Public mental health in the post-war period – Ani Yengibaryan

Ani Yengibaryan ist eine Psyhologin aus Armenien und arbeitet mit Menschen, die direkt oder indirekt vom Krieg in Arzach (Berg-Karabach) betroffen wurden. Ihr Artikel ist ein Ergebnis der Teilnahme an internationaler Weiterbildung „Traumatherapie durch Mediation in Konflikt- und Postkonfliktregionen“, die im Dezember 2021 online und vor Ort in Armenien (Aghveran) von aritas-Armenia und European Ways e.V. (Leipzig) durchgeführt wurde. Unter anderem wurden Mechanismen entwickelt, um sich als Traumatherapeut_in vor einem Burnout zu schützen, und um andererseits weiterhin den vielen Betroffenen strukturiert helfen zu können. Die empfindlichen Reaktionen der lokalen Fachkräfte in diesem Aufarbeitungsprozess zeigten exemplarisch, wie wichtig es ist, solche Themen auch für die Armenier_innen in Westeuropa zu thematisieren und weiterhin Unterstützung von außen zu leisten. Das Projekt wurde vom Auswärtigen Amt Deutschlands finanziert.

Abstract: Modern life is full of all kinds of stressful situations, first of all, these are critical life events that require prolonged social adaptation, accompanied by a large expenditure of strength and energy.

The variety of social conflicts accompanied by violence and cruelty (local military conflicts, terrorism, criminal situation, etc.), severe natural disasters (natural disasters) and man-made disasters further aggravate human life than it was in the last century. These universal crisis factors in our country are combined with the specifics of its development.

This article is focused on the consideration of the current issue of extreme crisis situations and their consequences, in particular, in relation to military situations.

The article may be of interest to people who have encountered this problem or may face it. It is addressed to practicing psychologists, doctors, philosophers, educators, social workers, as well as researchers interested in personality problems in extreme conditions and crisis situations of life.

The events of recent years in Armenia, especially those related to the military situation, socio-economic distress, a decrease in the standard of living, manifested in an increase in the level of general anxiety, an increase in such experiences as loneliness, uselessness, meaninglessness of existence, uncertainty, fear for the future and much more.

The second Artsakh war, which took place in 2020, can be considered the most incredible crisis situation of the 21st century, since it contributed to the development of meaninglessness, exacerbation of depression and other mental problems in a person.

Taking into account this circumstance, based on the psychological work carried out in crisis situations in recent months, we consider it possible to develop new approaches to the application of psychological support strategies and methods. The latter are discussed in this article.

Purpose of the article: to emphasize especially attention to the perception of psychologists in relation to this topic and to develop a practical recommendation aimed at reducing the level of mental stress, to briefly substantiate the effectiveness of the integral approach in psychotherapy of personality disorders․

Introduction. A person constantly experiences the influence of natural and social factors, destructive forces that destroy the personality and psychosomatics of the individual. The struggle for survival requires constant efforts from the individual. But especially a person needs help in crisis situations. I.G. Malkina-Pykh notes that people who find themselves in extreme situations go through a number of stages. The first stage is accompanied by acute emotional shock, despair and fear, confusion, panic reactions, lowering of moral norms of behavior. At the second stage (the stage of resolution), mood and well-being gradually stabilize, while maintaining a reduced emotional background and contact with people around.

In the recovery stage, interpersonal communication is activated. At the third stage, there is an emotional and cognitive processing of the situation, an assessment of one’s own experiences and sensations. Factors traumatizing the psyche are gaining relevance, contributing to the formation of relatively persistent psychogenic disorders.

What is considered an extreme and crisis situation?
The conditions in which the vital activity of a modern person takes place is often rightly called extreme and stimulating the development of stress, which is associated with many factors and threats, including political, informational, socio-economic, ecological, natural [1. Aleksandrova L.A. to the concept of resilience in psychology Siberian psychology today: Sat. n. works. Issue 2 / ed. MM. Gorbatova, A.V. Seryogo, M.S. Yanitsky.].
Traditionally, the problem of extreme and crisis phenomena is mostly considered in the direction of research and prevention of mental disorders resulting from the impact of extreme factors. The unfavorable consequences of experiencing such situations are manifested in a general decrease in a person’s sense of safety and security.

