Applied Psychology in Armenia: A Brief History and Contemporary Perspective Matt Johnson University of Minnesota - Twin Cities Armenia & Georgia 2015 Advisor: Artyom Tonoyan, PhD Submitted in 2016 in partial fulfillment of the requirements of the Student Project for Amity among Nations (SPAN), as organized under Foreign Studies Seminar Program (FSSP) 5960 and 5970W (Writing Intensive) at the University of Minnesota This Project was completed in accordance with the Institutional Review Board Study Number 1203S12061. Principal Investigator: Theofanis G. Stavrou, PhD  Table of Contents Acknowledgements Abstract Introduction Earthquake Contemporary Issues Interviews Conclusion Works Cited  Acknowledgements Artyom Tonoyan, PhD - For patiently sharing with me a new and foreign world, allowing me to see anew. SPAN - For the contagious passion and support, with which I accomplished things I would never have imagined possible. Theofanis G. Stavrou, PhD - Without whom none of this would have happened. I went into his office for test advice, I came out with flight plans. Scholarship Donors - For investing in me and providing a connection to a rich SPAN history. My Mother, Shelley - For her unwavering support and belief in me, which made this all possible. My Sister, Jennie - For her guidance and courage imparted through her own worldly travels. AYG Psychological Center - Margarit Melkonyan, PhD, Ruben Poghosyan, PhD, Taras Vavryk, PhD, and Inga Mukuchyan, MA Urartu University - Sedrak Sedrakyan, PhD, Armine Stepanyan, MSW, Lilit Vardanyan Yerevan State University - Narine Khachatryan, PhD Yerevan State University Center for Applied Psychology - Davit Gevorgyan, PhD Hilfmann Psychological Services - Arman Begoyan, PsyS, ECP Open Society Foundations: Armenia - Anahit Papikyan IntraClinic - Khachatur Gasparyan, PhD Abstract Matt Johnson. Applied Psychology in Armenia: A Brief History and Contemporary Perspective. Armenia & Georgia, 2015. University of Minnesota - Twin Cities. Research was conducted via the examination of relevant scholarly material. Additionally, a series of interviews were conducted with members of the psychological community in Armenia. The Spitak Earthquake of 1988 saw an influx of international humanitarian aid to Armenia, including those providing mental health services. Methodologies of applied psychology arrived with aid workers which were previously non-existent in Soviet Armenia. However, the psychiatric model of somatic and medicinal treatment continued to dominate the field. This model features psychiatric hospitals as the primary means of treatment. A series of reports published in the later 2000’s exposed human rights violations and ineffective treatments in these institutions. Present day members of the applied psychological community were interviewed. Interview subjects expressed some common beliefs and were divided regarding many issues of the present and future of applied psychology in Armenia.  Introduction The treatment of those with mental health conditions as well as the fields of psychiatry and applied psychology have undergone significant change in Armenia since 1988. As international relief workings came to offer aid following the Spitak earthquake of 1988, they also brought western methods of applied psychology such as psychotherapy. Prior to this, the then Soviet state of Armenia treated mental health conditions exclusively with psychiatric care, relying on medication and hospitalization. While methods of applied psychology continued to be present in Armenia, treatment was still dominated by psychiatry. In the late 2000’s two reports revealed human rights abuses and ineffective treatment methodologies in psychiatric hospitals in Armenia. One of the primary recommendations of each report was that the Republic of Armenia transition from psychiatric hospital care to community based treatment centers. Finally, a series of interviews were conducted with various members of the applied psychological community in Armenia to ascertain the current state of many issues within the field. Subjects included psychological services offered, legacy of soviet psychology, psychology in the media, education, licensing, and mental illness stigma. There were varying degrees of agreement and disagreement between interviewees on the different subjects. This topic was selected by the author for a few reasons. First, psychology is the focus of his undergraduate study, and this was seen as a fantastic opportunity to learn more about the subject, particularly from a perspective other than that of the United States. Also, the author was curious about how other cultures related to the human phenomenon of mental illness, and how they treated and responded to such individuals.   Earthquake Just before noon on the morning of December 7th, 1988 an earthquake registering 6.9 on the Richter scale struck northern Armenia, with its epicenter near the town of Spitak. Also significantly impacted was Gyumri, the second largest city in Armenia. Estimates of the death toll range from 25,000 to 50,000 (Goenjian, 1993; Najarian, 2004). The city of Spitak was almost completely destroyed, as was half of Gyumri including substantial damage to 90% of its buildings, leaving 530,000 Armenians homeless (Goenjian, 1993). Although some survivors relocated throughout the region, a majority remained in their devastated cities, living in temporary housing (Goenjian, 1993). Living conditions were one of many complications for the survivors in the following years and months. Then Soviet Union President Mikhail Gorbachev assured the displaced that rebuilding would be completed within two years. This did not come to fruition, as only 15% of residential construction projects were completed by June 1990 (Goenjian, 1993). Also causing substantial grief for the survivors was the reality that poor construction and subpar building materials had contributed to the large death toll (Goenjian, 1993). This issue would become one held on to many of the survivors, making it more difficult to come to terms with the injustice of the disaster (Goenjian, 1993). Psychological Aid for Earthquake Survivors There was a great outpouring of humanitarian support following the earthquake. Although Armenia was still a member of the Soviet Union, the USSR government allowed foreign aid and workers into the country as they were overwhelmed by the scope of the disaster (Goenjian, 1993). Many of these foreign aid workers were members of the Armenian diaspora, ethnically Armenian but living abroad. Many in the diaspora desired to have a liberated, autonomous, and prosperous Armenia, and viewed providing aid as a means of contributing to this process (Najarian, 2004). The largest outreach program to provide mental health services to earthquake victims was entitled the Psychiatric Outreach Program (POP). The POP was collaboration between the Armenian government and the Armenian Relief Society of the Western United States, a humanitarian organization dedicated to dispensing aid to Armenians worldwide (Goenjian, 1993; Najarian 2004). This influx of practitioners and western models of treatment could be seen as a dramatic shift in the approach to mental health treatment in Armenia. Prior to the earthquake, mental health care consisted almost exclusively of psychiatric care, treating those with severe mental illness using medication and hospitalization (Goenjian, 1993). Outpatient care was scarce and its principal function was medication management (Najarian 2004). The Armenian family unit was the source of assistance, counsel, and emotional care for disturbed relatives (Goenjian, 1993). There was significant stigma attached to receiving psychiatric treatment, and a lack of trust in psychiatry due to its political abuses under the Soviet Union (Najarian 2004). Before the earthquake there were four psychologists certified by the Ministry of Health to provide psychological services residing in Armenia (Goenjian, 1993). Additionally, there were no marriage and family therapists or clinical social workers in country. Clinics to provide mental health services were established by POP in the two cities most significantly impacted by the earthquake, Spitak and Gyumri (Goenjian, 1993; Najarian 2004). Armenian mental health practitioners from the diaspora in North America and Europe responded to the needs in their native homeland and joined POP in Armenia. Between February 1989 and December 1990, teams of two to six mental health practitioners each spent three weeks working in each city (Goenjian, 1993; Najarian 2004). A total of forty-five practitioners spent three weeks to three months serving in Armenia (Goenjian, 1993). Approximately half of these served additional such terms. Training was conducted to familiarize practitioners with the hardships of the situation, instruct them on therapeutic techniques, and to provide opportunities to resolve their own feelings regarding injustice, suffering, and death (Goenjian, 1993). Following their tours of service many of these practitioners experienced mild and passing bouts of mood disturbances as they processed experiences they were unable to while in Armenia. An initial assessment of eighty child and adult victims revealed that a significant percentage were suffering from post-traumatic stress disorder (PTSD) and mood disorders, such as depression and anxiety (Goenjian, 1993). This guided the development of treatment methodology. As