Category: Mental Health History

On This Day … 27 February

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People (Births)

People (Deaths)

  • 2012 – Tina Strobos, Dutch physician and psychiatrist (b. 1920).

Roberto Assagioli

Roberto Assagioli (27 February 1888 to 23 August 1974) was an Italian psychiatrist and pioneer in the fields of humanistic and transpersonal psychology. Assagioli founded the psychological movement known as psychosynthesis, which is still being developed today by therapists and psychologists, who practice the psychological methods and techniques he developed. His work, expounded in two books and many monographs published as pamphlets, emphasized the possibility of progressive integration, or synthesis, of the personality.

Assagioli received his first degree in neurology and psychiatry at Istituto di Studii Superiori Pratici e di Perfezionamento, in Florence in 1910. It was during this time he began writing articles that criticised psychoanalysis in which Assagioli argued a more holistic approach.

Once he finished his studies in Italy, Assagioli went to Switzerland, where he was trained in psychiatry at the psychiatric hospital Burghölzli in Zürich. This led to him opening the first psychoanalytic practice in Italy, known as Istituto di Psicosintesi. However, his work in psychoanalysis left him unsatisfied with the field of psychiatry; as a whole, as he felt that psychoanalysis was incomplete.

Tina Strobos

Tina Strobos, née Tineke Buchter (19 May 1920 to 27 February 2012), was a Dutch physician and psychiatrist from Amsterdam, known for her resistance work during World War II. While a young medical student, she worked with her mother and grandmother to rescue more than 100 Jewish refugees as part of the Dutch resistance during the Nazi occupation of the Netherlands. Strobos provided her house as a hiding place for Jews on the run, using a secret attic compartment and warning bell system to keep them safe from sudden police raids. In addition, Strobos smuggled guns and radios for the resistance and forged passports to help refugees escape the country. Despite being arrested and interrogated nine times by the Gestapo, she never betrayed the whereabouts of a Jew.

After the war, Strobos completed her medical degree and became a psychiatrist. She studied under Anna Freud in England. Strobos later emigrated to the United States to study psychiatry under a Fulbright scholarship, and she subsequently settled in New York. She married twice and had three children. Strobos built a career as a family psychiatrist, receiving the Elizabeth Blackwell Medal in 1998 for her medical work, and finally retired from active practice in 2009.

In 1989, Strobos was honoured as Righteous Among the Nations by Yad Vashem for her rescue work. In 2009, she was recognised for her efforts by the Holocaust and Human Rights Education Centre of New York City.

What is a Major Depressive Episode?

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Introduction

A major depressive episode (MDE) is a period characterised by the symptoms of major depressive disorder.

Sufferers primarily have a depressed mood for two weeks or more, and a loss of interest or pleasure in everyday activities, accompanied by other symptoms such as feelings of emptiness, hopelessness, anxiety, worthlessness, guilt and irritability, changes in appetite, problems concentrating, remembering details or making decisions, and thoughts of suicide. Insomnia or hypersomnia, aches, pains, or digestive problems that are resistant to treatment may also be present. The description has been formalized in psychiatric diagnostic criteria such as the DSM-5 and ICD-10.

Biological, psychological, and social factors are believed to be involved in the cause of depression, although it is still not well understood. Factors like socioeconomic status, life experience, and personality tendencies play a role in the development of depression and may represent increases in risk for developing a MDE. There are many theories as to how depression occurs. One interpretation is that neurotransmitters in the brain are out of balance, and this results in feelings of worthlessness and despair. Magnetic resonance imaging shows that brains of people who have depression look different than the brains of people not exhibiting signs of depression. A family history of depression increases the chance of being diagnosed.

Emotional pain and economic costs are associated with depression. In the United States and Canada, the costs associated with major depression are comparable to those related to heart disease, diabetes, and back problems and are greater than the costs of hypertension. According to the Nordic Journal of Psychiatry, there is a direct correlation between major depressive episode and unemployment.

Treatments for a major depressive episode include psychotherapy and antidepressants, although in more serious cases, hospitalization or intensive outpatient treatment may be required.

Signs and Symptoms

The criteria below are based on the formal DSM-V criteria for a major depressive episode. A diagnosis of major depressive episode requires that the patient has experienced five or more of the symptoms below, and one of the symptoms must be either depressed mood or loss of interest or pleasure (although both are frequently present). These symptoms must be present for at least 2 weeks and represent a change from the patient’s normal behaviour.

Depressed Mood and Loss of Interest (Anhedonia)

Either depressed mood or a loss of interest or pleasure must be present for the diagnosis of a MDE. Depressed mood is the most common symptom seen in major depressive episodes. Interest or pleasure in everyday activities can be decreased; this is referred to as anhedonia. These feelings must be present on an everyday basis for two weeks or longer to meet DSM-V criteria for a MDE. In addition, the person may experience one or more of the following emotions: sadness, emptiness, hopelessness, indifference, anxiety, tearfulness, pessimism, emotional numbness, or irritability. In children and adolescents, a depressed mood often appears more irritable in nature. There may be a loss of interest in or desire for sex, or other activities once found to be pleasant. Friends and family of the depressed person may notice that they have withdrawn from friends, or neglected or quit doing activities that were once a source of enjoyment.

Sleep

Nearly every day, the person may sleep excessively, known as hypersomnia, or not enough, known as insomnia. Insomnia is the most common type of sleep disturbance for people who are clinically depressed. Symptoms of insomnia include trouble falling asleep, trouble staying asleep, or waking up too early in the morning. Hypersomnia is a less common type of sleep disturbance. It may include sleeping for prolonged periods at night or increased sleeping during the daytime. The sleep may not be restful, and the person may feel sluggish despite many hours of sleep, which may amplify their depressive symptoms and interfere with other aspects of their lives. Hypersomnia is often associated with an atypical depression, as well as seasonal affective disorder.

