Category: Mental Health History

On This Day … 13 March

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People (Deaths)

  • 1990 – Bruno Bettelheim, Austrian-American psychologist and author (b. 1903).

Bruno Bettelheim

Bruno Bettelheim (28 August 1903 to 13 March 1990) was an Austrian-born psychologist, scholar, public intellectual and author who spent most of his academic and clinical career in the United States. An early writer on autism, Bettelheim’s work focused on the education of emotionally disturbed children, as well as Freudian psychology more generally. In the US, he later gained a position as professor at the University of Chicago and director of the Sonia Shankman Orthogenic School for Disturbed Children, and after 1973 taught at Stanford University.

Bettelheim’s ideas, which grew out of those of Sigmund Freud, theorised that children with behavioural and emotional disorders were not born that way, and could be treated through extended psychoanalytic therapy, treatment that rejected the use of psychotropic drugs and shock therapy. During the 1960s and 1970s he had an international reputation in such fields as autism, child psychiatry, and psychoanalysis.

Much of his work was discredited after his death due to fraudulent academic credentials, allegations of abusive treatment of patients under his care, accusations of plagiarism, and lack of oversight by institutions and the psychological community.

What is the National Supervisory Authority for Welfare & Health (Finland)?

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Introduction

The National Supervisory Authority for Welfare and Health (Valvira; Finnish: Sosiaali- ja terveysalan lupa- ja valvontavirasto, Swedish: Tillstånds- och tillsynsverket för social- och hälsovården) is a centralised body operating under the Ministry of Social Affairs and Health in Finland.

Background

Its statutory purpose is to supervise and provide guidance to healthcare and social services providers, alcohol administration authorities and environmental health bodies and to manage related licensing activities.

On This Day … 11 March

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People (Births)

  • 1915 – J.C.R. Licklider, American computer scientist and psychologist (d. 1990).

People (Deaths)

  • 1999 – Herbert Jasper, Canadian psychologist, anatomist, and neurologist (b. 1906).
  • 1999 – Camille Laurin, Canadian psychiatrist and politician (b. 1922).

J.C.R. Licklider

Joseph Carl Robnett Licklider (11 March 1915 to 26 June 1990), known simply as J.C.R. or “Lick”, was an American psychologist and computer scientist who is considered among prominent figures in computer science development and general computing history.

He is particularly remembered for being one of the first to foresee modern-style interactive computing and its application to all manner of activities; and also as an Internet pioneer with an early vision of a worldwide computer network long before it was built. He did much to initiate this by funding research which led to much of it, including today’s canonical graphical user interface, and the ARPANET, the direct predecessor to the Internet.

He has been called “computing’s Johnny Appleseed”, for planting the seeds of computing in the digital age; Robert Taylor, founder of Xerox PARC’s Computer Science Laboratory and Digital Equipment Corporation’s Systems Research Center, noted that “most of the significant advances in computer technology—including the work that my group did at Xerox PARC—were simply extrapolations of Lick’s vision. They were not really new visions of their own. So he was really the father of it all”.

Herbert Jasper

Herbert Henri Jasper, OC GOQ FRSC (27 July 1906 to 11 March 1999) was a Canadian psychologist, physiologist, neurologist, and epileptologist.

Born in La Grande, Oregon, he attended Reed College in Portland, Oregon and received his PhD in psychology from the University of Iowa in 1931 and earned a Doctor of Science degree from the University of Paris for research in neurobiology.

From 1946 to 1964 he was Professor of Experimental Neurology at the Montreal Neurological Institute, McGill University and then from 1965 to 1976 he was Professor of Neurophysiology, Université de Montréal. He did his most important research with Wilder Penfield at McGill University. He was a member of the American Academy of Neurology and the American Association for the Advancement of Science. He was also a member of the Canadian Neurological Society and the Royal Society of Medicine. He wrote more than 350 scientific publications.

Camille Laurin

Camille Laurin (06 May 1922 to 11 March 1999) was a psychiatrist and Parti Québécois (PQ) politician in the province of Quebec, Canada. MNA member for the riding of Bourget, he is considered the father of Quebec’s language law known informally as “Bill 101”.

Born in Charlemagne, Quebec, Laurin obtained a degree in psychiatry from the Université de Montréal where he came under the influence of the Roman Catholic priest, Lionel Groulx. After earning his degree, Laurin went to Boston, Massachusetts, where he worked at the Boston State Hospital. Following a stint in Paris, France, in 1957, he returned to practice in Quebec. In 1961, he authored the preface of the book Les fous crient au secours, which described the conditions of psychiatric hospitals of the time.

He was one of the early founders of the Quebec sovereignty movement. As a senior cabinet minister in the first PQ government elected in the 1976 Quebec election, he was the guiding force behind Bill 101, the legislation that placed restrictions on the use of English on public signs and in the workplace of large companies, and strengthened the position of French as the only official language in Quebec.

Laurin resigned from his cabinet position on 26 November 1984 because of a disagreement with Lévesque on the future of the sovereignty movement. He resigned from his seat in the National Assembly on 25 January 1985. He was elected once again to the Assembly on 12 September 1994 but did not run in the 1998 election for health reasons.

He died after a long battle with cancer.

What is Melancholic Depression?

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Introduction

Melancholic depression, or depression with melancholic features, is a DSM-IV and DSM-5 subtype of clinical depression.

Refer to Melancholia.

