AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 12, NUMBER 1, 1991 /51-66 Copyright 1 991 American Journal of Forensic Psychiatry, Volume 12, Issue 1. The Journal is a publication of the American College of Forensic Psychiatry, 26701 Quail Creek, Number 295, Laguna Hills, California 92656. Travel Log IN SEARCH OF MULTIPLES IN MOSCOW Ralph B. Allison, M.D. Was the sun going up or coming down? As a passenger on a KLM 747 heading east over Scotland at 40,000 feet, I couldn't tell. The bright crescent on the horizon stayed the same height and didn't get larger or smaller, as it did when viewed from the ground. My watch read 1:00 am California time, so I decided to try sleeping. But the stewardess announced breakfast would be served shortly, as it was dawn in our destination airport in Amsterdam, and the crew was operating on Dutch time. I was doomed to miss a full night's sleep this trip. Such was the price I was paying to share notes with psychiatrists in Russia. My wife and I had left California the day before, staying overnight near the John F. Kennedy Airport in New York. We joined our group of mental health professionals the next afternoon at JFK. Our leader, Dr. Don Jacobson, a portly Midwestern psychiatrist, had met us at JFK as we were lugging our bags to the KLM counter. Dr. Jacobson's invitation for a trip to Russia for a group of psychotherapists, all interested in multiple personality disorder (MPD), had come indirectly through a psychologist in Michigan, Dr. Jacobson's home state. She had heard that Dr. Jacobson had been in touch with psychiatrists in the USSR who were interested in MPD and dissociation, a surprise to me. In 1977, I had lectured on the subject in Sweden, which is far ahead of Russia, and even the Swedes were reluctant to accept MPD as a valid subject of study. When I asked Dr. Jacobson about this trip, he assured me that he did have such contacts in Russia. He had spent a year in Moscow studying Russian ten years before and looked forward to a return visit. He planned to have groups of Russian psychiatrists interested in discussing dissociation meet with us in Moscow, Kiev, Odessa and Leningrad. It sounded too good to be true, but I asked him to send me written information so I could discuss it with my wife. The official itinerary provided by the travel agency showed planned visits to the USSR Academy of Medical Sciences, National Mental Health Research Center in Moscow on June 8, 1990, and to the National Mental Health Research Center in Leningrad on June 15, 1990. No professional meetings were scheduled in Kiev or Odessa. When I called Dr. Jacobson about this, he was baffled and started making transatlantic calls to his contact in Moscow. He knew what he had been promised, but delivery seemed to be something else. With all the toppling Communist governments in eastern Europe, with the Berlin Wall coming down, and with so many changes being proposed for the Russian economy, my wife and I decided that this tour was timed perfectly to put us where the action was. We decided to take the gamble and go where the Red Star flies. We sent in our applications and told our supervisors we would be taking vacations from June 6-16, 1990. The group was composed of eight mental health professionals (which we found to be an excellent number for sitting around the dinner table). There were three psychiatrists (two of them in corrections), three psychologists, one occupational therapist and one registered nurse. Our leader, Dr. Jacobson, was fluent in Russian and German. All our arrangements were made through Intourist, the monopolistic Soviet travel agency, which had arranged for prepaid room and board, a translator, a driver and a bus for our group in each city we visited. AMSTERDAM After the breakfast aloft, we landed at the airport in Amsterdam, exchanged dollars for guilders, stashed our bags in lockers and discovered that a sightseeing bus and guide were waiting to show us the local terrain. While driving through the narrow streets, we saw Dutch citizens hurrying along, busily attending to their affairs. Everywhere were small shops with loaded shelves. On the ever present canals were long narrow boats which were homes to a large portion of the Dutch population. We were clearly in a prosperous, happy, active city with energetic citizens who were using limited resources to the full. The driver turned us over to the tour-boat driver who took us under the bridges we had just driven over. We went through numerous canals into the harbor before coming back to the dock. If this was typical of Western Europe, we would have been glad to stay our entire time there. But such was not to be, as we had a flight on another KLM 747 ticketed to Moscow that evening. Moscow When we landed at Moscow and walked into the dreary airport, I expected to have my luggage searched by a surly customs officer. We were surprised to have our luggage waved on without any inspection whatsoever. Then we met Natasha, our attractive blonde Intourist guide. (When Moscow's MacDonald's opened, she