Diana Foșha (17 December 1952 to Present) is a Romanian-American psychologist, known for developing accelerated experiential dynamic psychotherapy (AEDP), and for her work on the psychotherapy of adults suffering the effects of childhood attachment trauma and abuse.
Education and Career
Fosha was born in Bucharest on 17 December 1952, but her family emigrated to the United States when she was 12 years old, settling in New York City. She studied psychology at Barnard College (graduating in 1974) and then went on to complete a doctorate in clinical psychology at the City College of New York. She also undertook post-doctoral training with Habib Davanloo, the developer of a form of psychodynamic psychotherapy called intensive short-term dynamic psychotherapy.
In her early career Fosha held teaching positions at the City College of New York and Adelphi University. She was also an adjunct professor of psychiatry at Bellevue Hospital, and was on the faculty of New York University and the St. Luke’s–Roosevelt Hospital Centre.
Accelerated Experiential Dynamic Psychotherapy
Fosha developed a theory and technique of psychotherapy, accelerated experiential dynamic psychotherapy (AEDP), based upon several conceptual premises as points of departure from the prevailing psychodynamic psychotherapies.[7] Her theory of how healing occurs in psychotherapy derives from her interpretation of research findings in several areas: the neuroscience of attachment, caregiver–infant interaction research, positive psychology, emotion research, psychotherapy research findings on therapist qualities associated with positive therapy outcomes, and phenomenology of the psychological experience of sudden change.[8] The AEDP Institute is actively engaged in ongoing research evaluating the effectiveness of AEDP.[9][10]
Her core premise is that the desire to heal and grow is a wired-in capacity, which she calls the transformance drive.[11] Emotional healing and brain re-wiring[12] the patient, with the help of the therapist, is able to experience, in a regulated manner, emotions that had been blocked due to traumatic overwhelm.[13] Healing is accelerated through a tracking of emerging affect, so the patient can have a complete emotional experience, and then reflect upon the experience of healing change itself, with the help of the therapist. Fosha terms this technique meta-therapeutic processing.
The AEDP Institute was formed in New York City in 2004. The institute has satellite institutes throughout the US, and in Brazil, Canada, France, Italy, Sweden, Israel, China, and Japan.
Selected Bibliography
Books
Fosha, D. (2000). The Transforming Power of Affect: A Model For Accelerated Change. Basic Books
Fosha, D, Siegel, D., Solomon M., Eds. (2009). The Healing Power of Emotion: Affective Neuroscience, Development & Clinical Practice. New York: W.W. Norton & Co.
Prenn, N., Fosha, D. (2016). Supervision Essentials for Accelerated Experiential Dynamic Psychotherapy. Part of the Clinical Supervision Essentials Series. American Psychological Association, Washington, D.C.
Fosha, D. (2021). Undoing Aloneness and the Transformation of Suffering Into Flourishing: AEDP 2.0. American Psychological Association, Washington, D.C. AAP Prose Award Winner.
Articles
Fosha, D. (2001). The dyadic regulation of affect. Journal of Clinical Psychology/In Session. 57 (2), pages 227–242.
Fosha, D. (2001). Trauma reveals the roots of resilience. Special September 11 Issue. Constructivism in the Human Sciences. 6 (1 & 2), pages 7–15.
Fosha, D. (2004). “Nothing that feels bad is ever the last step”: The role of positive emotions in experiential work with difficult emotional experiences. Special issue on Emotion, L. Greenberg (Ed.). Clinical Psychology and Psychotherapy. 11, pages 30–43.
Fosha, D. (2004). Brief integrative psychotherapy comes of age: reflections. Journal of Psychotherapy Integration. 14, pages 66-92.
Fosha, D. (2005). Emotion, true self, true other, core state: toward a clinical theory of affective change process. Psychoanalytic Review. 92 (4), pages 513–552.
Emotionally focused therapy and emotion-focused therapy (EFT) are related humanistic approaches to psychotherapy that aim to resolve emotional and relationship issues with individuals, couples, and families. These therapies combine experiential therapy techniques, including person-centred and Gestalt therapies, with systemic therapy and attachment theory. The central premise is that emotions influence cognition, motivate behaviour, and are strongly linked to needs. The goals of treatment include transforming maladaptive behaviours, such as emotional avoidance, and developing awareness, acceptance, expression, and regulation of emotion and understanding of relationships. EFT is usually a short-term treatment (eight to 20 sessions).
Emotion-focused therapy for individuals was originally known as process-experiential therapy, and continues to be referred to by this name in some contexts. EFT should not be confused with emotion-focused coping, a separate concept involving coping strategies for managing emotions. EFT has been used to improve clients’ emotion-focused coping abilities.
Brief History
EFT began in the mid-1980s as an approach to helping couples. EFT was originally formulated and tested by Sue Johnson and Les Greenberg in 1985, and the first manual for emotionally focused couples therapy was published in 1988.
To develop the approach, Johnson and Greenberg began reviewing videos of sessions of couples therapy to identify, through observation and task analysis, the elements that lead to positive change. They were influenced in their observations by the humanistic experiential psychotherapies of Carl Rogers and Fritz Perls, both of whom valued (in different ways) present-moment emotional experience for its power to create meaning and guide behaviour. Johnson and Greenberg saw the need to combine experiential therapy with the systems theoretical view that meaning-making and behaviour cannot be considered outside of the whole situation in which they occur. In this “experiential–systemic” approach to couples therapy, as in other approaches to systemic therapy, the problem is viewed as belonging not to one partner, but rather to the cyclical reinforcing patterns of interactions between partners. Emotion is viewed not only as a within-individual phenomena, but also as part of the whole system that organizes the interactions between partners.
In 1986, Greenberg chose “to refocus his efforts on developing and studying an experiential approach to individual therapy”. Greenberg and colleagues shifted their attention away from couples therapy toward individual psychotherapy. They attended to emotional experiencing and its role in individual self-organisation. Building on the experiential theories of Rogers and Perls and others such as Eugene Gendlin, as well as on their own extensive work on information processing and the adaptive role of emotion in human functioning, Greenberg, Rice & Elliott (1993) created a treatment manual with numerous clearly outlined principles for what they called a process-experiential approach to psychological change. Elliott et al. (2004) and Goldman & Greenberg (2015) have further expanded the process-experiential approach, providing detailed manuals of specific principles and methods of therapeutic intervention. Goldman & Greenberg (2015) presented case formulation maps for this approach.
Johnson continued to develop EFT for couples, integrating attachment theory with systemic and humanistic approaches, and explicitly expanding attachment theory’s understanding of love relationships. Johnson’s model retained the original three stages and nine steps and two sets of interventions that aim to reshape the attachment bond: one set of interventions to track and restructure patterns of interaction and one to access and reprocess emotion (refer to Stages and Steps below). Johnson’s goal is the creation of positive cycles of interpersonal interaction wherein individuals are able to ask for and offer comfort and support to safe others, facilitating interpersonal emotion regulation.
Greenberg & Goldman (2008) developed a variation of EFT for couples that contains some elements from Greenberg and Johnson’s original formulation but adds several steps and stages. Greenberg and Goldman posit three motivational dimensions:
(1) Attachment;
(2) Identity or power; and
(3) Attraction or liking—that impact emotion regulation in intimate relationships.
Similar Terminology, Different Meanings
The terms emotion-focused therapy and emotionally focused therapy have different meanings for different therapists.
In Les Greenberg’s approach the term emotion-focused is sometimes used to refer to psychotherapy approaches in general that emphasize emotion. Greenberg “decided that on the basis of the development in emotion theory that treatments such as the process experiential approach, as well as some other approaches that emphasized emotion as the target of change, were sufficiently similar to each other and different from existing approaches to merit being grouped under the general title of emotion-focused approaches.” He and colleague Rhonda Goldman noted their choice to “use the more American phrasing of emotion-focused to refer to therapeutic approaches that focused on emotion, rather than the original, possibly more English term (reflecting both Greenberg’s and Johnson’s backgrounds) emotionally focused.” Greenberg uses the term emotion-focused to suggest assimilative integration of an emotional focus into any approach to psychotherapy. He considers the focus on emotions to be a common factor among various systems of psychotherapy:
“The term emotion-focused therapy will, I believe, be used in the future, in its integrative sense, to characterize all therapies that are emotion-focused, be they psychodynamic, cognitive-behavioral, systemic, or humanistic.”
