irkutsk region, Perm and the Perm region.

Subject of research - states emotional stress, stress reactions in various types of situations arising in the activities of firefighters; the severity of symptoms of post-traumatic stress disorder and its usual comorbidities (anxiety, depressive symptoms, obsessions, etc.).

The purpose of the work is to study the nature of the impact of professionally specific extreme situations on the mental state of firefighters, both directly during the events they experience and after them, and to develop a system for diagnosing and preventing stress disorders that arise as a result of such exposure.

Research objectives: 1. Analyze current state problems of stress disorders among firefighters, study foreign experience in researching the psychological consequences of critical incidents and emergency circumstances.

2. Conduct a comprehensive study of the prevalence of symptoms of post-traumatic stress disorder (PTSD) among employees of operational fire departments who continue to work.

3. Compare the severity of PTSD symptoms among firefighters and employees of other police departments.

4. Establish which of the situations encountered in labor activity fire department employees are most likely to result in the development of PTSD.

5. Create a methodological complex for the timely identification of those individuals who may exhibit maladaptive reactions associated with experienced extreme situations.

6. Develop decisive rules and diagnostic criteria for determining whether the surveyed firefighters belong to the risk group for developing PTSD.

7. Determine the most effective methods for both direct and indirect assessment of the risk of stress disorders in firefighters.

8. Formulate proposals for measures to prevent and correct the negative psychological consequences of extreme situations characteristic of the professional activities of firefighters.

Research hypotheses.

1. In terms of the severity of symptoms of stress disorders, firefighters are similar to representatives of other professions whose work involves participation in extreme events.

2. There is a direct connection between the length of service in the fire department, experience of extreme situations and the severity of PTSD symptoms. The tendency to “accumulate” the psychological consequences of extreme situations experienced by firefighters prevails over the tendency of professional adaptation.

3. It is possible to predict the risk of stress disorders in firefighters using: a), indirect assessment of the condition; b), structured observation of behavior.

The following provisions are submitted for defense: 1. Occupational traumatic experiences of firefighters are a significant predictor of the development of post-traumatic stress disorder symptoms. The firefighter stress questionnaire, the data for which is processed in the manner proposed in the work, can serve as a tool for quantitative assessment of the severity of the first of the diagnostic criteria for PTSD - experienced events and emotional reactions during them.

2. The nature and magnitude of the psychological consequences of exposure to occupational stress are generally similar among employees of the fire department, other services of internal affairs bodies and rescuers.

3. It is possible to predict the risk of developing stress disorders in firefighters based on indirect signs using the methodology for assessing “psychological defenses.”

4. Some of the manifestations of post-stress maladjustment can be identified by observing the behavior of employees from the outside and interviewing department heads.

5. An integrated approach to assessing the traumatic experience and the nature of mental reactions of people who encountered emergency circumstances in their work activities allows us to most accurately identify a group of people with a high probability of developing stress disorders. Depending on the specifics of the tasks of practical psychologists, it is possible to use variants of the methodological complex that vary in scope, which ensures the necessary balance of its brevity and information content.

Scientific novelty. A comprehensive study of the severity of PTSD symptoms among Russian firefighters in accordance with the diagnostic criteria for this disorder was carried out for the first time. Until now, only individual manifestations of stress reactions and maladaptive states of this professional contingent have been studied in our country.

A new methodology for assessing traumatic professional experiences of firefighters has been developed; for the first time, the degree of negative psychological impact on employees of various situations encountered when working on fires is quantified, which is new in comparison with both domestic and foreign studies conducted previously. Also, together with colleagues, we have developed a method for structured observation of behavioral manifestations of symptoms of stress disorders “from the outside.”

The method proposed in the work for predicting the risk of stress disorders using a technique for assessing the mechanisms of “psychological defense” (without direct questions about symptoms) has not yet been used either in Russia or in other countries.

For the first time in our country, the results of a survey of this category of people were obtained using a number of psychometric techniques used in world practice to study PTSD. The similarity of the nature and severity of delayed reactions to mental trauma among firefighters and other workers in hazardous professions - employees of various police departments and rescuers - is shown.

An unparalleled set of techniques has been created that allows for examinations of varying degrees of detail to identify the risk of developing PTSD among firefighters. An algorithm has been developed that determines the rules and criteria for classifying the surveyed firefighters into groups characterized by one or another level of risk of stress disorders.

Practical significance of the research results.

The conducted research made it possible to create a scientific and practical basis for improving the system for identifying, preventing and correcting mental maladaptation of firefighters, due to the nature of their work activity.

The results of the study are used in the development of guidelines for the diagnosis and prevention of stress disorders in firefighters, as well as software product, used for data processing and drawing up a conclusion based on the results of a psychodiagnostic examination /11/. The use of these recommendations and the software product by practical psychologists will contribute to the timely identification of the need for medical and psychological assistance individuals, carrying out targeted measures to prevent the occurrence of states of psychological distress that cause serious problems in the professional and personal lives of fire service employees.

In order to assist practical psychologists and psychotherapists, the author examined employees of some units involved in extinguishing fires that resulted in casualties (in the cities of Novokuznetsk and Samara). Based on the results of these examinations, the need for psychotherapeutic assistance was identified, and psychological consultations were conducted for personnel.

Approbation of the results The main results of the study were approved by the leadership of the State Fire Service of the Ministry of Internal Affairs of Russia and recommended for implementation in the activities of practical psychologists and personnel staff of regional fire service departments.

The results of the study were reported and discussed at the III scientific and practical conference “Post-traumatic and post-war stress. Problems of rehabilitation and social adaptation of participants in emergency situations: an interdisciplinary approach" (Perm, May 1998); seminar on psychological diagnosis and correction of stress disorders among employees of internal affairs bodies (Kemerovo, September 1998); scientific and practical conference "Problems of training personnel for the fire department" (Moscow Institute of Fire Safety, November 1998); XIV annual conference of the International Society for the Study of Traumatic Stress (Washington (USA), November 1998). IV scientific and practical conference "Post-traumatic and post-war stress. Problems of rehabilitation and social adaptation of participants in emergency situations" (Perm, May 1999); VI scientific and practical conference on the problems of psychological and pedagogical support for the activities of law enforcement officers (Omsk, May 1999).

The author expresses gratitude to: psychologists of the State Fire Service of the Perm Region Gorbenko (Avdeeva) O.S., Yurchenko O.V., Burdina M.S. and Soldatova I.V. - for participation in data collection; to the staff of the Institute of Psychology of the Russian Academy of Sciences N.V. Tarabrina. and Agarkov V.A. - for organizational and methodological assistance; employees of the All-Russian Research Institute of Fire Defense S.I. Lovchan and Bobrinev E.V. - for advisory assistance. and THEORETICAL FRAMEWORKS FOR STUDYING STRESS DISORDERS IN FIREFIGHTERS History of the formation of the concept of stress disorders The problem of psychological, medical and social consequences of exposure to extreme situations on the human psyche has been studied for many centuries. Thus, Lucretius (1st century BC), apparently, was the first to point out the phenomena of traumatic nervous disorder in soldiers, in which reminiscences are the main element /21/.

Psychological problems of the influence of a combat (extreme) situation on a person were studied by doctors of the times Civil War in America Da Costa and R. Gabriel (1871). Based on these studies, a military psychiatric hospital and homes were created to provide psychotherapeutic assistance to veterans.

During those same years, psychiatrists received increasing attention nervous disorders resulting from accidents. Since most of these disorders arose after accidents on railway, even the terms “railway spine” and “railway brain” (literally “railway spinal cord and brain”) appeared to designate correspondingly localized disorders. These concepts covered a set of both neurological and mental symptoms, the origin of which was attributed to the predominant influence of mechanical shock /10/.

Since the mid-80s of the 19th century, the term “traumatic neurosis” began to be used, and at the beginning of this century it established itself as an independent nosological category, and the leading importance of mental trauma in its etiology began to be recognized. Kraepelin (1904) proposed for nervous diseases due to accidents, the name “neurosis of fear and melancholy.” The peculiar clinical picture of traumatic neurosis, according to researchers, was formed from a combination various symptoms hysterical, neurasthenic and hypochondriacal neurosis. The psychotic symptoms noted after the injury (amnesia, confusion, hallucinations), as well as “a peculiar post-traumatic perversion of personality” and “post-traumatic dementia, reminiscent of the picture of progressive paralysis, but without a deep disintegration of the personality and without a progressive course” were not attributed by scientists to the picture of traumatic neurosis, i.e. .To. it was believed that these states differ significantly from it in the mechanism of their genesis. It was proposed to distinguish between mental trauma: 1. As a result of the accident itself - “primary”; 2. The traumatist’s chronic anxiety about his plight is “secondary.” Even then, the question of disability in connection with this disorder was raised. There was a significant dependence of the percentage of recovery on social policy in relation to the victims /10/.

During the Russo-Japanese War in 1904, a department was created at the Harbin Military Hospital for soldiers with mental disorders acquired in combat situations. The department was headed by G.E. Shumkov, who was the first in Russia to study the signs of psychogenic disorders (dreams about combat episodes, increased irritability, weakened will, fatigue). In his work “Behavior of a Soldier Under Shelling” G.E. Shumkov identified many psychotraumatic factors of extreme conditions (1910). The problem of the consequences of human activity in a combat situation was further developed in the works of M.I. Astvatsaturov (1912), V.M. Bekhterev (1915), and others /21, 53/.

Thanks to these studies, the concept of mental combat losses was introduced into scientific circulation during the First World War. Delayed mental phenomena observed in fighters were considered within the framework of the concept of traumatic neurosis. Average losses due to mental disorders during this period were 6-10 cases per 1000 people.

3. Freud defined these phenomena as “war neurosis,” which he interpreted as a state of ego conflict. He called mental trauma received in extreme conditions “traces of affective experiences” (1909). In introductory lectures according to psychoanalysis (1915-1917), mental trauma is considered as the result of a large and intense irritation, from which one cannot get rid of it or which cannot be processed in a normal way. 3. Freud suggested that the nightmares of soldiers who took part in the war reflect the primary localization of “traumatic images”, and their repetition is an infantile form of defense, when constant unconscious recollection of misfortune leads to the formation of a protective experience. Later, he expressed the idea of ​​two forms of reaction to a traumatic event: a negative one, which displaces the trauma with suppression, avoidance and phobias, and a positive one, which manifests the traumatic experience in the form of memories, images, and fixation. These ideas are reflected in modern concepts of delayed reactions to traumatic stress /13/.

