On This Day … 14 January

People (Deaths)

Harry Stack Sullivan

Herbert “Harry” Stack Sullivan (21 February 1892 to 14 January 1949) was an American Neo-Freudian psychiatrist and psychoanalyst who held that “personality can never be isolated from the complex interpersonal relationships in which [a] person lives” and that “[t]he field of psychiatry is the field of interpersonal relations under any and all circumstances in which [such] relations exist”.

Having studied therapists Sigmund Freud, Adolf Meyer, and William Alanson White, he devoted years of clinical and research work to helping people with psychotic illness.

Early Life

Sullivan was a child of Irish immigrants and grew up in the then anti-Catholic town of Norwich, New York, resulting in a social isolation which may have inspired his later interest in psychiatry. He attended the Smyrna Union School, then spent two years at Cornell University from 1909, receiving his medical degree in Chicago College of Medicine and Surgery in 1917.

Work

Along with Clara Thompson, Karen Horney, Erich Fromm, Otto Allen Will, Jr., Erik H. Erikson, and Frieda Fromm-Reichmann, Sullivan laid the groundwork for understanding the individual based on the network of relationships in which they are enmeshed. He developed a theory of psychiatry based on interpersonal relationships where cultural forces are largely responsible for mental illnesses (see also social psychiatry). In his words, one must pay attention to the “interactional”, not the “intrapsychic”. This search for satisfaction via personal involvement with others led Sullivan to characterise loneliness as the most painful of human experiences. He also extended the Freudian psychoanalysis to the treatment of patients with severe mental disorders, particularly schizophrenia.

Besides making the first mention of the significant other in psychological literature, Sullivan developed the idea of the “Self System”, a configuration of the personality traits developed in childhood and reinforced by positive affirmation and the security operations developed in childhood to avoid anxiety and threats to self-esteem. Sullivan further defined the Self System as a steering mechanism toward a series of I-You interlocking behaviours; that is, what an individual does is meant to elicit a particular reaction.

Sullivan called these behaviours Parataxical Integrations and he noted that such action-reaction combinations can become rigid and dominate an adult’s thinking pattern, limiting their actions and reactions toward the world as the adult sees the world and not as it really is. The resulting inaccuracies in judgment Sullivan termed parataxic distortion, when other persons are perceived or evaluated based on the patterns of previous experience, similar to Freud’s notion of transference. Sullivan also introduced the concept of “prototaxic communication” as a more primitive, needy, infantile form of psychic interchange and of “syntactic communication” as a mature style of emotional interaction.

Sullivan’s work on interpersonal relationships became the foundation of interpersonal psychoanalysis, a school of psychoanalytic theory and treatment that stresses the detailed exploration of the nuances of patients’ patterns of interacting with others.

Sullivan was the first to coin the term “problems in living” to describe the difficulties with self and others experienced by those with mental illnesses. This phrase was later picked up and popularised by Thomas Szasz, whose work was a foundational resource for the antipsychiatry movement. “Problems in living” went on to become the movement’s preferred way to refer to the manifestations of mental disturbances.

In 1927, he reviewed the controversial, anonymously published The Invert and his Social Adjustment and in 1929 called it “a remarkable document by a homosexual man of refinement; intended primarily as a guide to the unfortunate sufferers of sexual inversion, and much less open to criticism than anything else of the kind so far published.”

He was one of the founders of the William Alanson White Institute, considered by many to be the world’s leading independent psychoanalytic institute, and of the journal Psychiatry in 1937. He headed the Washington, DC School of Psychiatry from 1936 to 1947.

In 1940, he and colleague Winfred Overholser, serving on the American Psychiatric Society’s committee on Military Mobilisation, formulated guidelines for the psychological screening of inductees to the United States military. He believed, writes one historian, “that sexuality played a minimal role in causing mental disorders and that adult homosexuals should be accepted and left alone.” Despite his best efforts, others included homosexuality as a disqualification for military service.

Beginning on 05 December 1940, Sullivan served as psychiatric adviser to Selective Service director Clarence A. Dykstra, but resigned in November 1941 after General Lewis B. Hershey, who was hostile to psychiatry, became the director. Sullivan then took part in establishing the Office of War Information in 1942. Beginning in 1927, Sullivan had a 22-year relationship with James Inscoe Sullivan, known as “Jimmie”, who was 20 years younger than Sullivan.