a previously supported method of treatment in such circumstances, brief crisis-oriented individual and group psychotherapy were employed by practitioners (Goenjian, 1993). This included revisiting traumatic events and investigating unresolved feelings surrounding them, including fantasies of revenge and reunion (Goenjian, 1993). Special efforts were made to legitimize the symptoms of patients. Also addressed were the current and anticipated social issues of the patients’ lives. Patients were educated regarding potential trajectories of their psychological symptoms, and cautioned against marital strife and excessive use of alcohol, which had been recorded in similar situations (Goenjian, 1993). Some practitioners utilized behavioral therapy techniques, which had been supported for the treatment of PTSD. Most patients received between one and five sessions, and discontinued treatment once they had received relief from their most severe symptoms. Roughly 20% of patients participated in longer-term treatment. As there were not sufficient resources to both provide treatment and conduct research, formal data was not gathered at this stage. Practitioners, however, recorded their observations surrounding treatment outcome. There was a general feeling among the practitioners and patients that symptoms of PTSD and depression had been improved following treatment. Initially, the symptoms showing improvement were interpersonal isolation, sleep disruptions, and regressive behaviors of children (Goenjian, 1993). Additionally, family units which had undergone treatment were seen to have a positive impact upon surrounding families. Following 1991, as the demand for services as a direct result of the earthquake had waned, the two centers began to function as community mental health clinics. New difficulties of unemployment, government corruption, and political turmoil placed substantial stress upon many Armenians. For these individuals the psychological centers provided treatment which had previously been unavailable and inconceivable (Najarian 2004). Additionally, patients, upon seeking aid at the centers, were surprised to find that it was their fellow countrymen who now provided treatment, as the founders had trained and incorporated native practitioners (Najarian 2004). Studies Many practitioners who came to Armenia to offer psychological services after the earthquake also took the opportunity to conduct research. The Spitak Earthquake is regarded as one of the most thoroughly studied natural disasters of the 20th century (Balassanian et al., 1995). Armenian et al. (2000) examined a potential link between loss in the earthquake and a diagnosis of post-traumatic stress disorder (PTSD). Loss was defined by damage to property estimated in rubles, injury, and death in a family. Researchers developed an assessment to screen for PTSD and other disorders, based on the diagnostic qualities detailed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) - III - Revised, which was the current version at the time. Employees of the Ministry of Health living in the earthquake zones served as the sample population. This sample population of 1,785 individuals, aged 16 to 70 years, were interviewed. Roughly half (49.6%) of the sample satisfied criteria for a PTSD diagnosis. A majority of these individuals also satisfied diagnostic criteria for an additional diagnoses, such as depression or anxiety. Comparing this interview data with demographic data obtained from government records, researchers were able to establish several relationships. More cases of PTSD were found among those individuals who had suffered greater loss, suggesting a relationship. Also, a relationship was observed between the intensity of the trauma experience and level of PTSD. Amount of education was correlated with PTSD severity, with those with the least education suffering more. Two protective factors were identified, highlighting the importance of interpersonal connection following disasters. Those who were in the company of another during the earthquake expressed fewer PTSD symptoms. Additionally, those who made new friends following the disaster also expressed fewer PTSD symptoms. Relocating outside the earthquake zone was not demonstrated to be effective in reducing PTSD occurrences. In summary, these findings are beneficial to take into consideration in future disasters. Indicating that those individuals suffering the most traumatic disaster experiences as well as those with lesser educational backgrounds should be targeted for mental health treatment to prevent the developing or worsening of PTSD symptoms. In another study, Goenjian et al. (1997) investigated the potential effectiveness of brief trauma and grief focused psychotherapy for adolescent survivors of the Spitak earthquake. This study was a part of the Psychiatric Outreach Program (POP), which provided mental health relief services following the earthquake. This study began an year and a half after the earthquake, as need for mental health services was so great during that time and there were no available resources. Sixty-four students from four schools in Gyumri were selected for inclusion in this study. Subjects were separated into two groups, a control (N=29) which received no treatment, and an experimental group (N=35) which received the brief trauma and grief focused psychotherapy. Five areas were targeted in this psychotherapy; trauma, traumatic reminders, post disaster difficulties, bereavement, and impacts on the adolescents’ development. Trauma and traumatic reminders were attended to in an attempt to resolve distortions and identify associations with the trauma. Proactive means of coping with post disaster realities were promoted alongside efforts to encourage acceptance. Bereavement was addressed through formulating mental depictions of those lost in the earthquake that did not include the recent traumatic memories. Finally, stages of adolescent development which were missed due to the traumatic events were identified and efforts to attend to these were supported. Subjects in both groups were assessed for PTSD symptomatology using the Child Posttraumatic Stress Disorder Reaction Index following the treatment stage and again one and a half years later. Results indicated a reduction from severe to moderate in PTSD symptoms as well as the prevention of escalating depression symptoms in the experimental group immediately following treatment, when compared with the control group. However, symptoms of these disorders did remain. These results were consistent when the groups were reassessed for symptomology a year and a half later. Additionally, those in the control group expressed worsened PTSD and depression symptoms in the follow up assessment. Intriguingly, in the follow up assessment, the control group did not display a worsening of PTSD avoidance symptoms. Researchers attributed this to the close knit nature of Armenian families, which values social interactions and discourages isolation. In summary, brief trauma and grief focused psychotherapy for adolescents following a disaster was demonstrated effective in lessening PTSD symptoms and preventing the escalation of depression symptoms. Contemporary Issues World Health Organization Report In 2009 a report was published by a collaboration of the Republic of Armenia Ministry of Health and the World Health Organization (WHO). This report, entitled WHO-AIMS Report on Mental Health System in Armenia, details many aspects of the state of the mental health system in Armenia as it was in 2009. Covered in the report is availability, quality, and types of resources, as well as mental health law, governmental involvement, stigma, and WHO recommendations for improvement. The report is critical of many aspects of the mental health system in Armenia. Additionally, as this report was published in 2009, its findings may not represent the current state of the Armenian mental health system. As a former member of the Soviet Union, gaining independence in 1991, Armenia inherited a Semashko model of health care, which was highly centralized and guaranteed free medical assistance for the entire population (World Health Organization, 2009). The system has since seen the decentralization of public services and ownership of health services placed in the responsibility of local and regional governments. Additionally, Armenia is ever more involved in reforms which shift the focus from the treatment of disease in response to epidemics to one that emphasizes prevention (World Health Organization, 2009). However, mental health treatment was a notable exception to a new focus on prevention. Due to cost and quality of resources, especially in rural areas, those in need had limited access to mental health services. As of 2009, 3% of governmental health care expenditures were allocated to mental health services (World Health Organization, 2009). An overwhelming proportion (88%) of these funds were spent on mental hospitals. Outpatient care, which was funded by a per capita government expenditure of 42 AMD (9 cents USD), features five facilities which were integrated with mental hospitals. Adult males were overrepresented in outpatient facilities, with 29% of those treated being female and 2% children and adolescents. In general, mental health and mental illness among children and adolescents was regarded with significantly less importance than physical health. None