was the translator for the MacDonald's executives.) With glasnost in force, she was open and honest with us about her opinions of the current scene. Dr. Jacobson readily noticed the difference from his prior stay when the natives could only tell him of their unpopular opinions with facial expressions, but never with words that could be overheard. Driving in from the airport, we saw dirty streets, dirty buildings, and no one who was hired to even try to make the city look better for the three million tourists who are there every day. There was no joy in the faces of the pedestrians we saw; they trudged along as if they were going to a funeral. All of us came to the conclusion that Moscow was one depressed city. Natasha confirmed that opinion. "Gorbachev has been in power for six years now. We have heard a lot of talk but don't see any improvement in our lives." They heard about his plan to change to a free market economy in a month. This filled the Russians with severe anxiety. How could this come about? Who knows what to do? How can they give up their guaranteed rent (3 percent of their salaries) and medical benefits? Without security, what will they do? This initial mood of depression and anxiety was noted, to some degree, in the other cities visited, but it was felt most strongly in Moscow. After all, Moscow is the seat of government in the USSR and the source of all economic wisdom in the nation. If those in power don't know what to do next, who does? Also, Moscow is not able to support itself because of its northern location and short crop growing season. Therefore, the planners order other republics, such as the Ukraine, to ship all of their crops to Moscow first. The best is taken for the Muscovites and the rest is redistributed according to plan. Now, with perestroika, the crop producing republics are refusing to send their crops to Moscow and will distribute them however they wish. This leaves the Muscovites short on anything they cannot grow themselves. After soaking up this ambience of depression and despair, we arrived at the Cosmos Hotel. The travel book had warned us that tipping was insulting to Russian workers, so we didn't want to insult the hulking man who wheeled all our bags to our room. But after bringing our suitcases in, he looked me in the eye and pill rolled with his right hand, speaking his favorite English words, "One dollar." Clearly he would not be insulted with a dollar tip for all the work he had done. Considering what we learned about the black market in dollars there, he did quite well compared to those with no access to tourists. The next morning, we gathered for breakfast and found their version of a class society. Those who were not Intourist groups could eat in the regular dining room and order individual meals. Those on the Intourist plan in which all meals and lodging were prepaid must eat in the gymnasium sized dining room. The long undecorated room had plain walls, long tables and identical items at exactly the same place at each table. Each group was assigned a table where they sat for every meal. There was no opportunity to meet anyone from another group. It was undoubtedly very efficient, and the food was adequate, but the environment was uninspiring. All of our psychiatric contacts had been made been made by Dr. Jacobson through Dr. M. E. Vartarius, director of the All-Union Research Centre for Mental Health, USSR Academy of Medical Science, in Moscow. On our second day there we were scheduled to see him and those of his colleagues who were allegedly interested in MPD. Or so we thought. What actually happened was that Dr. Vartarius, a slight blonde man in a white coat, met our bus when we arrived at the Centre and ushered us into the office of Alexander S. Tiganov, M.D., Professor, Director of the Institute of Clinical Psychiatry and Chief Chair of the Psychiatry Central Institute for Post Graduate Training of Doctors. Dr. Tiganov was a stolid man who sat at the head of the table in his office under an organizational chart of the Centre on the wall behind him. We Americans sat around the table wondering where the other Russian psychiatrists were. They never came, Dr. Tiganov apparently had no idea why we were there, other than we were another group of curious American psychiatrists. He delivered his standard speech about how the Institute is organized into divisions for Borderlines, Psychotics, Geriatrics, Preventative, Middle Age and Children. Since it soon became apparent that he was unaware of our interest in MPD, we asked rather timidly if he had some awareness of the problems caused by child abuse, a common historical precedent in American patients with MPD. At first he said that he didn't know what we meant by "sexual child abuse." My reaction was that he had just answered our question. But our two translators, Natasha and Dr. Jacobson, gave him the benefit of the doubt and retranslated the question, hoping that he didn't understand the English words, as he only spoke Russian. This time he emphasized that they (his division