The issue of the consequences of mental trauma associated with wartime experiences was also touched upon by P.B. Gannushkin (1926). He attributed the combination of physical and mental overload to the main etiological factor of “acquired mental disability” - “physical, intellectual, and even more affective and moral fatigue.” The scientist drew attention to facts proving that prolonged and intense shocks “do not pass without results for the body and leave behind very definite traces and flaws.” He came to the conclusion that pathogenetically in these cases we are talking about diffuse sclerotic lesions of small vessels of the brain /43/.

The French psychiatrist and psychologist, student of Z. Freud A. Kardiner, was the first to describe the structure of long-term mental disorder under the influence of extreme circumstances and proposed the concept of adaptation /86/; Later, these ideas received a modern interpretation in the works of M. Horowitz /82, 84/.

A. Kardiner considered the basis of mental disorders to be a decrease in the internal resources of the body and a weakening of the strength of the “Ego”. For this reason, the world begins to be perceived as hostile. Traumatic neuroses of war, as A. Kardiner believed, have both a physiological and psychological nature. The basis for the violation of a number of personal functions that ensure successful adaptation to the surrounding world, in his opinion, is “central physioneurosis,” the concept of which he introduced himself, relying on Freud’s ideas. He identified 5 most characteristic delayed mental reactions to traumatic events: - a decrease in the general level of mental activity, withdrawal from reality; - excitability and irritability; - a tendency to uncontrollable, explosive aggressive reactions; - fixation on the circumstances of the traumatic event; - typical dreams.

In studies devoted to mental consequences During the Great Patriotic War, V.A. Gilyarovsky (1946) found that the adverse effects of extreme (combat) conditions increase sensitivity to traumatic factors. This is facilitated by general asthenia, decreased tone, lethargy and apathy. V.A. Gilyarovsky developed the concept of thymogenies, incorporating into it the idea of ​​a pathogenic principle affecting a person’s feelings in a global sense, i.e. leading to various clinical conditions, united by a common affective genesis. The concept of thymogenesis he proposed differed from the widespread concept of psychogenesis. For the latter to arise, he considered it necessary not to have affect in general as something pointless, but to have an affective experience with specific intellectual content. V.A. Gilyarovsky pointed out the exceptional complexity of the differentiated picture of psychogenic disorders that arise as a result of exposure to a traumatic situation /14, 21/.

Research also continued in the West mental states people who have experienced extreme situations. After World War II, the word “stress” became popular in the United States. This term is borrowed from engineering, where it is used to denote an external force applied to a physical object and causing its tension, i.e. temporary or permanent change in structure /8/. R.R. Grinker and J.P. Spiegel (1945) understood “stress” to mean certain unusual conditions or demands of life, in particular the dangers of war and psychological conflicts. The authors conducted clinical studies of the psychological reactions of pilots diagnosed with front-line fatigue. They included impatience, aggressiveness, irritability, apathy and fatigue, personality changes, depression, tremors, fixation on war, nightmares, suspicion, phobic reactions, and addiction to alcohol as delayed reactions to combat stress. Much attention was paid to restoring self-esteem in the process of psychological rehabilitation of combatants/8, 14, 15/.H.Selye (1950, 1956), who introduced the concept of stress into physiology, calls harmful stimulating conditions stressors, and conditions caused by stressors, i.e. e. reactions to external influences - stress. Initially, this concept in physiology denoted a nonspecific reaction of the body (“general adaptation syndrome”) in response to any adverse impact, and later began to be used to describe the states of an individual in extreme conditions at the physiological, biochemical, psychological, and behavioral levels. The relative independence of the body's adaptation process from the characteristics of the influencing factors was shown. G. Selye substantiated the existence of three stages of the adaptation syndrome: 1. The stage of anxiety when a stressor appears, when some somatic and vegetative functions are disrupted and mechanisms for regulating protective processes are activated; 2. Stage of resistance, when in the event of prolonged exposure to a stressor, a balanced expenditure of adaptation reserves occurs with adequate external conditions tension; 3. The stage of exhaustion, when the mechanisms of regulation of protective and adaptive processes are disrupted and the body’s resistance decreases. Such conditions are also called “distress,” which literally means “distress, need.” R.S. Lazarus (1966) proposed to distinguish between physiological and psychological types of stress. In his opinion, they differ from each other in the characteristics of the influencing stimulus, the mechanism of occurrence and the nature of the response. Analysis of psychological stress, according to R. Lazarus, requires taking into account the significance of the situation for the subject, the characteristics of intellectual processes, and personal characteristics. Under physiological stress, reactions are highly stereotypical, while under psychological stress they are individual and cannot always be predicted. R. Lazarus developed a cognitive theory of psychological stress, which is based on provisions about the role of a subjective cognitive assessment of the threat of adverse effects and one’s ability to overcome stress / 8, 14, 15. / By the end of the 70s, a large amount of clinical material had been accumulated from examining participants in the Vietnam War . For 25% of veterans (who were not seriously injured or disabled), the war experience caused them to develop adverse personality changes. Among the wounded and crippled, this figure reached 42% /53/. In the United States, as part of a government program, a special system of research centers and social assistance centers for participants in the Vietnam War was created. Mental disorders among veterans were significantly specific, so Figley /76/ even suggested using the term “post-Vietnam syndrome”.

It was also found that, despite the difference in mental trauma, victims of war and other disasters experience a number of common and recurring symptoms. At the same time, the peculiarity of the condition is that it tends not only not to disappear over time, but also to become more clearly expressed, and also to appear suddenly against the background of the person’s general well-being. Since these disorders did not correspond to any of the generally accepted nosological forms, M. Horowitz proposed identifying them as an independent syndrome. He was the first to introduce the term “post-traumatic stress syndrome” /13, 21/.

M. Horowitz’s concept was formed under the influence of psychoanalysis, as well as the cognitive psychology of J. Piaget, R. Lazarus and others. The two forms of reactions in traumatic neurosis (negative and positive), identified by Freud, in Horowitz correspond to two interrelated groups of symptoms: “denials” ( avoidance) and “re-experiencing” (intrusion). He reveals the pathogenetic mechanism as follows. The response to stressful events contains 4 phases: - primary emotional reaction; - “denial” - avoidance of thoughts about trauma; - alternation of “denial” and “invasion” of these thoughts; - processing of traumatic experience.

The duration of the response process can last from several weeks to several months /81, 82, 84/.

Thus, the concept of post-traumatic stress disorder (PTSD) as a specific form of mental disorder was developed, due to which in 1980 it was identified as an independent diagnostic category by the American Psychiatric Association. These developments were documented in the Diagnostic Manual of Mental Disorders, 3rd revision (DSM-III)/63/. Subsequently, depending on the duration of the observed symptoms, they began to distinguish between acute (ASD) and post-traumatic stress disorders (PTSD) /64/. They are assigned to the class anxiety disorders along with phobic disorders and generalized anxiety. It has been established that PTSD should not be classified as a special type of neurosis, because it may include undoubtedly psychotic components of psychogenic origin /63, 64, 99/.

At present, as P.V. Kamenchenko notes /13/, the most promising theoretical developments of pathogenesis are those that take into account both psychological and biological aspects of the development of PTSD. In accordance with biological models, the pathogenetic mechanism of PTSD is caused by dysfunction of the endocrine system caused by extreme stress. It has been established that as a result of extreme intensity and duration of stimulating effects, changes occur in the neurons of the cerebral cortex, blockade of synaptic transmission and even death of neurons. First of all, the areas of the brain associated with the control of aggressiveness and the sleep cycle are affected.

R. Pitman proposed a theory of pathological associative emotional “networks”, based on the concept of Lang /53/, who suggested that there is a specific information structure of memory, organized according to an associative type - a “network”. It includes 3 components: information about external events and the conditions for their manifestation; information about a person's reaction to these events; information about the semantic assessment of stimuli and acts of response. Provided that such an element as imagination is included in the “network,” it begins to work as a single whole, producing an emotional effect. This hypothesis was confirmed by the fact that the inclusion in the experiment of reproducing a traumatic situation in the imagination (based on an event that took place in reality) reveals significant differences between healthy and PTSD-suffering Vietnam War veterans. The latter experienced an intense emotional reaction while imagining elements of their combat experience, which caused an increase in recorded physiological indicators (heart rate, galvanic skin response, electromyogram of the frontal muscles) /104/. The difficulties inherent in those suffering from PTSD in the processes of highly organized information processing and voluntary attention are shown /98/. Some symptoms of increased general physiological excitability, characteristic of most PTSD sufferers, were studied by recording reactivity to the presentation of loud sounds. In the group diagnosed with PTSD, adaptation (attenuation of reactions) occurs significantly more slowly when the stimulus is repeated /101, 102, 105/. The following explanations can be found in the mechanisms of operation of the neural structures of the brain and the biochemical processes occurring at this level. specific manifestations PTSD as a “flashback” phenomenon (see below), obsessive memories of experiences, dreams and nightmares about trauma. Physiological indicators are essential as an objective criterion for the presence of a disorder. This is important, in particular, for determining sanity in some cases judicial practice: A person suffering from PTSD is not generally mentally ill, but may experience short-term states (due to the events experienced) when conscious control of behavior disappears or decreases.

In domestic psychiatry, PTSD for a long time was not recognized as an independent diagnostic category. Approaches to the problems of disorders caused by stress, definitions and terminology remained typical of classical psychiatry. Thus, Yu.A. Aleksandrovsky and co-authors /2, 3/ provide the following classification of the psychological consequences of the impact of catastrophic situations on humans: 1. Non-pathological psycho-emotional reactions, which are characterized by a direct dependence on the situation and a short duration, and in which the critical analysis their behavior, performance and ability to communicate with others; 2. Pathological reactions, or psychogenies (reactive states), which are divided into two groups: with non-psychotic symptoms - neurotic reactions and psychogenic states (neuroses); with psychotic symptoms - acute affective-shock reactions and prolonged reactive psychoses.

