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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.