Feelings of Guilt or Worthlessness

Depressed people may have feelings of guilt that go beyond a normal level or are delusional. These feelings of guilt and/or worthlessness are excessive and inappropriate. MDE’s are notable for a significant, often unrealistic, drop in self-esteem. The guilt and worthlessness experienced in a MDE can range from subtle feelings of guilt to frank delusions or to shame and humiliation. Additionally, self-loathing is common in clinical depression, and can lead to a downward spiral when combined with other symptoms.

Loss of Energy

Persons going through a MDE often have a general lack of energy, as well as fatigue and tiredness, nearly every day for at least 2 weeks. A person may feel tired without having engaged in any physical activity, and day-to-day tasks become increasingly difficult. Job tasks or housework become very tiring, and the patient finds that their work begins to suffer.

Decreased Concentration

Nearly every day, the person may be indecisive or have trouble thinking or concentrating. These issues cause significant difficulty in functioning for those involved in intellectually demanding activities, such as school and work, especially in difficult fields. Depressed people often describe a slowing of thought, inability to concentrate and make decisions, and being easily distracted. In the elderly, the decreased concentration caused by a MDE may present as deficits in memory. This is referred to as pseudodementia and often goes away with treatment. Decreased concentration may be reported by the patient or observed by others.

Change in Eating, Appetite, or Weight

In a major depressive episode, appetite is most often decreased, although a small percentage of people experience an increase in appetite. A person experiencing a depressive episode may have a marked loss or gain of weight (5% of their body weight in one month). A decrease in appetite may result in weight loss that is unintentional or when a person is not dieting. Some people experience an increase in appetite and may gain significant amounts of weight. They may crave certain types of food, such as sweets or carbohydrates. In children, failure to make expected weight gains may be counted towards this criteria. Overeating is often associated with atypical depression.

Motor Activity

Nearly every day, others may see that the person’s activity level is not normal. People suffering from depression may be overly active (psychomotor agitation) or be very lethargic (psychomotor retardation). Psychomotor agitation is marked by an increase in body activity which may result in restlessness, an inability to sit still, pacing, hand wringing, or fidgeting with clothes or objects. Psychomotor retardation results in a decrease in body activity or thinking. In this case, a depressed person may demonstrate a slowing of thinking, speaking, or body movement. They may speak more softly or say less than usual. To meet diagnostic criteria, changes in motor activity must be so abnormal that it can be observed by others. Personal reports of feeling restless or feeling slow do not count towards the diagnostic criteria.

Thoughts of Death and Suicide

A person going through a MDE may have repeated thoughts about death (other than the fear of dying) or suicide (with or without a plan), or may have made a suicide attempt. The frequency and intensity of thoughts about suicide can range from believing that friends and family would be better off if one were dead, to frequent thoughts about committing suicide (generally related to wishing to stop the emotional pain), to detailed plans about how the suicide would be carried out. Those who are more severely suicidal may have made specific plans and decided upon a day and location for the suicide attempt.

Comorbid Disorders

MDE’s may show comorbidity (association) with other physical and mental health problems. About 20-25% of individuals with a chronic general medical condition will develop major depression. Common comorbid disorders include: eating disorders, substance-related disorders, panic disorder, and obsessive-compulsive disorder. Up to 25% of people who experience a major depressive episode have a pre-existing dysthymic disorder.

Some persons who have a fatal illness or are at the end of their life may experience depression, although this is not universal.

Causes

The cause of a MDE is not well understood. However, the mechanism is believed to be a combination of biological, psychological, and social factors. A MDE can often follow an acute stress in someone’s life. Evidence suggests that psychosocial stressors play a larger role in the first 1-2 depressive episodes, while having less influence in later episodes. People who experience a major depressive episode often have other mental health issues.

Other risk factors for a depressive episode include:

  • Family history of a mood disorder;
  • Recent negative life events;
  • Personality (insecure, worried, stress-sensitive, obsessive, unassertive, dependent);
  • Early childhood trauma;
  • Postpartum; and
  • Lack of interpersonal relationships.

One gene by itself has not been linked to depression. Studies show that depression can be passed down in families, but this is believed to be due to a combined effect of genetic and environmental factors. Other medical conditions, like hypothyroidism for example, may cause someone to experience similar symptoms as a MDE, however this would be considered a mood disorder due to a general medical condition, according to the DSM-V.

Diagnosis

Criteria

The two main symptoms in a major depressive episode are a depressed mood or a loss of interest or pleasure. From the list below, one bold symptom and four other symptoms must be present for a diagnosis of MDE. These symptoms must be present for at least 2 weeks and must be causing significant distress or impairment in functioning.

  • Depressed mood.
  • Loss of interest or pleasure.
  • Change in appetite.
  • Change in sleep.
  • Change in body activity (psychomotor changes).
  • Loss of energy.
  • Feelings of worthlessness and excessive or inappropriate guilt.
  • Indecisiveness or a decrease in concentration.
  • Suicidal ideation.

To diagnose a major depressive episode, a trained healthcare provider must make sure that:

  • The symptoms do not meet the criteria for a mixed episode.
  • The symptoms must cause considerable distress or impair functioning at work, in social settings or in other important areas in order to qualify as an episode.
  • The symptoms are not due to the direct physiological effects of a substance (e.g. abuse of a drug or medication) or a general medical condition (e.g. hypothyroidism).

Workup

No labs are diagnostic of a depressive episode. But some labs can help rule out general medical conditions that may mimic the symptoms of a depressive episode. Healthcare providers may order some routine blood work, including routine blood chemistry, CBC with differential, thyroid function studies, and Vitamin B12 levels, before making a diagnosis.