on psychotics) didn't specialize in the area of child abuse. Also, he had no awareness of any clinical case of MPD. He later mentioned one resident who was working on a paper on depersonalization. He suggested that she might be the one who should read our literature. Dr. Tiganov was personally interested in Endogenous Psychoses, such as schizophrenia and affective disorders. He works with "slowly developing schizophrenia." A frustrated Dr. Jacobson finally delivered with a lecture on the initial presentation of a female patient with MPD, describing in vivid detail all of the symptoms, history and physical appearance one would expect to note. His presentation was so detailed and clear that anyone who had ever seen such a patient would immediately know the diagnosis. Dr. Tiganov's response was that he would have to see such a patient to be able to talk intelligently about the problem. Then Dr. Anderson, the other prison psychiatrist, described an inmate/patient who seemed to have MPD and who had killed another patient in the prison hospital. Dr. Tiganov didn't seem to react to that story either, so I tried appealing to his interest in schizophrenia by telling him that I had seen several similar cases for court evaluations but believed them to be dissociating schizophrenics instead of multiples. Sensing an apparent disagreement in diagnoses, he laughed and said that those patients would make for an interesting case conference. He still didn't admit to having seen any patient who might have had the symptoms we had so graphically described to him. Finally, hoping to meet on common ground, I asked about psychiatric training for work in courts and corrections. He said that any training in that field was under the Courts Division. He recognized that any psychiatrists working in prisons would be isolated from other professionals and thus not keeping up with them. Those who worked in prisons were those at the bottom of the profession. Such deficiencies in skill and knowledge were matters that still needed correction, he said, quite diplomatically. Two hours had passed and Dr. Tiganov offered to let us visit with some practicing psychiatrists on the wards. We wanted to accept his offer, but Natasha warned us that we had a long trip back to our hotel on the other side of Moscow and there was no time to spare. We made our farewells to Dr. Tiganov and climbed back on the bus to drive through more dirty streets trod by more depressed Muscovites. Since our dream of colleague-to-colleague discussion with practicing psychiatrists did not seem to be working out as we had hoped, Dr. Jacobson made phone calls to the medical centers in the other stops on our itinerary-Kiev, Odessa and Leningrad. When he came back to report to the group, his grim face gave him away. No one at any of these centers had ever heard of us! Obviously, our contact in Moscow had done nothing to make the promised arrangements. We were now on our own to make something out of our trip. We had not come all this way just to see museums. The contacts in the medical centers in Kiev and Odessa told Dr. Jacobson that there was no time to get the approvals of the officials who must approve our visits. No matter what he said, he was blocked by the bureaucracy. We accepted our fate and decided to be pure tourists in those two cities. However, in Leningrad, he found a warm welcome at the V.M. Bekhterev Psychoneurological Research Institute. There we were welcome to meet with several psychiatrists at the time originally scheduled by Intourist for that activity. They would supply a translator from their staff. We might have a chance to break through some barriers and find out what psychiatrists really did with dissociators, in Russia. KIEV On June 10, we flew on Aeroflot to Kiev. That thrilling experience is another tale which belongs in a book called "Trips I Wish I Hadn't Made." Aeroflot planes are designed for quick conversion to troop transports simply by painting a red star on the fuselage. Seats are barely bolted to the frame. No safety instructions are provided passengers. Our group renamed the airline "Aeroflop," and we were grateful for the efforts of our own FAA in trying to keep us safe while flying. Fortunately, we landed unscathed in Kiev, 110 kilometers south of Chernobyl. Here our guide was a motherly woman named Tammy, who took us on the usual novice visitor sights of the town. On June 12, she stopped the bus in front of the hospital where she had delivered her only daughter 24 years ago, Clinical Hospital #21. We stepped out and looked around, trying to locate the front entrance so we could locate the receptionist. There was no front entrance! So we looked for the emergency entrance where the ambulance might unload patients. There was no evidence of any emergency entrance, either! We saw nurses walking across the courtyard into the building, so we knew there were doors somewhere. Tammy did not dare come in, since it was not on her approved route, but Dr. Jacobson had no such scruples. He polled the group, and the consensus