The threat to life in the modern world is increasingly becoming a familiar characteristic of life. This is due to the increased threat of physical and other violence, terrorist acts, man-made and environmental disasters. Trans-ordinary existence, according to M. Magomed-Eminov, is increasingly intruding into ordinary existence, endowing it with the features of anomalousness, catastrophicness [Magomed-Eminov M.Sh. Extreme psychology. – T. 2. From mental trauma to psycho-transformation. – M.: Psychoanalytic Association, 2006. – 576 p.].

The threat of non-being becomes a nonspecific characteristic not only of the existential situation, but also of the everyday life situation and determines the existence of a person. Zones of crisis and extremeness are becoming an ordinary element of the picture of the world, and as an objective reality of our life, they require psychologists to carry out certain, first of all, educational work to correct people’s ideas about their content and about the most successful, effective ways of staying in it. It is necessary to overcome the anxious, fearful attitude of people towards extreme and crisis situations – and in every possible way to promote the formation of a new attitude towards them – more tolerant, more prominent and full-fledged, less tragic and clinically-centered ․

The importance of identifying the positive resources of extreme situations (hereinafter referred to as ES) can hardly be overestimated.
The following terms are directly adjacent to the concept of an extreme situation (ES) and are often used synonymously: traumatic situation; emergency; risk situation (extreme risk, emergency); difficult (difficult) situation; extreme; hyperstress (stressful) situations. in the above terms, the environmental, physiological and information-semantic, internal-personal „conditions“ of the situation, which make it extreme, are separated. However, all of the above terms are combined into one – an extreme situation, and can be replaced in any context with this concept [Stolyarenko A.M. Extreme psychopedagogy. – M.: UNITI-DANA, 2002. – 607 s].

To date, there is no clear differentiation of the concepts of „crisis“ and „extreme“ situation. in their definitions and descriptions, they clearly mix, flow, complement each other features of both. A crisis or critical situation is singled out by psychologists as a characteristic of special classes of situations, which primarily include situations of stress, frustration, conflict or crisis. These situations are defined as the impossibility of realizing the inner necessities of one’s life, their criticality is determined by the generation of a lack of meaning in a person’s life.

Difficult and problematic situations, as well as extreme and crisis ones, are associated with special internal states of people, although they can be caused by ․ / Bocharov V.V., Karpova E.B., Chulkova V.A., Yalov A.M. Extreme and crisis situations from the standpoint of clinical psychology // Bulletin of St. Petersburg. un-that. 2010/

Crisis and extreme situations are manifested as internal states of a person, while the word „emergency“ we call situations characterized by super-strong external influences of potentially destructive properties. Speaking of emergency situations, they usually mean those in which external influences can be so strong that even the possibility of surviving, resisting, adapting to them is excluded for a person (organism, psyche, personality). Individual characteristics of a person’s mental state in the case of superstrong external influences can be leveled, and in this regard, situations associated with the presence of superstrong influences, such as an earthquake, volcanic eruption, tsunami, nuclear explosion, can be described exclusively in the language of so-called objective circumstances. Coping with such circumstances and (or) their consequences is not subject to a person and becomes predominantly not an individual matter, but a social one.

I would especially like to emphasize that the limit of these states is determined not so much by the intensity of externally expressed and internally felt emotions, but by the scale of mental costs that are necessary to preserve the integrity and identity of the individual.
Common to extreme and crisis situations is their danger associated with possible mental trauma. We define „mental trauma“ as an internal state characterized by impaired autoplastic adaptation, resulting from a significant imbalance of influences and mental capabilities of the individual. In this regard, psychotrauma, from our point of view, should be considered as a result of pathogenic experiences of extreme conditions or crises.
Our analysis of the main factors of an extreme situation allows us to conclude that an extreme situation is the result of an active interaction of the subject with the environment, characterized by: an objective threat to life, health, leading life values of the subject; suddenness of the offensive; the need for a sharp exit of the subject outside the norm of habitual actions and operations, the proximity of the adaptation barrier; the need for self-regulation activities; the eventual status of a given situation on the life path of an individual.

We define a psychological crisis as a state of an individual that arises as a result of a feeling of an internal dead end, which disrupts the usual course of life and causes intense negative experiences that reach the maximum capabilities of a person. A crisis situation is such a turning point in the development of personality, which is associated with frustration not only and not so much of vital needs, as with the blocking of spiritual needs, primarily in self-actualization.