Although some contemporaries and historians have regarded Inscoe as an unofficially adopted son, and Sullivan as closeted, one should remember that to be open about it would have made his professional interest in the area and further research very difficult. His colleague Helen Swick Perry’s biography of Sullivan mentions the relationship and it is clear his close friends were well aware they were partners.

Writings

Although Sullivan published little in his lifetime, he influenced generations of mental health professionals, especially through his lectures at Chestnut Lodge in Rockville, Maryland, outside Washington, DC. Leston Havens called him the most important underground influence in American psychoanalysis. His ideas were collected and published posthumously, edited by Helen Swick Perry, who also published a detailed biography in 1982 (Perry, 1982, Psychiatrist of America).

Works

The following works are in Special Collections (MSA SC 5547) at the Maryland State Archives in Annapolis: Conceptions of Modern Psychiatry, Soundscriber Transcriptions (February 1945 to May 1945); Lectures 1-97 (begins 02 October 1942); Georgetown University Medical School Lectures (1939); Personal Psychopathology (1929-1933); The Psychiatry of Character and its Deviations-undated notes.

His writings include:

  • The Interpersonal Theory of Psychiatry (1953).
  • “The Psychiatric Interview” (1954).
  • Conceptions of Modern Psychiatry (1947/1966).
  • Schizophrenia as a Human Process (1962).

Associates

After Sullivan’s death, Saul B. Newton and his wife Dr. Jane Pearce (a psychiatrist who studied with Sullivan in the late 1940s) established the Sullivan Institute for Research in Psychoanalysis in New York City.

What is a Mental Health Professional?

Introduction

A mental health professional is a health care practitioner or social and human services provider who offers services for the purpose of improving an individual’s mental health or to treat mental disorders.

This broad category was developed as a name for community personnel who worked in the new community mental health agencies begun in the 1970s to assist individuals moving from state hospitals, to prevent admissions, and to provide support in homes, jobs, education, and community. These individuals (i.e. state office personnel, private sector personnel, and non-profit, and now voluntary sector personnel) were the forefront brigade to develop the community programmes, which today may be referred to by names such as supported housing, psychiatric rehabilitation, supported or transitional employment, sheltered workshops, supported education, daily living skills, affirmative industries, dual diagnosis treatment, individual and family psychoeducation, adult day care, foster care, family services and mental health counselling.

Psychiatrists also are working in clinical fields with psychologists including in sociobehavioural, neurological, person-centred and clinical approaches (often office-based), and studies of the “brain disease” (which came from the community fields and community management and are taught at the MA to PhD level in education). For example, Nat Raskin (at Northwestern University Medical School) who worked with the illustrious Carl Rogers, published on person-centred approaches and therapy in 2004. The term counsellors often refers to office-based professionals who offer therapy sessions to their clients, operated by organisations such as pastoral counselling (which may or may not work with long term services clients) and family counsellors. Mental health counsellors may refer to counsellors working in residential services in the field of mental health in community programmes.

As Community Professionals

As Dr. William Anthony, father of psychiatric rehabilitation, described, psychiatric nurses (RNMH, RMN, CPN), clinical psychologists (PsyD or PhD), clinical social workers (MSW or MSSW), mental health counselors (MA or MS), professional counselors, pharmacists, as well as many other professionals are often educated in “psychiatric fields” or conversely, educated in a generic community approach (e.g. human services programmes or health and human services in 2013). However, his primary concern is education that leads to a willingness to work with “long-term services and supports” community support in the community to lead to better life quality for the individual, the families and the community.

The community support framework in the US of the 1970s is taken-for-granted as the base for new treatment developments (e.g. eating disorders, drug addiction programmes) which tend to be free-standing clinics for specific “disorders”. Typically, the term “mental health professional” does not refer to other categorical disability areas, such as intellectual and developmental disability (which trains its own professionals and maintains its own journals, and US state systems and institutions). Psychiatric rehabilitation has also been reintroduced into the transfer to behavioural health care systems.