Greenberg co-authored a chapter on the importance of research by clinicians and integration of psychotherapy approaches that stated:
In addition to these empirical findings, leaders of major orientations have voiced serious criticisms of their preferred theoretical approaches, while encouraging an open-minded attitude toward other orientations. Furthermore, clinicians of different orientations recognised that their approaches did not provide them with the clinical repertoire sufficient to address the diversity of clients and their presenting problems.
Sue Johnson’s use of the term emotionally focused therapy refers to a specific model of relationship therapy that explicitly integrates systems and experiential approaches and places prominence upon attachment theory as a theory of emotion regulation. Johnson views attachment needs as a primary motivational system for mammalian survival; her approach to EFT focuses on attachment theory as a theory of adult love wherein attachment, care-giving, and sex are intertwined. Attachment theory is seen to subsume the search for personal autonomy, dependability of the other and a sense of personal and interpersonal attractiveness, love-ability and desire. Johnson’s approach to EFT aims to reshape attachment strategies towards optimal inter-dependency and emotion regulation, for resilience and physical, emotional, and relational health.
Features
Experiential Focus
All EFT approaches have retained emphasis on the importance of Rogerian empathic attunement and communicated understanding. They all focus upon the value of engaging clients in emotional experiencing moment-to-moment in session. Thus, an experiential focus is prominent in all EFT approaches. All EFT theorists have expressed the view that individuals engage with others on the basis of their emotions, and construct a sense of self from the drama of repeated emotionally laden interactions.
The information-processing theory of emotion and emotional appraisal (in accordance with emotion theorists such as Magda B. Arnold, Paul Ekman, Nico Frijda, and James Gross) and the humanistic, experiential emphasis on moment-to-moment emotional expression (developing the earlier psychotherapy approaches of Carl Rogers, Fritz Perls, and Eugene Gendlin) have been strong components of all EFT approaches since their inception. EFT approaches value emotion as the target and agent of change, honouring the intersection of emotion, cognition, and behaviour. EFT approaches posit that emotion is the first, often subconscious response to experience. All EFT approaches also use the framework of primary and secondary (reactive) emotion responses.
Maladaptive Emotion Responses and Negative Patterns of Interaction
Greenberg and some other EFT theorists have categorized emotion responses into four types (see § Emotion response types below) to help therapists decide how to respond to a client at a particular time: primary adaptive, primary maladaptive, secondary reactive, and instrumental. Greenberg has posited six principles of emotion processing:
(1) Awareness of emotion or naming what one feels;
(2) emotional expression;
(3) Regulation of emotion;
(4) Reflection on experience;
(5) Transformation of emotion by emotion; and
(6) Corrective experience of emotion through new lived experiences in therapy and in the world.
While primary adaptive emotion responses are seen as a reliable guide for behaviour in the present situation, primary maladaptive emotion responses are seen as an unreliable guide for behaviour in the present situation (alongside other possible emotional difficulties such as lack of emotional awareness, emotion dysregulation, and problems in meaning-making).
Johnson rarely distinguishes between adaptive and maladaptive primary emotion responses, and rarely distinguishes emotion responses as dysfunctional or functional. Instead, primary emotional responses are usually construed as normal survival reactions in the face of what John Bowlby called “separation distress”. EFT for couples, like other systemic therapies that emphasize interpersonal relationships, presumes that the patterns of interpersonal interaction are the problematic or dysfunctional element. The patterns of interaction are amenable to change after accessing the underlying primary emotion responses that are subconsciously driving the ineffective, negative reinforcing cycles of interaction. Validating reactive emotion responses and reprocessing newly accessed primary emotion responses is part of the change process.
Individual Therapy
Goldman & Greenberg 2015 proposed a 14-step case formulation process that regards emotion-related problems as stemming from at least four different possible causes: lack of awareness or avoidance of emotion, dysregulation of emotion, maladaptive emotion response, or a problem with making meaning of experiences. The theory features four types of emotion response (refer to Emotion Response Types below), categorises needs under “attachment” and “identity”, specifies four types of emotional processing difficulties, delineates different types of empathy, has at least a dozen different task markers (refer to Therapeutic Tasks below), relies on two interactive tracks of emotion and narrative processes as sources of information about a client, and presumes a dialectical-constructivist model of psychological development and an emotion schematic system.
The emotion schematic system is seen as the central catalyst of self-organisation, often at the base of dysfunction and ultimately the road to cure. For simplicity, we use the term emotion schematic process to refer to the complex synthesis process in which a number of co-activated emotion schemes co-apply, to produce a unified sense of self in relation to the world.
Techniques used in “coaching clients to work through their feelings” may include the Gestalt therapy empty chair technique, frequently used for resolving “unfinished business”, and the two-chair technique, frequently used for self-critical splits.
Emotion Response Types
Emotion-focused theorists have posited that each person’s emotions are organized into idiosyncratic emotion schemes that are highly variable both between people and within the same person over time, but for practical purposes emotional responses can be classified into four broad types:
Primary adaptive emotion responses are initial emotional responses to a given stimulus that have a clear beneficial value in the present situation—for example, sadness at loss, anger at violation, and fear at threat. Sadness is an adaptive response when it motivates people to reconnect with someone or something important that is missing. Anger is an adaptive response when it motivates people to take assertive action to end the violation. Fear is an adaptive response when it motivates people to avoid or escape an overwhelming threat. In addition to emotions that indicate action tendencies (such as the three just mentioned), primary adaptive emotion responses include the feeling of being certain and in control or uncertain and out of control, and/or a general felt sense of emotional pain—these feelings and emotional pain do not provide immediate action tendencies but do provide adaptive information that can be symbolised and worked through in therapy. Primary adaptive emotion responses “are attended to and expressed in therapy in order to access the adaptive information and action tendency to guide problem solving.”
Primary maladaptive emotion responses are also initial emotional responses to a given stimulus; however, they are based on emotion schemes that are no longer useful (and that may or may not have been useful in the person’s past) and that were often formed through previous traumatic experiences. Examples include sadness at the joy of others, anger at the genuine caring or concern of others, fear at harmless situations, and chronic feelings of insecurity/fear or worthlessness/shame. For example, a person may respond with anger at the genuine caring or concern of others because as a child he or she was offered caring or concern that was usually followed by a violation; as a result, he or she learned to respond to caring or concern with anger even when there is no violation. The person’s angry response is understandable, and needs to be met with empathy and compassion even though his or her angry response is not helpful. Primary maladaptive emotion responses are accessed in therapy with the aim of transforming the emotion scheme through new experiences.
Secondary reactive emotion responses are complex chain reactions where a person reacts to his or her primary adaptive or maladaptive emotional response and then replaces it with another, secondary emotional response. In other words, they are emotional responses to prior emotional responses. (“Secondary” means that a different emotion response occurred first.) They can include secondary reactions of hopelessness, helplessness, rage, or despair that occur in response to primary emotion responses that are experienced (secondarily) as painful, uncontrollable, or violating. They may be escalations of a primary emotion response, as when people are angry about being angry, afraid of their fear, or sad about their sadness. They may be defences against a primary emotion response, such as feeling anger to avoid sadness or fear to avoid anger; this can include gender role-stereotypical responses such as expressing anger when feeling primarily afraid (stereotypical of men’s gender role), or expressing sadness when primarily angry (stereotypical of women’s gender role). “These are all complex, self-reflexive processes of reacting to one’s emotions and transforming one emotion into another. Crying, for example, is not always true grieving that leads to relief, but rather can be the crying of secondary helplessness or frustration that results in feeling worse.” Secondary reactive emotion responses are accessed and explored in therapy in order to increase awareness of them and to arrive at more primary and adaptive emotion responses.
Instrumental emotion responses are experienced and expressed by a person because the person has learned that the response has an effect on others, “such as getting them to pay attention to us, to go along with something we want them to do for us, to approve of us, or perhaps most often just not to disapprove of us.” Instrumental emotion responses can be consciously intended or unconsciously learned (i.e. through operant conditioning). Examples include crocodile tears (instrumental sadness), bullying (instrumental anger), crying wolf (instrumental fear), and feigned embarrassment (instrumental shame). When a client responds in therapy with instrumental emotion responses, it may feel manipulative or superficial to the therapist. Instrumental emotion responses are explored in therapy in order to increase awareness of their interpersonal function and/or the associated primary and secondary gain.