Observable brightness and intensity of experiences during a crisis contrasts with the imperceptibility of the fact that the primary intrapsychic task in a crisis is the task of intensive internal work on self-change. Thus, the psychological task of resolving the crisis is an intense inner mental work associated with a reassessment and rethinking of life values, priorities, goals and life meaning.

By the concept of „extreme state“ we mean a state of an extremely pronounced imbalance between the force of the impact of an external situation and internal adaptive capabilities. An extreme situation, being, as a rule, a sudden, life-threatening and often common for a large number of people, on the contrary, is not always personal in nature and is not always associated with a personal response associated with an essential restructuring of the system of relations. This state arises in response to excessive pressure on the individual from external circumstances (in the broadest sense).
The main thing in differentiating the concepts of “extreme” and “crisis” state 12 is that the former is determined by the logic of interaction between the individual and the world, while the latter (crisis) is determined by the internal logic of human development. The psychological task of getting out of these situations can be the gradual restoration of mental balance. We define the impossibility of solving this problem, as mentioned above, as a mental trauma, the consequence of which is the most various forms of mental maladjustment. If a person copes with such a psychological task, he not only restores mental balance, but also, integrating new experience, has the ability to expand identity and personal growth.

2 „War as a crisis“ is an extreme situation.
Specialists in the field of extreme psychology support the fact that it is difficult to make an equal introduction to the volume, as the type of CS indicates the most painful consequences of the psychic state, and it is difficult to understand.
Based on the analysis of the literature, it is possible to distinguish six typical consequences of extreme situations:

1. Dangerous subjective division of life in „before“ and „after“ extreme situations;
2. Disorganization of persons subject to extreme situations;
3. Modification of the face of peace and the system of centenarianism;
4. Reactions adaptations, development of phobias, fear of close relatives;
5. Anxious and aggressive reactions;
6. A sense of worthlessness․

The main subjects of extreme military situations are military service and the peaceful population of the territories, to which military actions are being developed. Basic Extreme Situations:

1. the conduct of hostilities (participation in a battle),
2. force in the vicinity of military actions,
3. development of occupied territories,
4. birth in a block,
5. development of territories, devastated war,
6. escape,
7. booty.

General coverage of all precarious situations is related to their sociogenicity, sufficiently high level of predictability, through the predictability of the development of relationships (with the position of the participant). In all situations there is an underestimation of human life, deformation of systems of personal and personal values, expression of moral norms.

Practical part
War and mental disorders in Armenia
In 2020, the Second Artsakh War, with its common form and degree of severity, developed a phenomenon in the mental sphere, which is characterized traumatic neurosis.

What does this mean? After severe mental trauma, permanent disorders that worsen over time may remain.

It had its impact not only on the participants of the war, but also in the public sphere.
As the bilateral crisis situation continues in Armenia due to the epidemic of Covid and war situations, the process of catharsis in the field of public psychology does not take place, but psychological tension is added.

First of all, let’s mention how the body of a war participant keeps what happened on the battlefield in his mental field. The intensity of the explosions of equipment and projectiles during the war and The sound waves, according to their intensity, affect the sensory stimuli of the organism. The information from these channels is taken over by every cell of the organism. It is stored in mobile memory. The nervous system regularly takes on the negative waves coming from the crisis zone and accumulates in the body.

The second Artsakh war, which lasted 44 days, was intense, unpredictable, unplanned, digest a huge amount of energy. Then, after that war, he developed a phenomenon in the war participant, which I call neurophysical shock. In the latter case, the person perceives any sound heard in peacetime, which can have sound waves of different frequencies, as a danger, and in the consciousness these waves immediately evoke associations on the battlefield. As a result of all this, a person loses the connection with reality, his moral and psychological condition worsens.

In the predetermined abilities of the human being to adapt to the battlefield, an important role is played by several socio-cultural factors:

1. the clarity and acceptability of the objectives of the war;
2. identification with military subdivision;
3. frequent uniforms;
4. quality command.

P.I. Sidorov, A.G. Maklakov points out the factors of transformations of military service personalities:

1. Combat accent. Here are the basic tips:

1. Emotional instability, excitability, irritability, inclination to violent aggressive outbursts;
2. anxiety and anxiety;
3. increased wounding, distrust of the surrounding environment (especially in relation to the state structure);
4. selectivity and complexity in the institutions of international contacts, art and quantities;
5. mutual sense of justice.