As Certified and Licensed (Across Institutions and Communities)

These professionals often deal with the same illnesses, disorders, conditions, and issues (though may separate on-site locations, such as hospital or community for the same clientele); however, their scope of practice differs and more particularly, their positions and roles in the fields of mental health services and systems. The most significant difference between mental health professionals are the laws regarding required education and training across the various professions. However, the most significant change has been the Supreme Court Olmstead Decision on the most integrated setting which should further reduce state hospital utilisation; yet with new professionals seeking right for community treatment orders and rights to administer medications (original community programmes, residents taught to self-administer medications, 1970s).

In 2013, new mental health practitioners are licensed or certified in the community (e.g., PhD, education in private clinical practice) by states, degrees and certifications are offered in fields such as psychiatric rehabilitation (MS, PhD), BA psychology (liberal arts, experimental/clinical/existential/community) to MA licensing is now more popular, BA (to PhD) mid-level programme management, qualified civil service professionals, and social workers remain the mainstay of community admissions procedures (licensed by state, often generic training) in the US. Surprisingly, state direction has moved from psychiatry or clinical psychology to community leadership and professionalisation of community services management.

Entry level recruitment and training remain a primary concern (since the 1970s, then often competing with fast food positions), and the US Direct Support Workforce includes an emphasis on also training of psychiatric aides, behavioural aides, and addictions aides to work in homes and communities. The Centres for Medicaid and Medicare have new provisions for “self-direction” in services and new options are in place for individual plans for better life outcomes. Community programs are increasingly using health care financing, such as Medicaid, and Mental Health Parity is now law in the US.

Professional Distinctions

Comparison of US Mental Health Professionals

OccupationDegreeCommon LicensesPrescription Privilege
PsychiatristMD/DOPsychiatrist.Yes
Psychiatric Rehabilitation CounsellorMaster of Rehabilitation Sciences or PhD.Similar to Related Personnel (Cognitive Sciences), Rehabilitation CounsellorsNo
Clinical PsychologistPhD/PsyD.Psychologist.Yes [1]
School Psychologist1. PhD/EdD/PsyD.
2. Post-master’s terminal degree (not doctoral level).
3. EdS Doctoral degrees.
4. PhD Inclusion educators.
5. Master’s level MA/MS
Certified School Psychology or National Certified School Psychologist.No
Counsellor/Psychotherapist (Doctorate)PhD/EdD/DMFT.Psychologist.No
Counsellor/Psychotherapist/Rehabilitation/Mental Health (Master’s)MA/MS/MC plus two to three years of post-master’s supervised clinical experience.Mental health counsellors/LMFT/LCPC/LPC/LPA/LMHC.No
Clinical or Psychiatric Social WorkerMSW/DSW/PhD plus two to three years of post-master’s supervised clinical experience.LCSW/LMSW/LSW.No
Social Worker (Agency-based Master’s/Doctorate)MSW/DWS/PhD.LMSW/GSW/LSW.No
Social Worker (Bachelor or Diploma)BSW or SSW.RSW, RSSW, SWA, social work assistant.No
Occupational Therapist (Doctorate/Master’s)MOT, MSOT, OTD, ScD, or PhD.Related supervised community personnel in physical, speech and communication, OTR, COTA.No
Licensed Behaviour Therapist (Doctorate/Master’s) [1]PhD/EdD/MS/MEd/MA.1. LBA/LBS/BCBA/BCBA-D.
2. Dual Licensed inclusion educator.
No
Psychiatric and Mental Health Nurse PractitionerMSN/DNP/PhD.PMHNP-BC.Yes
Physician’s AssistantMPAS/MHS/MMS/DScPA.PA/PA-C/APA-C/RPA/RPA-C.Yes
Expressive Therapist/Creative Arts TherapistMA/ATR/ATR-BC.ATR-BC/MT-BC/BC-DMT/RDT/CPT.No

Notes:

  1. Currently, psychologists may prescribe in US five states: Iowa, Idaho, Illinois, New Mexico, and Louisiana, as well as in the Public Health Service, the Indian Health Service, the US military, and Guam.
  2. Includes licensed dual inclusion educators, behaviour analyst, substance abuse and behavioural disorders, “inclusion educator”.