of the psychiatric hospitals were equipped with specialized services for children or adolescents, nor were beds available in these facilities for children. Mental illness and disorders were viewed with a high level of stigmatization in Armenia (World Health Organization, 2009). In the five years prior to 2009, a few non-governmental organizations (NGOs) and international organizations had implemented mental health awareness campaigns. These campaigns were not supported by the government. The law on Psychiatric Care provides employees in Armenia with protection from discrimination in the form of dismissal or lower wages based on a mental health condition. However, all of the provisions were not regularly enforced. The rights of individuals with mental health conditions were not entirely protected by existing policy. No national or regional organization was in existence to conduct inspections to determine if there were human rights violations. The Ministry of health handled the review of human rights complaints but had no authority or ability to initiate sanctions based on their findings. Social welfare and free treatment was provided for all severe and some mild mental health conditions. Of those who received social welfare benefits, 11% do so for a mental health condition. Although the state provides financial resources for treatment, most health care was paid for by formal and informal out-of-pocket payments. Psychiatric inpatient care was the primary method of mental health treatment in Armenia. There were eleven psychiatric hospitals in Armenia, providing 37.3 beds per 100,000 people. This represented an overcapacity of beds in psychiatric hospitals and resulted in the admission of patients who would be more properly treated in an outpatient setting. Due to a lack of overall funding and the majority of such funding devoted to psychiatric hospitals, outpatient care was underdeveloped. There existed no rehabilitation units, community day care, or crises centers. This resulted in overwhelming admissions to inpatient psychiatric facilities. Also burdening admissions is a lack of residential facilities for detoxification, the homeless, and those with mental retardation, as such cases were also sent to these facilities. There existed no formalized means of developing outpatient mental health services outside of a few small-scale trial programs supported by international organizations. Additionally, there was great distance between the Armenian government and a hypothetical discussion of the development of outpatient services. As few patients in psychiatric hospitals received one or more psychosocial interventions in the last year, those services are considered to be underrepresented. The most prevalent diagnosis is schizophrenia (37%). The average patient hospitalization time is 34.61 days. Training and education of mental health practitioners was a concern of the WHO report. Neither the police force nor legal judges had engaged in mental health education in the last five years. In the one year preceding the publishing of this report (2009) there were zero recorded graduating psychiatrists, psychologists, or social workers with at least one year training in mental health care. Roughly 20% of psychiatrists were emigrating from Armenia within five years of the completion of their training. Medical doctors received training in mental health issues which accounted for 5% of their education and nurses received such training accounting for 1% of their education. Nurses working in psychiatric facilities have no specialized training in psychiatry or in dealing with mental health concerns. Ongoing training is lacking for psychiatrists. Although professional training was supported by the government every five years, psychiatrists were unsatisfied with the information presented during this training. Some practitioners attend international workshops and conferences on their own accord. This lack of training in new treatments and updated medications resulted in avoidably lengthy inpatient experiences. There was limited international experience exchange at the governmental level. The report includes several recommendations for the mental health system in Armenia. The WHO acknowledges the difficult financial situation of Armenia and recommended reforms to improve governmental state budgeting as well as more efficient use of resources. Additionally, the development of a response plan for mental health was needed in the event of an emergency or disaster. The WHO recommended making ongoing professional training a priority, including incorporating updated treatment methodology and medications. Finally, the WHO report recommends shifting focus to outpatient services and strengthening those services, with accommodations for children and adolescents. Helsinki Report In 2011 a report was published detailing a 2009 investigation into mental health facilities in Armenia. This report represents a collaboration between Open Society Foundations, which provided financial support, and Helsinki Citizens’ Assembly (HCA) - Vanadzor, which conducted the monitoring of the facilities. The report is entitled Human rights situation in mental health facilities in the republic of Armenia. This impetus for this report was provided by the HCA - Vanadzor 2007 human rights monitoring of the Lori Regional Neuro-Psychiatric Dispensary, a mental health facility located in northern Armenia. Based on the problematic findings, it was decided that all mental health facilities should be monitored (Open Society Foundation, 2011). Thus this report was commissioned. Monitors were prepared for their human rights investigative duties with training provided by the Helsinki Foundation for Human Rights. This training included discussion of relevant Armenian national legislation, international standards pertaining to patients with mental health problems, and practical methodology related to the collection and summarizing of data (Open Society Foundation, 2011). Monitoring was conducted at eight mental health facilities: Syunik Regional Neuro-psychiatric Dispensary, Gyumri Mental Health Center, Sevan Psychiatric Hospital, Armash Health Center, and the Nubarashen, Nork, Avan, and Kasakh clinics of the Psychiatric Medical Center. Monitors collected data on each facility through observations of conditions, legislative analysis, evaluation of written information sources, and analysis of documents obtained from the Republic of Armenia (RA) Ministry of Healthcare as well as the RA Police Service. Additionally, a total of 463 interviews were conducted with patients, their relatives, and various employees of the facilities such as directors, nurses, and psychiatrists. Monitoring took place between July 23 and November 27, 2009. The expressed purpose of these monitoring sessions was to expose human rights violations against those with mental health issues. Particularly, conditions which violated the European Convention of Human Rights and Fundamental Freedoms and the UN Convention against Torture and other Cruel, Inhumane or Degrading Treatment or Punishment, both of which had been adopted by the Republic of Armenia. The findings of the monitors included problems related to the quality of the facilities, conduct toward patients, treatment methodology, and quality of care. Conduct toward patients and violations of their human rights are at the core of this report. In their time observing the facilities, monitors witnessed acts of torture, induced psychological duress, violence, and an overall inhumane view of patients (Open Society Foundation, 2011). Physical restraints were used regularly on patients, frequently without a doctor's authorization, and often merely as a means of imposing discipline. Occasionally, the use of physical restraints was implemented by fellow patients. Standard procedure dictated that there was no documentation of the use of physical restraints or the duration of such use, which could last several days or longer. When admitted to the facilities, patients were not informed of their rights and responsibilities. Additionally, there was a general low level of awareness among employees of the rights and responsibilities of the patients. The patients’ right to legal aid was not guaranteed by the institutions. Patients were only able to be discharged from an institution if deemed eligible by a doctor or the psychiatric commission, which was not subject to outside or legal oversight. There were no recorded examinations of the psychiatric commission prompted by a patient’s petition, giving explanation to why many patients remained in the institutions against their will. Additionally, there were documented cases of acts of violence toward patients perpetrated by the police and ambulance workers when transporting clients to the facilities. Based on this combined evidence, monitors concluded that no professional methodologies were in use, particularly among the junior staff. Monitors noted many concerns surrounding the quality and methodology of treatments. Medication was the primary method of mental health treatment in these facilities (Open Society Foundation, 2011). There was variation in medication dosages for treatment of the same condition between facilities. The medications used for treatment had remained constant over the last twenty years even as newer, more effective drugs had become available internationally. In fact, over that same span of time, medications