2. Combat psychopathization – It sharpens the character trait, eliminating the basic criteria of „character traits“.
Basic benefits:

1. aggression – aggression in parts of intense anger, aggression with destructive actions;
2. Illness – leads to antisocial actions, criminal episodes and gross social maladaptation.

3. Fighting psychological trauma – a complex of symptoms, characteristic of psychogenic disorders, observed in military service during the period of combat activities. It concludes in the redistribution of resources of the human organism, the development of a set of adaptive mechanisms and the increase of psychophysiological changes, which continue to affect the field. This indicates a secondary injury-affecting effect and the cause of the disorder is psychic activity.

Pathological manifestations of war psychiatric trauma include:

1. New behaviors and stereotypes. With the increase of the duration of overcoming in the extreme conditions, the specific stability of the organism to the increase of stress increases, new behaviors and stereotypical names are formed. The number of aggressive, aggressive and antisocial forms of behavior increases. An increase in aggressiveness precedes a mental breakdown, perfected accidents, loss of the legacy of abusive actions or abusive solutions. In connection with this, it is understood that aggression is perceived as insufficient development of personalities or as an indicator of complex psycho-regulatory disorders, leading to psychogenic disorders.
2. „Escape from reality“ It appears in the form of neurotic somatoform and dissociative disorders, addictive and suicidal behavior. Such disorders most often develop in the first months of being in an extreme environment, while various forms of aggressive behavior increase as the length of stay in these conditions increases. In persons injured in the process of performing official duties in an extreme situation, there are changes in the mental state of two types: hypersthenic and asthenodepressive with pronounced reactions of fear and anxiety. Often, similar conditions can be observed in persons who have witnessed particularly destructive natural disasters or man-made disasters.

The main factor that makes it possible to consider living in a territory ravaged by war as an extreme situation is the inability to meet the basic needs of the population. The same applies to being in a blockade, but in this case the extremeness of the situation is greatly enhanced. Refugees are people forced to leave their habitual place of residence due to the impossibility of further staying there without a threat to their lives.

As can be seen from the definitions, the psychological state of refugees and internally displaced persons is often characterized by total maladjustment. Those who arrived from areas of social tension feel fear of uncertainty and need social and psychological help. There is a language barrier, which is overcome in a shorter time by children and men. Of particular concern for forced migrants is the lack of comfortable permanent housing and work with stable wages. The problems of adaptation to new conditions primarily affect children. Post traumatic stress provokes a nervous atmosphere in families ․

As a result of the psychological work carried out in Armenia from October 2020 to September 2021, the main psychological problems that developed during the Artsakh war in 2020 were highlighted.

The psychological work was aimed at the families of war participants, soldiers and victims.

The most commonly encountered mental disorders were found to be post-traumatic stress disorder (PTSD) at 57․5%, depression at %, anxiety at 45.2% and somatization disorder at 22.2%. The prevalence of suicidal thought was recorded as 35.7% and that of alcohol abuse as 28.2%. The mentioned psychological problems are active in the public sphere. Added to all this is the fact that today the general mental health of the society is damaged, it is in a state of mental traumatic neurosis.

Taking into account the fact that the war situation in Armenia is still continuous, it should be emphasized that the development of mental problems is facilitated by the feeling of uncertainty about the future, which is reflected in the degradation of behavioral and mental abilities.

Traumatic neurosis occurs, as a rule, after catastrophes, accidents, natural disasters, violence, that is, in those cases when the traumatic effects go beyond the usual experiences. Traumatic neurosis is a ’stress-induced‘ anxiety disorder that is often severe enough to be called panic. In terms of duration, traumatic neurosis is usually divided into acute, protracted and chronic. A person can cope with anxiety through various neurotic mechanisms – hysterical (somatic symptoms or states of prostration, called traumatic hysteria), obsessive or phobic.

Symptoms of traumatic neurosis include the experience of constant reproduction of the traumatic situation, slowing down responses to various stimuli, limiting contact with the outside world, as well as a number of dysphoric disorders and cognitive impairments.

After the traumatic event, the individual feels a change in himself; he does not perceive himself as he used to be. He loses self-confidence and does not feel light in behavior. He senses changes in himself, but does not understand how these changes occurred. The person no longer feels able to trust himself and believes that others, too, cannot protect him.