The intensive development of reactive states is associated with the climax of a natural disaster. But subsequently, a significant number of people experience breakdowns in neuropsychic activity, changes in somatic health within 1-20 years after the situation. Various states transform into each other without sharp boundaries, which creates difficulties in diagnosing the victims. Meanwhile, the approach to making a diagnosis can be of fundamental importance for determining ways to correct existing mental disorders. There have been cases where veterans suffering from PTSD Afghan war ended up in psychiatric clinics with a diagnosis of schizophrenia and received treatment with potent antipsychotic drugs (aminazine, haloperidol, etc.), causing powerful side effects.

Neurotic disorders diagnosed in victims of the earthquake in Armenia /37/ corresponded, according to the International Classification of Diseases (ICD-9), used at that time, to acute reactions to stress and adaptive reactions, and according to DSM-III - PTSD. It was suggested that the diagnostic category of PTSD more fully and accurately reflects the essence of these phenomena.

Since the beginning of the 90s, a number of research works have been carried out in our country, which were carried out on the basis of the theoretical provisions of the doctrine of PTSD using the appropriate arsenal of methods, and were devoted to the problems of the psychological consequences of various military conflicts, as well as natural and man-made disasters /12, 17-19, 54-57, 88, 109/. The severity of PTSD symptoms in representatives of certain high-risk professions has also been studied, regardless of the events in which they participated /5, 17-19, 40, 52, 60/. Many researchers have noted significant similarities in the nature of psychological problems and difficulties in social adaptation among veterans of Vietnam and Afghanistan /53, 57/. The problem of diagnosing and correcting post-traumatic conditions has now become especially acute in connection with military operations in Chechnya. To determine the correct strategy for rehabilitation work, as emphasized by I.V. Solovyov /51/, it is necessary to understand the differences between the traumatic stress of a combat situation and additional psychotraumatization that occurs after returning to normal conditions of peaceful life. “Secondary” psychotraumatic effects for veterans are: exclusion from the system of social connections with comrades in arms, which provide the opportunity to receive psychological support; a situation in a family when loved ones themselves need psychological rehabilitation, and a contradiction arises between the need to help and the need to receive help. Among the participants in hostilities continuing military service, post-traumatic phenomena are much less pronounced than among those transferred to the reserve.

A comparison of the results of a survey of two numerous categories of people who experienced psychologically traumatic situations - veterans of the war in Afghanistan and liquidators of the consequences of the Chernobyl nuclear power plant accident - prompted domestic specialists in the field of PTSD to distinguish between “event-based” and “invisible” types of traumatic stress, each of which has its own consequences specifics /54-56, 109/. It has been established that the majority of Chernobyl liquidators who are diagnosed with clinically significant PTSD do not have the characteristic physiological reactivity to reminders of the traumatic event /56/. It is assumed that this fact is due to the absence of a violent emotional reaction during the event.

In recent years, experience has emerged in using the diagnosis of PTSD to establish the necessary disability /43/. It is allowed to establish the 3rd disability group in connection with the actual manifestations of PTSD, when they are protracted and reduce activity, ability to psycho-emotional stress. A conclusion about the definition of disability group 2 is possible when psychogenic symptoms are combined with concomitant disabling somatic pathology.

Diagnostic criteria for stress disorders For the diagnosis of post-stress disorders, a system of diagnostic criteria has been developed that generally correspond to the ideas substantiated by Kardiner, Horowitz and other researchers. These criteria were included in the Diagnostic Manual of Nervous Diseases (DSM) 3rd and 4th revisions /63, 64/, and later in the International Classification of Diseases /39/. The main diagnostic method is a specially organized interview with standardized recording of results, carried out in two versions: the PTSD module from the clinical structured diagnostic interview (SCID) and the scale clinical assessment PTSD (CAPS) /69/. In the second option, not only the presence or absence of each symptom is recorded, but also a numerical assessment (from 0 to 4) of its occurrence and intensity is given. A symptom is considered present if its occurrence is rated at least 1 (for most symptoms - 1-2 times or 10-20% of the time during the month), and its intensity is rated at least 2.

Criterion A, according to DSM-IV, consists of two parts. A (1): the fact of an individual’s encounter with an event that goes beyond ordinary human experience, capable of traumatizing the psyche of almost any healthy person, for example, a serious threat to life and health, both one’s own and that of relatives or friends; sudden destruction of housing or public buildings, etc. “Ordinary” human experience here refers to events such as the loss of a loved one due to natural causes, a chronic serious illness, job loss, or family conflict. Stressors that cause these disorders include natural disasters, man-made (man-made) disasters, as well as events that are the result of purposeful, often criminal, activity. A (2): A necessary condition probable development PTSD is also the fact that the experienced event was accompanied by intense emotions of fear, horror or a feeling of helplessness of the individual in the face of dramatic circumstances, which is the main etiological factor in the occurrence of post-stress disorders.

Criterion B - Constantly recurring experience of a traumatic event (“intrusion”). It is considered identified if at least one of the following symptoms is detected: 1. Recurrent intrusive memories of an event that cause distress, appearing while awake when nothing is happening to remind you of it. Intensity is assessed by how difficult it is to get rid of the memories and continue the activity that a person is engaged in at the time they occur.

2. Intense, difficult feelings, excitement and discomfort under circumstances that symbolize or resemble in one way or another the traumatic event, including anniversaries of the injury. Distress occurs under the influence of “key stimuli” that are reminiscent of some aspect of the event, also called “triggers” (literally, a “trigger” that suddenly triggers stress reactions).

3. A feeling as if the traumatic event is happening again or corresponding sudden actions (including the feeling of reliving experiences, illusions, hallucinations,) - even those that appear in the waking state. This is the most powerful symptom, called “flashback” (literally means “reverse flash”, i.e. a flash in the consciousness of a previously experienced event. The intensity is assessed by the feeling of realism of the situation, its perception by all senses, loss of connection with the environment at the moment the symptom appears In the worst cases, a complete loss of control over oneself is possible, followed by amnesia for this episode - an “eclipse”, a loss of memory.

4. Recurring dreams about an event that cause difficult feelings. Intensity is assessed by whether these dreams cause awakening and whether the person easily falls back to sleep.

5. Physiological reactivity (rapid heartbeat, muscle tension, trembling hands, sweating, etc.) when exposed to circumstances that resemble or symbolize various aspects of the traumatic event. Originally (DSM-III) the symptom was classified as diagnostic criterion "D" (see below) and is currently (DSM-IV) classified as criterion "B" due to its strong association with symptom 2 of this group.

Criterion C - Sustained avoidance of stimuli associated with trauma or "blocking" of the general ability to respond ("numbing"), not observed before the trauma. It is considered identified if at least any three of the following symptoms are present: 1. Efforts to avoid thoughts or feelings associated with the trauma. Attempts to ward them off include distraction, suppression, and de-arousal with alcohol or drugs.

2. Efforts to avoid activities or situations that trigger memories of the trauma. For example, reluctance to be near certain places, refusal to participate in veteran events, etc.

3. Inability to remember important aspects of the trauma (psychogenic amnesia). It is assessed by what part (in percentage) of the circumstances of the incident is difficult to remember, how impaired the ability to reproduce the event in memory is.

4. A noticeable loss of interest in favorite activities that were important or enjoyable to the person, such as sports or hobbies. It is assessed by the number of activities in which interest has decreased and by whether the pleasure derived from them has remained.

5. A feeling of detachment or estrangement from others that is different from how the person felt before the event. When the intensity of the symptom is low, a person periodically feels “out of step” with others, and when it is high, he loses his sense of belonging to the world around him and the ability to interact and maintain close relationships with others.

6. Reduced levels of affect, such as an inability to experience feelings such as love and happiness. It is expressed in a feeling of “insensitivity”, in the worst case - a complete absence of emotions. The symptom is sometimes mistakenly classified as psychotic (schizophrenia).

7. Feeling of lack of prospects for the future. For example, a person does not expect promotion, marriage, children, long life, and feels that there is no need to make plans. The symptom ranges from a slight feeling of shortened life prospects to a complete belief in premature death (without medical reasons).

Criterion D - Persistent symptoms of hyperexcitability (physiological hyperactivation), not observed before the injury. It is considered identified if at least any two of the following symptoms are present: 1. Difficulty falling asleep or staying asleep. Includes waking up in the middle of the night or early in the morning. Intensity is assessed by the amount of sleep time lost from the duration that is desirable for the subject.

2. Irritability or attacks of anger, aggressiveness in various forms. The intensity of the symptom is rated based on how the person expresses their anger, from raising their voice to episodes of physical violence.

3. Difficulty concentrating. The amount of effort required to concentrate on an activity or on something that surrounds a person is assessed.

4. Increased alertness, vigilance, even when there is no obvious need for this. At low intensity - slightly increased curiosity about what is happening around, at moderate - alertness and choosing a safe place in public places, at high - significant expenditure of time and energy on efforts to ensure safety.

5. Exaggerated startle response ("start" response) to sudden stimuli - such as loud unexpected sounds (for example, car exhaust, pyrotechnic effects, the sound of a door slamming, etc.) or something that the person suddenly sees (for example , movement noticed at the periphery of the visual field - the “corner of the eye”). Includes flinching, “bouncing”, etc. The intensity varies from a minimal fear reaction to overt defensive behavior, and also depends on the duration of arousal during such a reaction. Sometimes similar phenomena called the “fight or flight” response.

Criterion F - distress and maladjustment. The presence of the described groups of symptoms is a necessary but not sufficient condition for making a diagnosis. Another criterion that complements the picture of a post-stress state is that the disorders cause clinically significant distress or interfere with social, occupational, or other significant activities. This criterion can be called functional: it is associated with a violation of psychological adaptation, a violation (or decrease) of professional performance, a deterioration in the quality of life in general due to mental trauma.

The structure of acute stress disorders includes a subgroup of so-called “dissociative” symptoms (the term “dissociation” was first used in his works in 1889 by P. Janet), observed either during the period of trauma or subsequently (criterion b). It is considered present if at least three of the following symptoms are present:1. subjective feeling of emotional dependence, 2. “dulling” or lack of emotional response; 3. narrowing of consciousness about the surrounding world (“confusion”); 4. derealization (a feeling of unreality of surrounding things, phenomena and ongoing events);5. depersonalization (violation of a person’s perception of himself, his body, thoughts and feelings);6. dissociative amnesia (inability to remember any important aspect of a traumatic event).