Signs and Symptoms

Requiring at least one of the following symptoms:

  • Anhedonia (the inability to find pleasure in positive things).
  • Lack of mood reactivity (i.e. mood does not improve in response to positive events).

And at least three of the following:

  • Depression that is subjectively different from grief or loss.
  • Severe weight loss or loss of appetite.
  • Psychomotor agitation or retardation.
  • Early morning awakening.
  • Guilt that is excessive.
  • Worse mood in the morning.

Melancholic features apply to an episode of depression that occurs as part of either major depressive disorder or bipolar disorder I or II.

Causes

The causes of melancholic-type major depressive disorder are believed to be mostly biological factors; some may have inherited the disorder from their parents. Sometimes stressful situations can trigger episodes of melancholic depression, though this is a contributing cause rather than a necessary or sufficient cause. People with psychotic symptoms are also thought to be more susceptible to this disorder. It is frequent in old age and often unnoticed by some physicians who perceive the symptoms to be a part of dementia. Major depressive disorder, melancholic or otherwise, is a separate condition that can be comorbid with dementia in the elderly.

Treatment

Melancholic depression is often considered to be a biologically based and particularly severe form of depression. Treatment involves antidepressants, electroconvulsive therapy, or other empirically supported treatments such as cognitive behavioural therapy and interpersonal therapy for depression. A 2008 analysis of a large study of patients with unipolar major depression found a rate of 23.5% for melancholic features. It was the first form of depression extensively studied, and many of the early symptom checklists for depression reflect this.

Incidence

The incidence of melancholic depression has been found to increase when the temperature and/or sunlight are low. According to the DSM-IV, the “melancholic features” specifier may be applied to the following only:

  • Major depressive episode, single episode.
  • Major depressive episode, recurrent episode.
  • Bipolar I disorder, most recent episode depressed.
  • Bipolar II disorder, most recent episode depressed.

What is Melancholia?

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Introduction

Melancholia (from Greek: µέλαινα χολή melaina chole “black bile”, “blackness of the bile”; compare also: lugubriousness, from Latin lugere, “to mourn”; moroseness, from Latin morosus, “self-will or fastidious habit”; wistfulness, from obsolete English whist; and saturnineness, from Latin Sāturnīnus, “under the influence of the planet Saturn”) is a condition characterised by extreme depression, bodily complaints, and sometimes hallucinations and delusions.

Melancholia as a concept derived from ancient or pre-modern medicine, which regarded melancholy as one of the four temperaments matching the four humours. Until the 19th century, medical doctors regarded “melancholia” as having physical symptoms as well as mental ones, and medicine classified melancholic conditions as such by their perceived common cause – an excess of black bile. At times, received wisdom associated all forms of mental illness with the concept of mis-balanced humours, with some mental disease deemed to be caused by a combination of excess black bile and a disorder of one of the other humours.

Despite there being a variety of mental and physical symptoms to this condition, clinicians in the 20th century came to attach the term “melancholia” almost exclusively to depression. As such, “melancholia” is the historical predecessor of the modern mental-health diagnosis of “clinical depression”, and the term currently characterises a subtype of major depression known as melancholic depression.

Background

Early History

The name “melancholia” comes from the old medical belief of the four humours: disease or ailment being caused by an imbalance in one or more of the four basic bodily liquids, or humours. Personality types were similarly determined by the dominant humour in a particular person. According to Hippocrates and subsequent tradition, melancholia was caused by an excess of black bile, hence the name, which means “black bile”, from Ancient Greek μέλας (melas), “dark, black”, and χολή (kholé), “bile”; a person whose constitution tended to have a preponderance of black bile had a melancholic disposition. In the complex elaboration of humourist theory, it was associated with the earth from the Four Elements, the season of autumn, the spleen as the originating organ and cold and dry as related qualities. In astrology it showed the influence of Saturn, hence the related adjective saturnine.

Melancholia was described as a distinct disease with particular mental and physical symptoms in the 5th and 4th centuries BC. Hippocrates, in his Aphorisms, characterised all “fears and despondencies, if they last a long time” as being symptomatic of melancholia. Other symptoms mentioned by Hippocrates include: poor appetite, abulia, sleeplessness, irritability, agitation. The Hippocratic clinical description of melancholia shows significant overlaps with contemporary nosography of depressive syndromes (6 symptoms out of the 9 included in DSM diagnostic criteria for a Major Depressive).

In addition to the symptoms Hippocrates identified, the first century physician Galen believed the condition included fixed delusions. The second century’s Aretaeus of Cappadocia also believed that melancholia involved both a state of anguish, and a delusion.

In the 10th century Persian physician Al-Akhawayni Bokhari described melancholia as a chronic illness caused by the impact of black bile on the brain. He described melancholia’s initial clinical manifestations as “suffering from an unexplained fear, inability to answer questions or providing false answers, self-laughing and self-crying and speaking meaninglessly, yet with no fever.”

In Middle-Ages Europe, the humoral, somatic paradigm for understanding sustained sadness lost primacy in front of the prevailing religious perspective. Sadness came to be a vice (λύπη in the Greek vice list by Evagrius Ponticus, tristitia vel acidia in the 7 vice list by Gregorius Magnus). When a patient could not be cured of the disease it was thought that the melancholia was a result of demonic possession.