Differential Diagnosis

There are other mental health disorders or medical conditions to consider before diagnosing a MDE:

  • Bipolar disorder.
  • Cyclothymic disorder.
  • Disruptive mood dysregulation disorder.
  • Persistent depressive disorder.
  • Anxiety disorder (Generalised anxiety, PTSD, obsessive compulsive disorder).
  • Substance abuse or Substance Use Disorder.
  • Personality disorder with depressive symptoms.
  • Adjustment disorder.
  • Depression due to a general medical condition.
  • Premenstrual dysphoric disorder.

Screening

Healthcare providers may screen patients in the general population for depression using a screening tool, such as the Patient Healthcare Questionnaire-2 (PHQ-2). If the PHQ-2 screening is positive for depression, a provider may then administer the PHQ-9. The Geriatric Depression Scale is a screening tool that can be used in the elderly population.

Treatment

Depression is a treatable illness. Treatments for a MDE may be provided by mental health specialists (i.e. psychologist, psychiatrists, social workers, counsellors, etc.), mental health centres or organisations, hospitals, outpatient clinics, social service agencies, private clinics, peer support groups, clergy, and employee assistance programmes. The treatment plan could include psychotherapy alone, antidepressant medications alone, or a combination of medication and psychotherapy.

For major depressive episodes of severe intensity (multiple symptoms, minimal mood reactivity, severe functional impairment), combined psychotherapy and antidepressant medications are more effective than psychotherapy alone. Meta-analyses suggest that the combination of psychotherapy and antidepressant medications is more effective in treating mild and moderate forms of depression as well, compared to either type of treatment alone. Patients with severe symptoms may require outpatient treatment or hospitalisation.

The treatment of a major depressive episode can be split into 3 phases:

  • Acute phase: the goal of this phase is to resolve the current major depressive episode.
  • Continuation: this phase continues the same treatment from the acute phase for 4-8 months after the depressive episode has resolved and the goal is to prevent relapse.
  • Maintenance: this phase is not necessary for every patient but is often used for patients who have experienced 2-3 or more MDE’s.
    • Treatment may be maintained indefinitely to prevent the occurrence and severity of future episodes.

Therapy

Psychotherapy, also known as talk therapy, counselling, or psychosocial therapy, is characterised by a patient talking about their condition and mental health issues with a trained therapist. Different types of psychotherapy are used as a treatment for depression. These include cognitive behavioural therapy, interpersonal therapy, dialectical behaviour therapy, acceptance and commitment therapy, and mindfulness techniques. Evidence shows that cognitive behavioural therapy can be as effective as medication in the treatment of a MDE.

Psychotherapy may be the first treatment used for mild to moderate depression, especially when psychosocial stressors are playing a large role. Psychotherapy alone may not be as effective for more severe forms of depression.

Some of the main forms of psychotherapies used for treatment of a major depressive episode along with what makes them unique are included below:

  • Cognitive psychotherapy: focus on patterns of thinking.
  • Interpersonal psychotherapy: focus on relationships, losses, and conflict resolution.
  • Problem-solving psychotherapy: focus on situations and strategies for problem-solving.
  • Psychodynamic psychotherapy: focus on defence mechanisms and coping strategies.

Medication

Medications used to treat depression include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine-dopamine reuptake inhibitors (NDRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and atypical antidepressants such as mirtazapine, which do not fit neatly into any of the other categories. Different antidepressants work better for different individuals. It is often necessary to try several before finding one that works best for a specific patient. Some people may find it necessary to combine medications, which could mean two antidepressants or an antipsychotic medication in addition to an antidepressant. If a person’s close relative has responded well to a certain medication, that treatment will likely work well for him or her. Antidepressant medications are effective in the acute, continuation, and maintenance phases of treatment, as described above.

The treatment benefits of antidepressant medications are often not seen until 1-2 weeks into treatment, with maximum benefits being reached around 4-6 weeks. Most healthcare providers will monitor patients more closely during the acute phase of treatment and continue to monitor at longer intervals in the continuation and maintenance phases.

Sometimes, people stop taking antidepressant medications due to side effects, although side effects often become less severe over time. Suddenly stopping treatment or missing several doses may cause withdrawal-like symptoms. Some studies have shown that antidepressants may increase short-term suicidal thoughts or actions, especially in children, adolescents, and young adults. However, antidepressants are more likely to reduce a person’s risk of suicide in the long run.

Below are listed the main classes of antidepressant medications, some of the most common drugs in each category, and their major side effects:

  • Selective serotonin reuptake inhibitors (citalopram, escitalopram, paroxetine, fluoxetine, sertraline): major side effects include nausea, diarrhoea, and sexual dysfunction.
  • Serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine, desvenlafaxine): major side effects include nausea, diarrhoea, increased heart rate, increased blood pressure, and tremor.
  • Tricyclic antidepressants (amitryptiline, desipramine, doxepin, imipramine, nortriptyline): major side effects include sedation, low blood pressure when moving from sitting to standing (orthostatic hypotension), tremor, and heart issues like conduction delays or arrhythmias.
  • Monoamine oxidase inhibitors (isocarboxazid, phenelzine, selegiline): major side effects include high blood pressure (emergency) if eaten with foods rich in tyramine (e.g. cheeses, some meats, and home-brewed beer), sedation, tremor, and orthostatic hypotension.

Alternative Treatments

There are several treatment options that exist for people who have experienced several episodes of major depression or have not responded to several treatments.

Electroconvulsive therapy is a treatment in which a generalised seizure is induced by means of electrical current. The mechanism of action of the treatment is not clearly understood but has been show to be most effective in the most severely depressed patients. For this reason, electroconvulsive therapy is preferred for the most severe forms of depression or depression that has not responded to other treatments, known as refractory depression.

Vagus nerve stimulation is another alternative treatment that has been proven to be effective in the treatment of depression, especially people that have been resistant to four or more treatments. Some of the unique benefits of vagus nerve stimulation include improved neurocognitive function and a sustained clinical response.

Transcranial magnetic stimulation is also an alternative treatment for a major depressive episode. It is a non-invasive treatment that is easily tolerated and shows an antidepressant effect, especially in more typical depression and younger adults.