manufactured abroad had been replaced by similar medications produced locally. There was concern regarding the effectiveness of these replacement medications. Additionally, patients lacked sufficient knowledge regarding the medications they were being administered. Psychological services such as counseling or psychotherapy, were not administered. No services of social work, such as case management, were available. Mental health stigma, the role of patients’ families, and the culture of the institutions all contributed to patients mindsets. Patients who had resided in the mental health facilities for many years were often forgotten by their families and had become disconnected to the outside world (Open Society Foundation, 2011). This disconnect damaged patient's mental states, undermined the effectiveness of treatment, and limited their potential for reintegration into society. Patients’ rights to outside communication were not honored as there were no mail or phone facilities on site in these institutions. In some cases patients paid for phone access and/or use of the personal phones of the facility employees, for which they were treated with a discriminating attitude. Patients’ rights to communication were viewed as irrational by some employees, as they believed that the patients’ families would have no desire to communicate with a mentally ill relative. Stigmatization of those with mental illness was quite severe in Armenia. Monitors concluded that the state government made little effort to combat prejudice or to change misconceptions surrounding mental illness through public education. Patients belongings were searched without their consent when they were not present, representing a boundary violation. Viewed as a form of therapy, patients were put to work at jobs inside and outside of the institution. However the jobs included duties of nursing assistants and junior medical personnel. Patients received little compensation for their work. Additionally, in some institutions, junior personnel used patients of higher seniority to make demands of less senior patients. In some of these situations violence resulted. Medical personnel did not intervene. There existed no formal method for resolving interpersonal issues between patients. Nurses and nursing assistants resolved these issues with threats and intimidation. Funding for the institutions was provided by the government and was distributed based on the total number of patients in each facility. As a result, the institutions had a financial incentive for patients to remain in treatment. That being said, there remained an insufficient number of beds to meet the demands for mental health treatment in Armenia. Various issues related to the physical conditions and operation of the mental health facilities were uncovered by monitors. There existed no formal methodology for preventing the spread of contagious diseases, especially in the methods of administering medical care to patients (Open Society Foundation, 2011). The personal hygiene of patients suffering chronic illness, who were unable to care for themselves, was lacking and not sufficiently attended to by employees. In addition, monitors noted a specific odor present in all the facilities. Almost universally at these institutions, there was great concern among patients and employees concerning the quality and amount of food received. The facilities for preparation and delivery of food were insufficient and worn. These issues resulted in many patients refusing to eat, causing additional health issues resulting from malnutrition. Finally, these facilities lacked fire security systems. The staff of the mental health facilities were found to be underpaid, overworked, and lacking necessary training. Nurses and nursing assistants, who represented a bulk of the personnel at these institutions, delivered a majority of the treatments yet had no training or specialized education (Open Society Foundation, 2011). There was no clear division of responsibilities and duties between various employees of the institutions. Caseloads for each psychiatrist was between thirty and thirty-five patients, which negatively impacted the effectiveness of their work. There existed no code of conduct for employees of these facilities. In addition, these employees are unaware of their rights and responsibilities in conducting their work. Additionally, and possibly influencing or influenced by previously discussed issues, the financial compensation received by employees was not sufficient for the expected workload. Finally, there was concern regarding the average age of psychiatrists in these institutions as there will exist a serious deficit of qualified personnel in five to six years. Included as an addendum at the end of the report was a response from the RA Minister of Healthcare, a Mr. Harutyun Kushkyan. Although he expressed gratitude to the agencies responsible for compiling the report, he took exception with several of its findings. Mr. Kushkyan noted that in the interim between monitoring and publication, several legal acts were adopted which addressed issues of the report, including the use of physical restraints (Open Society Foundation, 2011). Additionally, he highlighted several specific findings of the report which he believed did not accurately reflect the reality of the situation. Most notable was the report’s contention that no statistics of patients’ deaths are recorded, and that no satisfactory investigation by outside authorities into such deaths occurred. Mr. Kushkyan states that in the cases of patient suicide or death a written report was presented by the institution’s management team to law enforcement. Also, that detailed statistics on all deaths did exist and were submitted to the RA Ministry of Healthcare on a monthly basis. After a review of all the collected data, monitors concluded that in Armenia there is no satisfactory program in place to deal with citizens with problems resulting from mental illness. The mental health facilities serve exclusively a responsive role, relying solely on the provision of medical treatment. Interviews In the summer of 2015, the author conducted a series of interviews with various members of the psychological community in Armenia. Included were professors, PhD’s, mental health practitioners, and members of non-governmental organizations. The express purpose of these interviews was to ascertain the current landscape of the practice of psychology in Armenia, including the current issues surrounding and within it. The content of the interviews, naturally, reflects the subjective experience of each individual interviewee. Several subjects and issues arose regularly during these interviews. Legacy of Soviet Psychology From 1922 to 1991 Armenia was a member of the Union of Soviet Socialist Republics. Psychology in the Soviet Union differed from that of the western world. The Soviet system valued psychology for its theoretic perspective, producing several prominent thinkers such as Lev Vygotsky and Aleksei Leontiev. Emphasis was placed on the worker and enhancing worker productivity, particularly in communication and integration with machines (N. Khachatryan, personal communication, June 8, 2016). Psychological perspectives on pedagogy, industry, engineering, sports, and ergonomics also received focus. Applied psychology, including counseling psychology, did not exist during the soviet era (A. Begoyan, personal communication, July 9, 2015). Those with mental health conditions were treated by psychiatrists. Soviet psychiatrists viewed mental illness exclusively from a medical, somatic perspective and thus medication was the primary treatment methodology (K. Gasparyan, personal communication, June 6, 2015). There were many documented cases of human rights violations via psychology during the Soviet period (Medvedev & Medvedev, 1971). Psychiatry was occasionally used as a tool of suppression by the Soviet government to silence many who were viewed as political dissidents. Those targeted were given the diagnosis of incipient or “sluggish” schizophrenia, institutionalized, and medicated without their consent (Medvedev & Medvedev, 1971). Perception of Psychology in Armenia There general consensus among interviewees was that in Armenia there is confusion, misinformation, and a general lack of knowledge as to what psychology is and does. One principal point of confusion is with the practice of psychiatry. Many Armenians assume psychiatry and applied psychology are one in the same, treating patients only with drugs. They are unaware of treatments such as talk therapy and behavioral conditioning, among others (A. Begoyan, personal communication, July 9, 2015). This perception is held more commonly by those over forty years of age, presumably because of their experiences having lived during Soviet times (A. Begoyan, personal communication, July 9, 2015). In contrast, members of the younger generations appear to be more knowledgeable and receptive to the ideas of psychology, as is reflected by their greater representation among those who seek psychological services and the psychology program enrollment rates at Yerevan State University (N. Khachatryan, personal communication, June 8, 2016). Another practitioner attributed the popularity of psychology among the youth of Armenia to its numerous representations in film and television (K. Gasparyan, personal communication, June 6, 