In his study of French and Burgundian courtly culture, Johan Huizinga noted that “at the close of the Middle Ages, a sombre melancholy weighs on people’s souls.” In chronicles, poems, sermons, even in legal documents, an immense sadness, a note of despair and a fashionable sense of suffering and deliquescence at the approaching end of times, suffuses court poets and chroniclers alike: Huizinga quotes instances in the ballads of Eustache Deschamps, “monotonous and gloomy variations of the same dismal theme”, and in Georges Chastellain’s prologue to his Burgundian chronicle, and in the late fifteenth-century poetry of Jean Meschinot. Ideas of reflection and the workings of imagination are blended in the term merencolie, embodying for contemporaries “a tendency”, observes Huizinga, “to identify all serious occupation of the mind with sadness”.

Painters were considered by Vasari and other writers to be especially prone to melancholy by the nature of their work, sometimes with good effects for their art in increased sensitivity and use of fantasy. Among those of his contemporaries so characterised by Vasari were Pontormo and Parmigianino, but he does not use the term of Michelangelo, who used it, perhaps not very seriously, of himself. A famous allegorical engraving by Albrecht Dürer is entitled Melencolia I. This engraving has been interpreted as portraying melancholia as the state of waiting for inspiration to strike, and not necessarily as a depressive affliction. Amongst other allegorical symbols, the picture includes a magic square and a truncated rhombohedron. The image in turn inspired a passage in The City of Dreadful Night by James Thomson (B.V.), and, a few years later, a sonnet by Edward Dowden.

The most extended treatment of melancholia comes from Robert Burton, whose The Anatomy of Melancholy (1621) treats the subject from both a literary and a medical perspective. His concept of melancholia includes all mental illness, which he divides into different types. Burton wrote in the 17th century that music and dance were critical in treating mental illness.

But to leave all declamatory speeches in praise of divine music, I will confine myself to my proper subject: besides that excellent power it hath to expel many other diseases, it is a sovereign remedy against despair and melancholy, and will drive away the devil himself. Canus, a Rhodian fiddler, in Philostratus, when Apollonius was inquisitive to know what he could do with his pipe, told him, “That he would make a melancholy man merry, and him that was merry much merrier than before, a lover more enamoured, a religious man more devout.” Ismenias the Theban, Chiron the centaur, is said to have cured this and many other diseases by music alone: as now they do those, saith Bodine, that are troubled with St. Vitus’s Bedlam dance.

In the Encyclopédie of Diderot and d’Alembert, the causes of melancholia are stated to be similar to those that cause Mania: “grief, pains of the spirit, passions, as well as all the love and sexual appetites that go unsatisfied.”

English Art Movement

During the later 16th and early 17th centuries, a curious cultural and literary cult of melancholia arose in England. In an influential 1964 essay in Apollo, art historian Roy Strong traced the origins of this fashionable melancholy to the thought of the popular Neoplatonist and humanist Marsilio Ficino (1433–1499), who replaced the medieval notion of melancholia with something new:

Ficino transformed what had hitherto been regarded as the most calamitous of all the humours into the mark of genius. Small wonder that eventually the attitudes of melancholy soon became an indispensable adjunct to all those with artistic or intellectual pretentions.

The Anatomy of Melancholy (The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it… Philosophically, Medicinally, Historically, Opened and Cut Up) by Burton, was first published in 1621 and remains a defining literary monument to the fashion. Another major English author who made extensive expression upon being of an melancholic disposition is Sir Thomas Browne in his Religio Medici (1643).

Night-Thoughts (The Complaint: or, Night-Thoughts on Life, Death, & Immortality), a long poem in blank verse by Edward Young was published in nine parts (or “nights”) between 1742 and 1745, and hugely popular in several languages. It had a considerable influence on early Romantics in England, France and Germany. William Blake was commissioned to illustrate a later edition.

In the visual arts, this fashionable intellectual melancholy occurs frequently in portraiture of the era, with sitters posed in the form of “the lover, with his crossed arms and floppy hat over his eyes, and the scholar, sitting with his head resting on his hand” – descriptions drawn from the frontispiece to the 1638 edition of Burton’s Anatomy, which shows just such by-then stock characters. These portraits were often set out of doors where Nature provides “the most suitable background for spiritual contemplation” or in a gloomy interior.

In music, the post-Elizabethan cult of melancholia is associated with John Dowland, whose motto was Semper Dowland, semper dolens (“Always Dowland, always mourning”). The melancholy man, known to contemporaries as a “malcontent”, is epitomized by Shakespeare’s Prince Hamlet, the “Melancholy Dane”.

A similar phenomenon, though not under the same name, occurred during the German Sturm und Drang movement, with such works as The Sorrows of Young Werther by Goethe or in Romanticism with works such as Ode on Melancholy by John Keats or in Symbolism with works such as Isle of the Dead by Arnold Böcklin. In the 20th century, much of the counterculture of modernism was fuelled by comparable alienation and a sense of purposelessness called “anomie”; earlier artistic preoccupation with death has gone under the rubric of memento mori. The medieval condition of acedia (acedie in English) and the Romantic Weltschmerz were similar concepts, most likely to affect the intellectual.

Modern Understandings

In the 18th to 19th centuries, the concept of “melancholia” became almost solely about abnormal beliefs, and lost its attachment to depression and other affective symptoms.

Melancholia was a category that “the well-to-do, the sedentary, and the studious were even more liable to be placed in the eighteenth century than they had been in preceding centuries.”

In the 20th century, “melancholia” lost its attachment to abnormal beliefs, and in common usage became entirely a synonym for depression.