Diagnostic criterion A is common to PTSD and OSD. In addition, criteria that correspond to the described criteria for PTSD are used to diagnose OSD. Thus, criterion c completely coincides with “B” for PTSD; criterion d includes only the first two symptoms of group “C” for PTSD, and is considered present when they are both present; criterion e for OSD includes all the symptoms of criterion “D” for PTSD, and one more symptom - the absence of physical fatigue and the need for rest. Criterion f is consistent with the “F” for PTSD, but differs slightly from the latter: it is that the disorder causes clinically significant distress or impairs the individual’s ability to obtain necessary help or communicate to family members about the trauma they have experienced. In addition, for OCP there is a criterion h; the disorder is not associated with the direct effect of physiologically active substances (narcotics, drugs) or the general somatic state of the body, does not fit the definition of a short psychotic disorder and is not an exacerbation (exacerbation) of an existing mental illness.

There is an additional list of symptoms that are not included in the main diagnostic criteria. Experts include the following: a feeling of “survivor’s guilt” towards those who died, or guilt for the actions that had to be performed; a sharp division of the retrospective life path into “before” and “after” a certain event or period of time, and the social environment into “we” (participants in certain events) and “they” (those who did not participate); feeling of loneliness; problems in the sexual sphere and family life; Substance abuse.

Stressful conditions and stress disorders in firefighters.

Extreme conditions, which often accompany the professional activities of firefighters, are characterized by a strong traumatic impact of events, incidents and circumstances on the employee’s psyche. This impact can be powerful and one-time in case of a threat to life and health, explosions, building collapses, etc., or multiple, requiring adaptation to constant sources of stress. It is characterized by varying degrees of suddenness and scale, and can serve as a source of both objectively and subjectively determined stress. The most powerful objective stressors include: a threat to one’s own life, the life of fellow employees, and certain categories of citizens (women, children, the elderly) /18, 19/. A specific stress-generating factor for the professional activities of firefighters is the regime of anxious waiting during daily combat duty /41/. Subjective causes of stress include: lack of experience, psychological unpreparedness, low emotional stability.

A document published by the US Fire Protection Association describes 5 types of “everyday” stressors characteristic of the fire service /79/: 1. High level of surprise, unpredictability of events; 2. Sudden alarms; 3. Tension in interpersonal relationships; 4. Confrontation with people's suffering; 5. Fear for your life and health, as well as for possible mistakes in your work. Foreign publications identify “critical incidents” that are most likely to cause mental trauma in firefighters: death or injury of a firefighter during work; death or injury of a child; a situation during a fire when access to the victim is impossible (especially when the victim is a child); a situation where the firefighter knows the victims personally; a rescue situation where the victim received severe burns, excluding the possibility of recovery /68/. According to Hildebrand "a /80/, tragic events in which there are no survivors cause a particularly strong state of frustration in firefighters. At the same time, stress can arise due to communication with survivors, who often direct their feelings towards firefighters negative emotions. For fire extinguishing managers, additional stressors are: the need to communicate with officials, greater responsibility with a lack of experience. It is noted that fire service managers are not sufficiently interested in the mental injuries suffered by employees during fires.

It should be noted that firefighters are at increased risk of experiencing both “event-related” and “invisible” stress, because not only face tragic situations, but often experience the impact of factors that can lead to unpredictable and irreversible changes in health - primarily radiation and complexes of toxic substances, the consequences of which manifest themselves after a long time (several years) with increasing intensity. The uncertainty of the prospect of changing one's physical condition and the possibility of negative consequences for the health of children born after the event are an additional powerful psychologically traumatic factor /22, 33, 34, 44/.

To prevent the development of long-term consequences of mental trauma, support groups are being created in the West to provide psychological assistance in the coming days after emergency incidents using the “debriefing” method. The method was proposed by J. Mitchell "oM, who himself was a member of a volunteer fire brigade in his youth /72/. Debriefing is a specially organized discussion and is used in groups of people who have jointly experienced a stressful or tragic event /61/. Its name implies as much as possible a detailed description by each of the participants of what happened to him, as opposed to the word "briefing", meaning the exchange of short messages. The method has become especially widespread in the fire department and other services that eliminate the consequences of natural and man-made disasters. Both professional psychologists and specially trained employees of departments /65/.

In early domestic studies on firefighting psychology, virtually no attention was paid to the possibility of traumatic neurosis in firefighters. However, there were acute nervous reactions employees during non-working hours at sounds reminiscent of a combat signal /41/. It was argued that nervous diseases should be considered occupational for firefighters /42/.

In recent decades, the problems of stressful conditions in firefighters have been discussed in domestic psychological studies devoted to: 1. Prevention of unfavorable functional states in the activities of firefighters /29, 30, 32, 33, 36, 46/; 2. Assessing the severity of the work of firefighters and justifying changes in the system of benefits /31, 32, 34/; 3. Psychological training of firefighters /33, 48/.

I.O. Kotenev /17/ studied a group of firefighters as a control sample, comparing the dynamics of situational anxiety in people working in stressful (fire department) and extreme (armed conflict zone) operating conditions.

The impact of extreme situations that arise during firefighting, as well as the mechanisms of development of post-traumatic conditions in firefighters, have not been sufficiently studied, although many studies contain statements that firefighters are at increased risk of stress disorders. It was discovered that when training combat alarm signals are given in fire departments guarding particularly dangerous objects, the neuropsychic reactions of employees significantly exceed the normal level. As a result of the studies, it was established that some of the personnel experience symptoms of low mood, anxiety, unmotivated aggressiveness, indiscipline, evasion of professional duties, deterioration in service performance, alcohol abuse, interpersonal conflicts in the family and at work, and suicidal tendencies /33 , 34/. Until now, there have been no domestic psychological studies that would allow: a) to correlate these maladaptive forms of behavior with a wide range of phenomena of post-traumatic states, b) to identify the relationship between the frequency and intensity of experienced traumatic situations with the characteristics of delayed reactions to mental trauma.

The Norwegian work /85/ deals with stress reactions and the phenomena of acute stress disorder in volunteer firefighters who extinguished a fire in a multi-storey hotel and rescued its guests (then 14 of the 128 people in the building died). According to the survey, the greatest stress was caused by such circumstances as finding the dead and wounded, working under time pressure and the need to wait in inaction. Particular difficulties arose when carrying out rescue operations in smoke-filled rooms. Among the acute stress reactions are: anxiety, restlessness, over-activity, fear, excitement, irritability. All of them are marked in moderate or high degree approximately half of the extinguishing participants. It was found that the severity of the symptoms of “intrusion” and “avoidance” after the event significantly correlates with the presence of states of anxiety, uncertainty, hyperactivity and restlessness during work. According to self-assessment of the condition, the level of symptoms of stress disorder is significantly higher in those who had no prior experience of operating in smoke conditions, but in absolute terms these differences are small. Overall, reactions considered clinically significant were observed in 10% of those examined. Pike et al /103/ report somatic comorbidities of PTSD characteristic of firefighters. Groups of firefighters who have been diagnosed with PTSD are significantly different in the higher incidence of complaints of cardiovascular, respiratory, musculoskeletal, neurological and gastrointestinal ailments.

Mishu & Jenkins /100/ examined the impact of emotional support from the social environment on firefighters working during and immediately after the devastating hurricane in Florida in 1992. Emotional support is divided into two types: 1. “Received”, which consists in the fact that other people (family members, friends, colleagues and others) allow a person to talk about problems and express their feelings, show a caring attitude; 2. “Felt” (empathy), which consists of the subjective feeling that other people (both those who experienced and those who did not experience the same event) understand what the person experienced and do not reject his feelings and thoughts associated with the event. It was found that the indicator of the first type of emotional support, determined by a special questionnaire, is positively associated with the level of PTSD symptoms, while the second is negatively associated. It remains controversial whether the feeling of empathy is a cause or a consequence of successfully coping with maladaptive states.

Analysis of the literature data allows us to draw some conclusions regarding the characteristics of the occurrence and course of post-traumatic stress disorders in firefighters: 1. Mental trauma can often result from a combination of emotional stress experienced during tragic events and exposure to harmful factors professions that cause “invisible” stress.

3. Firefighters often experience re-experiencing events in the form of images and thoughts, but this is not always combined with other PTSD symptoms.

4. A comparison of data from different studies shows that, in percentage terms, clinically significant stress disorders in firefighters who survived particularly severe and large-scale disasters are as common as in people who participated in the war (18 and 16-21%, respectively). As for the indicators of psychometric methods that assess the severity of symptoms, they have not been used to compare firefighters with other categories of people.

5. The diagnosis in most cases turns out to be multiple, i.e. PTSD in firefighters is found along with other mental disorders.

6. There are indications that the nature of the traumatic experience of firefighters (both the events they experienced and individual reactions to them) significantly influences the severity and characteristics of the course of stress disorders. However, since no specific approach to quantifying traumatic experiences has been developed (more on this in Chapter 2), different researchers measure slightly different phenomena. Therefore, it is not possible to draw general conclusions about the connection between the professional traumatic experience of firefighters and the phenomena of post-traumatic mental disorders.

7. The lack of development of the problem of PTSD in firefighters in domestic psychology necessitates the need to conduct comprehensive psychodiagnostic studies and create a system of preventive and rehabilitation measures.

EMPIRICAL STUDY OF THE REPRESENTATION OF STRESS DISORDERS IN FIREFIGHTERS At the first stage of the work, a pilot sample of 138 firefighters from Moscow and Irkutsk was examined. Then, after a statistical analysis of the data obtained and the development of an algorithm for identifying the risk of stress disorders and other forms of maladaptive conditions (see Chapter 3), 145 firefighters from Perm and the Perm region were examined to test the reliability of the methodological complex. The sociodemographic characteristics of the sample are presented in Appendix 2. The sample of employees of the fire service of Moscow Perm and the Perm region consisted of practically healthy individuals working mainly as firefighters and guard chiefs. In addition, 6 inspection and preventive personnel were examined in the Perm region. A significant part of the surveyed Muscovites were recruited to serve in fire departments during 1993-94. in connection with the replacement of conscripts with contract employees, which explains the relatively large percentage among them of persons with less than 5 years of service. However, due to the tense situation with fires in Moscow, their experience of facing complex and dangerous situations was quite significant.