Treatment Diversity and Community Mental Health

Mental health professionals exist to improve the mental health of individuals, couples, families and the community-at-large (In this generic use, mental health is available to the entire population, similar to the use by mental health associations). Because mental health covers a wide range of elements, the scope of practice greatly varies between professionals. Some professionals may enhance relationships while others treat specific mental disorders and illness; still, others work on population-based health promotion or prevention activities. Often, as with the case of psychiatrists and psychologists, the scope of practice may overlap often due to common hiring and promotion practices by employers.

As indicated earlier, community mental health professionals have been involved in the beginning and operating community programmes which include ongoing efforts to improve life outcomes, originally through long term services and supports (LTSS). Termed functional or competency-based programmes, this service also stressed decision making and self-determination or empowerment as critical aspects. Community mental health professionals may also serve children who have different needs, as do families, including family therapy, financial assistance and support services. Community mental health professionals serve people of all ages from young children with autism, to children with emotional (or behavioural) needs, to grandma who has Alzheimer’s or dementia and is living at home after dad passes away.

Most qualified mental health professionals will refer a patient or client to another professional if the specific type of treatment needed is outside of their scope of practice. The main community concern is “zero rejection” from community services for individuals who have been termed “hard to serve” in the population (think schizophrenia or dual diagnosis) or who have additional needs such as mobility and sensory impairments. Additionally, many mental health professionals may sometimes work together using a variety of treatment options such as concurrent psychiatric medication and psychotherapy and supported housing. Additionally, specific mental health professionals may be utilised based upon their cultural and religious background or experience, as part of a theory of both alternative medicines and of the nature of helping and ethnicity.

Primary care providers, such as internists, paediatricians, and family physicians, may provide initial components of mental health diagnosis and treatment for children and adults; however, family physicians in some states refuse to even prescribe a psychotropic medication deferring to separately funded “medication management” services. Community programmes in the categorical field of mental health were designed (1970s) to have a personal family physician for every client in their programmes, except for institutional settings and nursing facilities which have only one or two for a large facility.

In particular, family physicians are trained during residency in interviewing and diagnostic skills, and may be quite skilled in managing conditions such as attention deficit hyperactivity disorder (ADHD) in children and depression in adults. Likewise, many (but not all) paediatricians may be taught the basic components of ADHD diagnosis and treatment during residency. In many other circumstances, primary care physicians may receive additional training and experience in mental health diagnosis and treatment during their practice years.

Relative Effectiveness

Both primary care physicians/general practitioners (GP’s) and psychiatrist are just as effective (in terms of remission rates) for the treatment of depression. However, treatment resistant depression, suicidal, homicidal ideation, psychosis and catatonia should be handled by mental health specialists. Treatment-resistant depression (or treatment refractory depression) refers to depression which remains at large after at least two antidepressant medications have been trailed on their own.

Peer Workers

Some think that mental health professionals are less credible when they have personal experience of mental health. In fact, the mental health sector goes out of its way to hire people with mental illness experience. Those in the mental health workforce with personal experience of mental health are referred to as ‘peer (support) workers’. The balance of evidence appears to favour their employment: Randomised controlled trials consistently demonstrate peer staff produce outcomes on par with non-peer staff in ancillary roles, but they actually perform better in reducing hospitalisation rates, engaging clients who are difficult to reach, and cutting substance use. There is research that indicates peer workers cultivate a perception among service users that the service is more responsive to non-treatment things, increases their hope, family satisfaction, self-esteem and community belonging.

Psychiatrists

Refer to Psychiatrist and Psychiatry.


Psychiatrists are physicians and one of the few professionals in the mental health industry who specialize and are certified in treating mental illness using the biomedical approach to mental disorders including the use of medications. However, biological, genetic and social processes as part of pre-medicine have been the basis of education in fields such as BA psychology since the 1970s, and in 2013, such academic degrees also may include extensive work on the status of brain, DNA research and its applications. Clinical psychologists were hired by states and served in institutions in the US, and were involved in the transition to community systems.

Psychiatrists may also go through significant training to conduct psychotherapy and cognitive behavioural therapy;. The amount of training a psychiatrist holds in providing these types of therapies varies from program to program and also differs greatly based upon region (Cognitive therapy also stems from cognitive rehabilitation techniques, and may involve long-term community clients with brain injuries seeking jobs, education and community housing). In the 1970s, psychiatrists were considered to be hospital-based, assessment, and clinical education personnel which was not involved in establishing community programmes.