In the early 20th century, some believed there was distinct condition called involutional melancholia, a low mood disorder affecting people of advanced age.

In 1996, Gordon Parker and Dusan Hadzi-Pavlovic described “melancholia” as a specific disorder of movement and mood. They are attaching the term to the concept of “endogenus depression” – depression caused by internal forces rather than environmental influences. They have developed the “Sydney Melancholia Prototype Index” which they believe has an 80% accuracy rate of being able to differentiate endogenus and non-endogenus depression. They believe that the two conditions benefit from different treatment.

In 2006, MA Taylor and M Fink similarly defined melancholia as a systemic disorder that is identifiable by depressive mood rating scales, verified by the present of abnormal cortisol metabolism (abnormal dexamethasone suppression test), and validated by rapid and effective remission with ECT or tricyclic antidepressant agents. They believe it has many forms, including retarded depression, psychotic depression and postpartum depression. They consider that it is characterised by depressed mood, abnormal motor functions, and abnormal vegetative signs.

What is the Geriatric Depression Scale?

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Introduction

The Geriatric Depression Scale (GDS) is a 30-item self-report assessment used to identify depression in the elderly.

The scale was first developed in 1982 by J.A. Yesavage and colleagues.

Outline

In the Geriatric Depression Scale, questions are answered “yes” or “no.” A five-category response set is not utilised in order to ensure that the scale is simple enough to be used when testing ill or moderately cognitively impaired individuals, for whom a more complex set of answers may be confusing, or lead to inaccurate recording of responses.

The GDS is commonly used as a routine part of a Comprehensive Geriatric Assessment. One point is assigned to each answer and the cumulative score is rated on a scoring grid. The grid sets a range of 0-9 as “normal”, 10-19 as “mildly depressed”, and 20-30 as “severely depressed”.

A diagnosis of clinical depression should not be based on GDS results alone. Although the test has well-established reliability and validity evaluated against other diagnostic criteria, responses should be considered along with results from a comprehensive diagnostic work-up. A short version of the GDS (GDS-SF) containing 15 questions has been developed, and the scale is available in languages other than English. The conducted research found the GDS-SF to be an adequate substitute for the original 30-item scale.

The GDS was validated against Hamilton Rating Scale for Depression (HRS-D) and the Zung Self-Rating Depression Scale (SDS). It was found to have a 92% sensitivity and an 89% specificity when evaluated against diagnostic criteria.

Scale Questions and Scoring

The scale consists of 30 yes/no questions. Each question is scored as either 0 or 1 points. The following general cutoff may be used to qualify the severity:

  • Normal 0-9.
  • Mild depressives 10-19.
  • Severe depressives 20-30.

Reference

Yesavage, J.A., Brink, T.L., Rose, T.L., et al. (1982) Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research. 17(1), pp.37-49.

What is Functional Analytic Psychotherapy?

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Introduction

Functional analytic psychotherapy (FAP) is a psychotherapeutic approach based on clinical behaviour analysis (CBA) that focuses on the therapeutic relationship as a means to maximise client change. Specifically, FAP suggests that in-session contingent responding to client target behaviours leads to significant therapeutic improvements.

FAP was first conceptualised in the 1980s by psychologists Robert Kohlenberg and Mavis Tsai who, after noticing a clinically significant association between client outcomes and the quality of the therapeutic relationship, set out to develop a theoretical and psychodynamic model of behavioural psychotherapy based on these concepts. Behavioural principles (e.g. reinforcement, generalisation) form the basis of FAP (See The five rules below).

FAP is an idiographic (as opposed to nomothetic) approach to psychotherapy. This means that FAP therapists focus on the function of a client’s behaviour instead of the form. The aim is to change a broad class of behaviours that might look different on the surface but all serve the same function. It is idiographic in that the client and therapist work together to form a unique clinical formulation of the client’s therapeutic goals, rather than one therapeutic target for every client who enters therapy.

The Basics

FAP posits that client behaviours that occur in their out-of-session interpersonal relationships (i.e. in the “real world”) will, if clients are given a therapeutic relationship of sufficiently high quality, occur in the therapy session as well. Based on these in-session behaviours, FAP therapists, in collaboration with their client, develop a case formulation that includes classes of behaviours (based on their function not their form) that the client wishes to increase and decrease.

In-session occurrence of a client’s problematic behaviour is called clinically relevant behaviour 1 (CRB1). In-session occurrence of improvements is called clinically relevant behaviour 2 (CRB2). The goal of FAP therapy is to decrease the frequency of CRB1s and increase the frequency of CRB2s.

The FAP therapist evokes (i.e. sets the context for) CRB1s and in response gradually shapes CRB2s.

The five Rules

“The five rules” operationalise the FAP therapist’s behaviour with respect to this goal. It is important to note that the five rules are not rules in the traditional sense of the word, but instead a set of guidelines for the FAP therapist.

  • Rule 1 – Watch for CRBs:
    • Therapists focus their attention on the occurrence of CRBs that are in-session problems (CRB1s) and improvements (CRB2s).
  • Rule 2 – Evoke CRBs:
    • Therapists set a context which evoke the client’s CRBs.
  • Rule 3 – Reinforce CRB2s naturally:
    • Therapists reinforce the occurrence of CRB2s (in-session improvements), increasing the probability that these behaviours will occur more frequently.
  • Rule 4 – Observe therapist impact in relation to client CRBs:
    • Therapists assess the degree to which they actually reinforced behavioural improvements by noting the client’s behaviour subsequent behaviour after Rule 3.
    • This is similar to the behaviour analytic concept of performing a functional analysis.
  • Rule 5 – Provide functional interpretations and generalise:
    • Therapists work with the client to generalise in-session behavioural improvements to the client’s out-of-session relationships.
    • This can include, but is not limited to, providing homework assignments.