The sample of employees of the fire service of Irkutsk and the Irkutsk region consisted of persons who were poisoned by a complex of toxic substances as a result of a fire at the cable plant in Shelekhov in December 1992 /22, 44/. When the cable insulation burned during this fire, dioxin was released, which, affecting the human body, leads to damage to the skin, and subsequently to the liver, kidneys and hematopoietic system. To this day, firefighters who took part in the extinguishing continue to experience the progressive consequences of this fire. Individuals who participated in the survey were still working in the fire department or were planning to retire. They are, on average, older than the rest of those surveyed, have more years of service in the fire department and experience in dealing with critical situations, and also differ in the scale and nature of the medical and psychological consequences of these situations.

Obviously, Irkutsk firefighters are a very specific part of the sample, and therefore their data were analyzed both together with data from Moscow firefighters and separately.

Research methods.

A comprehensive study of stress disorders among Russian firefighters was conducted for the first time. Therefore, one of the most important tasks was to determine the set of the most diagnostically significant psychological techniques. Diagnosing PTSD among police officers in departmental medical institutions is not yet widely used, and among fire service psychologists there are no specialists who know the clinical interview method for diagnosing PTSD. At the same time, the clinical interview is the main and most reliable method used by foreign experts to study PTSD. The lack of widespread application of this method was compensated for by the large number of psychometric tests used. This made it possible to conduct mass examinations, which is difficult when conducting a clinical interview, which requires a face-to-face conversation with each subject. A number of techniques were used that are traditionally used to study post-traumatic stress disorders and accompanying symptoms of mental ill-health, primarily anxiety and affective disorders. In addition, methods were developed for assessing the experience of encountering extreme situations, taking into account the specifics of this professional contingent, and at the next stage of work, also for assessing the external manifestations of stress disorders based on outside observations (see Appendix 1).

Development of a methodology for assessing traumatic professional experiences (questionnaire for stressful situations) of firefighters.

However, there is currently no unified approach to assessing the traumatic experience of firefighters in the global practice of PTSD research. Methods have not been developed for studying the experience of firefighters encountering extreme situations throughout their professional lives. Also, there has not been a detailed comparative analysis of various situations specific to the professional activities of firefighters, with quantitative assessment the degree of their negative psychological impact. In general, the question of the quantitative measure of professional and life traumatic experience is highly controversial. Even when reasoning within the framework of everyday concepts, it is often difficult to determine who has “experienced more” and who has “experienced less.” Our proposed approach to assessing traumatic experiences and the developed methodology seem to allow us to resolve a similar issue for fire department employees; In the future, provided that uniform methods are created, it will become possible to compare the severity of traumatic experiences of representatives of different professions.

For our study, a special questionnaire of events (situations) encountered by firefighters was developed, called the Questionnaire of Stressful Situations of Firefighters (OSSP). /25/. It consists of 57 points. It describes situations that are typical for the professional experience of fire service employees and that cause stress reactions (Appendix 1). In addition to questions about situations encountered directly when putting out fires, questions are included about cases that can be regarded as “moral pressure”, usually occurring after combat work during analysis and discussion of what happened and causing “secondary” stress (last 4 lines of the questionnaire). The questionnaire was compiled with the participation of 11 experts - employees of fire extinguishing services on duty and teachers of the Department of Fire Tactics of the Moscow Institute of Fire Safety, who served in the fire department for at least 10 years. The subjects - firefighters and guard chiefs - noted how often each of the described situations occurred to them, and how strong emotional experiences it was accompanied by. Three types of such experiences are considered: fear, anxiety and helplessness, the presence of which during events occurring to a person is a significant factor influencing the development of stress disorders in the future. Thus, the questionnaire is constructed in accordance with the first diagnostic criterion(Criterion A) post-traumatic stress disorder according to DSM or ICD-10 /39, 63, 64/, including two subcriteria: 1. The individual experienced an event associated with a serious threat to the life and health of people or beyond the scope of ordinary human experience; 2. The event was accompanied by an intense experience of fear, horror, and helplessness.

Since almost all experts regarded the word “horror” as an actual synonym for the word “fear”, it was replaced in the questionnaire with the word “anxiety”, because Experts considered the experience of anxiety to be very characteristic of the situations under consideration. Both the occurrence of events and the intensity of experiences are assessed on a 5-point scale. In assessing occurrence, it is important to record both the very fact of a person’s collision with a situation, even if only once, and the frequency of collision with the situation, if it occurs repeatedly. Therefore, occurrence is assessed at 1 point if an event (situation) occurred only once, and an occurrence rating of 2, 3, 4, and 5 points measures the frequency of a person’s collision with an event (situation) that occurred repeatedly, and formulations are used that allow one to navigate into generally accepted or understandable units of time for the subjects (year, month, duty every 4 days).

ROS SII s* A*" ffccyA^cTSEHj^ - lisKVSOT"si"Has loss of consciousness occurred during work? - No. - Then we mark nothing in this line and move on. Have you ever found out about the death of your closest employees - from your guard, unit? - I had to once. I note the occurrence - one? “Yes.”, etc., until it is clear that the subject has fully understood the instructions. The questionnaire can serve as a kind of tool for conducting a conversation preceding the main examination. As experience shows, in some cases, when filling out a questionnaire, traces of mental trauma can clearly make themselves felt (see Appendix 4): nervous reactions arise, attacks against the experimenter also occur, for example: “Why are you reminding us about all this again, It’s hard without you.” Individuals with obvious symptoms of PTSD may find it difficult to fill out the right side of the form (evaluate their experiences). In these cases, we sometimes suggested first filling out only the “Occurrence” column, and returning to the assessment of experiences later - after working with other methods, a conversation and a short break.

As practice shows, the use of an event questionnaire can be effective when a psychotherapist provides assistance to firefighters /24/. Referring to the questionnaire completed by the patient helps to update emotional states associated with mentally traumatic situations, which is often necessary to “work through” and correct these states. Self-assessment of emotions accompanying experienced events in numerical form, performed while working with the technique, is one of necessary elements many psychotherapy techniques.

Based on the data obtained, for each item of the questionnaire (each situation), we determined an indicator that we called the “stress index” (hereinafter referred to as SI), calculated as the weighted average of the assessments of emotional experiences characteristic of a given situation by respondents and experts, according to the formula: SI = (1PEREZhexp +1PEREZhshzh*SG2exp/SG2L)/(p + t*SG2.zhsp/SG2[South),n mwhere pit is, respectively, the number of experts and the number of subjects (firefighters) who assessed this situation, EPEREZhexp and 2d1EREZhPozh is the total sum of severity assessments three types of experiences (“fear” + “anxiety” + “helplessness”), respectively, by all experts and all firefighters who assessed this situation, sg exp and<Т пож - дисперсия оценок переживаний, характерных для данной ситуации, соответственно экспертами и пожарными. Вычисление средневзвешенного значения мы сочли необходимым потому, что группы экспертов и пожарных являются достаточно разнородными: эксперты на момент опроса не занимались тушением пожаров, однако были хорошо знакомы практически со всеми рассматриваемыми ситуациями по собственному опыту или по опыту людей, с которыми непосредственно взаимодействовали, т.е. обладали более отстраненно-аналитическим взглядом; пожарные же обладали большей «свежестью» эмоциональных впечатлений от событий, но многие из них имели еще недостаточно опыта для их оценки. Также для всех пунктов опросника были вычислены коэффициенты корреляции между показателями левой и правой части строки ответов (встречаемостью события и суммой оценок трех видов переживаний, связанных с ним). При отрицательных значениях этой корреляции для какой-либо из рассматриваемых ситуаций можно предположить, что люди к ней «привыкают», т.к. при большей встречаемости ситуации уменьшается её субъективная стрессогенность. При положительных же значениях корреляции дело обстоит противоположным образом: с ростом встречаемости ситуации её воздействие «усугубляется», т.к. субъективная стрессогенность увеличивается. Поэтому эти корреляции были названы «индексами привыкания» (ИП); строго говоря, их следовало бы назвать индексами «не-привыкания». Описания ситуаций по тексту опросника, расчет ИС, а также значения ИП представлены в табл. 1.

2 “turning on” means putting on a gas mask and bringing it into working condition.

Other methods used in the work.

1. The Horowitz Impact of Event Scale (IOES) /83, 110, 111/ allows you to determine the presence of PTSD syndrome in a subject based on the severity of one of two tendencies: the desire for obsessive experiences about the trauma (constant return to thoughts and feelings about the event that occurred, regardless of the person’s will) or avoidance of everything connected with it (the desire to reduce the influence of memories of the event on the emotional state and behavior, up to the complete denial of this influence and the desire to forget the event itself), as well as the presence of increased nervous excitability. In the modern version /110/, the scale contains 22 statements that allow you to determine the severity of these trends over the past seven days. Indicators calculated using the method measure 3 main areas of responses to traumatic stress: the phenomenon of obsessive experiences, or “intrusion” (“Intrusion”, IN), the phenomenon of avoiding any reminders of the trauma (“Avoidance”, AV) and the phenomenon of physiological excitability ( "Arousal", AR). When inviting the subject to fill out this questionnaire, you should remind him that the questions relate to the event that he considers the most difficult and terrible of what he has encountered at work and in life, or which has left the most difficult mark in his memory to date. Before answering, he can optionally write in the line specially designated for this purpose what kind of event it was, or not do so.

2. Mississippi Scale for Combat Related PTSD /87/ is used in the practice of studying PTSD - a syndrome associated with participation in combat or with mentally traumatic events in civilian life. It consists of 39 statements reflecting the internal state of people who have experienced one or another traumatic situation. The behavioral reactions and emotional experiences described in the questionnaire are combined into several groups and include: intrusive memories, depression, communication difficulties, affective lability, memory problems, sleep disorders, and various personal problems. Each statement is rated on a 5-point scale. As a result, a total score is calculated, which allows one to identify the extent of the impact of the traumatic experience and assess the degree of general psychological distress of the subject. According to foreign data, the Mississippi scale score allows one to determine the presence of PTSD in 93% of cases, and in 89% of cases its absence. The criterion value of PTSD on the scale is 107 points.