The Therapeutic Process with Different Emotion Responses
Emotion-focused theorists have proposed that each type of emotion response calls for a different intervention process by the therapist. Primary adaptive emotion responses need be more fully allowed and accessed for their adaptive information. Primary maladaptive emotion responses need to be accessed and explored to help the client identify core unmet needs (e.g. for validation, safety, or connection), and then regulated and transformed with new experiences and new adaptive emotions. Secondary reactive emotion responses need empathic exploration in order to discover the sequence of emotions that preceded them. Instrumental emotion responses need to be explored interpersonally in the therapeutic relationship to increase awareness of them and address how they are functioning in the client’s situation.
Primary emotion responses are not called “primary” because they are somehow more real than the other responses; all of the responses feel real to a person, but therapists can classify them into these four types in order to help clarify the functions of the response in the client’s situation and how to intervene appropriately.
Therapeutic Tasks
A therapeutic task is an immediate problem that a client needs to resolve in a psychotherapy session. In the 1970s and 1980s, researchers such as Laura North Rice (a former colleague of Carl Rogers) applied task analysis to transcripts of psychotherapy sessions in an attempt to describe in more detail the process of clients’ cognitive and emotional change, so that therapists might more reliably provide optimal conditions for change. This kind of psychotherapy process research eventually led to a standardised (and evolving) set of therapeutic tasks in emotion-focused therapy for individuals.
The tasks are classified into five broad groups: empathy-based, relational, experiencing, reprocessing, and action. The task marker is an observable sign that a client may be ready to work on the associated task. The intervention process is a sequence of actions carried out by therapist and client in working on the task. The end state is the desired resolution of the immediate problem.
In addition to the task markers, other markers and intervention processes for working with emotion and narrative have been specified: same old stories, empty stories, unstoried emotions, and broken stories.
Experienced therapists can create new tasks; EFT therapist Robert Elliott, in a 2010 interview, noted that “the highest level of mastery of the therapy—EFT included—is to be able to create new structures, new tasks. You haven’t really mastered EFT or some other therapy until you actually can begin to create new tasks.”
The interventions and the structure of emotion-focused therapy have been adapted for the specific needs of psychological trauma survivors. A manual of emotion-focused therapy for individuals with complex trauma (EFTT) has been published. For example, modifications of the traditional Gestalt empty chair technique have been developed.
Other Versions of EFT for Individuals
Brubacher (2017) proposed an emotionally focused approach to individual therapy that focuses on attachment, while integrating the experiential focus of empathic attunement for engaging and reprocessing emotional experience and tracking and restructuring the systemic aspects and patterns of emotion regulation. The therapist follows the attachment model by addressing deactivating and hyperactivating strategies. Individual therapy is seen as a process of developing secure connections between therapist and client, between client and past and present relationships, and within the client. Attachment principles guide therapy in the following ways: forming the collaborative therapeutic relationship, shaping the overall goal for therapy to be that of “effective dependency” (following John Bowlby) upon one or two safe others, depathologising emotion by normalising separation distress responses, and shaping change processes. The change processes are: identifying and strengthening patterns of emotion regulation, and creating corrective emotional experiences to transform negative patterns into secure bonds.
Gayner (2019) integrated EFT principles and methods with mindfulness-based cognitive therapy and mindfulness-based stress reduction.
Couples Therapy
A systemic perspective is important in all approaches to EFT for couples. Tracking conflictual patterns of interaction, often referred to as a “dance” in Johnson’s popular literature, has been a hallmark of the first stage of Johnson and Greenberg’s approach since its inception in 1985. In Goldman and Greenberg’s newer approach, therapists help clients “also work toward self-change and the resolution of pain stemming from unmet childhood needs that affect the couple interaction, in addition to working on interactional change.” Goldman and Greenberg justify their added emphasis on self-change by noting that not all problems in a relationship can be solved only by tracking and changing patterns of interaction:
In addition, in our observations of psychotherapeutic work with couples, we have found that problems or difficulties that can be traced to core identity concerns such as needs for validation or a sense of worth are often best healed through therapeutic methods directed toward the self rather than to the interactions. For example, if a person’s core emotion is one of shame and they feel “rotten at the core” or “simply fundamentally flawed,” soothing or reassuring from one’s partner, while helpful, will not ultimately solve the problem, lead to structural emotional change, or alter the view of oneself.
In Greenberg and Goldman’s approach to EFT for couples, although they “fully endorse” the importance of attachment, attachment is not considered to be the only interpersonal motivation of couples; instead, attachment is considered to be one of three aspects of relational functioning, along with issues of identity/power and attraction/liking. In Johnson’s approach, attachment theory is considered to be the defining theory of adult love, subsuming other motivations, and it guides the therapist in processing and reprocessing emotion.
In Greenberg and Goldman’s approach, the emphasis is on working with core issues related to identity (working models of self and other) and promoting both self-soothing and other-soothing for a better relationship, in addition to interactional change. In Johnson’s approach, the primary goal is to reshape attachment bonds and create “effective dependency” (including secure attachment).
Stages and Steps
EFT for couples features a nine-step model of restructuring the attachment bond between partners. In this approach, the aim is to reshape the attachment bond and create more effective co-regulation and “effective dependency”, increasing individuals’ self-regulation and resilience. In good-outcome cases, the couple is helped to respond and thereby meet each other’s unmet needs and injuries from childhood. The newly shaped secure attachment bond may become the best antidote to a traumatic experience from within and outside of the relationship.
Adding to the original three-stage, nine-step EFT framework developed by Johnson and Greenberg, Greenberg and Goldman’s emotion-focused therapy for couples has five stages and 14 steps. It is structured to work on identity issues and self-regulation prior to changing negative interactions. It is considered necessary, in this approach, to help partners experience and reveal their own underlying vulnerable feelings first, so they are better equipped to do the intense work of attuning to the other partner and to be open to restructuring interactions and the attachment bond.
Johnson (2008) summarizes the nine treatment steps in Johnson’s model of EFT for couples: “The therapist leads the couple through these steps in a spiral fashion, as one step incorporates and leads into the other. In mildly distressed couples, partners usually work quickly through the steps at a parallel rate. In more distressed couples, the more passive or withdrawn partner is usually invited to go through the steps slightly ahead of the other.”
Stage 1. Stabilisation (Assessment and De-escalation Phase)
Step 1: Identify the relational conflict issues between the partners
Step 2: Identify the negative interaction cycle where these issues are expressed
Step 3: Access attachment emotions underlying the position each partner takes in this cycle
Step 4: Reframe the problem in terms of the cycle, unacknowledged emotions, and attachment needs
During this stage, the therapist creates a comfortable and stable environment for the couple to have an open discussion about any hesitations the couples may have about the therapy, including the trustworthiness of the therapist. The therapist also gets a sense of the couple’s positive and negative interactions from past and present and is able to summarise and present the negative patterns for them. Partners soon no longer view themselves as victims of their negative interaction cycle; they are now allies against it.
Stage 2. Restructuring the Bond (Changing Interactional Positions Phase)
Step 5: Access disowned or implicit needs (e.g. need for reassurance), emotions (e.g. shame), and models of self
Step 6: Promote each partner’s acceptance of the other’s experience
Step 7: Facilitate each partner’s expression of needs and wants to restructure the interaction based on new understandings and create bonding events
This stage involves restructuring and widening the emotional experiences of the couple. This is done through couples recognising their attachment needs and then changing their interactions based on those needs. At first, their new way of interacting may be strange and hard to accept, but as they become more aware and in control of their interactions they are able to stop old patterns of behaviour from re-emerging.
Stage 3. Integration and Consolidation
Step 8: Facilitate the formulation of new stories and new solutions to old problems
Step 9: Consolidate new cycles of behaviour
This stage focuses on the reflection of new emotional experiences and self-concepts. It integrates the couple’s new ways of dealing with problems within themselves and in the relationship.
Styles of Attachment
Johnson & Sims (2000) described four attachment styles that affect the therapy process:
Secure attachment: People who are secure and trusting perceive themselves as lovable, able to trust others and themselves within a relationship. They give clear emotional signals, and are engaged, resourceful and flexible in unclear relationships. Secure partners express feelings, articulate needs, and allow their own vulnerability to show.
Avoidant attachment: People who have a diminished ability to articulate feelings, tend not to acknowledge their need for attachment, and struggle to name their needs in a relationship. They tend to adopt a safe position and solve problems dispassionately without understanding the effect that their safe distance has on their partners.