2015). Television shows featuring and discussing psychology have become quite prevalent in Armenia over the last fifteen years. Topics discussed include family, child development, existentialism, marriage, depression and the behavior of politicians (R. Poghosyan, personal communication, June 27, 2015). Married couples seek psychological information to better understand their spouses, and to avoid marital conflict. Child development appears to be a particularly popular topic, featuring its own television program entitled Mother’s Club which features professors from many fields. Armenian mothers now desire knowledge and new ways of thinking in order to prepare their children for the future (R. Poghosyan, personal communication, June 27, 2015). In contrast, fifteen years prior, mothers were concerned only with matters of the present. One explanation for the rise in popularity over the last fifteen years may be that some Armenians now have the luxury to be concerned matters of the distant future. Some believe that to be their best they require more than lay thinking, they desire the scientific knowledge of psychology (R. Poghosyan, personal communication, June 27, 2015). The increase in interest in psychology, particularly personal and child development, over the last fifteen years may coincide with an improving economy. The 1990s was a turbulent economic period in Armenia, which featured broad de-sovietization and a switch to a market economy. Dr. Ruben Poghosyan regularly appears on television and in print, discussing various matters from a psychological perspective. He believes in the importance of the media as a medium to create a culture of psychology, communicating to the public its ideas and methods of thinking (R. Poghosyan, personal communication, June 27, 2015). Dr. Poghosyan is often contacted by members of the media regarding major issues and events. He believes they are correct in seeking a psychological perspective, but thinks reporters often ask the wrong questions. Although he makes special efforts to educate inquirers on the issues surrounding their questions, they often merely desire to recruit him in endorsing the narrative they have previously established. Dr. Poghosyan believes he has been misrepresented by the media on occasion. Although there are many television programs featuring the subject, the quality of psychological content is varied. One show in particular, entitled Sixth Sense, portrays psychologists as seers who predict the future (A. Begoyan, personal communication, July 9, 2015). Television programs also feature psychologists utilizing projective testing. During such testing a subject responds to ambiguous stimuli in some way and the practitioner interprets these responses, supposedly unearthing the subject’s hidden emotions and desires. In the United States projective testing has significantly fallen out of favor over the last fifty years, as their results have been demonstrated to be unreplicable and unverifiable. Nevertheless, many individuals with little or no legitimate psychological training present themselves as psychologists on these programs and share their opinions. In fact many have become famous out of this exposure. When asked his thoughts on his field and profession being represented in this manner Dr. Arman Begoyan expressed personal shame (personal communication, July 9, 2015). He believed that he was viewed by the public in a similar way. The author felt this to be a curious response and a possible cultural divide. In a more individualistic society such as the United States, the instinct in this case may be to turn the frustration outward, toward those who misrepresent themselves and sully the public perception of the field. Such was not the case for this practitioner in Armenia. Finally, some in the public believe the practice of psychology is exclusively hypnotism. This myth is perpetuated by one well known practitioner, Solak Hagobyan, whose practice is primarily hypnotism (A. Begoyan, personal communication, July 9, 2015). Former clients of Dr. Hagobyan who sought treatment elsewhere have reported a loss of faith in psychology following their experience. The Armenian government’s perception of psychology is important as it impacts current and future policy. One interviewee believes that the government does not think psychology is an important or necessary field, at times going so far as to act as if they had just heard of psychology (M. Melkonyan, personal communication, June 27, 2015). There may, in fact, not be a single psychologist in the government (A. Begoyan, personal communication, July 9, 2015). The field of mental health is represented in the government by a strong psychiatric lobby, which views conditions exclusively from a medical, biological perspective (A. Begoyan, personal communication, July 9, 2015). The strength of this lobby obscures the psychological and integrative perspectives. The government provides no funding for psychotherapy, citing that there is no room in the budget (M. Melkonyan, personal communication, June 27, 2015). Stigma Because of the nature of mental illness there exist varied, often negative, beliefs about illnesses and those suffering from them. This is commonly referred to as mental illness stigma. Armenia and its populace and not void of such stigma. Described as “classical stigma”, which was solidified and perpetuated during soviet times, views those who receive treatment for psychological conditions as very affected and dysfunctional (D. Gevorgyan, personal communication, June 26, 2015). This type of stigma is particularly attached to psychiatry, as it was the primary means of treatment in the Soviet Union. Stigma exists today in Armenia among lay people, mostly regarding cases of severe mental illness. Such individuals are viewed as dangerous and unable to function in society (N. Khachatryan, personal communication, June 8, 2015). Also the target of stigmatization are members of the lesbian, gay, bisexual, and transgender community, who often do not seek psychological services for fear of additional stigma (A. Begoyan, personal communication, July 9, 2015). One interview subject expressed the idea that the Armenian people were willing to give money to those suffering, but did not want to deal directly with them (A. Stepanyan, personal communication, June 17, 2015). Because of this stigma surrounding mental illness, many Armenian families choose to keep a sick relative in the home and provide care themselves (N. Khachatryan, personal communication, June 8, 2015). These families believe it is their familiar duty to care for their kin. Also, in many of these situations, attempts are made to keep the sick sequestered in the home, away from the public eye. There is fear of additional stigma being applied to other members of the family (K. Gasparyan, personal communication, June 6, 2015). In these situations a significant burden is placed upon the family, as it is nearly impossible for them to provide adequate treatment without formal training or outside resources (N. Khachatryan, personal communication, June 8, 2015). These families often receive a small stipend from the government. In the inverse of these situations, as a result of stigma, some individuals with mental illnesses are abandoned by their family (A. Papikan, personal communication, July 14, 2015). These outcasts, due to lack of options, must remain in overburdened psychiatric hospitals. Three practitioners believe that mental illness stigma has lessened over the past five to ten years (D. Gevorgyan, N. Khachatryan, & I. Mukuchyan, personal communications, 2015). Inga Mukuchyan recalled five years earlier, when stigma was more significant, clients would make efforts to disguise their identity and give fake names when seeking psychological services (personal communication, June 27, 2015). She cites the increased availability of psychological information via the internet as well as the popularity of talk shows featuring psychologists for the decrease of mental illness stigma in Armenia. Clientele As there are varied perceptions of psychological services in Armenia, an investigation into what kinds of individuals seek treatment and for what conditions is warranted. As the economic situation is difficult for many in Armenia, cost seems to be a significant barrier to seeking treatment. The cost for a single therapeutic session ranges from 5000 to 15000 AMD, approximately $10 to $30 USD (I. Mukuchyan, personal communication, June 27, 2015). This is a significant expenditure for many Armenians, resulting in many individuals waiting to seek treatment only when their problems have become quite serious (I. Mukuchyan, personal communication, June 27, 2015). One practitioner who had worked in both the United States and Armenia stated that because of this, working with one Armenian client was as taxing and difficult as working with five clients in the United States (A. Begoyan, personal communication, July 9, 2015). Often clients seek treatment for one issue and it is discovered that there are more significant, underlying problems (A. Begoyan, personal communication, July 9, 2015). It was proposed that this phenomenon could be explained by a general lack of awareness of mental health conditions and their symptoms. The most commonly cited reasons for seeking psychological services are difficulty in interpersonal relations, anxiety, depression, conflict management, personal