3. The Traumatic Stress Questionnaire (TSQ) by I.O. Kotenev /18, 19/ is intended to assess the severity of symptoms of post-stress disorders based on the criteria contained in DSM-4. The wording of most of the questionnaire items is based on the results of many years of research into the consequences of mental trauma among police officers. At the same time, based on the concept of PTSD as a normal human reaction to extreme circumstances, items that had obvious psychopathological overtones and were negatively perceived by the subjects were excluded from the set of statements whenever possible.

The questionnaire consists of instructions, 110 statement items and a response form. A 5-point Likert scale is used, allowing the subject to rank each statement (from “absolutely true” to “absolutely false”) depending on its correspondence to his own state. 56 points are “key” for assessing the severity of symptoms of post-stress disorders, 9 points make up 3 rating scales - “lies”, “aggravation” and “dissimulation”, which allow you to control the degree of sincerity of the subject, his tendency to emphasize the severity of his condition or deny the presence of psychological problems. In addition, the Questionnaire includes reserve and so-called. “masking” statements that prevent subjects from involuntarily understanding the main focus of the test. First, the values ​​of the control and main subscales of PTSD and OSD are calculated:

Conclusion of the dissertation scientific article on the topic "Work psychology. Engineering psychology, ergonomics."

1. It has been established that about 26% of employees of territorial fire service units are at risk of developing acute and post-traumatic stress disorder, while 6.5% experience conditions that can cause a significant disruption of adaptation, cause inappropriate behavior and reduce the effectiveness of professional activities of personnel fire department. Data have been obtained that the level of severity of symptoms of stress disorders among firefighters is no lower, and for a number of symptoms even higher than that of employees of other police departments.

2. The prognostic significance of such a factor as professional traumatic experience was determined, i.e. experience of encountering events that cause professional stress regarding the risk of developing PTSD and other forms of mental maladaptation in firefighters. The importance of professional experience in the emergence and development of unfavorable mental states of fire service personnel is manifested in the fact that firefighters with more service experience and more frequent exposure to emergencies are more likely to suffer from post-traumatic stress disorder.

3. For the first time, a methodological complex has been compiled to determine the risk of negative psychological consequences of the activities of firefighters in extreme conditions. It includes methods for determining the experience of encountering extreme situations, specific symptoms of PTSD and general psychopathological symptoms. When conducting surveys in the field, taking into account the brevity and informativeness of diagnostic techniques, it is recommended to use 4 survey options of varying degrees of detail.

4. The developed methodological complex and decisive rules make it possible to divide the subjects according to the degree of risk of developing PTSD into four groups. Methods and methods of medical and psychological support and correction of maladaptive states vary depending on whether the subjects belong to the risk groups for developing PTSD.

5. The risk of stress disorders was assessed based on indirect signs, which is the severity of certain psychological defense mechanisms characteristic of the subjects.

6. To more accurately identify groups at risk of developing PTSD, it is advisable to use data from structured observation of manifestations of maladaptation at the behavioral level as an external criterion, which allows us to establish facts of dissimulation and stimulate the psychological observation of commanders and their attention to the psycho-emotional state of subordinates.

7. It has been discovered that firefighters who have been exposed to extreme exposure to dangerous and harmful factors in working conditions, causing irreversible damage to their health (radiation, toxic substances, etc.), subsequently suffer more severe emotional trauma from encounters with tragic events. This is due to the depletion of protective mental resources as a result of the combined impact of a “critical incident” and “invisible” stress, which is characteristic of the firefighter profession.

CONCLUSION

The study made it possible to analyze in detail the possibilities of using a set of psychodiagnostic techniques to study the phenomena of post-stress mental disorders in firefighters. This is about identifying the risk of stress disorders rather than diagnosing them per se, since the diagnosis can only be made through a clinical interview. This is justified for the reason that the psychological service of the fire department is mainly faced with the need to conduct mass examinations of people, the vast majority of whom are practically healthy physically and mentally; in these cases, survey methods are significantly more effective than interviews.

The set of methods considered in the work covers the following areas of research:

1. Self-assessment of traumatic experience, which is a necessary part of studying the risk of stress disorders, and is carried out taking into account the professional specificity of the situations experienced by the subjects. For this purpose, the author's questionnaire of stressful situations of firefighters, developed in full and abbreviated versions, is used.

2. Self-assessment of symptoms of post-traumatic and acute stress disorder, as well as other psychopathological phenomena. This is especially important because, as foreign studies have shown, among firefighters, clinically significant PTSD is usually accompanied by other mental disorders. The methods used make it possible to obtain fairly complete information about the psychological consequences of extreme situations.

3. Assessment of the risk of stress disorders based on indirect signs, which can be carried out, as shown in the work, by using the methodology for studying “psychological defenses.”

4. Assessing the external manifestations of maladaptive states by recording observations “from the outside” of a person’s behavior. A specially designed questionnaire for department heads serves this purpose.

Groups of subjects characterized by varying degrees of risk for the occurrence of maladaptive states were identified on the basis of a significant array of psychodiagnostic data. Further statistical analysis showed the possibility of establishing the subjects' belonging to each of these groups with high accuracy using a significantly smaller number of indicators.

The work proposes a new method for assessing a person’s experience of stressful situations, both for domestic and foreign psychology: the stressogenicity of various events and circumstances, attributed both to “critical incidents” and simply to stressful conditions, and typical for professional activities, is calculated by expert means. subjects (averaging assessments of emotional reactions to each type of event reported by several people makes it possible to obtain, to some extent, “objective” indicators of their stressogenicity); this makes it possible to then evaluate an individual's traumatic experience by taking into account how often and what type of situations the person encountered, and what the characteristics of his condition were during them. Stable connections between the indicators calculated using the author’s “Firefighter Stress Situations Questionnaire” and the severity of symptoms of post-stress disorders give reason to consider this method effective.

Currently, an in-depth examination is being conducted aimed at identifying PTSD in firefighters, using clinical interviews and psychophysiological techniques (one of the cases of such examination is described in Appendix 3). In the future, it is planned to conduct a longitudinal study of the dynamics of post-stress syndromes, as well as to study the connection between the likelihood of stress disorders in firefighters and basic personality traits and characteristics of professional motivation. The introduction of the developed set of methods into the activities of the psychological service of the fire department provides the opportunity to create an extensive database on stress disorders among firefighters in our country.

Dissertation bibliography author of the scientific work: Doctor of Psychology, Levi, Maxim Vladimirovich, Moscow

1. Aleksandrovsky Yu. A., Rumyantseva G.M., Shchukin B.P. Medical and psychological assistance during and after natural disasters and catastrophes // Military Medical Journal, 1990, No. 8, p. 73-76.

2. Aleksandrovsky Yu. A., Lobastov O. S., Spivak L. I. Shchukin B.P. Psychogenics in extreme conditions. M.: Medicine, 1991. 96 p.

4. Weinberg J., Shumecker J. Statistics. M.: “Statistics”, 1979. 389 p.

5. Biryukov A. A. We invite you to take a steam bath. 2nd edition M.: FiS, 1987. - 63 p.

6. Bodrov V.A. Psychological stress: development of the doctrine and the current state of the problem. M., IP RAS, 1995, 128 p.

7. Glass J., Stanley J. Statistical methods in pedagogy and psychology. M.: Progress, 1976. 496 p.

8. Greidenberg, B.S., et al. Traumatic neurosis: a summary of the current state of the issue. Kharkov, 1918. 148 p.

9. Kamenchenko P.V. Post-traumatic stress disorder. // Journal of Neurology and Psychiatry. Korsakova, 1993. T. 93, No. 3, p. 95 - 99.

10. Katkov V., Panteleev A., Steshina I. Post-traumatic stress disorder syndrome (PTSD): the state of the problem in domestic and foreign psychology. Perm, 1996. 40 p.

11. Kitaev-Smyk A.A. Psychology of stress. M.: Nauka, 1983. - 367 p.

12. Kolodzin B. How to live after mental trauma. M., 1992. 96 p.

13. Kotenev I.O. Psychological consequences of the impact of emergency circumstances on the personnel of internal affairs bodies. Author's abstract. diss. . Ph.D. psychol. Sci. M., Academy of the Ministry of Internal Affairs of Russia, 1994. 30 p.

14. Kotenev I.O. Traumatic stress questionnaire for diagnosing the psychological consequences of serving as law enforcement officers in extreme conditions. M., Academy of the Ministry of Internal Affairs of Russia, 1996. 42 p.

15. Kotenev I.O. Psychological diagnostics of post-stress states. Methodological manual for practical psychologists. Perm, 1998. 41 p.

16. Krasnyansky A.N. Post-traumatic stress disorders (literature review) // Synapse, 1993, No. 3, p. 14 34.

17. Kuznetsov G. The liquidators of Shelekhov’s “Chernobyl” themselves were left without protection. //East Siberian Truth, No. 51(23159). Irkutsk, 03/17/1998, p. 1-2.

18. Levi M.V., Lovchan S.I., Tarabrina N.V., Agarkov V.A., Post-traumatic stress of firefighters. Abstract. report // “Modern problems of fire extinguishing.” Materials of the scientific and practical conference. M., 1999 (in print).

19. Levi M.V., Sviridenko T.A. Using the Psychological Defense Questionnaire to identify risk for stress disorders. // Psychopedagogy in law enforcement agencies. Omsk, 1999 (in print).

20. Leonova A.B., Kuznetsova A.S. Psychoprophylaxis of unfavorable functional states of a person. M.: MSU, 1987.-105 p.

21. Maryin M.I., Hegel A.L., Apostolova L.O. Results of assessing the functional state and performance of firefighters. // Problems of fire safety of buildings and structures. M.: VNIIPO, 1990. - P. 243.

22. Maryin M.I. Criteria for assessing the severity of work of firefighters. // Firefighting. 1990, N3.-S. 32.

23. Maryin M.I., Sobolev E.S. Study of the influence of working conditions on the functional state of firefighters. // Psychological Journal, Volume I, No. 1, 1990. p. 102 - 108.

24. Maryin M.I., Lovchan S.I., Efanova, I.N. The influence of working conditions at the Chernobyl nuclear power plant in the post-accident period on the mental state of fire department workers. Psychological Journal, Vol. 13, 4, 1992, p.75.