Prognosis

If left untreated, a typical MDE may last for several months. About 20% of these episodes can last two years or more. About half of depressive episodes end spontaneously. However, even after the MDE is over, 20% to 30% of patients have residual symptoms, which can be distressing and associated with disability. 50% of people will have another major depressive episode after the first. However, the risk of relapse is decreased by taking antidepressant medications for more than 6 months.

Symptoms completely improve in six to eight weeks in 60%-70% of patients. The combination of therapy and antidepressant medications has been shown to improve resolution of symptoms and outcomes of treatment.

Suicide is the 8th leading cause of death in the United States. The risk of suicide is increased during a MDE. However, the risk is even more elevated during the first two phases of treatment. There are several factors associated with an increased risk of suicide, listed below:

  • Greater than 45 years of age;
  • Male;
  • History of suicide attempt or self-injurious behaviours;
  • Family history of suicide or mental illness;
  • Recent severe loss;
  • Poor health;
  • Detailed plan;
  • Inability to accept help;
  • Lack of social support
  • Psychotic features (auditory or visual hallucinations, disorganisation of speech, behaviour, or thought);
  • Alcohol or drug use or comorbid psychiatric disorder; and/or
  • Severe depression.

Epidemiology

Estimates of the numbers of people suffering from MDE’s and major depressive disorder (MDD) vary significantly. Overall, 13-20% of people will experience significant depressive symptoms at some point in their life. The overall prevalence of MDD is slightly lower ranging from 3.7-6.7% of people. In their lifetime, 20% to 25% of women, and 7% to 12% of men will suffer a MDE. The peak period of development is between the ages of 25 and 44 years. Onset of major depressive episodes or MDD often occurs to people in their mid-20s, and less often to those over 65. The prevalence of depressive symptoms in the elderly is around 1-2%. Elderly persons in nursing homes may have increased rates, up to 15-25%. African-Americans have higher rates of depressive symptoms compared to other races. Prepubescent girls are affected at a slightly higher rate than prepubescent boys.

In a National Institute of Mental Health study, researchers found that more than 40% of people with post-traumatic stress disorder suffered from depression four months after the traumatic event they experienced.

Women who have recently given birth may be at increased risk for having a major depressive episode. This is referred to as postpartum depression and is a different health condition than the baby blues, a low mood that resolves within 10 days after delivery.

On This Day … 26 February

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People (Births)

People (Deaths)

  • 1930 – Mary Whiton Calkins, American philosopher and psychologist (b. 1863).
  • 1969 – Karl Jaspers, German-Swiss psychiatrist and philosopher (b. 1883).

Emile Coue

Émile Coué de la Châtaigneraie (26 February 1857 to 02 July 1926) was a French psychologist and pharmacist who introduced a popular method of psychotherapy and self-improvement based on optimistic autosuggestion.

Considered by Charles Baudouin to represent a second Nancy School, Coué treated many patients in groups and free of charge.

Sandie Shaw

Sandie Shaw, MBE (born Sandra Ann Goodrich; 26 February 1947) is an English singer. One of the most successful British female singers of the 1960s, she had three UK number one singles with “(There’s) Always Something There to Remind Me” (1964), “Long Live Love” (1965) and “Puppet on a String” (1967). With “Puppet on a String”, she became the first British entry to win the Eurovision Song Contest. She returned to the UK top 40, for the first time in 15 years, with her 1984 cover of the Smiths song “Hand in Glove”. Shaw announced her retirement from the music industry in 2013.

Mary Whiton Calkins

Mary Whiton Calkins (30 March 1863 to 26 February 1930) was an American philosopher and psychologist. As a psychologist, she taught at Wellesley College for many years and conducted research on dreams and memory. Calkins was the first woman to become president of the American Psychological Association and the American Philosophical Association.

Karl Jaspers

Karl Theodor Jaspers 23 February 1883 to 26 February 1969) was a German-Swiss psychiatrist and philosopher who had a strong influence on modern theology, psychiatry, and philosophy. After being trained in and practicing psychiatry, Jaspers turned to philosophical inquiry and attempted to discover an innovative philosophical system. He was often viewed as a major exponent of existentialism in Germany, though he did not accept the label.

What is a Licensed Professional Counsellor?

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Introduction

Licensed professional counsellor (LPC) is a licensure for mental health professionals in some countries.

In the US, licensed professional counsellors (or in some states, “licensed clinical mental health counsellors” or “licensed clinical professional counsellors” or “licensed mental health counsellors”) provide mental health and substance abuse care to millions of Americans.

LPCs are doctoral and master’s-level mental health service providers, trained to work with individuals, families, and groups in treating mental, behavioural, and emotional problems and disorders. LPCs make up a large percentage of the workforce employed in community mental health centres, agencies, universities, hospitals and organisations, and are employed within and covered by managed care organisations and health plans. LPCs also work with active duty military personnel and their families, as well as veterans.

Licenses are awarded for professional counsellors (LPC) and professional counsellor supervisors (LPC-S); Interns are identified with the corresponding suffix “I” (LPC-I), and Licensed Professional Counsellor Associates, with the suffix “-A”; this also applies to licensed therapists, as in the case of Licensed Marriage and Family Therapists (LMFT) who are designated as: LMFTA. Texas prohibits the use of “I” after the term LPC, and requires that LPC Interns spell out the word Intern each time.

In the US, the exact title varies by state, but the other most frequently used title is licensed mental health counsellor (LMHC). Several US states, including Illinois, Maine, and Tennessee, have implemented a two-tier system whereby both the LPC and LCPC (or equivalent) are used. In those states, higher tier professionals are granted the privilege to practice independently. However, in most states, LPC’s or LMHC’s may practice independently. Licensed Professional Counsellors are one of the six types of licensed mental health professionals who provide psychotherapy in the US.