Anxious attachment: People who are psychologically reactive and who exhibit anxious attachment. They tend to demand reassurance in an aggressive way, demand their partner’s attachment and tend to use blame strategies (including emotional blackmail) in order to engage their partner.
Fearful–avoidant attachment: People who have been traumatized and have experienced little to no recovery from it vacillate between attachment and hostility. This is sometimes referred to as disorganised attachment.
Family Therapy
The emotionally focused family therapy (EFFT) of Johnson and her colleagues aims to promote secure bonds among distressed family members. It is a therapy approach consistent with the attachment-oriented experiential–systemic emotionally focused model in three stages:
(1) De-escalating negative cycles of interaction that amplify conflict and insecure connections between parents and children;
(2) restructuring interactions to shape positive cycles of parental accessibility and responsiveness to offer the child or adolescent a safe haven and a secure base; and
(3) consolidation of the new responsive cycles and secure bonds.
Its primary focus is on strengthening parental responsiveness and care-giving, to meet children and adolescents’ attachment needs. It aims to “build stronger families through:
(1) recruiting and strengthening parental emotional responsiveness to children,
(2) accessing and clarifying children’s attachment needs, and
(3) facilitating and shaping care-giving interactions from parent to child”.
Some clinicians have integrated EFFT with play therapy.
One group of clinicians, inspired in part by Greenberg’s approach to EFT, developed a treatment protocol specifically for families of individuals struggling with an eating disorder. The treatment is based on the principles and techniques of four different approaches:
Emotion-focused therapy;
Behavioural family therapy;
Motivational enhancement therapy; and
The New Maudsley family skills-based approach.
It aims to help parents “support their child in the processing of emotions, increasing their emotional self-efficacy, deepening the parent–child relationships and thereby making ED [eating disorder] symptoms unnecessary to cope with painful emotional experiences”. The treatment has three main domains of intervention, four core principles, and five steps derived from Greenberg’s emotion-focused approach and influenced by John Gottman:
(1) Attending to the child’s emotional experience;
(2) Naming the emotions;
(3) Validating the emotional experience;
(4) Meeting the emotional need; and
(5) Helping the child to move through the emotional experience, problem solving if necessary.
Efficacy
Johnson, Greenberg, and many of their colleagues have spent their long careers as academic researchers publishing the results of empirical studies of various forms of EFT.
The American Psychological Association considers emotion-focused therapy for individuals to be an empirically supported treatment for depression. Studies have suggested that it is effective in the treatment of depression, interpersonal problems, trauma, and avoidant personality disorder.
Practitioners of EFT have claimed that studies have consistently shown clinically significant improvement post therapy. Studies, again mostly by EFT practitioners, have suggested that emotionally focused therapy for couples is an effective way to restructure distressed couple relationships into safe and secure bonds with long-lasting results. Johnson et al. (1999) conducted a meta-analysis of the four most rigorous outcome studies before 2000 and concluded that the original nine-step, three-stage emotionally focused therapy approach to couples therapy had a larger effect size than any other couple intervention had achieved to date, but this meta-analysis was later harshly criticised by psychologist James C. Coyne, who called it “a poor quality meta-analysis of what should have been left as pilot studies conducted by promoters of a therapy in their own lab”. A study with an fMRI component conducted in collaboration with American neuroscientist Jim Coan suggested that emotionally focused couples therapy reduces the brain’s response to threat in the presence of a romantic partner; this study was also criticised by Coyne.
A 2019 meta-analysis on EFT effectiveness for couples therapy concluded that the approach significantly improves relationship satisfaction, with these improvements being sustained for up to two years at follow-up.
Strengths
Some of the strengths of EFT approaches can be summarised as follows:
EFT aims to be collaborative and respectful of clients, combining experiential person-centred therapy techniques with systemic therapy interventions.
Change strategies and interventions are specified through intensive analysis of psychotherapy process.
EFT has been validated by 30 years of empirical research. There is also research on the change processes and predictors of success.
EFT has been applied to different kinds of problems and populations, although more research on different populations and cultural adaptations is needed.
EFT for couples is based on conceptualisations of marital distress and adult love that are supported by empirical research on the nature of adult interpersonal attachment.
Criticism
Psychotherapist Campbell Purton, in his 2014 book The Trouble with Psychotherapy, criticised a variety of approaches to psychotherapy, including behaviour therapy, person-centred therapy, psychodynamic therapy, cognitive behavioural therapy, emotion-focused therapy, and existential therapy; he argued that these psychotherapies have accumulated excessive and/or flawed theoretical baggage that deviates too much from an everyday common-sense understanding of personal troubles. With regard to emotion-focused therapy, Purton argued that “the effectiveness of each of the ‘therapeutic tasks’ can be understood without the theory” and that what clients say “is not well explained in terms of the interaction of emotion schemes; it is better explained in terms of the person’s situation, their response to it, and their having learned the particular language in which they articulate their response.”
In 2014, psychologist James C. Coyne criticized some EFT research for lack of rigor (for example, being underpowered and having high risk of bias), but he also noted that such problems are common in the field of psychotherapy research.
In a 2015 article in Behavioural and Brain Sciences on “memory reconsolidation, emotional arousal and the process of change in psychotherapy”, Richard D. Lane and colleagues summarised a common claim in the literature on emotion-focused therapy that “emotional arousal is a key ingredient in therapeutic change” and that “emotional arousal is critical to psychotherapeutic success”. In a response accompanying the article, Bruce Ecker and colleagues (creators of coherence therapy) disagreed with this claim and argued that the key ingredient in therapeutic change involving memory reconsolidation is not emotional arousal but instead a perceived mismatch between an expected pattern and an experienced pattern; they wrote:
The brain clearly does not require emotional arousal per se for inducing deconsolidation. That is a fundamental point. If the target learning happens to be emotional, then its reactivation (the first of the two required elements) of course entails an experience of that emotion, but the emotion itself does not inherently play a role in the mismatch that then deconsolidates the target learning, or in the new learning that then rewrites and erases the target learning (discussed at greater length in Ecker 2015). […] The same considerations imply that “changing emotion with emotion” (stated three times by Lane et al.) inaccurately characterizes how learned responses change through reconsolidation. Mismatch consists most fundamentally of a direct, unmistakable perception that the world functions differently from one’s learned model. “Changing model with mismatch” is the core phenomenology.
Other responses to Lane et al. (2015) argued that their emotion-focused approach “would be strengthened by the inclusion of predictions regarding additional factors that might influence treatment response, predictions for improving outcomes for non-responsive patients, and a discussion of how the proposed model might explain individual differences in vulnerability for mental health problems”, and that their model needed further development to account for the diversity of states called “psychopathology” and the relevant maintaining and worsening processes.
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The British Journal of Psychiatry is a peer-reviewed medical journal covering all branches of psychiatry with a particular emphasis on the clinical aspects of each topic.
The journal is owned by the Royal College of Psychiatrists and published monthly by Cambridge University Press on behalf of the college. The journal publishes original research papers from around the world as well as editorials, review articles, commentaries on contentious articles, short reports, a comprehensive book review section and correspondence column. The complete archive of contents from 1855 to the present is available online. All content from January 2000 on is made freely available 1 year after publication.
Brief History
The journal was established in 1853 as the Asylum Journal, changing title in 1855 to the Asylum Journal of Mental Science and changing title again to Journal of Mental Science from 1858 to 1963, when it obtained its present name.
Reception
According to the Journal Citation Reports, the journal has a 2018 impact factor of 7.233.
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Conolly Norman (12 March 1853 to 23 February 1908) was an Irish alienist, or psychiatrist, of the late nineteenth and early twentieth centuries. He was the Resident Medical Superintendent of a number of district asylums, most notably Ireland’s largest asylum, the Richmond District Lunatic Asylum, now known as St. Brendan’s Hospital.
Early Life
Norman was born on 12 March 1853 at All Saints’ Glebe, Newtown Cunningham, County Donegal, Ireland. The fifth child of six boys, his father, Hugh Norman, was the rector of All Saints’ and later of Barnhill. His family were prominent and politically active in Derry with several members serving as mayor of Derry. Two members of his family were also elected to parliament.