3․ Approaches to psychological help
In psychological assistance to a person in crisis, the main emphasis, from our point of view, should be on creating conditions for the individual’s awareness of the need for new ways and means of existence. In an extreme situation, on the contrary, the most important task is to restore the victim’s sense of his own identity, value and significance. The noted position, however, does not exclude the fact that, in an extreme situation, in the foreground, as a rule, are not strategic ones related to personality recovery, but tactical tasks of arresting mental shock, emotional response, etc.

In fact, it is necessary to recognize the mental work that takes place in the framework of recovery and development, and differentiate it from the psycho-traumatic laws of the work of the psyche. It is always necessary to understand whether the current state mainly refers to one of the variants of the norm or whether it acquires a psychopathological dimension. The main problem here is that the normally ongoing transformation process inevitably includes psychopathological elements.

At any moment, a person in an extreme or crisis situation can “break down”, mentally “collapse”. However, he can also endure and enrich his life experience. Whether he will withstand can be determined from the standpoint of clinical psychology.

How should we identify individuals who require interventions, and when should such interventions be delivered?

First of all, it is important to know the primary and secondary manifestations of the war participant:

Primary manifestations

• Explosion sounds
• Feeling of insecurity
• Audio and video associations
• Strengthening the episodes of the war
• Emotional tension

Secondary manifestations

• self-esteem
• Inadequate expression of actions: „I want to go to the battlefield“
• feeling of inability
• Critical approaches to one’s own person and other situations, persons

Reality review

• Assessment of one’s own abilities
• Review of existing opportunities, evaluation
• construction of own actions

In the aftermath of other community-wide traumas (e.g., natural disasters, community violence, etc.), psychological or emotional symptoms often diminish over time or change in frequency, nature, and severity for many exposed individuals. In addition, symptomatic individuals are not always impaired. These findings, however, are from populations exposed to events that are less pervasive and traumatic than war. A better understanding of the longitudinal and developmental effects of exposure to war would improve the ability to target interventions to those individuals most in need, when they need it. Optimally meeting exposed individuals‘ MH needs requires careful consideration of when and how to best commit resources, and in some cases may require policymakers to weigh the pros and cons of acute interventions to address the most pressing needs vs. longer term strategies to address the broad range of persistent and impairing MH problems that may result from exposure to war.

How should we choose and implement effective interventions? 
Every person involved in hostilities has feelings, memories, which are related only to the situations that took place during the war, but which in many cases may not be expressed or even felt.

Before conducting a psychological assessment, it is important to know in advance that the following manifestations can be seen in a person on the battlefield:

• Periodically recalling a traumatic event and telling stories about it, which can be accompanied by emotional thoughts, descriptions of nightmares. You may experience extreme emotional and physical reactions, such as uncontrollable tremors and palpitations,
• Extremely avoid incidents that are reminiscent of a traumatic event, including people, places, thoughts, or situations associated with bad memories,
• Negative changes in thoughts and moods, such as exaggerated negative beliefs about oneself or the world, feelings of fear, guilt, or shame. You may notice a weak motivation to want to live,
• Constantly emotionally responsive, indicating irritability, anger, reckless behavior, difficulty sleeping, difficulty concentrating, and hyper-control (heightened alertness).

Further work is needed to develop and deliver interventions that best address the MH needs of individuals exposed to war. Expert consensus groups have recommended core elements that should exist in these MH interventions. These include addressing the individual’s trauma in the context of his family, community, and society, addressing cultural influences on exposed individuals experiences, and realizing that the appropriate interventions in the context of ongoing conflict and its immediate aftermath may differ from those in subsequent periods. While there is an increasing evidence base of effective interventions for traumatized individuals, there remains a paucity of empirical data to guide clinicians and policymakers with respect to the optimal content of interventions to be provided to individuals exposed to war.

Psychological Primary grounding

The psychological work to be done with a war participant or a person in a crisis situation should start from the ground up, which means working with emotions and thoughts that cause a shocking state of mind.

The purpose of grounding techniques is to allow a person to step away from negative thoughts or flashbacks. Techniques such as these can decrease the intensity of a person’s feelings or trauma by distracting them using the five senses: sight, touch, hearing, taste, and smell.