In addition to their education, LPCs must obtain supervised clinical experience and must pass a state licensing exam. Different states require one of several different licensing examinations. Examples are the National Counsellor Examination for Licensure and Certification (NCE) as well as the National Certified Mental Health Counsellor Examination (NCMHCE). LPCs are regulated by federal and state laws, which either protect the title of LPC or LMHC or actually define the scope of practice of a professional counsellor and stipulate certain client protections. If an LPC is also a member of a professional association or has received additional certifications, they must adhere to the codes of ethics of the professional association or certification body with which they have aligned.

Requirements for Professional Counsellors

United States

LPC (or variation, e.g. LCPC, LMHC, etc.) licensure is recognised in 50 states in the US, as well as the District of Columbia, Guam, and Puerto Rico. The requirements vary from one jurisdiction to the next. Most states require some combination of a master’s degree, counselling experience and supervision, as well as passing a national examination, such as the National Counsellor Examination (NCE) and/or the National Clinical Mental Health Counselling Examination (NCMHCE).

A summary of requirements from the state of Texas LPC board serves as an example; requirements vary from state to state. For example, practicum/internship requirements (during the master’s degree) vary significantly between states (i.e. 300 in Texas and 1000 in Vermont). Course requirements and credit amount also vary, making reciprocity between states difficult for many licensed counsellors.

  • A master’s degree or doctoral degree in counselling or a related field.
  • Academic course work in each of the following areas: normal human growth and development; abnormal human behaviour; appraisal or assessment techniques; counselling theories; counselling methods or techniques (individual and group); research; lifestyle and career development; social, cultural and family issues; and professional orientation.
  • As part of the graduate programme, a supervised practicum experience that is primarily counselling in nature. The practicum should be at least 300 clock-hours with at least 100 clock-hours of direct client contact. Academic credit for the practicum must appear on the applicant’s transcript.
  • After completion of the graduate degree and before application, an applicant must take and pass the National Counsellor Exam and the Texas Jurisprudence Exam. After receiving a temporary LPC license from the board, the applicant may begin the supervised post-graduate counselling experience (internship). 3000 clock-hours with at least 1,500 being direct client contact of internship under the supervision of a board-approved supervisor is required. The 3000 clock-hours may not be completed in a time period of less than 18 months.”

Exemptions (US)

Some states, such as Oregon, have broad exemptions that allow the practice of professional counselling without a license.

In Alabama, nothing in the chapter regulating professional counselling applies to the activities, services, titles, and descriptions of persons employed, as professionals or as volunteers, in the practice of counselling for IRS recognised 501(c)(3) public and private non-profit organisations or charities. [Alabama Code 34-8A-3-a-6].

Canada

In the Canadian province of Quebec, the Ordre des conseillers et conseilleres d’orientation et psychoeducateurs et psychoeducatrices du Quebec (OCCOPPQ) grants counsellor licensure. The Canadian Counselling and Psychotherapy Association, CCPA offers a distinct certification, Canadian Certified Counsellor (CCC), separate from the regular professional membership.

The Canadian Professional Counsellors Association (CPCA) is a national competency-based association that provides the designation of Registered Professional Counsellor (RPC) to its members. Unlike degree-based associations, a specific degree level does not automatically qualify applicants for membership. Instead, the CPCA requires core competencies in education and experience prior to taking a qualifying exam and undergoing psychological testing as part of the membership application process. Counsellors must then embark on a two-year candidacy under the supervision of an approved Clinical Supervisor prior to becoming a full member. The CPCA membership roles are a mixture of Diploma, Bachelor, Master, and PhD level degree holders, and its primary purpose is the protection of the public and the promotion of competency in the mental health profession in Canada.

As well; the Canadian Addiction Counsellors Certification Federation (CACCF) promotes, certifies and monitors the competency of addiction specific counsellors in Canada using current and effective practices, which are internationally recognized. The certifications CACCF issues and its professional conduct review process provide public protection for counsellors, employers, regulatory agencies, clients and their families.

China

The Ministry of Labour and Human Resources grants counsellor licensure.

Malaysia

In Malaysia, Lembaga Kaunselor Malaysia grants counsellor licensure.

What is a Licensed Behaviour Analyst?

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Introduction

A licensed behaviour analyst is a type of behavioural health professional in the United States.

They have at least a master’s degree, and sometimes a doctorate, in behaviour analysis or a related field.

Behaviour analysts apply radical behaviourism, or applied behaviour analysis, to people.

Defining the Scope of Practice

The Behaviour Analyst Certification Board (BACB) defines behaviour analysis as follows:

“The analysis. The experimental analysis of behavior (EAB) is the basic science of this field and has over many decades accumulated a substantial and well-respected research literature. This literature provides the scientific foundation for applied behavior analysis (ABA), which is both an applied science that develops methods of changing behavior and a profession that provides services to meet diverse behavioral needs. Briefly, professionals in applied behavior analysis engage in the specific and comprehensive use of principles of learning, including operant and respondent learning, in order to address behavioral needs of widely varying individuals in diverse settings. Examples of these applications include: building the skills and achievements of children in school settings; enhancing the development, abilities, and choices of children and adults with different kinds of disabilities; and augmenting the performance and satisfaction of employees in organizations and businesses.”

As the above suggests, behaviour analysis is based on the principles of operant and respondent conditioning. This places behaviour analysis as one of the dominant models of behaviour management, behavioural engineering and behaviour therapy. Behaviour analysis is an active, environmental based approach and some behaviour analytic procedures are considered highly restrictive (see least restrictive environment). For example, these service may make access to preferred items contingent on performance. This has led to abuses in the past, in particular where punishment programmes have been involved. In addition, failure to be an independent profession often leads behaviour analysts and other behaviour modifiers to have their ethical codes supplanted by those of other professions. For example, a behaviour analyst working in the hospital setting might design a token economy, a form of contingency management. He may desire to meet his ethical obligation to make the program habilitative and in the clients’ best long-term interest. The physicians and nurses in the hospital who supervise him may decide that the token economy should instead create order in the nursing routines so clients get their medication quickly and efficiently. Instead of the ethical code of the BACB and the Association for Behaviour Analysis International’s position that those receiving treatment have a right to effective treatment and a right to effective education. In addition, failure on the part of a behaviour analyst to adequately supervise his or her workers could lead to abuse. Finally, misrepresentations of the field and historical problems between academics has led to frequent calls to professionalise behaviour analysis.