was that we would brave this fortress and see what secrets lurked inside. We timidly entered a side door and found a circular staircase which led to the second floor. Then the elevator door next to the stairs opened and out stepped a group of Russian women in white gowns. One took a look at us and started yapping away in Russian, obviously asking us to identify ourselves immediately. Dr. Jacobson took full responsibility for our invasion and asked if we could look around her hospital. The woman, probably a charge nurse, herded us into the office of the Medical Director, a stem woman in her 50s who wore a starched white stove pipe cap while she talked to a young blond doctor on her right. Her eyes were glinty and stem as she focused on these naughty children who were caught sneaking around her backyard. What was she to do with us? Dr. Jacobson put forth his most eloquent plea for leniency and understanding, and her eyes softened as a smile came over her face. We relaxed when we realized our transgression was forgiven. Once we were welcomed guests, nothing was too good for us. She offered us the services of the surgeon, Dr. Yuri G. Kuzenko, with whom she had been speaking when we were ushered into her office. He is a Candidate in Medical Endoscopy, Central Clinic, Radyansky District, Kiev. He proudly showed us his endoscopy lab where he and three other doctors do all the electronic endoscopy for the entire Ukraine. He informed us that this hospital was build about 1840 and is the tertiary care center for the Ukrainian republic for such services. This lab had been set up by a joint venture with a European company. He showed us his Commodore computer, with Cyrillic letters printed on the keys over the English ones. He demonstrated his Sony video player by showing us one of the tapes of a bowel being scoped. They had collected a large series of such tapes for educational purposes. Dr. Kazenko then handed us over to a most delightful surgical resident in her late 20s whose name went by me while she had us change our jackets for white "sterile" gowns. These skimpy outfits, which were not large enough to tie around the waist, magically made us sterile so we could go into the surgical area. She explained that, after graduation from high school, she had gone directly into medical school. After six years in medical school, she went into a one year surgical residency, which she was now completing. She explained that they did scheduled surgery only one day a week, a concept I believe would make American surgeons feel mighty underutilized. Since no surgery was scheduled that day, there was nothing to see in the operating rooms. In the ward, we found a dozen male patients lying on steel cots in their own clothing with little to do but read magazines. None of them looked sick, and none had IVs hooked up. One of the patients courteously left the ward to operate the elevator for us. Our resident/guide showed us into a small room that appeared to be a part of central supply, as instruments and packs were laid about on the steel tables. On one table was an open metal box containing various surgical instruments. My wife, a former surgical nurse, and I both looked at the instruments with some surprise as the two scalpels on the top were rusted from point to handle! My wife had a hard time containing her comments since she has gone through many hospital inspections where such a lapse would be very costly to the hospital. Our surgeon/guide was such a sweet and pleasant lady we dared not ask her how such a situation came about and thus possibly embarrass her. As a side-bar, the Russians we spoke with reported that the quality of medical care has been going down during the past five years. They don't feel the doctors are as qualified now, and bedside manner has been deteriorating. Also, the Russians have decided that a totally free health system is not working, and they are planning to change over to a Swedish system. That plan means that a fee will be paid by all citizens into a health fund, which then will finance the delivery of medical care. As it is now, with the doctor making no more money than anyone else, the incentives to be excellent are minimal. When I commented on the extreme age of the hospital building, the resident commented, "Well, it lasts longer than our new hospitals." So I must assume they have the same trouble with quality of construction of hospitals as they do with other big buildings. (No one is happy with apartment building construction methods which have led to serious renters' strikes.) As the resident escorted us out of the surgery area, we had finished our limited in-service training in how medicine is practiced in a high quality tertiary medical care center in the Ukraine. We had no desire to take a look at the primary and secondary care centers. ODESSA The next day we were bussed to the Kiev Airport for the Aeroflot flight to Odessa on the Black Sea. After a pleasant wait in the International Lounge with real English language magazines to read, we were ushered out to