growth, neurosis, anxiety, and mood disorders. Dr. Arman Begoyan estimated that 70 - 80% of his clients have issues with anxiety, often resulting from trauma (personal communication, July 9, 2015). For some clients, the source of this trauma was the Spitak Earthquake in 1988 and/or proximity to the Karabakh war of the 1990s. Although he believes rates of alcoholism and drug use are comparatively low because of culture and traditions, the “real drug” is gambling. He stated that this has been a significant issue for some clients. While in country for two months, the author became casually aware of the prominence and abundance of gambling establishments throughout the capital city of Yerevan. In Armenia there exists a paradigm in which young men’s sexual pursuits are quietly tolerated or encouraged. Whereas sex before marriage for women is taboo, potentially shameful for the family, and damaging to the woman’s value as a marriage prospect (D. Gevorgyan, personal communication, June 26, 2015). For many women the issue of navigating sexual desires and demands before marriage can be a source of psychological distress (T. Vavryk, personal communication, July 24, 2015). One prominent practitioner had several female clients who had impulses toward sexual acts with men and boyfriends, but feared how they would be perceived by their families (D. Gevorgyan, personal communication, June 26, 2015). To the practitioner this was significant because it had caused enough distress in the women’s lives to warrant addressing in treatment. There appear to be two consensus attributes of those who more predominantly seek the aid of psychological services, being young and female. Possibly explaining the discrepancy in gender is a stigmatized belief that it is not good or normal for men to meet with a counselor (T. Vavryk, personal communication, July 24, 2015). For those men who do seek aid in spite of these cultural pressures, it is often for issues of finding better employment and attaining a prosperous life (T. Vavryk, personal communication, July 24, 2015). Younger Armenians, including students and those under the age of 40, are believed to seek psychological in greater numbers because of an awareness of psychology and a more positive perception of the field (N. Khachatryan, personal communication, June 8, 2016). Services Offered Present since ancient times, the traditional Armenian response to mental health issues was to gather together with friends and neighbors to solve the problems (D. Gevorgyan, personal communication, June 26, 2015). Under the church there existed special clergy, men who knew of all problems and would be called upon to deal with these difficult situations. Another traditional source of consul for Armenians is the Kavor. Similar to the role of the godfather in western Christianity, the Kavor is an advisor looked to for consul by married or soon to married couples (D. Gevorgyan, personal communication, June 26, 2015). As discussed previously, applied and counseling psychology was virtually non-existent in Soviet Armenia. The Spitak earthquake of 1988 can be looked to as the entry point for client directed psychological services. Psychoanalysis and its offshoots were popular in this initial wave because of influx of practitioners from the Armenian diaspora in France and its popularity there. This lead to the development of many psychoanalysis centers during the 1990s (N. Khachatryan, personal communication, June 8, 2016). Although the popularity of psychoanalytic practice has declined in recent years, the Armenian Psychoanalytic Association remains a prominent institution. Although many various methodologies are in practice throughout Armenia, the most frequently cited in these interviews was cognitive behavioral therapy (CBT). Also popular in the United States, CBT combines methods from two different school, cognitive and behavioral. The basic goals of cognitive therapy are to identify patterns of maladaptive thinking in the client and confront those patterns through a process of examination called hypothesis testing. This is combined with behavioral techniques such as conditioning and systematic desensitization, which exclude any examination of the workings of the mind. One explanation for the rise in popularity of CBT may be the relatively small amount of time needed to produce results, especially when compared to the lengthy time requirement of traditional psychoanalysis. Despite its popularity, there is currently a lack of trained CBT specialists in Armenia (D. Gevorgyan, personal communication, June 26, 2015). Dr. Davit Gevorgyan is the founder and director the Yerevan State University Center for Applied Psychology, possibly the most significant site of applied psychology practice and learning in Armenia. In his opinion, the most commonly practiced method in Armenia is Humanism, or client-centered approach. Humanism is characterized by the practitioner maintaining unconditional positive regard toward the client, and the belief that this relationship is the primary element of healing and change. Other methodologies which are reportedly used in Armenia include scent therapy, art therapy, eye movement desensitization and reprocessing therapy (EMDR), applied behavioral analysis, narrative therapy (NCP), Jungian analysis, neuro linguistic programs, psychodrama, psychodynamic, and transcendental psychoanalysis. Another application of applied psychology is coaching. The focus of coaching is not mental illness. Its goal is to aid the client in finding a solution to their problem or issue (T. Vavryk, personal communication, July 24, 2015). Clients who seek out this coaching service often desire personal growth, particularly to aid themselves in business. Taras Vavryk describes his coaching process as not teaching, but asking. He believes that within the client’s subconscious there are answers. By asking questions and noting what the client responds to, answers often reveal themselves. If a client lacks the imagination for that process, case studies are recounted to demonstrate how other individuals were successful when confronted with similar issues. Broadly speaking, the practice of coaching is about helping clients find their own solutions to their requests (T. Vavryk, personal communication, July 24, 2015). Group seminars and trainings on topics within psychology are also available in Armenia. These seminars are held at various psychological institutions around Yerevan and are open to the public. Topics include, but are not limited to, body language, stress, communication, emotions, and dance therapy (I. Mukuchyan, personal communication, June 27, 2015). These seminars are mostly attended by women, although some men do attend (T. Vavryk, personal communication, July 24, 2015). The cost of attending one seminar is 1000 dram per hour, or roughly $2 USD. A few practitioners also offer their counseling services via the internet and video conferencing software such as Skype. Arman Begoyan stated that this medium allows him to offer services to Armenians members of the diaspora who have relocated. His rate for an online session is 7000 dram, roughly $15 USD. Internet counseling practice has grown in popularity in the United States as well. The field of psychology has also made its way into Armenian schools. Given the popularity of psychology among parents in informing their child rearing, this comes as no surprise. In recent years techniques informed by psychology have become integrated into schools. Teachers and school administrators have received psychological training and utilize it. Also, particular schools for students with special needs are staffed by those who have received psychological training (N. Khachatryan, personal communication, June 8, 2016). Mental Health Community & Licensing In Armenia there is currently no formal licensing or certification to provide non-psychiatric psychological services including mental health counseling. There are no qualifications required to present oneself as a psychologist. In fact, psychologist is not a legally recognized profession by the ministry of health (A. Begoyan, personal communication, July 9, 2015). This results in a myriad of ethical and practical issues. Although there is agreement in the psychological community that formal licensing is essential to their future, there is disagreement on how to proceed. One point of contention is whether licensing mandates should come from the ministry of health, or if an independent organization should be formed (A. Begoyan, personal communication, July 9, 2015). As previously discussed, the Ministry of Health, as far as mental illness is concerned, is dominated by a psychiatric focus. This psychiatric focus is viewed as an impediment in forming an independent psychological association or gaining acknowledgement for psychology from the Ministry of Health (A. Begoyan, personal communication, July 9, 2015). Arman Begoyan believes this exists because of the composition of the members of the Ministry of Health and the complicated nature of connections within Armenia. He contends that many of the the members of the Ministry of Health are Soviet holdovers, who were appointed to prominent positions without psychological training. Many have advanced training in philosophy, pedagogy, or mathematics, but not psychology (A. Begoyan, personal communication, July 9, 2015). Dr. Begoyan believes that such individuals oppose the