In general, there is wide support within the profession for licensure.

Range of Populations Worked With

The professional practice of behaviour analysis ranges from treatment of individuals with autism and developmental disabilities to behavioural coaching and behavioural psychotherapy. In addition to treatment of mental health problems and corrections, the professional practice of behaviour analysis includes organisational behavioural management, behavioural safety and even maintaining the behavioural health of astronauts while within and beyond earth’s orbit.

Certification

The BACB offers a technical certificate in behaviour analysis. This certification is internationally recognised. This certification states the level of training and requires an exam to show a minimum level of competence to call oneself a board certified behaviour analyst (BCBA). Certification came about because of many ethical issues with behavioural interventions being delivered including the use of aversive and humiliating treatments in the name of behaviour modification. The American Psychological Association offers a diplomate (post Ph.D. and licensed certification) in behavioural psychology.

The Meaning of Certification

BACB is a private non-profit organisation without governmental powers to regulate behaviour analytic practice. While the BACB certification means that candidates have satisfied entry-level requirements in behaviour analytic training, certificants may require a government license for independent practice when treating behavioural health or medical problems. Licensed certificants must operate within the scope of their license and must practice within their areas of expertise. Where the government regulates behavior analytic services unlicensed certificants must be supervised by a licensed professional and operate within the scope of their supervisor’s license when treating disorders. Unlicensed certificants who provide behaviour analytic training for educational or optimal performance purposes do not require licensed supervision. Where the government does not regulate the treatment of medical or psychological disorders certificants should practice in accord with the laws of their state, province, or country. All certificants must practice within their personal areas of expertise.

Licensure

Recently, a move has occurred to license behaviour analysts. Licensure’s purpose is to protect the public from employing unqualified practitioners.

The model licensing act states that a person is a behaviour analyst by training and experience. The person seeking licensure must have mastered behaviour analysis by achieving a master’s degree in behaviour analysis or related subject matter. Like all other master level licensed professions the model act sets the standard for a master’s degree. This requirement states that the person has achieved textbook knowledge of behaviour analysis which can be then tested through the exam offered by the BACB or the one offered by the World Centre for Behaviour Analysis. It also requires an internship in which a behaviour analysts works under another master or Ph.D. level behaviour analyst for a period of one year (750 hours) with at least two hours/week of supervision. Finally, those 750 hours are considered tutelage time. After that, the behaviour analyst must engage in supervised practice under a behaviour analyst for a period of another 2 years (2,000 hours).

Once this process is complete, the person applies to a state board who ensures that he or she has indeed met the above conditions. Once the person is licensed public protection is still monitored by the licensing board, which makes sure that the person receives sufficient ongoing education, and the licensing board investigates ethical complaints. A licensed behaviour analyst would have equal training, knowledge, skills and abilities in their discipline as would a mental health counsellor or marriage and family therapist in their discipline. In February 2008, Indiana, Arizona, Massachusetts, Vermont, Oklahoma and other states now have legislation pending to create licensure for behaviour analysts. Pennsylvania was the first state in 2008 to license “behaviour specialists” to cover behaviour analysts. Arizona, less than three weeks later, became the first state to license “behaviour analysts.” Other states such as New York, Nevada and Wisconsin also have passed behaviour analytic licensure.

Professional Organisations

The Association for Behaviour Analysis International has a special interest group for practitioner issues, which focuses on key issues related to licensing behaviour analysts. In addition, they have a practice board and a policy board to handle legislative issues ABA:I. Finally, the association has recently put out its own model licensing act for behaviour analysts.

Association for behaviour analysis international serves as the core intellectual home for behaviour analysts. The Association for Behaviour Analysis International sponsors 2 conferences per year – one in the US and one international.

What is Interpersonal Psychotherapy?

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Introduction

Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centres on resolving interpersonal problems and symptomatic recovery.

It is an empirically supported treatment (EST) that follows a highly structured and time-limited approach and is intended to be completed within 12-16 weeks. IPT is based on the principle that relationships and life events impact mood and that the reverse is also true.

It was developed by Gerald Klerman and Myrna Weissman for major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders, and is more effective when used in combination with psychiatric medications.

Along with cognitive behavioural therapy (CBT), IPT is recommended in treatment guidelines as a psychosocial treatment of choice.

Brief History

Originally named “high contact” therapy, IPT was first developed in 1969 at Yale University as part of a study designed by Gerald Klerman, Myrna Weissman and colleagues to test the efficacy of an antidepressant with and without psychotherapy as maintenance treatment of depression. IPT has been studied in many research protocols since its development. The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Programme (TDCRP) demonstrated the efficacy of IPT as a maintenance treatment and delineated some contributing factors.

Foundations

IPT was influenced by CBT as well as psychodynamic approaches. It takes its structure from CBT in that it is time-limited, employs structured interviews and assessment tools. In general, however, IPT focuses directly on affects, or feelings, whereas CBT focuses on cognitions with strong associated affects. Unlike CBT, IPT makes no attempt to uncover distorted thoughts systematically by giving homework or other assignments, nor does it help the patient develop alternative thought patterns through prescribed practice. Rather, as evidence arises during the course of therapy, the therapist calls attention to distorted thinking in relation to significant others. The goal is to change the relationship pattern rather than associated depressive cognitions, which are acknowledged as depressive symptoms.