The ACL Model

Researchers at the Centre for the Science of Social Connection at the University of Washington are developing a model of social connection that they believe is relevant to FAP. This model – called the ACL model – delineates behaviours relevant to social connection based on decades of scientific research.

  • Awareness (A):
    • Behaviours include paying attention to your own and the other’s needs and values within an interpersonal relationship.
  • Courage (C):
    • Behaviours include experiencing emotion in the presence of another person, asking for what you need, and sharing deep, vulnerable experiences with another person in the service of improving the relationship.
  • Love (L):
    • Behaviours involve responding to another’s courage behaviours with attunement to what that person needs in the moment. These include providing safety and acceptance in response to a client’s vulnerability.

FAP has the potential to target awareness, courage, and love behaviours as they occur in session as described by the five rules above. More research is needed to confirm the utility of the ACL model.

Research Support

Radical behaviourism and the field of clinical behaviour analysis have strong scientific support. Additionally, researchers have conducted a number of case studies, component process analyses, a study with non-randomised design on FAP-enhanced cognitive therapy for depression, and a randomised controlled trial on FAP-enhanced acceptance and commitment therapy for smoking cessation.

Third Generation behaviour Therapy

FAP belongs to a group of therapies referred to as third-generation behaviour therapies (or third-wave behaviour therapies) that includes dialectical behaviour therapy (DBT), acceptance and commitment therapy (ACT), behavioural activation (BA), and integrative behavioural couples therapy (IBCT).

Criticism

FAP has been criticised for “being ahead of the data”, i.e. having not enough empirical support to justify its widespread use. Challenges encountered by FAP researchers are widely discussed There is also criticism of using the ACL model as it detracts from the idiographic nature of FAP.

What is Derealisation?

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Introduction

Derealisation is an alteration in the perception of the external world, causing sufferers to perceive it as unreal, distant, distorted or falsified. Other symptoms include feeling as though one’s environment is lacking in spontaneity, emotional colouring, and depth. It is a dissociative symptom that may appear in moments of severe stress.

Derealisation is a subjective experience pertaining to a person’s perception of the outside world, while depersonalisation is a related symptom characterised by dissociation towards one’s own body and mental processes. The two are commonly experienced in conjunction with one another, but are also known to occur independently.

Chronic derealisation is fairly rare, and may be caused by occipital-temporal dysfunction. Experiencing derealisation for long periods of time or having recurring episodes can be indicative of many psychological disorders, and can cause significant distress among sufferers. However, temporary derealisation symptoms are commonly experienced by the general population a few times throughout their lives, with a lifetime prevalence of up to 26-74% and a prevalence of 31–66% at the time of a traumatic event.

Description

The experience of derealisation can be described as an immaterial substance that separates a person from the outside world, such as a sensory fog, pane of glass, or veil. Individuals may report that what they see lacks vividness and emotional colouring. Emotional response to visual recognition of loved ones may be significantly reduced. Feelings of déjà vu or jamais vu are common. Familiar places may look alien, bizarre, and surreal. One may not even be sure whether what one perceives is in fact reality or not. The world as perceived by the individual may feel as if it were going through a dolly zoom effect. Such perceptual abnormalities may also extend to the senses of hearing, taste, and smell.

The degree of familiarity one has with their surroundings is among one’s sensory and psychological identity, memory foundation and history when experiencing a place. When persons are in a state of derealisation, they block this identifying foundation from recall. This “blocking effect” creates a discrepancy of correlation between one’s perception of one’s surroundings during a derealisation episode, and what that same individual would perceive in the absence of a derealisation episode.

Frequently, derealisation occurs in the context of constant worrying or “intrusive thoughts” that one finds hard to switch off. In such cases it can build unnoticed along with the underlying anxiety attached to these disturbing thoughts, and be recognised only in the aftermath of a realisation of crisis, often a panic attack, subsequently seeming difficult or impossible to ignore. This type of anxiety can be crippling to the affected and may lead to avoidant behaviour. Those who experience this phenomenon may feel concern over the cause of their derealisation. It is often difficult to accept that such a disturbing symptom is simply a result of anxiety, and the individual may often think that the cause must be something more serious. This can, in turn, cause more anxiety and worsen the derealisation. Derealisation also has been shown to interfere with the learning process, with cognitive impairments demonstrated in immediate recall and visuospatial deficits. This can be best understood as the individual feeling as if they see the events in third person; therefore they cannot properly process information, especially through the visual pathway.

People experiencing derealisation describe feeling as if they are viewing the world through a TV screen. This, along with co-morbidities such as depression and anxiety, and other similar feelings attendant to derealisation, can cause a sensation of alienation and isolation between the person suffering from derealisation and others around them. This is particularly the case as Derealisation Disorder is characteristically diagnosed and recognised sparsely in clinical settings. This is in light of general population prevalence being as high as 5%, skyrocketing to as high as 37% for traumatised individuals.