25. Drug correction of states of mental maladaptation among fire department employees in stressful and extreme operating conditions. Guidelines. M., 1992. 16 p.

26. Melnikov A.V. Psychogenic disorders in victims of the earthquake // Mental disorders in victims of the earthquake in Armenia (Collected scientific works). M., 1989, p. 54 62.

27. Methods for diagnosing and correcting psycho-vegetative disorders among liquidators of the consequences of the Chernobyl accident and persons exposed to harmful factors of other disasters. A manual for doctors and students. M., 1997.

28. International classification of diseases (ICD-10). Classification of mental and behavioral disorders. Research and diagnostic criteria. -WHO, Geneva, St. Petersburg, 1995.

29. Pshtselko A.V. Psychology of post-traumatic stress. Tutorial. Domodedovo, Republican Institute for Advanced Training of Employees of the Ministry of Internal Affairs of Russia, 1998. 68 p.

30. Firefighters. 4.1. Levigurovich G.I., Netsky G.O., Reytynbarg D.I. Studying the firefighter profession. -M., Ed. NKVD, 1928, p. 4 130.

31. Firefighters. 4.2. Obukhov G. O. Injuries and occupational diseases of firefighters. M., Ed. NKVD, 1928, p. 131 - 194.

32. Post-traumatic stress disorders in the practice of medical and social expertise. Guidelines. / Compiled by: G.P.Kindras, O.A.Mironova. M., 1997. 23 p.

33. Prosekin A. Little Chernobyl in little Shelekhov. // "Number one". Irkutsk, 12/11/1996, p. 12-13.

34. Mental stress and personality. The problem of post-traumatic stress disorder. Correction and psychotherapy. (Methodological manual for practical psychologists, psychotherapists, social workers). Perm, 1996. 52 p.

35. Psychophysiological support for the performance of State Fire Service employees. Benefit. M., 1998. 178 p.

36. Romanova E.S., Grebennikov L.R. Mechanisms of psychological defense: genesis, functioning, diagnosis. Mytishchi, 1996. - 144 p.

37. Samonov A.P. Psychological training of firefighters. M.: Stroyizdat, 1982. 78 p.

38. Skakov S. Method of K.P. Buteyko. Institute of Century Medicine, 1992. - 38 p.

39. Consciousness and breathing: Mat. IV International Conference on Free Breathing./ Ed. Kozlova V.V. M.: 1993. - 151 p.

40. Tarabrina N.V., Lazebnaya E.O. Post-traumatic stress disorder syndrome: current status and problems. Psychological Journal, 1992. T. 13. N2. With. 14-29.

41. Tarabrina N.V., Lazebnaya E.O., Zelenova M.E. Psychological characteristics of post-traumatic stress states among liquidators of the consequences of the Chernobyl accident // Psychological Journal, 1994, Vol. 15, No. 5, p. 67 77.

42. Tarabrina N.V., Lazebnaya E.O., Zelenova M.E., Lasko N.B., Orr S.F., Pitman R.K. Psychophysiological reactivity among liquidators of the consequences of the Chernobyl accident // Psychological Journal, 1996, Vol. 17, No. 2, p. 30-45.

43. Tarabrina N.V., Lazebnaya E.O., Zelenova M.V., Agarkov V.A., Misko E.A. Psychological characteristics of people who have experienced war stress. Proceedings of IP RAS, Moscow, 1997.

44. Factor, cluster and discriminant analysis. M.: Finance and Statistics, 1989. -216 p.

45. Characteristics of states of mental maladjustment among fire department employees in stressful and extreme operating conditions and their prevention: Methodological recommendations. 1992. - 19 p.

46. ​​Khokhlova N.G. Questionnaire of life events “Life”: Assessment of the risk of mental maladjustment among police officers // Psychological diagnostics and correction of post-stress states among police officers. M.: Academy of the Ministry of Internal Affairs of Russia, 1997, p. 45-49.

47. Cherepanova E. M. Self-regulation and self-help when working in extreme conditions. M., 1995. 34 p.

48. Shapiro F. Psychotherapy of emotional trauma using eye movements. M.: Independent company “Class”, 1998. 496 p.

49. American Psychiatric Association. Diagnostical and statistical manual of mental disorders (3rd ed., revised). Washington, DC: 1987.

50. American Psychiatric Association. Diagnostical and statistical manual of mental disorders (4th ed.). Washington, DC: 1994.

51. Barneff Queen T., Bergmann L.H. Maintaining Posttrauma programs // Fire Engineering., 1988, Vol. 141, No. 10, P. 73 - 75.

52. Beck, A.T., Steer, R.A. Internal consistencies of the original and revised Beck Depression Inventory//J. Of Clinical Psychology, 1984, V.40, P. 1365-1367.

53. Beck, A.T., Steer, R.A. BDI: Manual. N.-Y., 1987.

54. Bergmann L.H., Queen T.R. Responding to critical incident // Fire chief, 1986, Vol. 30, No. 6, P. 43 49.

55. Blake, D.D., Weathers, F.W., Nagy, L.M., Charney, C.S., Keane, T.M. A clinical rating scale for assessing current and lifetime PTSD: The CAPS // Behavior Therapist, 1990, Vol.13, P. 187-188.

56. Carlson, E. & Putnam, F.W. An update on the Dissociative Experience Scale. Dissociation, 1993, Vol. 6(1), pp. 16-27.

57. Carlson, E.B. & Rosser-Hogan, R. Cross* Cultural Response to Trauma: A Study of Traumatic Experiences and Posttraumatic Symptoms in Cambodian Refugees. J. of Traumatic Stress, 1994, Vol. 7, No.l, P. 43-58.

58. CISD teams help those who help others. // Community Update, 1993, Vol. 3, no. 3, p. 14.

59. Derogatis, L.R. SCL-90-R: Administration, Scoring & Procedures Manual II for the R(evised) Version. Clinical Psychometric Research, Towson, 1983, MD. 21204

60. Drescher, K.D., Abueg, F.R. Psychophysiological indicators of PTSD following Hurricane Iniki: The Multi-sensory interview // National Center for PTSD Veterans Affairs Medical Center. Palo Alto, C A, 1995.

61. Egendorf, A., Kadushin, C., Laufer, R., Rothbart, G., Sloan, L. Legacies of Vietnam: Comparative adjustment of Veterans and their Peers. N.Y.: Center for Policy Research, 1981, 900 p.

62. Figley Ch.R. Introduction/Stress disorders among Vietnam veterans./Ed. Ch. R. Figley.-New-York: Brunner/Mazel, 1978. 326 p.

63. Fullerton C.S., McCarroll J.E., Ursano R.J., Wright K.M. Psychological responses of rescue workers: fire fighters and trauma. Amer. J. Orthopsychiat. 1992, Vol. 62, pp. 371 -378.

64. Goldberg D.P. The detection of psychiatric illness by questionnaire. L., Oxford University Press, 1972.

65. Hildebrand J.R. Stress research. Part 1. // Fire Command. 1984. - Vol.51, No. 5., P. 20 -21.

66. Hildebrand J.R. Stress research. Part 2. // Fire Command. 1984. - Vol.51, No. 6., P. 55 -58.

67. Horowitz M.J. Phase-oriented treatment of stress response syndromes. // Amer. J. of Psychotherapy. 1973, Vol. 27, pp. 506-515.

68. Horowitz M.J. Stress response syndromes N.Y.: Aronson, 1976.

69. Horowitz M.J., Wilmer, N., & Alvares, W. Impact of Event Scale: A measure of subjective stress. // Psychosomatic Medicine, 1979, Vol. 41, pp. 209 218.

70. Horowitz M.J., Weiss D.S., Marmar C. Diagnosis of posttraumatic stress disorder. J. Nerv. Ment. Dis., 1987, Vol. 175, pp. 276-277.

71. Hytten K., Hasle A. Fire-fighters: a study of stress and coping. // Acta Psychiatrica Scandinavica, SuppL355. 1989, Vol. 80, P". 50-55.

72. Kardiner A. The Traumatic Neuroses of War. New York, Harper & Row Publishers Inc, 1941. -258 p.

73. Keane T.M., Caddel J.M., Taylor KL. Mississippi Scale for Combat-Related Posttraumatic Stress Disorder: three studies in reliability and validity. Journal of Consulting and Clinical Psychology, 1988, Vol. 58, pp. 329-335

74. Lazebnaya E.O., Zelenova M.E., Tarabrina N.V., Lasko N. The Empirical Study Of Traumatic Exposure Among Russian Veterans Of The Afghanistan War. XIII Annual Meeting of The International Society for Traumatic Stress Studies, Nov., 1997 Montreal, Canada.

75. Marmar C.R., Weiss D.S., Metzler T.J. The peritraumatic dissociative experience questionnaire. In Wilson J.R., Keane T.M. (eds.): Assessing Psychological Trauma and PTSD. N.Y., Guilford Press, 1997, pp. 412-428.

76. McFarlane A.C. The Ash Wednesday bushfires in South Australia. // The medical J. of Australia, 1984, Vol. 141, pp. 286-291.

77. McFarlane A.C. Long-term psychiatric morbidity after a natural disaster // The medical J. of Australia, 1986, Vol. 145, pp. 561-563.

78. McFarlane A.C. Life events and psychiatric disorder: the role of a natural disaster. Brit. J. Psychiat., 1987, Vol. 151, pp. 362-367.

79. McFarlane A.C. The phenomenology of posttraumatic stress disorder following a natural disaster. J. Nerv. Ment. Dis., 1988, Vol 176, P. 22-29

80. McFarlane A.C. The longitudinal course of posttraumatic morbidity. J. Nerv. Ment. Dis., 1988, Vol 176, P. 30-39.

81. McFarlane A.C. The Etiology of Post-traumatic morbidity: Predisposing, Precipitating and Perpetuating Factors. // Brit. J. Psychiat., 1989, Vol. 154, pp. 221-228.

82. McFarlane A.C. Avoidance and intrusion in posttraumatic stress disorders. J. Nerv. Ment. Dis., 1992, Vol. 180, pp. 439-445.

83. McFarlane A.C., Papay P. Multiple diagnoses in posttraumatic stress disorder in the victims of a natural disaster. J. Nerv. Ment. Dis., 1992, Vol. 180, pp. 498-504.