The content of IPT’s therapy was inspired by Attachment theory and Harry Stack Sullivan’s Interpersonal psychoanalysis. Social theory is also influenced in a lesser role to emphasis on qualitative impact of social support networks for recovery. Unlike psychodynamic approaches, IPT does not include a personality theory or attempt to conceptualise or treat personality but focuses on humanistic applications of interpersonal sensitivity.

  • Attachment Theory, forms the basis for understanding patients’ relationship difficulties, attachment schema and optimal functioning when attachment needs are met.
  • Interpersonal Theory, describes the ways in which patients’ maladaptive metacommunication patterns (Low to high Affiliation & Inclusion and dominant to submissive Status) lead to or evoke difficulty in their here-and-now interpersonal relationships.

The aim of IPT is to help the patient to improve interpersonal and intrapersonal communication skills within relationships and to develop social support network with realistic expectations to deal with the crises precipitated in distress and to weather ‘interpersonal storms’.

Clinical Applications

It has been demonstrated to be an effective treatment for depression and has been modified to treat other psychiatric disorders such as substance use disorders and eating disorders. It is incumbent upon the therapist in the treatment to quickly establish a therapeutic alliance with positive countertransference of warmth, empathy, affective attunement and positive regard for encouraging a positive transferential relationship, from which the patient is able to seek help from the therapist despite resistance. It is primarily used as a short-term therapy completed in 12-16 weeks, but it has also been used as a maintenance therapy for patients with recurrent depression. A shorter, 6-week therapy suited to primary care settings called Interpersonal counselling (IPC) has been derived from IPT.

Interpersonal psychotherapy has been found to be an effective treatment for the following:

  • Bipolar disorder.
  • Bulimia nervosa.
  • Post-partum depression.
  • Major depressive disorder.
  • Cyclothymia.

Adolescents

Although originally developed as an individual therapy for adults, IPT has been modified for use with adolescents and older adults.

IPT for children is based on the premise that depression occurs in the context of an individual’s relationships regardless of its origins in biology or genetics. More specifically, depression affects people’s relationships and these relationships further affect our mood. The IPT model identifies four general areas in which a person may be having relationship difficulties:

  • Grief after the loss of a loved one;
  • Conflict in significant relationships, including a client’s relationship with his or her own self;
  • Difficulties adapting to changes in relationships or life circumstances; and
  • Difficulties stemming from social isolation.

The IPT therapist helps identify areas in need of skill-building to improve the client’s relationships and decrease the depressive symptoms. Over time, the client learns to link changes in mood to events occurring in his/her relationships, communicate feelings and expectations for the relationships, and problem-solve solutions to difficulties in the relationships.

IPT has been adapted for the treatment of depressed adolescents (IPT-A) to address developmental issues most common to teenagers such as separation from parents, development of romantic relationships, and initial experience with death of a relative or friend. IPT-A helps the adolescent identify and develop more adaptive methods for dealing with the interpersonal issues associated with the onset or maintenance of their depression. IPT-A is typically a 12- to 16-week treatment. Although the treatment involves primarily individual sessions with the teenager, parents are asked to participate in a few sessions to receive education about depression, to address any relationship difficulties that may be occurring between the adolescent and his/her parents, and to help support the adolescent’s treatment.

Elderly

IPT has been used as a psychotherapy for depressed elderly, with its emphasis on addressing interpersonally relevant problems. IPT appears especially well suited to the life changes that many people experience in their later years.

On This Day … 24 February

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People (Births)

  • 1900 – Irmgard Bartenieff, German-American dancer and physical therapist, leading pioneer of dance therapy (d. 1981).

Irmgard Bartenieff

Irmgard Bartenieff (1900 to 1981) was a dance theorist, dancer, choreographer, physical therapist, and a leading pioneer of dance therapy. A student of Rudolf Laban, she pursued cross-cultural dance analysis, and generated a new vision of possibilities for human movement and movement training. From her experiences applying Laban’s concepts of dynamism, three-dimensional movement and mobilization to the rehabilitation of people affected by polio in the 1940s, she went on to develop her own set of movement methods and exercises, known as Bartenieff Fundamentals.

Bartenieff incorporated Laban’s spatial concepts into the mechanical anatomical activity of physical therapy, in order to enhance maximal functioning. In physical therapy, that meant thinking in terms of movement in space, rather than by strengthening muscle groups alone. The introduction of spatial concepts required an awareness of intent on the part of the patient as well, that activated the patient’s will and thus connected the patient’s independent participation to his or her own recovery. “There is no such thing as pure “physical therapy” or pure “mental” therapy. They are continuously interrelated.”

Bartenieff’s presentation of herself was quiet and, according to herself, she did not feel comfortable marketing her skills and knowledge. Not until June 1981, a few months before she died, did her name appear in the institute’s title: Laban/Bartenieff Institute of Movement Studies (LIMS), a change initiated by the Board of Directors in her honour.

Dance Therapy

She held a position of dance therapy research assistant (1957-1967) to Dr. Israel Zwerling at the Day Hospital Unit of Albert Einstein College of Medicine. Zwerling, a psychiatrist […] was very receptive to further exploration of dance as a therapeutic tool for defusing aggression and anxiety. What particularly reinforced his interest in her was that she had a vocabulary and a notation for recording observations of movement. This became a vital factor in daily observations through the one-way screen, especially of family and therapeutic groups.

Dance therapy was then an emerging field of adjunctive therapy. Bartenieff’s special contribution was in bringing Laban’s work to a field very much in need of movement documentation: [It] provided a method of movement analysis and a system of notation which placed dance therapists on their own professional ground, giving them a language for describing patients’ movements, and eliminating the need to rely on less accurate jargon borrowed from other disciplines.

What is the Hamilton Rating Scale for Depression?

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Introduction

The Hamilton Rating Scale for Depression (HRSD), also called the Hamilton Depression Rating Scale (HDRS), abbreviated HAM-D, is a multiple item questionnaire used to provide an indication of depression, and as a guide to evaluate recovery.