Partial symptoms would also include depersonalisation, a feeling of being an “observer”/having an “observational effect”. As if existing as a separate entity on the planet, with everything happening, being experienced and alternatively perceived through their own eyes (similar to a first person camera in a game, e.g. Television or Computer-Vision).

Causes

Derealisation can accompany the neurological conditions of epilepsy (particularly temporal lobe epilepsy), migraine, and mild TBI (head injury). There is a similarity between visual hypo-emotionality, a reduced emotional response to viewed objects, and derealisation. This suggests a disruption of the process by which perception becomes emotionally coloured. This qualitative change in the experiencing of perception may lead to reports of anything viewed being unreal or detached.

The instances of recurring or chronic derealisation among those who have experienced extreme trauma and/or suffer from post traumatic stress disorder (PTSD) have been studied closely in many scientific studies, whose results indicate a strong link between the disorders, with a disproportionate amount of post traumatic stress patients reporting recurring feelings of derealisation and depersonalisation (up to 30% of all sufferers) in comparison to the general populace (only around 2%), especially in those who experienced the trauma in childhood. Many possibilities have been suggested by various psychologists to help explain these findings, the most widely accepted including that experiencing trauma can cause sufferers to distance themselves from their surroundings and perception, with the aim of subsequently distancing themselves from the trauma and (especially in the case of depersonalisation) their emotional response to it. This could be either as a deliberate coping mechanism or an involuntary, reflexive response depending of circumstance. This possibly not only increases the risk of experiencing problems with derealisation and its corresponding disorder, but with all relevant dissociative disorders. In the case of childhood trauma, not only are children more likely to be susceptible to such a response as they are less able to implement more healthy strategies to deal with the emotional implications of experiencing trauma, there is also a lot of evidence that shows trauma can have a substantial detrimental effect on learning and development, especially since those who experience trauma in childhood are far less likely to have received adequate parenting. These are factors proven to increase susceptibility to maladaptive psychological conditions, which of course includes dissociative disorders and subsequently derealisation symptoms.

Some neurophysiological studies have noted disturbances arising from the frontal-temporal cortex, which could explain the correlation found between derealisation symptoms and temporal lobe disorders. This is further supported by reports of people with frontal lobe epilepsy, with those who suffered epilepsy of the dorsal premotor cortex reporting symptoms of depersonalisation, while those with temporal lobe epilepsy reported experiencing derealisation symptoms. This implies that malfunction of these specific brain regions may be the cause of these dissociative symptoms, or at the very least that these brain regions are heavily involved.

Derealisation can possibly manifest as an indirect result of certain vestibular disorders such as labyrinthitis. This is thought to result from anxiety stemming from being dizzy. An alternative explanation holds that a possible effect of vestibular dysfunction includes responses in the form of the modulation of noradrenergic and serotonergic activity due to a misattribution of vestibular symptoms to the presence of imminent physical danger resulting in the experience of anxiety or panic, which subsequently generate feelings of derealisation. Likewise, derealisation is a common psychosomatic symptom seen in various anxiety disorders, especially hypochondria. However, derealisation is presently regarded as a separate psychological issue due to its presence as a symptom within several pathologies.

Derealization and dissociative symptoms have been linked by some studies to various physiological and psychological differences in individuals and their environments. It was remarked that labile sleep-wake cycles (labile meaning more easily roused) with some distinct changes in sleep, such as dream-like states, hypnogogic, hypnopompic hallucinations, night-terrors and other disorders related to sleep could possibly be causative or improve symptoms to a degree. Derealisation can also be a symptom of severe sleep disorders and mental disorders like depersonalisation disorder, borderline personality disorder, bipolar disorder, schizophrenia, dissociative identity disorder, and other mental conditions.

Cannabis, psychedelics, dissociatives, antidepressants, caffeine, nitrous oxide, albuterol, and nicotine can all produce feelings of derealisation, or sensations mimicking them, particularly when taken in excess. It can also result from alcohol withdrawal or benzodiazepine withdrawal. Opiate withdrawal can also cause feelings of derealisation, often alongside psychotic symptoms such as anxiety, paranoia and hallucinations.

Interoceptive exposure exercises have been used in research settings a means to induce derealisation, as well as the related phenomenon depersonalisation, in people who are sensitive to high levels of anxiety. Exercises with documented successes include timed intervals of hyperventilation or staring at a mirror, dot, or spiral.

What is Acceptance and Commitment Therapy?

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Introduction

Acceptance and commitment therapy (ACT, typically pronounced as the word “act”) is a form of psychotherapy and a branch of clinical behaviour analysis.

It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behaviour-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. Steven C. Hayes developed acceptance and commitment therapy in 1982 in order to create a mixed approach which integrates both covert conditioning and behaviour therapy. There are a variety of protocols for ACT, depending on the target behaviour or setting. For example, in behavioural health areas a brief version of ACT is called focused acceptance and commitment therapy (FACT).

The objective of ACT is not elimination of difficult feelings; rather, it is to be present with what life brings us and to “move toward valued behaviour”. Acceptance and commitment therapy invites people to open up to unpleasant feelings, and learn not to overreact to them, and not avoid situations where they are invoked. Its therapeutic effect is a positive spiral where feeling better leads to a better understanding of the truth. In ACT, ‘truth’ is measured through the concept of ‘workability’, or what works to take another step toward what matters (e.g. values, meaning).

Technique

Basics

ACT is developed within a pragmatic philosophy called functional contextualism. ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is an offshoot of behaviour analysis. Both ACT and RFT are based on B.F. Skinner’s philosophy of Radical Behaviourism.