Medical Education
Educated at home due to his fragile health as a child, at the age of seventeen Norman began his medical studies at Trinity College, Dublin, the Carmichael Medical School, and the Richmond Surgical Hospital, gaining a M.D. In 1874 he became a licentiate of the Royal College of Physicians and Surgeons, a fellow of the Royal College of Surgeons in 1878 and a fellow of the Royal College of Physicians in 1890.
Early Career
After he graduated in 1874, Norman immediately took up a post as an assistant medical officer in the Monaghan District Lunatic Asylum. He remained in that post until 1880 when he joined the staff of the Bethlem Royal Hospital in London where he worked under the prominent English alienist Sir George Savage. Returning to Ireland in 1882 he was appointed the Resident Medical Superintendent of Castlebar District Lunatic Asylum in Co. Mayo. He remained there until 1885 when he was appointed Resident Medical Superintendent of the Monaghan Asylum. In 1886, he was appointed by the Lord Lieutenant as Resident Medical Superintendent to Ireland’s largest asylum, the Richmond District Lunatic Asylum. He would remain in this last post until his death in 1908 at the age of fifty-five.
Richmond District Lunatic Asylum
While the Richmond asylum prior to Norman’s arrival has been described as primitive and prisonlike this is perhaps to overlook the international praise that his predecessor, John Lalor had received, particularly in regard to his educational initiatives in establishing a national school for the patients in the grounds of the hospital. In any case, by 1904, Connolly could assert like a growing number of reforming alienists, that Emil Kraepelin‘s dementia praecox (a concept intimately linked with schizophrenia) was not incurable.
Publications
(1885). ‘On Insanity Alternating with Spasmodic Asthma’. Journal of Mental Science. 31: 1–12.
(1886). ‘Some Points in Irish Lunacy Law’. Journal of Mental Science. 31: 459–67.
(1886). ‘Two Cases of Larvated Insanity’. Journal of Mental Science. 32: 36–44.
(1887). ‘Cases Illustrating the Sedative Effects of Aceto-phenone (hypnone)’. Journal of Mental Science. 32: 519–25.
(1887). ‘Variations in form of mental affections in relation to the classification of insanity’. The Dublin Journal of Medical Science. 83: 228–35.
(1888). ‘A Rare Form of Mental Disease (Grübelsucht)’. Journal of Mental Science. 34: 400–08.
(1889). ‘On Sulphonal’. The Dublin Journal of Medical Science. 87: 19–27.
(1890). ‘Acute confusional insanity’. The Dublin Journal of Medical Science. 89: 506–18.
(1890). ‘Case of Intracranial Tumour’. Journal of Mental Science. 36: 361–67.
(1892). ‘A Note on Cocainism’. Journal of Mental Science. 38: 195–99.
(1894). ‘Presidential Address (Medico-Psychological Association), delivered at the Royal College of Physicians, Dublin, 12 June 1894’. Journal of Mental Science. 40: 487–99.
(1894). ‘A Case of Porencephaly’. Journal of Mental Science 40: 649–65.
(1896). ‘The domestic treatment of the insane’. The Dublin Journal of Medical Science. 101: 111–21.
(1899). ‘Considerations on the Mental State in Aphasia’. Journal of Mental Science.45: 326–37.
(1899). ‘A Brief Note on Beri-beri in Asylums’. Journal of Mental Science. 45: 503–12.
(1899). ‘Emphysema of the Subcutaneous Areolar Tissue Occurring in a Case of Acute Mania’. Journal of Mental Science. 45: 749–58.
(1899). ‘Reports on the Progress of Neurology and Psychiatry’. The Dublin Journal of Medical Science. 107: 209–21.
(1900). ‘The Clinical Features of Beri-Beri’. The Dublin Journal of Medical Science. 109(337): 1–16.
(1900). ‘Remarks on Senile Demenita’. The Dublin Journal of Medical Science. 110(346): 250–265.
(1902). ‘Notes on Hallucinations. I’. Journal of Mental Science. 48: 45–53.
(1903). ‘Notes on Hallucinations. II’. Journal of Mental Science. 49: 272–91.
(1903). ‘Notes on Hallucinations. III’. Journal of Mental Science. 49: 454–73.
(1904). ‘Gossip about Gheel’. Journal of Mental Science. 50: 53–64.
(1904). ‘Dementia Praecox’. The British Medical Journal. 2(2285): 972–76.
(1904). ‘On the Need for Family Care of Persons of Unsound Mind in Ireland’. Journal of Mental Science. 50: 461–73.
(1905). ‘Modern Witchcraft: a Study of a Phase of Paranoia’. Journal of Mental Science. (1905) 51: 116–25.
(1905). ‘The Family Care of the Insane’. Medical Press and Circular. 29 November – 6 December.
(1906). ‘Multiple Lipomata in General Paralysis’. Journal of Mental Science. 52: 62–9.
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Eleonora Lilian Fleury (1867–1960) sometimes known as Norah Fleury was the first woman to graduate in medicine from the Royal University of Ireland (1890). She was also the first woman member of the Medico Psychological Association (now the Royal College of Psychiatrists), elected in 1894. After graduating medical school, she worked at the Homerton Fever Hospital in London for a year, and then worked at the Richmond Asylum (later called Grangegorman) in Ireland for 27 years, eventually becoming deputy medical director there. From 1921 until 1926 she worked at Portrane Asylum in Donabate, and then she retired. She was arrested in 1921 by Irish state forces for being involved in an assistance and escape programme for anti-treaty prisoners which was centred on the asylum at Portrane. After she was released she returned to her work at the asylum.
Early Life and Education
Eleonora Fleury was born in Manchester in 1867. Her father was Charles Robert Fleury, who was a doctor/surgeon. She was home schooled. She attended the Royal University of Ireland and in 1887 came first in the list of the examinations in medicine and was commended in the Dublin Medical Press. She became the first woman to graduate in medicine from the Royal University of Ireland, with MB first-class honours and a first-class exhibition in 1890 and then MD degree and a Gold Medal in 1893. There were a comparatively large number of women students at the University at this time because Trinity College Dublin did not accept women until 1904. After graduation she attended clinical instruction at the Richmond Hospital, in Dublin and the London School of Medicine for Women for a three-month course of clinical instruction in mental diseases.
Work
Fleury became a successful psychiatrist, as well as the first woman to join the Medico-Psychological Association (MPA), now known as the Royal College of Psychiatrists. Following qualification, she worked at the Homerton Fever Hospital in London for a year before returning to Ireland to work at the Richmond District Asylum at Grangegorman for 27 years. This was the largest asylum in Ireland. She was initially a clinical assistant and her promotion was slow with suggestions that she always ‘passed over for male colleagues’. However, her active involvement with Irish nationalism may also have been a factor. From 1921 she worked at its associated Portrane Asylum, Donabate, (now known as St. Ita’s Hospital) and she eventually rose to be the deputy resident medical superintendent. She retired in 1926.
In 1893, she was proposed for membership of the Medico-Psychological Association. Her proposer was Conolly Norman, director of the Richmond District Asylum where she worked and also the president of the Medico-Psychological Association in 1895, and editor of the Journal of Mental Science. Her application was declined on the grounds that the Association rules had to be changed to allow women to become members. In 1894 she was elected by 23 votes to 7. She remained a member until 1924. This made her the first woman psychiatrist in Ireland or Great Britain.
While at the Richmond Asylum she was not only involved in treating patients but she was also with teaching nurses and attendants who were studying for the new certificate of proficiency Mental Nursing. She published scientific papers including Agitated Melancholia in Women, which was read at the 1895 Irish Divisional meeting of the Medico-Psychological Association.
In 1923 she was arrested and imprisoned in Kilmainham Gaol in Dublin. While in prison she served as medical officer to the republican prisoners. She became concerned about the women inmates’ medical welfare and after her release she continued to advocate for improved conditions for women prisoners. On her release, she returned to her duties at Portrane.
Death
She lived in Upper Rathmines Road in Dublin and led an active life until her death in 1960. She is buried at Mount Jerome Cemetery in Harold’s Cross, Dublin.
Legacy
An exhibition on the Women of the Peninsula or “Mná Na Leithinse” celebrated Fleury’s work and achievements during the Bleeding Pig Cultural Festival at the Donabate and Portrane peninsula on 08 March 2017.
The Royal College of Psychiatrists is the main professional organisation of psychiatrists in the United Kingdom, and is responsible for representing psychiatrists, for psychiatric research and for providing public information about mental health problems. The college provides advice to those responsible for training and certifying psychiatrists in the UK.