84. McFarlane A.C., Weber D.L., Clark C.R. Abnormal Stimulus Processing in Posttraumatic Stress Disorder. Biol. Psychiat., 1993, Vol. 34, pp. 311-320.

85. Mendelson G. The concept of posttraumatic stress disorder: A review //J. Low Psychiat 1987-Vol.10-P.45-62.

86. Pike K, Beaton R., Murphy S., Corneil W. Gastrointestinal symptoms in Fire service personnel with post-traumatic stress disorder. // University of Washington, University of Ottawa. (Unpublished manuscript), 1997.

87. Pitman K.R., Orr S.P., Forgue D.F., de Jong, J.B., Claiborn J.M. Psychophysiological Assessment of Posttraumatic Stress Disorder Imagery in Vietnam Combat Veterans // Archives of General Psychiatry, 1987, V.44, P. 970 975.

88. Shalev A.Y., Orr S.P., Peri T., Schreiberg S., Pitman K.R. Physiologic Responses to Loud Tones in Israeli Patients With Posttraumatic Stress Disorder // Archives of General Psychiatry, 1992, V.49, P. 870 875.

89. Singh B.S. Long-term psychological consequences of disaster // The medical J. of Australia, 1986, Vol. 145, pp. 555-556.

90. Spielberger, C.D., Gorsuch, R.L., Lushene, R.E. Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Palo Alto: Consulting Psychologists Press, 1970.

91. Tarabrina, N. V., Levy, M. V., Maryin, M. I., Kotenev, I., 0., Agarkov, V. A., Lasko, N., Orr, S. Trauma responses among Moscow firefighters // ISTSS XIV Annual Meeting, Washington, 1998 , p. 118.

92. Tarabrina N., Lazebnaya E., Zelenova M., Petrukhin E.V., “Levels of Subjective-Personal Perception and Experiencing of “Invisible” Stress. The Humanities in Russia: Soros Laureates, M., 1997, pp. 48-56 .

93. Weiss D.S., Marmar C.R. (1997) The Impact of Event Scale Revised. In Wilson J.R., Keane T.M. (eds.): Assessing Psychological Trauma and PTSD. N.Y., Guilford Press, pp. 399-411.

94. Zilberg N.J., Weiss D.S., Horowitz M.J. (1982) Impact of event scale: A cross validation study and some empirical evidence supporting a conceptual model of stress syndromes. J.Couns. Clin. Psychol., Vol. 50, pp.407-414.

It

Materials from the book: Y. Zilberman, “Vladimir Horowitz. Kyiv years". Kyiv. 2005.

Vladimir Horowitz was born in 1903 in Kyiv. He was the fourth and youngest child in the family. Father - Samuel Joachimovich Horowitz, a graduate of the Faculty of Physics and Mathematics of the University of St. Vladimir. Mother Sofya Yakovlevna Bodik. “As biographers report from the pianist’s words, he, as the youngest member of the family, was very pampered. So, (...) when little V. Horowitz was sleeping, the whole family walked around the apartment in specially made slippers so as not to wake the child. The pianist’s cousin, Natalya Zaitseva, also spoke about the incredible family spoiling of V. Horowitz. She recalled the extremely early manifestation of musicality in her cousin, talked about how little Volodya improvised on the piano, depicting musical pictures of a thunderstorm, a storm, or a pantheistic idyll. Let us only note a very important fact, mentioned by everyone: the pianist’s childhood years passed in an unusually rich atmosphere of music.”

“The surname Horowitz comes from the name of a town (Horovice) in the Czech Republic. The first documented information about the relatives of the great pianist who lived in Ukraine relates to his grandfather Joachim Horowitz. They have a direct bearing on the question of the place of birth of Vladimir Horowitz, which has so far remained controversial.” The possible place of birth of V. Horowitz is considered to be Berdichev, “an unremarkable small Jewish town located near Kyiv.” Berdichev in 1909 belonged to the 3rd class of Russian cities. Very significant centers were included in this class: Arkhangelsk, Astrakhan, Vitebsk, Voronezh, Yekaterinburg, Kursk, Penza, Orenburg, etc. Kiev was assigned the 2nd class in this list, along with Kronstadt, Ryazan, Rzhev, Tver, Serpukhov, etc. “...Of the banking houses in Berdichev, the house of the Jew Galperin, Kamyanka, Manzon’s office, Horowitz and his son, etc. are remarkable in terms of wealth and credit.” (N. Chernyshev, editor of the Kyiv Provincial Gazette, reports in the Memorable Book of the Kyiv Province for 1856). Y. Zilberman: “...Unfortunately, the birth certificate (V. Horowitz - E.Ch.) does not exist.” According to another version, Vladimir Horowitz was born in Kyiv.

“Joachim Horowitz (grandfather) studied in Odessa. At the age of 18 he graduated from the Odessa Richelieu Gymnasium with a Gold Medal. The exact time of his appearance in Kyiv could not be established. (...) In the birth certificate of Samuel Horowitz (1871), in the column “father” it is written: “Berdichevsky 2nd guild merchant Joachim Samoilovich Horowitz.” “We can [speak] with confidence about the two sons of I.S. Horowitz (grandfather of Vladimir Horowitz): Alexandra and Samuel.” Samuel Horowitz, the father of V. Horowitz, could meet his future wife, Sophia Bodik, when she studied at the Kiev College of Music in the class of the famous musician and teacher V. Pukhalsky. The marriage with S. Bodik took place in 1894.

Alexander Horowitz (1877-1927), uncle of V.G., musician. His influence on the formation of the young pianist is enormous. He entered the Kiev Music College in 1891 in the class of Grigory Khodorovsky immediately for the secondary course, which in itself means the presence of solid home preparation. According to G. Plaskin, Alexander Joachimovich’s mother (V.G.’s grandmother) was allegedly an excellent pianist.

V. Horowitz's father Samuel Joachimovich Horowitz (1871-?) was born in Kyiv, entered the Kiev University of St. Vladimir at the Faculty of Physics and Mathematics. Immediately after graduating from university, he went to Belgium and entered the Electrical Engineering Institute of Liege, where he graduated with a degree in electrical engineering in 1896. Until 1910, Samuel Horowitz worked as the chief engineer of the General Electricity Company in Kyiv. In 1910, S. Horowitz founded a small construction and technical company for the energy sector of sugar factories. In 1921, V. Horowitz's father was arrested. [Addition 2018: Y. Zilberman reports that, despite the five-year sentence specified in the “Case,” Samuel Horowitz managed to get out no later than next year.] To organize a concert of Vladimir Horowitz and R. Milstein (violin) with the Persimfans orchestra in Moscow, the musician’s father, according to N. Milstein’s descriptions, went already in 1922. Then S.I. Horowitz lived in Kyiv before Vladimir left abroad, and in 1926 he moved to Moscow, where he worked as a manager. Electrical engineering section of the State Institute for the Design of Sugar Factories “Hydrosakhar” of the People's Commissariat for Food Industry. Very little was known about the tragic fate of Vladimir Horowitz’s father in the last years of his life - researchers limited themselves to stating the fact that he was arrested by the GUGB NKVD of the USSR on charges that “being anti-Soviet, he carried out sabotage activities, producing substandard projects for the construction of sugar factories” (Cit . according to Yu. Zilberman). Shortly before the Great Patriotic War, Regina Horowitz visited her father in the camp and, upon arriving, told the family that she found him in very bad condition. A few weeks after this trip, the family received notice of S.I.'s death. Horowitz. This document was not preserved in the family archives. According to O.M. Dolberg (granddaughter of R. S. Horowitz), her great-grandfather died in 1939 or 1940.

Moses Yakovlevich Bodik was born in 1865 and was a Kyiv merchant of the 1st guild, which is confirmed by the statement of his wife with a request to accept his son Yakov as a student at the Kyiv Music School. Moisei Bodik's second son, Sergei, was enrolled in the school in 1912 as a violinist in the class of the outstanding performer and teacher Mikhail Erdenko.

The daughter of Yakov Bodik and the mother of Vladimir Horowitz, Sofya (Sonya) Yakovlevna Bodik, was born on August 4, 1872. Almost nothing is known about her mother (grandmother V.G.), only her name is Ephrusinia. The name, frankly speaking, is not at all typical for Jewish families in a provincial town - rather Christian. Perhaps the complex character of Vladimir Horowitz described by his contemporaries was partially inherited from his mother. A typical example of suspiciousness and, at the same time, strong attachment to his mother is the dramatic episode of his more than four-year break from concert activity and illness in 1935-1938. All biographers note that on the basis of the news of his mother’s death from peritonitis, as a consequence of an unsuccessful and belated operation for appendicitis, he began to be overcome by gloomy forebodings, he constantly complained of pain in the intestines. V. Horowitz showed himself to doctors and demanded removal of the appendix, while all the doctors who examined him refused to operate on a healthy organ. In the end, Horowitz convinced the doctors to perform an operation on him, which was not very successful; he was bedridden for a long time. And the consequences of this operation tormented the pianist all his life. In 1987, V. Horowitz admitted to G. Schonberg: “Of course, they (pains - Y. Zilberman) were definitely psychosomatic. But you never know.”

So, Vladimir Horowitz’s childhood and youth were spent in a large, prosperous, quite successful and cultured Jewish family, quite typical for large cities of the Russian Empire. It is appropriate here to note two factors that contributed to the early musical development of V. Horowitz. The first is the presence of several musicians in the family. In accordance with the lists of students of the Kiev Music School and the Kiev Conservatory, 10 members of the Horowitz-Bodik family studied at this educational institution: Sonya Bodik (mother of V. Horowitz), Alexander Horowitz (brother of Vladimir Horowitz's father - Samuil Joachimovich), Elizaveta Horowitz and Ernestina Bodik (aunts of V. Horowitz), Yakov and Grigory Horowitz (brothers of V.G.), Regina Horowitz (sister of V.G.), Yakov and Sergey Bodiki (his cousins). It should be added to this that the father of the family, Samuel Horowitz, was an amateur musician and played the cello well, and his mother, V. Horowitz’s grandmother, was allegedly a brilliant pianist. When Vladimir Horowitz was five years old, his mother began teaching him to play the piano.