ACT differs from some other kinds of cognitive behavioural therapy (CBT) in that rather than trying to teach people to better control their thoughts, feelings, sensations, memories and other private events, ACT teaches them to “just notice,” accept, and embrace their private events, especially previously unwanted ones. ACT helps the individual get in contact with a transcendent sense of self known as self-as-context – the you who is always there observing and experiencing and yet distinct from one’s thoughts, feelings, sensations, and memories. ACT aims to help the individual clarify their personal values and to take action on them, bringing more vitality and meaning to their life in the process, increasing their psychological flexibility.

While Western psychology has typically operated under the “healthy normality” assumption which states that by their nature, humans are psychologically healthy, ACT assumes, rather, that psychological processes of a normal human mind are often destructive. The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioural steps in accord with core values. As a simple way to summarise the model, ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR:

  • Fusion with your thoughts.
  • Evaluation of experience.
  • Avoidance of your experience.
  • Reason-giving for your behaviour.

And the healthy alternative is to ACT:

  • Accept your reactions and be present.
  • Choose a valued direction.
  • Take action.

Core Principles

ACT commonly employs six core principles to help clients develop psychological flexibility:[9]

  • Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories.
  • Acceptance: Allowing unwanted private experiences (thoughts, feelings and urges) to come and go without struggling with them.
  • Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness. (e.g., mindfulness)
  • The observing self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging.
  • Values: Discovering what is most important to oneself.
  • Committed action: Setting goals according to values and carrying them out responsibly, in the service of a meaningful life.

Correlational evidence has found that absence of psychological flexibility predicts many forms of psychopathology. A 2005 meta-analysis showed that the six ACT principles, on average, account for 16-29% of the variance in psychopathology (general mental health, depression, anxiety) at baseline, depending on the measure, using correlational methods. A 2012 meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components.

Research

A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment, and raised methodological concerns about the research base. A 2009 meta-analysis found that ACT was more effective than placebo and “treatment as usual” for most problems (with the exception of anxiety and depression), but not more effective than CBT and other traditional therapies. A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety.

A 2015 review found that ACT was better than placebo and typical treatment for anxiety disorders, depression, and addiction. Its effectiveness was similar to traditional treatments like cognitive behavioural therapy (CBT). The authors suggested that the CBT comparison of the previous 2012 meta-analysis may have been compromised by the inclusion of nonrandomised trials with small sample sizes. They also noted that research methodologies had improved since the studies described in the 2008 meta-analysis.

The number of randomised clinical trials (RCT) and controlled time series evaluating ACT for a variety of problems is growing. In 2006, only about 30 such studies were known, but in 2011 the number had approximately doubled. The website of the Association for Contextual Behavioural Science states that there were 171 RCTs of ACT published as of December 2016, and over 20 meta-analyses and 45 mediational studies of the ACT literature as of Spring 2016. Most studies of ACT so far have been conducted on adults and therefore the knowledge of its effectiveness when applied to children and adolescents is limited.

Professional Organisations

The Association for Contextual Behavioural Science is committed to research and development in the area of ACT, RFT, and contextual behavioural science more generally. As of 2017 it had over 7,600 members worldwide, about half outside of the United States. It holds annual “world conference” meetings: The 16th will be held in Montreal, in July 2018.

The Association for Behaviour Analysis International (ABAI) has a special interest group for practitioner issues, behavioural counselling, and clinical behaviour analysis ABA:I. ABAI has larger special interest groups for autism and behavioural medicine. ABAI serves as the core intellectual home for behaviour analysts. ABAI sponsors three conferences/year – one multi-track in the US, one specific to Autism and one international.

The Association for Behavioural and Cognitive Therapies (ABCT) also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. ACT work is commonly presented at ABCT and other mainstream CBT organisations.

The British Association for Behavioural and Cognitive Psychotherapies (BABCP) has a large special interest group in ACT, with over 1,200 members.

Doctoral-level behaviour analysts who are psychologists belong to the American Psychological Association’s (APA) Division 25 – Behaviour analysis. ACT has been called a “commonly used treatment with empirical support” within the APA-recognized specialty of behavioural and cognitive psychology.

Similarities

ACT, dialectical behaviour therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches are commonly grouped under the name “the third wave of cognitive behaviour therapy”. The first wave, behaviour therapy, commenced in the 1920s based on Pavlov’s classical (respondent) conditioning and operant conditioning that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions. In the late 1980s empirical limitations and philosophical misgivings of the second wave gave rise to Steven Hayes’ ACT theory which modified the focus of abnormal behaviour away from the content or form towards the context in which it occurs. ACT research has suggested that many of the emotional defences individuals use with conviction to try to solve their problems actually entangle humans into greater suffering. Rigid ideas about themselves, lack of focus on what is important in their life and struggling to change sensations, feelings or thoughts that are troublesome only serve to create greater distress.

Steven C. Hayes described this group in his ABCT President Address as follows:

Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes.

ACT has also been adapted to create a non-therapy version of the same processes called Acceptance and Commitment Training. This training process, oriented towards the development of mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results. This is somewhat similar to the awareness-management movement in business training programmes, where mindfulness and cognitive-shifting techniques are employed.

The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psycho-therapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic behavioural science programme, including approaches such as Gestalt therapy, Morita therapy and Voice Dialogue, IFS and others.