In addition to publishing many books and producing several journals, the college produces, for the public, information about mental health problems. Its offices are located at 21 Prescot Street in London, near Aldgate. The college’s previous address was Belgrave Square.
Brief History
The college has existed in various forms since 1841, having started as the Association of Medical Officers of Asylums and Hospitals for the Insane. In 1865 it became the Medico-Psychological Association. In 1926, the association received its royal charter, becoming the Royal Medico-Psychological Association. In 1971, a supplemental charter gave the association the name of the Royal College of Psychiatrists.
Eleanora Fleury, became the first female member of the Medico Psychological Association in 1894, when she was elected by 23 votes to 7. She remained a member until 1924. This made her the first woman psychiatrist in Ireland or Great Britain.
Coat of Arms
The coat of arms incorporates the traditional serpent-entwined Rod of Asclepius symbolic of medicine, and butterflies associated with Psyche. Previous to the grant of these arms, the Medico-Psychological Association had used a device showing the seated Psyche with butterfly’s wings. The arms were originally granted to the Royal Medico-Psychological Association in 1926, and were confirmed to the college on its formation in 1971 by the College of Arms. They were also registered in Scotland by the Court of the Lord Lyon.
Policy and Campaigns
The college runs campaigns, including Choose Psychiatry, which has helped increase the fill rate of posts from 78% in 2018 to 100% in 2020, as well as calling for parity in the funding of mental health services.
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Samuel Richard Slavson (25 December 1890 to 05 August 1981) was an American engineer, journalist and teacher, who began to engage in group analysis in 1919. He is considered one of the pioneers of group psychotherapy for his contributions to its recognition as a scientific discipline. Slavson wrote over 20 books and served as the founding president of the American Group Psychotherapy Association (AGPA). He also established children’s group therapy and developed a specific small group model.
Life and Work
Slavson, born Amstislavski, came to New York in 1903 after escaping the Ukrainian pogroms. Early on, he became involved in self-culture clubs for children and young people. While studying to become a civil engineer, he developed youth support programmes, because he believed there was inherent creative potential in every human being. He sympathized with the ideas of progressive education and Freud’s theories, as well as the child guidance movement. He was also a part of the Jewish Board of Guardians in New York, a care centre for girls and boys with developmental disabilities, where he worked from 1934 to 1956. In 1934, he was able to start proving the efficacy of group work with emotional disorders.
In 1943, Slavson published An introduction to Group Therapy, the first and fundamental work on the use of group psychotherapy with children and youth. This work gained wide recognition and was for instance ranked by the Menninger Foundation among the 10 Classics of Psychotherapy. He was a founding member and the first President of the AGPA, which was keen to be well-recognised by psychiatrists; all of the 12 direct successors of the non-medical practitioner Slavson were in fact psychiatrists. Moreover, Slavson – who still exerted substantial influence in the organisation after the end of his presidency in 1940 – strictly ensured that the institution remained classically Freudian, orthodox and in a clear defensive position to Neo-Freudians, existentialists and transactional analysts. Slavson worked as a teacher, supervisor and de facto editor of the International Journal of Group Psychology, at both the national and international level. His was involved in a decades-long controversy and rivalry with Jacob L. Moreno, the founder of psychodrama.
According to Stumm et al. (1992):
“Slavson justified the recognition of group psychotherapy as a scientific discipline, provided fundamental theoretical contributions to this end and established a professional organization in the United States, which laid out binding guidelines for qualified training for the first time.”
Children’s Group Psychotherapy
Slavson is considered the founder of children’s group psychotherapy. He saw games as methods of therapy and used modelling clay, puppet theatres and building blocks. He believed that by these means, children would develop their social skills and strengthen their community spirit. He said that children can change their behaviour while in a group of peers, believing that an otherwise quiet child becomes more open and bold and that a loud child becomes more reserved. He believed children would be able to relate to each other’s problems. Through the group, according to Slavson, a feeling of unity can be created and a sense of identity can become strengthened. Developmentally, he thought this is particularly important for children aged 6 to 7 years.
Small Group Model
After decades of work with children and young people, in the late 1940s Slavson started working with adults as well. His small group model is designed for a maximum of 8 participants and is based on groups homogeneous in terms of age, sex and symptoms. Slavson developed several disorder-specific models, with exact descriptions for clinical use. Distinctions were made between counselling, guidance and psychotherapy. His parent groups around child welfare were particularly well known as well as vita-erg therapy with psychotic women.
In 1964, Slavson put forward a summary of his theoretical developments and practical experience in the volume A Textbook in Analytic Group Psychotherapy. He combined Freud’s theory of psychosexual development with terms from the field of sociology and recognized the human search for relationships and acceptance as a primary need. He saw the group as an “I (ego) therapy” within a collective “we-superego”, which opens up a path out of selfishness and psychological isolation. He is credited for synthesizing the principles of the founding generation of psychoanalytical theory with the requirements of American psychiatry.
Awards
1969 Award from the American Academy of Psychotherapists 1972 Father of group psychotherapy
In Popular Culture
A. Klein: He lets them grow. Survey 85 (1949): 75-80
Hyman Spotnitz: In tribute to S.R.Slavson. Intern’ Journal of Group Psychotherapy 21 (1971): 402-405
Scheidlinger/Schamess: Fifty years of AGPA 1942–1992: An overview. Intern’ Journal of Group Psychotherapy 42 (1992): 1-22
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The American Group Psychotherapy Association (AGPA) is a not-for-profit multi-disciplinary organisation dedicated to enhancing the practice, theory and research of group psychotherapy.
Brief History
The inception of the American Group Psychotherapy Association began in 1942 with the actual decision to found the organisation being made in February 1943 during a meeting of the American Orthopsychiatric Association in New York City. The organisation was first named the American Group Therapy Association. In 1952, the name was officially changed to the American Group Psychotherapy Association. Samuel R. Slavson was one of the founders and served as the first president of the AGPA.
Membership
American Group Psychotherapy Association is a national organisation with over 2000 members internationally and 31 affiliate societies. Members come from disciplines such as psychology, creative art therapy, psychiatry, nursing, social work, professional counselling, addictions, and marriage and family therapy. AGPA’s annual meeting attracts approximately 1000 attendees.
Certification
The International Board for Certification of Group Psychotherapists is a not-for-profit corporation formed to function autonomously from AGPA. The International Board for Certification of Group Psychotherapists (IBCGP) awards group therapists certification after they have presented documentation demonstrating the completion of a significant amount of training through coursework, experience, and supervision. A Certified Group Psychotherapist (CGP) is also required to continue lifelong learning by obtaining continuing education credits (CEU’s) in effective leadership of psychotherapy groups.
Organisational Involvement
The diversity of AGPA membership has been actively involved in the promotion of group therapy as an alternative treatment to the public and private sectors. The development of ethical and practice standards. AGPA membership has also responded to the nation’s disasters; for example, September 11 and Hurricane Katrina. AGPA has also developed a set of standards of practice for group therapy for use by practitioners. This resource assists the clinician in the development of evidence-based and best practices. AGPA does not de-certify its members or monitor its membership for quality of practice, instead, they go by the state licensing. The only time an AGPA member would lose their CGP certification is if their license was suspended by their state’s board of psychologists.
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Neuroepigenetics is the study of how epigenetic changes to genes affect the nervous system. These changes may effect underlying conditions such as addiction, cognition, and neurological development.
Mechanisms
Neuroepigenetic mechanisms regulate gene expression in the neuron. Often, these changes take place due to recurring stimuli. Neuroepigenetic mechanisms involve proteins or protein pathways that regulate gene expression by adding, editing or reading epigenetic marks such as methylation or acetylation. Some of these mechanisms include ATP-dependent chromatin remodelling, LINE1, and prion protein-based modifications. Other silencing mechanisms include the recruitment of specialised proteins that methylate DNA such that the core promoter element is inaccessible to transcription factors and RNA polymerase. As a result, transcription is no longer possible. One such protein pathway is the REST co-repressor complex pathway. There are also several non-coding RNAs that regulate neural function at the epigenetic level. These mechanisms, along with neural histone methylation, affect arrangement of synapses, neuroplasticity, and play a key role in learning and memory.