our plane, bypassing all security checks, even the electronic metal detector. Our pleasant airport attendant informed us that we would be flying on the smallest passenger jet they had, with 30 seats, two by each window. She told us to sit in the first three rows behind the pilot's cabin. When we were seated, she let on the Russian passengers, who were to sit behind us. They entered on the ramp in the rear. When the plane was half filled and many passengers were still stowing their carryon luggage, a Russian man sitting just behind us on the left came up behind me, tapped me sharply on the shoulder and demanded, in excellent English, that I get up and give him my seat. He yelled in my ear that his ticket was marked Seat IA, and that since I was sitting in IA, I must let him have my seat. I told him as firmly as I dared that I had been instructed to sit where I was, and that I was not going to move. My wife, sitting next to me, told him that he was quite definitely not going sit next to her. All of this was going on while his seat was still empty, so I could discover no logical reason why he should have my seat. He still kept stubbornly demanding that I get up and give him my seat, and I kept telling him to forget the idea. In my head I was weighing the options I had. Fortunately he understood English, so I could still verbally negotiate with him. I thought that maybe he was drunk, but he didn't smell of alcohol. (But vodka doesn't smell, I remembered.) I didn't know if I could throw him off the plane or not. Even if I wanted to, numerous other passengers were standing in the aisle preparing to depart. Before I had to pull a John Wayne on him, a petite stewardess noticed he had not seated himself and came forward to investigate. When she asked the problem, he repeated, "He's in my seat. My ticket says I have Seat 1 A, so I want him to get up and give me my seat!" This stewardess was smart. She was much smaller than he was, so she could not have physically moved him. She pointed to the markings on the fuselage on the side opposite to where I was seated and showed him where the markings did indeed show a "IA." She said, "Here is where Seat IA used to be, but we pulled it out to make room for luggage." Moving back to his seat, she pointed to it and announced with authority, "I now designate your seat 1 A! Sit down in Seat IA! " Without a murmur, the Russian man went to his seat, sat down, put his seat belt on and spent the rest of the short trip in silence. I kept looking back to see if he had any second thoughts, but he was totally compliant with the stewardess' command and never moved from his seat again. I wondered if his irrational stubbornness and ready response to authority was typical of Russians or only peculiar to him. My subsequent reading of Russian history leads me to the conclusion that these traits were typical of the Russian character. Since Odessa is a Black Sea resort and vacation spot for many Russians, we drove to a popular recreation park on the edge of the beach. Being used to the vast expanses of sand on California beaches being protected by ardent environmentalists, I was shocked to see beaches covered by acres of wooden lawn chairs, all in neat rows and columns. It seemed that no one dared to move any one chair out of its assigned spot. These lawn chairs covered most of the two beach areas we saw near the pier. After we left, our guide told us that farther down the road was the nude beach. Naturally she had to tell us that as we were leaving, with no time to spare! While in Odessa, one of our group found she would run out of insulin syringes if she didn't get more while there. Several of us hunted for a pharmacy, since in the U.S. that is where syringes are sold. We knew there were none of the supermarket chains of pharmacies we have in the U.S., but we had seen small drugstores that we hoped might be like the neighborhood pharmacies we have at home. Several blocks from our hotel we found one in a single room no bigger than our living room at home. When we entered, we found glass counters covering bottles and boxes filled with pills, marked with their prices. Nowhere to be seen were the items one sees in an American pharmacy, such as toothpaste, hairbrushes and nose drops. Out of the back storage area came the "pharmacist," a chunky middle-aged woman wearing a white labcoat over her dress. Dr. Jacobson politely asked if she had any insulin syringes for sale. She didn't carry such items, she said, as they were only for sale at the surgical supply house on the other side of town. Since it seemed unlikely that we could find the supply house at all, even with her directions, our needy member decided that she would just have to prolong the life of the syringes she had. We wondered just what it was like for a Russian patient who had such needs. Can they even get prescriptions filled at such pharmacies? My thinking failed to take into account the fact that all medical care is free in Russia. Therefore, there would be no prescriptions for druggists to sell as they