psychological community gaining a foothold in the Ministry of Health as it exposes their lack of ability and knowledge of applied psychology. Also fueling this paradigm of disconnect are complicated connections between members of neighboring professions. Arman explained that Armenia is a small country, dominated by traditions. That family and morality are more important than laws and regulations. Despite these complications, some in the psychological community still desire to negotiate with the Ministry of Health. Those who wish to negotiate may be motivated by strong paternal feelings, and expectations of governmental change (A. Begoyan, personal communication, July 9, 2015). There are differing opinions among those who favor the creation of an independent licensing body to govern and regulate the practice of psychology in Armenia. Dr. Margarit Melkonyan believes that the field of psychology is not developed sufficiently enough for such an institution (personal communication, June 27, 2015). He contends that as each psychological center has its own methods of communicating and offering services, and that the field in Armenia lacks clarity and delineation. Once a common language of psychology is established in Armenia, Dr. Melkonyan feels they will be ready to establish an institution of psychological licensing. Drs. Poghosyan and Begoyan also favor the community coming together, albeit in a more immediate timeframe. If a psychological licensing institution were to be formed, interviewees voiced significant overlap in the kinds of things they believe would be necessary to attain licensing to deliver psychological services. Broadly speaking this included undergraduate and advanced education, working with an advisor, and each candidate undergoing psychotherapy themselves. Dr. Gevorgyan stated emphatically that he believes there must exist a gap between counselors, those with advanced trainings but without a doctoral degree, and psychologists, those with a doctoral degree (personal communication, June 26, 2015). As there is no accrediting body in Armenia, questions of ethics arise. As previously discussed, some individuals misrepresent themselves and their qualifications in regards to psychological training. Included among this group are some who begin practicing psychotherapy straight out of undergraduate university, with no formal training or advanced education (D. Gevorgyan, personal communication, June 26, 2015). Margarit Melkonyan believes that the psychological community in Armenia agrees that establishing ethical rules and laws is essential to the future of their shared field (personal communication, June 27, 2015). Intergenerational Trauma It has been theorized that because of the massive loss of life of one and a half million Armenians due to the brutality of the Ottoman Turks, and the loss of land in Eastern Anatolia that a lasting impact may have been passed down through generations to the descendants of the victims of the Armenian Genocide. Although the interview subjects were divided on whether they had seen evidence of intergenerational trauma (IGT) manifest in their practice, all were in agreement that discussion of the Genocide and its potential lasting effects is present in the Armenian consciousness. One position held is that the trauma of the genocide is not as personal as it has been in the past, instead it is felt more on the national level (N. Khachatryan, personal communication, June 8, 2016). Some view the legacy as unresolved, as Turkey and many significant members of the international community, including the United States, fail to recognize the crimes committed against the Armenian people with the term genocide. In fact, some Armenians feel that the term “trauma” is not an ideal or possibly even accurate term. There may be a greater sense of trauma related to the genocide among members of the Armenian diaspora for a variety of reasons (N. Khachatryan, personal communication, June 8, 2016). The loss of land may have been more significant for members of the diaspora as they were directly, or the descendants of, the displaced. This potentially holds true in the inverse, that the trauma resulting from loss of land was less significant for those who remain in modern Armenia. It has also been proposed that the genocide provides a significant source of cultural identity and provides a familial narrative for members of the diaspora (N. Khachatryan, personal communication, June 8, 2016). Often they are socialized within these family stories of genocide loss and survival. Due to a strong connection between their national identity and events of the past, members of the diaspora have been said to be more concerned with the legacy of the genocide than with the modern day civic problems of Armenia (N. Khachatryan, personal communication, June 8, 2016). In fact, many diaspora Armenians never return to their homeland, maintaining an idealized, internal version of it. Many of those who do make the journey to the homeland are disappointed when confronted with the traditional values and social shortcomings (N. Khachatryan, personal communication, June 8, 2016). Two practitioners spoke about the appearance of IGT in their practice and clients. Dr. Arman Begoyan has not seen IGT manifest directly in his practice. Instead, more often, his clients are suffering side effects of trauma experienced more recently, such as the Spitak earthquake and the war in Nagorno-Karabakh (A. Begoyan, personal communication, July 9, 2015). Dr. Davit Gevorgyan has seen IGT trauma in clients, although not often. In his experience and opinion IGT presents with unconscious, subtle links to trauma of the past (D. Gevorgyan, personal communication, June 26, 2015). He has seen it manifest in the dreams and lives of clients, with symptoms likened to postponed trauma. One female client in particular had the same dream for five years. In it she saw an old woman desperately trying to escape. Dr. Gevorgyan attempted to find a connection between the dream and the client's life, as the dream evoked a significant emotional response from the client. He was unable to discover such a connection. In fact there was a sense that the substance of the dream did not belong to her, that it was connected to something larger. Finally, while the client was watching a movie about the genocide, she had a breakthrough and connected the persistent dream to her traumatic ethnic past. Dr. Reuben Poghosyan is a second generation descendant of Genocide survivors. His grandparents fled the Turkish onslaught between 1915 and 1918 (R. Poghosyan, personal communication, June 27, 2015). He believes he is a product of intergenerational trauma. Although his grandparents were silent about the genocide, as he grew older, he began to understand and explain their actions as connected to their traumatic experiences. His grandmother never told him that she loved him, but he knew that she did. He believes that she hid her love because, in her mind, people she loved died. Instead, she put her love into the food she prepared. When Reuben would complement her on a meal she would attempt to hide her smile, but he saw it. He recalls watching his grandmother hide money in the ground and lighting candles. The money was a remembrance, to keep value for those lost. Reuben thinks she may have done this because of the lack of proper burials for the victims of the Genocide. It is not difficult to imagine these relationships and events having a lasting impact. As a man presumably in his 70s, Reuben spoke of these events with somber passion and detail. Psychological Centers: Education and Treatment In Armenia, psychological services and education are frequently offered at the same locations as one another. One such location is Yerevan State University (YSU), which appears to be a leading institution in Armenia. The popularity of psychology as a focus of study by students has increased greatly in the last ten years, with interests focused mainly on applied psychology (N. Khachatryan, personal communication, June 8, 2015). Narine Khachatryan believes that psychology is popular with some students as it allows them to explore their own issues. Each year YSU has 60 to 70 students complete their undergraduate psychology program. Most of these graduates go on to work in schools, human resources, management, or for non-governmental organizations which focus on vulnerable groups. A small portion of graduates pursue advanced education in the form of a master's program, which eventually allows them to practice and deliver psychological services. Finally, an even smaller group continues on to a PhD program, which enables them to teach or conduct research (N. Khachatryan, personal communication, June 8, 2015). At YSU there appears to be a divide in teaching methodology, separated by old and new. Some of the older instructors who were educated in the Soviet system continue to teach in that manner with cold lecturing and a lack of dialog or interaction with students (N. Khachatryan, personal communication, June 8, 2015). It is important to distinguish that while they lecture in the Soviet style, they do not teach soviet ideology. A younger generation of instructors embody educational reforms made in recent years which feature a student centered approach that is more collaborative in instruction (N. Khachatryan, personal communication, June 8, 2015). Located physically and academically inside YSU is