Max Hamilton originally published the scale in 1960 and revised it in 1966, 1967, 1969, and 1980. The questionnaire is designed for adults and is used to rate the severity of their depression by probing mood, feelings of guilt, suicide ideation, insomnia, agitation or retardation, anxiety, weight loss, and somatic symptoms.

The HRSD has been criticised for use in clinical practice as it places more emphasis on insomnia than on feelings of hopelessness, self-destructive thoughts, suicidal cognitions and actions. An antidepressant may show statistical efficacy even when thoughts of suicide increase but sleep is improved, or for that matter, an antidepressant that as a side effect increase sexual and gastrointestinal symptom ratings may register as being less effective in treating the depression itself than it actually is. Hamilton maintained that his scale should not be used as a diagnostic instrument.

The original 1960 version contained 17 items (HDRS-17), but four other questions not added to the total score were used to provide additional clinical information. Each item on the questionnaire is scored on a 3 or 5 point scale, depending on the item, and the total score is compared to the corresponding descriptor. Assessment time is about 20 minutes.

Methodology

The patient is rated by a clinician on 17 to 29 items (depending on version) scored either on a 3-point or 5-point Likert-type scale. For the 17-item version, a score of 0-7 is considered to be normal while a score of 20 or higher (indicating at least moderate severity) is usually required for entry into a clinical trial. Questions 18-20 may be recorded to give further information about the depression (such as whether diurnal variation or paranoid symptoms are present), but are not part of the scale. A structured interview guide for the questionnaire is available.

Although Hamilton’s original scale had 17 items, other versions included up to 29 items (HRSD-29).

Unstructured versions of the HAM-D provide general instructions for rating items, while structured versions may provide definitions and/or specific interview questions for use. Structured versions of the HAM-D show more reliability than unstructured versions with informed use.

Levels of Depression

The UK National Institute for Health & Clinical Excellence (NICE) established the levels of depression in relation to the 17 item HRSD compared with those suggested by the American Psychiatrists Association (APA):

  • Not depressed: 0-7.
  • Mild (subthreshold): 8-13.
  • Moderate (mild): 14-18.
  • Severe (moderate): 19-22.
  • Very severe (severe): >23.

Other Scales

Other scales include:

What is the Montgomery-Asberg Depression Rating Scale?

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Introduction

The Montgomery-Åsberg Depression Rating Scale (MADRS) is a ten-item diagnostic questionnaire which psychiatrists use to measure the severity of depressive episodes in patients with mood disorders.

It was designed in 1979 by British and Swedish researchers as an adjunct to the Hamilton Rating Scale for Depression (HRSD) which would be more sensitive to the changes brought on by antidepressants and other forms of treatment than the Hamilton Scale was. There is, however, a high degree of statistical correlation between scores on the two measures.

Interpretation

Higher MADRS score indicates more severe depression, and each item yields a score of 0 to 6. The overall score ranges from 0 to 60.

The questionnaire includes questions on the following symptoms:

  1. Apparent sadness.
  2. Reported sadness.
  3. Inner tension.
  4. Reduced sleep.
  5. Reduced appetite.
  6. Concentration difficulties.
  7. Lassitude.
  8. Inability to feel.
  9. Pessimistic thoughts.
  10. Suicidal thoughts.

Usual cut-off points are:

  • 0 to 6: normal/symptom absent.
  • 7 to 19: mild depression.
  • 20 to 34: moderate depression.
  • >34: severe depression.

MADRS-S

A self-rating version of this scale (MADRS-S) is often used in clinical practice and correlates reasonably well with expert ratings.

The MADRS-S instrument has nine questions, with an overall score ranging from 0 to 54 points.

On This Day … 23 February

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People (Births)

  • 1883 – Karl Jaspers, German-Swiss psychiatrist and philosopher (d. 1969).

Karl Jaspers

Karl Theodor Jaspers (23 February 1883 to 26 February 1969) was a German-Swiss psychiatrist and philosopher who had a strong influence on modern theology, psychiatry, and philosophy. After being trained in and practicing psychiatry, Jaspers turned to philosophical inquiry and attempted to discover an innovative philosophical system. He was often viewed as a major exponent of existentialism in Germany, though he did not accept the label.

Jaspers earned his medical doctorate from the University of Heidelberg medical school in 1908 and began work at a psychiatric hospital in Heidelberg under Franz Nissl, successor of Emil Kraepelin and Karl Bonhoeffer, and Karl Wilmans. Jaspers became dissatisfied with the way the medical community of the time approached the study of mental illness and gave himself the task of improving the psychiatric approach. In 1913 Jaspers habilitated at the philosophical faculty of the Heidelberg University and gained there in 1914 a post as a psychology teacher. The post later became a permanent philosophical one, and Jaspers never returned to clinical practice. During this time Jaspers was a close friend of the Weber family (Max Weber also having held a professorship at Heidelberg).

In 1921, at the age of 38, Jaspers turned from psychology to philosophy, expanding on themes he had developed in his psychiatric works. He became a philosopher, in Germany and Europe.

After the Nazi seizure of power in 1933, Jaspers was considered to have a “Jewish taint” (jüdische Versippung, in the jargon of the time) due to his Jewish wife, and was forced to retire from teaching in 1937. In 1938 he fell under a publication ban as well. Many of his long-time friends stood by him, however, and he was able to continue his studies and research without being totally isolated. But he and his wife were under constant threat of removal to a concentration camp until 30 March 1945, when Heidelberg was liberated by American troops.

In 1948 Jaspers moved to the University of Basel in Switzerland. In 1963 he was awarded the honorary citizenship of the city of Oldenburg in recognition of his outstanding scientific achievements and services to occidental culture. He remained prominent in the philosophical community and became a naturalized citizen of Switzerland living in Basel until his death on his wife’s 90th birthday in 1969.