Grounding techniques may help people with anxiety or PTSD. The purpose of grounding techniques is to return the person to reality during a panic attack or traumatic flashback. By focusing on the present surroundings, a person can become more aware of their safe reality and start to feel calmer.

In psychological work we encounter quite wrong approaches, which become harmful for a soldier participating in the war.

To avoid these mistakes, you may want to know the following

• try not to go to the soldier with a pen and paper from the very beginning (do not take any assessment tool in your hand),
• do not start the conversation immediately after the soldier tells about the war,
• do the work with a look at the soldier, not standing on the soldier’s head,
• try to be more natural, warm և not formal,
• avoid „simple“ questions: „Why didn’t you help your friend? Are you still offended? Isn’t it nice to talk to me? Are you nervous about that question?
• try to stay within professional boundaries do not turn your work into intimate communication,
• be vigilant about your gestures,
• the soldier should be immediately informed about his / her mental state,

While communicating with a war participant it is possible to pay attention to the three main sides and try not to upset the balance of those fields.

• Emphasize hope և when emphasizing help, reinforce the realistic aspects of a specific action. For example, I will help you to walk, guide you to English courses, etc.
• Create a community where he or she will feel comfortable, complete; that community should be his or her choice, not your limitations.
• Indicate the way in which he will be able to use his resources. For example, to work, to do his favorite job, etc.

These are the main fields that will help the participant of the war in the post-war period to assess his / her potential և to return to real life.

Conclusions. Clinicians and policymakers must consider how best to meet the MH needs of individuals within the environment that exists in a post-conflict community. This may be especially challenging since the capacity for MH care is often   degraded during conflict, and in many conflict ridden or impoverished countries the system for providing MH care was often limited prior to war.

We have made tremendous progress in our understanding of the psychological impact of war on exposed individuals. The challenge of the coming decades is enhancing our ability to make more informed decisions about how to best address the psychological needs of these individuals.

It is very important that primary psychological care in one form or another chosen by a specialist in the optimal form was provided immediately after the injury in order to strengthen the victim’s degree of awareness of what happened. That is why, a psychologist must be sent to the scene of an accident or terrorist attack in order to very carefully and with the help of a special technique help the victims to restore in their memory the details and sequence of what happened to them, to verbally describe the emotions and their intensity.

In the language of physiology, the awareness of what happened, as it were, allows you to move “ fears from the lower parts of the brain directly to the cerebral cortex itself, which makes them (fears) more amenable to subsequent psychocorrection.

We believe that despite the existing difference in the mechanisms of adequate and inadequate risk, it seems that individuals have an unsaturated need for risk in both cases.

Resilience is associated with a stable experience of a person’s actions and events happening around them „as interesting and joyful (involvement), as the results of personal choice and initiative (control) and as an important incentive to assimilate new things (risk taking).“ Obviously, some people are more resilient than others. But resilience is not a fixed quality, but rather a dynamic process that operates in different ways at different stages of life.

Thus, the propensity to take risks and the search for new sensations can be essential determinants of a person’s behavior in an extreme situation.

REFERENCES

1. Alexandrova L.A. Towards the concept of resilience in psychology // Siberian psychology today: Sat. scientific. works. Issue 2 / ed. MM. Gorbatova, A.V. Seryogo, M.S. Yanitsky. Kemerovo: Kuzbassvuzizdat, 2004. -P. 90.
2. Magomed-Eminov M.Sh. Extreme psychology. – T. 2. From mental trauma to psycho-transformation. – M.: Psychoanalytic Association, 2006. – 576 p.
3. Stolyarenko A.M. Extreme psychopedagogy. – M .: UNITI-DANA, 2002. – 607 s
4. Bocharov V.V., Karpova E.B., Chulkova V.A., Yalov A.M. Extreme and crisis situations from the standpoint of clinical psychology // Bulletin of St. Petersburg. un-that. 2010. Ser. 12.
5. Sidorov P.I., Mosyagin I.G., Marunyak S.V.Psychology of Catastrophes: Textbook for Universities / ed. P.I. Sidorov. –Arkhangelsk: Publishing Center of SSMU, 2007.

Keywords
practical psychologist, psychotherapist Ani Yengibaryan, Armenia, Yerevan, Saint Grigor Lusavorich Medical Centre, consciousness, personality, extreme situation, attunement, soul, higher „I“, integral psychotherapy, altered state of consciousness