Wilson, Hayes & Byrd explore at length the compatibilities between ACT and the 12-step treatment of addictions and argue that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities. Both approaches endorse acceptance as an alternative to unproductive control. ACT emphasizes the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasizes the acceptance of powerlessness over addiction. Both approaches encourage a broad life-reorientation, rather than a narrow focus on the elimination of substance use, and both place great value on the long-term project of building of a meaningful life aligned with the clients’ values. ACT and 12-step both encourage the pragmatic utility of cultivating a transcendent sense of self (higher power) within an unconventional, individualised spirituality. Finally they both openly accept the paradox that acceptance is a necessary condition for change and both encourage a playful awareness of the limitations of human thinking.

Criticisms

Some published empirical studies in clinical psychology have argued that ACT is not different from other interventions. Stefan Hofmann argued that ACT is similar to the much older Morita therapy.

A meta-analysis by Öst in 2008 concluded that ACT did not yet qualify as an “empirically supported treatment”, that the research methodology for ACT was less stringent than cognitive behavioural therapy, and that the mean effect size was moderate. Supporters of ACT have challenged those conclusions by showing that the quality difference in Öst’s review was accounted for by the larger number of funded trials in the CBT comparison group.

Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One major theoretical concern was that the primary authors of ACT and of the corresponding theories of human behaviour, relational frame theory (RFT) and functional contextualism (FC), recommended their approach as the proverbial holy grail of psychological therapies. Later, in the preface to the second edition of Acceptance and Commitment Therapy, the authors clarified that “ACT has not been created to undercut the traditions from which it came, nor does it claim to be a panacea.” Psychologist James C. Coyne, in a discussion of “disappointments and embarrassments in the branding of psychotherapies as evidence supported”, said: “Whether or not ACT is more efficacious than other therapies, as its proponents sometimes claim, or whether it is efficacious for psychosis, is debatable”. The textbook Systems of Psychotherapy: A Transtheoretical Analysis provides criticisms of third-wave behaviour therapies including ACT from the perspectives of other systems of psychotherapy.

Psychologist Jonathan W. Kanter said that Hayes and colleagues “argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present contextual behavioural science (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of ACT and Relational Frame Theory (RFT) and demotion of earlier cognitive and behaviour change techniques in the absence of clear logic and empirical support.” Nevertheless, Kanter concluded that “the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice.”

ACT currently appears to be about as effective as standard CBT, with some meta-analyses showing small differences in favour of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT. ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compare to CBT for anxiety and quality of life. The author did find separation between ACT and CBT on the “primary outcome” – a heterogeneous class of 14 separate outcome measures that were aggregated into the effect size analysis. This analysis however is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which has the tendency to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety and quality of life decrease the NNT, making the analysis more clinically relevant, and on these measures ACT did not outperform CBT.

A 2013 paper comparing ACT to cognitive therapy (CT) concluded that “like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects.” The authors of the paper suggested that many of the assumptions of ACT and CT “are pre-analytical, and cannot be directly pitted against one another in experimental tests.”

On This Day … 07 March

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People (Births)

  • 1924 – Morton Bard, American psychologist (d. 1997).
  • 1978 – Jaqueline Jesus, Brazilian psychologist and activist.

Morton Baird

Morton Bard (07 March 1924 to 04 December 1997) was an American psychologist, known for the research he undertook on the psychology of crime victims. He was a one-time member of the New York Police Department, a psychologist, and a professor who studied the reactions of crime victims.

Bard, in partnership with the police, conducted studies of crime victims (e.g. hostages, rape victims, and the families of murder victims). He published two volumes on domestic violence and crisis intervention. He also is recognised for having laid the foundation of victim-focused training into many law enforcement academies and the FBI National Academy.

In 1979, Bard co-authored The Crime Victim’s Book. This volume provides practical information on how best to identify and support the needs of crime victims. The Crime Victim’s Book was considered a “bible” for not only advocates but also crime victims. He is considered to have been a pivotal critical thinker in the development of the modern discipline of crisis intervention. He also wrote scholarly articles on the training of police officers in the application of different forms of crisis intervention out in the field.

Jaqueline Jesus

Jaqueline Gomes de Jesus (born 07 March 1978) is a Brazilian psychologist, writer, and activist.

Jesus is the daughter of a computer operator and a mining science teacher. She has a sibling, a younger brother. Jesus lived most of her life in Ceilândia. A good student, she studied chemistry, for a year before switching majors. She holds an M.Sc. in Psychology from the University of Brasília, and a PhD in Social Psychology, Work and Organisations from the same institution. She worked at the University of Brasília from 2003-2008 as a diversity adviser and also coordinated a center for black students. She was one of the organizers of Brasilia’s Pride parade, and participated in the development of Brazil’s goals for the UN’s Millennium Dome. Jesus has proactively addressed discriminatory actions, refusing to accept passive prejudice. She began her human rights activism in 1997, with “Estructuración”, a Brasilia homosexual group, serving first as secretary and in 1999, became president. In that period, she worked alongside government and educational institutions, in fighting prejudice and valuing differences, speaking at the opening of the 5th National Conference on Human Rights. Jesus participated in various social movements. In 2000, with Luiz Mott, she cofounded the Academic Association of Gays, Lesbians and Sympathizers of Brazil, serving as general secretary. She was appointed to the editorial board of the Grupo Gay Negro de Bahia; and founded the NGO Acciones Ciudades en Orientación sexual.