would get them free from the doctor or hospital. Most likely, what was for sale in this store would be what we call over-the-counter drugs. Since this store certainly did not have a supply of any of the nonmedication items sold in every American drugstore, there was little for anyone to buy or sell here. LENINGRAD On June 14, we flew in an Aeroflot cattle car with wings to Leningrad where we were met by Irene, our Intourist guide with a Ph.D. in history. She knew all there was to know about the Czars and Czarinas and the dungeons in the Peter-and-Paul Fortress, where enemies of the state were imprisoned. As a correctional psychiatrist, it was startling to learn about the cells which were the homes of state prisoners for up to 30 years before they stood trial (and probably not so long after trial). Leon Trotsky, Maxim Gorky and Lenin's elder brother were among those held there prior to its closure in 1921. When asked what happened if any of those inmates got sick, Irene replied, "Nobody cared about them. If they didn't get well by themselves, they died." As a result of our findings in Moscow, Dr. Jacobson had contacted the psychiatric staff at the Leningrad V.M. Bekhterev Psychoneurological Institute and arranged for a meeting with several of their psychiatrists. On the appointed afternoon, our bus driver dropped us off at the doorway of a rather unimpressive old building which he assured us was known as the Bekhterev Institute. Our initial greeter introduced himself as Dr. Aleksandr S. Lomachenkov, a Senior Scientific Associate. He escorted us into an office furnished in the decor of the 1920s, with heavy furniture with leather cushions. He introduced Dr. Vladimir Ikhanov, their interpreter. He explained about the organization of the Institute and advised us that their top professor in adolescent psychiatry, Dr. Lickho, would be coming soon to talk with us. Dr. Lickho arrived a few minutes later and took his seat behind the massive desk, obviously the man in charge. Dr. Lornachenkov retreated to the opposite end of the room, where he sat with Dr. George Barosky, a psychologist who was the one person we later learned who was interested in MPD as the result of his clinical work there. Dr. Barosky later showed me his invitation to come to work in the U.S. at the Bangor, Maine Mental Health Service. We soon learned the format was to be the same as in Moscow-the professor spoke and we were to listen, then ask polite questions. Apparently, this was the preferred way to deal with such visiting dignitaries as us and was meant to please us, as this is how they would like to be pleased while visiting a U.S. medical center. The idea of us sitting down with Dr. Barosky, for example, and discussing his patients was just not what foreign visitors were supposed to do. We did, however, sneak discussions in after the formal part was over, but that left little time to share ideas. Dr. Lickho seemed weathered but wily. He had just published a book on adolescent schizophrenia and related most of his answers to that diagnosis. He had never heard of MPD but did, for once, acknowledge the negative effects of sexual abuse on children. He had collected a series of 14 boys who were incest victims, who developed schizophrenia (by his definition) and neurotic traits. Of course, without studying the case histories, none of us could know if these boys used dissociative defenses. Otherwise he did not seem to be very concerned about the negative effects of childhood trauma in general. The impression he gave me was the Soviet ideal of the perfect social order making a perfect Soviet person. If we just have a good social system now for these adolescents, there will be no reason to look to childhood traumas to explain why any symptoms existed. We can ignore the existence of bad parenting because all will be cured by wise social engineering by the Soviet state in later years. I must emphasize, however, that this concept is my assumption of what underlay what he said. He never came out and expressed such an opinion bluntly. As in Moscow, Dr. Jacobson tried valiantly to find out if they had seen any neurotic results of child abuse. Nothing more was admitted beyond the collection of his 14 incest victims mentioned above. Again, I asked about the psychiatric services to inmates in prison. Dr. Lickho minced no words. "When we put men behind bars, we forget about them." When Professor Lickho excused himself, we were able to talk more informally with Dr. Lomachenkov and Dr. Barosky, who were quite friendly and open. Dr. Barosky wondered if a female patient in the hospital might be a multiple. He had given her the Dissociative Experiences Scale (DES) (1) but she had not "passed" it. He wondered what he should do next to make or rule out the diagnosis. At last we had found a clinician in our mold to whom we could talk about real live patients! We crowded around him and tried, through the translator, Dr. Ikhanov, to explain some of our ideas to him. The Bekhterev Institute seems to be a top center for research and training