Methylation
DNA methyltransferases (DNMTs) are involved in regulation of the electrophysiological landscape of the brain through methylation of CpGs. Several studies have shown that inhibition or depletion of DNMT1 activity during neural maturation leads to hypomethylation of the neurons by removing the cell’s ability to maintain methylation marks in the chromatin. This gradual loss of methylation marks leads to changes in the expression of crucial developmental genes that may be dosage sensitive, leading to neural degeneration. This was observed in the mature neurons in the dorsal portion of the mouse prosencephalon, where there was significantly greater amounts of neural degeneration and poor neural signalling in the absence of DNMT1. Despite poor survival rates amongst the DNMT1-depleted neurons, some of the cells persisted throughout the lifespan of the organism. The surviving cells reaffirmed that the loss of DNMT1 led to hypomethylation in the neural cell genome. These cells also exhibited poor neural functioning. In fact, a global loss of neural functioning was also observed in these model organisms, with the greatest amounts neural degeneration occurring in the prosencephalon.
Other studies showed a trend for DNMT3a and DNMT3b. However, these DNMT’s add new methyl marks on unmethylated DNA, unlike DNMT1. Like DNMT1, the loss of DNMT3a and 3b resulted in neuromuscular degeneration two months after birth, as well as poor survival rates amongst the progeny of the mutant cells, even though DNMT3a does not regularly function to maintain methylation marks. This conundrum was addressed by other studies which recorded rare loci in mature neurons where DNMT3a acted as a maintenance DNMT. The Gfap locus, which codes for the formation and regulation of the cytoskeleton of astrocytes, is one such locus where this activity is observed. The gene is regularly methylated to downregulate glioma related cancers. DNMT inhibition leads to decreased methylation and increased synaptic activity. Several studies show that the methylation-related increase or decrease in synaptic activity occurs due to the upregulation or downregulation of receptors at the neurological synapse. Such receptor regulation plays a major role in many important mechanisms, such as the ‘fight or flight’ response. The glucocorticoid receptor (GR) is the most studied of these receptors. During stressful circumstances, there is a signalling cascade that begins from the pituitary gland and terminates due to a negative feedback loop from the adrenal gland. In this loop, the increase in the levels of the stress response hormone results in the increase of GR. Increase in GR results in the decrease of cellular response to the hormone levels. It has been shown that methylation of the I7 exon within the GR locus leads to a lower level of basal GR expression in mice. These mice were more susceptible to high levels of stress as opposed to mice with lower levels of methylation at the I7 exon. Up-regulation or down-regulation of receptors through methylation leads to change in synaptic activity of the neuron.
Hypermethylation, CpG Islands, and Tumour Suppressing Genes
CpG Islands (CGIs) are regulatory elements that can influence gene expression by allowing or interfering with transcription initiation or enhancer activity. CGIs are generally interspersed with the promoter regions of the genes they affect and may also affect more than one promoter region. In addition they may also include enhancer elements and be separate from the transcription start site. Hypermethylation at key CGIs can effectively silence expression of tumour suppressing genes and is common in gliomas. Tumour suppressing genes are those which inhibit a cell’s progression towards cancer. These genes are commonly associated with important functions which regulate cell-cycle events. For example, PI3K and p53 pathways are affected by CGI promoter hypermethylation, this includes the promoters of the genes CDKN2/p16, RB, PTEN, TP53 and p14ARF. Importantly, glioblastomas are known to have high frequency of methylation at CGIs/promoter sites. For example, Epithelial Membrane Protein 3 (EMP3) is a gene which is involved in cell proliferation as well as cellular interactions. It is also thought to function as a tumour suppressor, and in glioblastomas is shown to be silenced via hypermethylation. Furthermore, introduction of the gene into EMP3-silenced neuroblasts results in reduced colony formation as well as suppressed tumour growth. In contrast, hypermethylation of promoter sites can also inhibit activity of oncogenes and prevent tumorigenesis. Such oncogenic pathways as the transformation growth factor (TGF)-beta signalling pathway stimulate cells to proliferate. In glioblastomas the overactivity of this pathway is associated with aggressive forms of tumour growth. Hypermethylation of PDGF-B, the TGF-beta target, inhibits uncontrolled proliferation.
Hypomethylation and Aberrant Histone Modification
Global reduction in methylation is implicated in tumorigenesis. More specifically, wide spread CpG demethylation, contributing to global hypomethylation, is known to cause genomic instability leading to development of tumours. An important effect of this DNA modification is its transcriptional activation of oncogenes. For example, expression of MAGEA1 enhanced by hypomethylation interferes with p53 function.
Aberrant patterns of histone modifications can also take place at specific loci and ultimately manipulate gene activity. In terms of CGI promoter sites, methylation and loss of acetylation occurs frequently at H3K9. Furthermore, H3K9 dimethylation and trimethylation are repressive marks which, along with bivalent differentially methylated domains, are hypothesized to make tumour suppressing genes more susceptible to silencing. Abnormal presence or lack of methylation in glioblastomas are strongly linked to genes which regulate apoptosis, DNA repair, cell proliferation, and tumour suppression. One of the best known examples of genes affected by aberrant methylation that contributes to formation of glioblastomas is MGMT, a gene involved in DNA repair which encodes the protein O6-methylguanine-DNA methyltransferase. Methylation of the MGMT promoter is an important predictor of the effectiveness of alkylating agents to target glioblastomas. Hypermethylation of the MGMT promoter causes transcriptional silencing and is found in several cancer types including glioma, lymphoma, breast cancer, prostate cancer, and retinoblastoma.
Neuroplasticity
Neuroplasticity refers to the ability of the brain to undergo synaptic rearrangement as a response to recurring stimuli. Neurotrophin proteins play a major role in synaptic rearrangement, amongst other factors. Depletion of neurotrophin BDNF or BDNF signalling is one of the main factors in developing diseases such as Alzheimer’s disease, Huntington’s disease, and depression. Neuroplasticity can also occur as a consequence of targeted epigenetic modifications such as methylation and acetylation. Exposure to certain recurring stimuli leads to demethylation of particular loci and remethylation in a pattern that leads to a response to that particular stimulus. Like the histone readers, erasers and writers also modify histones by removing and adding modifying marks respectively. An eraser, neuroLSD1, is a modified version of the original Lysine Demethylase 1(LSD1) that exists only in neurons and assists with neuronal maturation. Although both versions of LSD1 share the same target, their expression patterns are vastly different and neuroLSD1 is a truncated version of LSD1. NeuroLSD1 increases the expression of immediate early genes (IEGs) involved in cell maturation. Recurring stimuli lead to differential expression of neuroLSD1, leading to rearrangement of loci. The eraser is also thought to play a major role in the learning of many complex behaviors and is way through which genes interact with the environment.
Neurodegenerative Diseases
Alzheimer’s Disease
Alzheimer’s disease (AD) is a neurodegenerative disease known to progressively affect memory and incite cognitive degradation. Epigenetic modifications both globally and on specific candidate genes are thought to contribute to the aetiology of this disease. Immunohistochemical analysis of post-mortem brain tissues across several studies have revealed global decreases in both 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC) in AD patients compared with controls. However, conflicting evidence has shown elevated levels of these epigenetic markers in the same tissues. Furthermore, these modifications appear to be affected early on in tissues associated with the pathophysiology of AD. The presence of 5mC at the promoters of genes is generally associated with gene silencing. 5hmC, which is the oxidised product of 5mC, via ten-eleven-translocase (TET), is thought to be associated with activation of gene expression, though the mechanisms underlying this activation are not fully understood.
Regardless of variations in results of methylomic analysis across studies, it is known that the presence of 5hmC increases with differentiation and aging of cells in the brain. Furthermore, genes which have a high prevalence of 5hmC are also implicated in the pathology of other age related neurodegenerative diseases, and are key regulators of ion transport, neuronal development, and cell death. For example, over-expression of 5-Lipoxygenase (5-LOX), an enzyme which generates pro-inflammatory mediators from arachidonic acid, in AD brains is associated with high prevalence of 5hmC at the 5-LOX gene promoter region.