the Yerevan State Center for Applied Psychology. Headed by Dr. Davit Gevorgyan, this center provides psychological services as well as advanced training in the delivery of such services. Included in their student body are bachelor and master level students, members of adjoining fields such as human resources and social workers, as well as established counselors seeking additional training. The center also offers supervised practice for specialists (D. Gevorgyan, personal communication, June 26, 2015). One notable exception is the IntraClinic, which offers exclusively psychological services. IntraClinic was founded and is headed by Dr. Khachatur Gasparyan following his ten year service at Yerevan State Medical School where he instructed medical students in general medical psychology (K. Gasparyan, personal communication, June 6, 2015). The foundation and workings of the clinic are funded by an Armenian couple living in England. Personal friends of Dr. Gasparyan, this couple had a child with schizophrenia who eventually died. Wanting to give something back a provide aid for those with mental illness, the couple was approached by Dr. Gasparyan and his dream of operating a mental health clinic in Yerevan. The couple agreed and IntraClinic was established. Upon relaying these happenings Dr. Gasparyan expressed to the author, with a musing grin, that one must be careful what they wish for. IntraClinic provides care exclusively for patients with chronic mental illness. The practitioners at the clinic provide services for patients in addition to the care they receive from their primary psychiatric providers. The services provided at the clinic are designed to teach and improve life skills, and to aid patients in integrating into society. There are also self-help groups and mental health information trainings for the family members of patients. Dr. Gasparyan has personally witnessed vast improvements in patients over the years. Research Psychology There was some variation in the views of the current state of research psychology in Armenia, with many interviewees expressing that it is unpopular, stagnant, or nonexistent. There are however, notable exceptions. Dr. Ruben Poghosyan expressed strong feelings on the issue, going so far as to state that “experimental psychology in Armenia is dead” (R. Poghosyan, personal communication, June 27, 2015). He believes that this kind of thinking died with the collapse of the Soviet Union. In his experience, practitioners use established tests and diagnostics instead of devising new ones, resulting in a lack of exportation of a thinking of psychology unique to the Armenian experience. However, Dr. Poghosyan did have some ideas for potential research topics. During the summer of 2015, large scale protests were conducted in the Armenian capital of Yerevan as a response to a proposed price increase of electricity in the country. While outrage was generally widespread, the protesters were largely from the younger generation, utilizing social media and the signifier #electricyerevan. Dr. Poghosyan believes the demonstrations come from an ethnic psychology, that the protesters are expressing themselves as Armenian and connecting to a historical, ethnic belonging. Also contributing to the situation as uniquely Armenian, he believes, are the police behaving like the Armenian father and trying to explain away the situation to the protestors. He believes this patriarchal relationship is typical of the Armenian experience, with its emphasis on the value of the child and the necessary roles of nurture and instruction. Dr. Poghosyan feels that the factors surrounding the #electricyerevan protests are fit for psychological research. Additionally, Dr. Poghosyan suspect’s productive psychological research may come out of an inquiry into the Armenian national identity and its tendency towards conservatism on certain issues. He believes that because of the size of Armenia and its geographical position between Europe and Asia, it must remain conservative for fear of losing its traditions. Additionally, he proposes that some of the vigor for maintaining a strong ethnic identity may stem from a fear of being engulfed by other cultures. Even the briefest examination of the history of the Armenian people may lend support to this theory and the conclusion that if such a fear were to exists it would not be completely unfounded. Dr. Narine Khachatryan is the head of the Department of Personality Psychology and the Principal Investigator of the Personality and Social Environment Lab at Yerevan State University. It is her opinion that the field of research psychology in Armenia is weak and underdeveloped (N. Khachatryan, personal communication, June 8, 2016). She speculates that one factor may be a lack of funding for research. Also, students are not as interested in pursuing research as they are in applied psychology. Finally, Dr. Khachatryan believes that developing the field and encouraging students to pursue psychological research should be one of the goals of the future of psychology in Armenia. Arman Begoyan, a member of Hilfman Psychological Services, has been developing the therapeutic methodology of Cognitive Conceptual Therapy (CCT) with his colleagues since 2008. Combining established elements from cognitive and existential psychotherapies, CCT aims to provide a theoretical framework of personality, learning, sources of psychopathology, and a treatment methodology (Arakelyan and Begoyan, 2014). Therapeutic techniques involve working with the client to change patterns of thought regarding upcoming events by analyzing potential narratives and planning for possible difficulties in those scenarios (Arakelyan and Begoyan, 2014). Dr. Begoyan utilizes CCT in his everyday practice. Dr. Khachatur Gasparyan is in the final stages of research examining the possibility of trauma suffered by survivors of the Armenian Genocide (1915-1917) being transmitted to subsequent generations of descendants. As previously discussed, this phenomenon has be labeled Intergenerational Trauma (IGT). Dr. Gasparyan’s research began in 2013 by gathering a sample group of ethnic Armenians, both native Armenians and those living abroad in the diaspora were included (K. Gasparyan, personal communication, June 6, 2015). This group was instructed to spontaneously reply with whichever word(s) came to mind when a researcher prompted them with questions about the events of the genocide. This technique of spontaneous response is termed ‘Free Association’. From this initial group, the eighteen most commonly freely associated words with the genocide were established. The main section of the research then began with an initial sample size of 1,400 participants. Dr. Gasparyan hopes to increase to a total of 2,400 participants by the conclusion of his research. This sample was subjected to three measurement procedures. In the first, subjects were prompted with the previously established eighteen most common words and instructed to free associate four new words with each of the eighteen. Next, the subjects were administered the TEMPS-A, a self-report questionnaire designed to measure variations in temperament and affect (Akiskal et al., 2005). Finally, a questionnaire was administered to determine whether each subject had an ancestral connection to Western Armenia, those lands where many of the atrocities of the genocide occurred and which are no longer part of Armenia. Using these results, subjects were placed into the experimental group if they had an ancestral connection to Western Armenia or in the control group if they had no connection or were unsure of their connection. The final section of the research involved gathering biofeedback information, that is, involuntary responses of the body such as heart rate and perspiration. Initially, baseline measurements of thirty-two biofeedback measures were recorded for each subject. Next, a researcher recounted each specific subject’s previously free associated genocide words and asked the subject to perform additional free associations. Biofeedback measures were recorded during this process and compared to baseline measures. Although the research is not fully complete, Dr. Gasparyan had some thoughts on his findings to date. Based on the data, he has no doubt that inherited trauma exists, although it may be subconscious. Conclusion The primary limitation of this study is the lack of comparison data. Some of which is due to that fact that no hard data was collected, allowing for easy comparison. Additionally, while the author has some knowledge of the operation of such things in the United States, there is no baseline for comparison, with which to judge how Armenia appears comparatively. It must also be stated that although this paper detailed many negative elements of the treatment of mental health in Armenia, there are many dedicated practitioners doing great work, guided by established and supported methods. Although Armenia has made strides in improving the treatment of mental illness in the recent past, much work remains. A transition to outpatient treatment and the formation of a formal licensing and ethics body are two of the most important issues going forward. However, one must acknowledge that this is one of many serious issues facing Armenia today. Additionally, financial constraints limit the ability to implement such reforms. 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