in Russia. It includes both psychological and neurosurgical services as well as rehabilitation activities. For those interested, a complete listing of departments is at the end of this article. The rest of our trip was traditionally tourist-cooperative restaurants (highly recommended), the Hermitage museum (take comfortable shoes and a strong back) and a nightclub. In the club, where everyone is supposed to be happy, I was not, in spite of the drinks, five course dinner and scantily clad showgirls. While sitting there in the smoke filled room remembering how my native San Luis Obispo had banned smoking in all public places a week before, I just couldn't get into the spirit of the festivities on this night before we were due to fly out. The next dawn we boarded the KLM 747 for Amsterdam before any sane person should get up. The seats were tight and the legroom was limited, but a smile crept over my face, without my conscious awareness or effort. Now I was happy, now that I has headed home! Three days after leaving Leningrad, I was back at work in a prison, seeing inmate/patients. Previously, whenever I had taken a vacation of more than a week to an American resort, I would feel 180 degrees out of phase with prison life when I returned to work. I could only follow established procedures for a week, when I would be twisted north for South again and would be in phase for the insanity that is my job. This time, when I left the USSR after ten days there and returned to prison there wasn't the slightest jolt to my nervous system. I simply left one prison to return to another one. GENERAL IMPRESSIONS 1) The Russian population is suffering from an adjustment disorder with depressive and anxious traits. They are frightened by the uncertainties of the future. Their security has been threatened. They want the better economic life they see in the West but have fantasies about not having to give up guaranteed social services to gain the benefits. 2) The medical system has been allowed to deteriorate due to lack of incentives to be excellent and lack of interaction with the world medical community. 3) The awareness of health-oriented problems is about where it was when I started medical school 36 years ago. This includes sanitation, tobacco, alcohol, drugs and all the other vices that have received increased public awareness in the U.S. This may be due to the control of media outlets. Now, with many new papers and magazines available and little censorship, this should change if there are health oriented readers and writers. 4) The USSR has received more than its share of major traumas over the centuries, with the invasions of the Tartars and the Nazis, oppression by the Czars and Czarinas, then mass assassinations by Stalin's agents. During all of this, there were traumatized survivors left to cope with the world around them. We all wondered how they lived, what quirks they developed, how they raised their own children as adults. We did not get any sense that the Russian psychiatrists are interested in researching and answering these questions. Personally, I feel that we are more likely to find these answers in the novels and short stories written by those very same traumatized people. REFERENCE 1. Bernstein EM, Putnam FW: Development, reliability, and validity of a dissociative scale. J Nerv and Mental Dis 1986; 174:727-735 An excellent reference for learning about the current Russian economic dilemma is What Is To Be Done? Soviets at the Edge, by John G. Gurley, published by the Stanford Alumni Association, Stanford, CA, 1990. THE LENINGRAD V. M. BEKHTEREV PSYCHONEUROLOGICAL INSTITUTE I. Department of Clinical Psychology A. Laboratory of Clinical Psychology B. Division of Neuroses and Psychotherapy C. Division of Adolescent Psychiatry II. Department of Rehabilitation A. Division of Restorative Treatment of Mental Patients B. Division of Restorative Treatment of Neurological Patients C. Division of Biological Therapy of Mental Patients with the Group for Testing Now Psychopharmacological Drugs D. Division of Geriatric Psychiatry E. Division of Psychoprophylaxis and Extramural Psychiatry Ill. Department of Narcology A. Division of Alcoholism Treatment B. Division of Drug Addiction and Substance Abuse C. Psychopharmacology Laboratory D. Biochemistry Laboratory IV. Epilepsy Department A. Division of Child Neuropsychiatry B. Division of Epilepsy C. Division of Neurosurgery D. Psychophysiology Laboratory 1. The Now Methods Implementation Group 2. The Functional Diagnostics Centre V. Department of Epidemiology of Neurological and Mental Disorders and Organization of the Neuropsychiatric Service VI. Department of Scientific Medicine Information (with Patenting, Editing and Publishing Services) VII. Clinics and Auxiliary Services A. Consultation Division B. Sheltered Employment Center C. Specialized Scientific Council ABOUT THE AUTHOR Ralph B. Allison, M.D. is a senior psychiatrist at the California Mens Colony in San Luis Obispo, California. 

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