Amyotrophic Lateral Sclerosis
DNA modifications at different transcriptional sites have been shown to contribute to neurodegenerative diseases. These include harmful transcriptional alterations such as those found in motor neuron functionality associated with Amyotrophic Lateral Sclerosis (ALS). Degeneration of upper and lower motor neurons, which contributes to muscle atrophy in ALS patients, is linked to chromatin modifications among a group of key genes. One important site that is regulated by epigenetic events is the hexanucleotide repeat expansion in C9orf72 within the chromosome 9p21. Hypermethylation of the C9orf72 related CpG Islands is shown to be associated with repeat expansion in ALS affected tissues. Overall, silencing of the C9orf72 gene may result in haploinsufficiency, and may therefore influence the presentation of disease. The activity of chromatin modifiers is also linked to prevalence of ALS. DNMT3A is an important methylating agent and has been shown to be present throughout the central nervous systems of those with ALS. Furthermore, over-expression of this de novo methyl transferase is also implicated in cell death of motor-neuron analogues.
Mutations in the FUS gene, that encodes an RNA/DNA binding protein, are causally linked to ALS. ALS patients with such mutations have increased levels of DNA damage. The protein encoded by the FUS gene is employed in the DNA damage response. It is recruited to DNA double-strand breaks and catalyses recombinational repair of such breaks. In response to DNA damage, the FUS protein also interacts with histone deacetylase I, a protein employed in epigenetic alteration of histones. This interaction is necessary for efficient DNA repair. These findings suggest that defects in epigenetic signalling and DNA repair contribute to the pathogenesis of ALS.
Neuro-oncology
A multitude of genetic and epigenetic changes in DNA profiles in brain cells are thought to be linked to tumourgenesis. These alterations, along with changes in protein functions, are shown to induce uncontrolled cell proliferation, expansion, and metastasis. While genetic events such as deletions, translocations, and amplification give rise to activation of oncogenes and deactivation of tumour suppressing genes, epigenetic changes silence or up-regulate these same genes through key chromatin modifications.
Neurotoxicity
Neurotoxicity refers to damage made to the central or peripheral nervous systems due to chemical, biological, or physical exposure to toxins. Neurotoxicity can occur at any age and its effects may be short-term or long-term, depending on the mechanism of action of the neurotoxin and degree of exposure.
Certain metals are considered essential due to their role in key biochemical and physiological pathways, while the remaining metals are characterized as being nonessential. Nonessential metals do not serve a purpose in any biological pathway and the presence and accumulation in the brain of most can lead to neurotoxicity. These nonessential metals, when found inside the body compete with essential metals for binding sites, upset antioxidant balance, and their accumulation in the brain can lead to harmful side effects, such as depression and intellectual disability. An increase in nonessential heavy metal concentrations in air, water and food sources, and household products has increased the risk of chronic exposure.
Acetylation, methylation and histone modification are some of the most common epigenetic markers. While these changes do not directly affect the DNA sequence, they are able to alter the accessibility to genetic components, such as the promoter or enhancer regions, necessary for gene expression. Studies have shown that long-term maternal exposure to lead (Pb) contributes to decreased methylation in areas of the foetal epigenome, for example the interspaced repetitive sequences (IRSs) Alu1 and LINE-1. The hypomethylation of these IRSs has been linked to increased risk for cancers and autoimmune diseases later in life. Additionally, studies have found a relationship between chronic prenatal Pb exposure and neurological diseases, such as Alzheimer’s and schizophrenia, as well as developmental issues. Furthermore, the acetylation and methylation changes induced by overexposure to lead result in decreased neurogenesis and neuron differentiation ability, and consequently interfere with early brain development.
Overexposure to essential metals can also have detrimental consequences on the epigenome. For example, when manganese, a metal normally used by the body as a cofactor, is present at high concentrations in the blood it can negatively affect the central nervous system. Studies have shown that accumulation of manganese leads to dopaminergic cell death and consequently plays a role in the onset of Parkinson’s disease (PD). A hallmark of Parkinson’s disease is the accumulation of α-Synuclein in the brain. Increased exposure to manganese leads to the downregulation of protein kinase C delta (PKCδ) through decreased acetylation and results in the misfolding of the α-Synuclein protein that allows aggregation and triggers apoptosis of dopaminergic cells.
Research
The field has only recently seen a growth in interest, as well as in research, due to technological advancements that facilitate better resolution of the minute modifications made to DNA. However, even with the significant advances in technology, studying the biology of neurological phenomena, such as cognition and addiction, comes with its own set of challenges. Biological study of cognitive processes, especially with humans, has many ethical caveats. Some procedures, such as brain biopsies of Rett Syndrome patients, usually call for a fresh tissue sample that can only be extricated from the brain of deceased individual. In such cases, the researchers have no control over the age of brain tissue sample, thereby limiting research options. In case of addiction to substances such as alcohol, researchers utilise mouse models to mirror the human version of the disease (even though mouse models do not translate very well to human models). However, the mouse models are administered greater volumes of ethanol than humans normally consume in order to obtain more prominent phenotypes. Therefore, while the model organism and the tissue samples provide an accurate approximation of the biology of neurological phenomena, these approaches do not provide a complete and precise picture of the exact processes underlying a phenotype or a disease.
Neuroepigenetics had also remained underdeveloped due to the controversy surrounding the classification of genetic modifications in matured neurons as epigenetic phenomena. This discussion arises due to the fact that neurons do not undergo mitosis after maturation, yet the conventional definition of epigenetic phenomena emphasizes heritable changes passed on from parent to offspring. However, various histone modifications are placed by epigenetic modifiers such as DNA methyltransferases (DNMT) in neurons and these marks regulate gene expression throughout the life span of the neuron. The modifications heavily influence gene expression and arrangement of synapses within the brain. Finally, although not inherited, most of these marks are maintained throughout the life of the cell once they are placed on chromatin.
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The American Osteopathic Board of Neurology and Psychiatry (AOBNP) is an organisation that provides board certification to qualified Doctors of Osteopathic Medicine (D.O.) and non-osteopathic (MD and equivalent) physicians who specialise in disorders of the nervous system (neurologists) and to qualified Doctors of Osteopathic Medicine and physicians who specialise in the diagnosis and treatment of mental disorders (psychiatrists).
The board is one of 16 medical specialty certifying boards of the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS) of the American Osteopathic Association (AOA). Established in 1941, the AOBNP is responsible for examining physicians who have completed an ACGME-accredited residency in neurology and/or psychiatry. Since its inception, over 630 physicians have achieved primary certification in psychiatry and 400 in neurology, along with physicians holding subspecialty certifications.
The AOBNP is one of two certifying boards for neurologists and psychiatrists in the United States. The other certifying authority is the American Board of Psychiatry and Neurology, Inc. (ABPN), a member board of the American Board of Medical Specialties.
Organisation
There are eight elected members of the AOBNP. Each member is an AOA board-certified physician, certified through the AOBNP. Membership includes a representatives from each area of neurology (4) and psychiatry (4), as well as representation from the subspecialties of the board and a representative from each of the time divisions of the United States whenever possible.
Board Certification
Initial certification is available to osteopathic and other neurologists and psychiatrists who have successfully completed an ACGME-accredited residency in neurology or psychiatry and successful completion of the written exam.
Board certified neurologists and psychiatrists (diplomates of the AOBNP) must participate in Osteopathic Continuous Certification on an ongoing basis to avoid expiration of their board certified status.
Effective 01 June 2019, all AOA specialty certifying boards implemented an updated continuous certification process for osteopathic physicians, called “(OCC)”, and are required to publish the requirements for OCC in their basic documents. The following components comprise the updated OCC process:
Component 1: Licensure. AOA board-certified physicians must hold a valid, active license to practice medicine in one of the 50 states or Canada.
Component 2: Lifelong Learning/Continuing Medical Education. A minimum of 75 CME credits in the specialty area of certification during each 3-year cycle. Of these 75 specialty CME credits, 18 must be AOA Category 1-A. The remaining 57 hours will have broad acceptance of specialty CME.
Component 3: Cognitive Assessment: AOBA board-certified physicians must complete the online cognitive assessment annually after entry into the Longitudinal Assessment process to maintain compliance with OCC.
Component 4: Practice Performance Assessment and Improvement. Attestation of participation in quality improvement activities. Physicians may view the Attestation Form by logging in with their AOA credentials to the AOA Physician Portal on the AOA website.
Diplomates of the AOBNP may also receive Subspecialty Certification or Certification of Special Qualifications in the following areas:
Addiction Medicine
Neurophysiology
Geriatric Psychiatry
Hospice and Palliative Medicine
Sleep Medicine
Effective 01 July 2020, allopathic (MD) physicians may apply for certification by the AOBNP.
Mental Health Matters 
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