Specialties of Psychiatrists

As part of their evaluation of the patient, psychiatrists are one of only a few mental health professionals who may conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning. A medical professional must evaluate the patient for any medical problems or diseases that may be the cause of the mental illness.

Historically psychiatrists have been the only mental health professional with the power to prescribe medication to treat specific types of mental illness. Currently, physician assistants response to the psychiatrist (in lieu of and supervised) and advanced practice psychiatric nurses may prescribe medications, including psychiatric medications. Clinical psychologists have gained the ability to prescribe psychiatric medications on a limited basis in a few US states after completing additional training and passing an examination.

Educational Requirements for Psychiatrists

Typically the requirements to become a psychiatrist are substantial but differ from country to country. In general there is an initial period of several years of academic and clinical training and supervised work in different areas of medicine, in order to become a licensed medical doctor, followed by several years of supervised work and study in psychiatry, in order to become a licensed psychiatrist.

In the United States and Canada one must first complete a Bachelor’s degree. Students may typically decide any major subject of their choice, however they must enrol in specific courses, usually outlined in a pre-medical programme. One must then apply to and attend 4 years of medical school in order to earn their MD or DO and to complete their medical education. Psychiatrists must then pass three successive rigorous national board exams (United States Medical Licensing Exams “USMLE”, Steps 1, 2, and 3), which draws questions from all fields of medicine and surgery, before gaining an unrestricted license to practice medicine. Following this, the individual must complete a four-year residency in Psychiatry as a psychiatric resident and sit for annual national in-service exams. Psychiatry residents are required to complete at least four post-graduate months of internal medicine (paediatrics may be substituted for some or all of the internal medicine months for those planning to specialise in child and adolescent psychiatry) and two months of neurology, usually during the first year, but some programmes require more. Occasionally, some prospective psychiatry residents will choose to do a transitional year internship in medicine or general surgery, in which case they may complete the two months of neurology later in their residency. After completing their training, psychiatrists take written and then oral specialty board examinations. The total amount of time required to qualify in the field of psychiatry in the United States is typically 4 to 5 years after obtaining the MD or DO (or in total 8 to 9 years minimum). Many psychiatrists pursue an additional 1-2 years in subspecialty fellowships on top of this such as child psychiatry, geriatric psychiatry, and psychosomatic medicine.

In the United Kingdom, the Republic of Ireland, and most Commonwealth countries, the initial degree is the combined Bachelor of Medicine and Bachelor of Surgery, usually a single period of academic and clinical study lasting around five years. This degree is most often abbreviated ‘MBChB’, ‘MB BS’ or other variations, and is the equivalent of the American ‘MD’. Following this the individual must complete a two-year foundation programme that mainly consists of supervised paid work as a Foundation House Officer within different specialties of medicine. Upon completion the individual can apply for “core specialist training” in psychiatry, which mainly involves supervised paid work as a Specialty Registrar in different subspecialties of psychiatry. After three years there is an examination for Membership of the Royal College of Psychiatrists (abbreviated MRCPsych), with which an individual may then work as a “Staff grade” or “Associate Specialist” psychiatrist, or pursue an academic psychiatry route via a PhD. If, after the MRCPsych, an additional 3 years of specialisation known as “advanced specialist training” are taken (again mainly paid work), and a Certificate of Completion of Training is awarded, the individual can apply for a post taking independent clinical responsibility as a “consultant” psychiatrist.

Clinical Psychologists

A clinical psychologist studies and applies psychology for the purpose of understanding, preventing and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. In many countries it is a regulated profession that addresses moderate to more severe or chronic psychological problems, including diagnosable mental disorders. Clinical psychology includes a wide range of practices, such as research, psychological assessment, teaching, consultation, forensic testimony, and program development and administration. Central to clinical psychology is the practice of psychotherapy, which uses a wide range of techniques to change thoughts, feelings, or behaviours in service to enhancing subjective well-being, mental health, and life functioning. Unlike other mental health professionals, psychologists are trained to conduct psychological assessment. Clinical psychologists can work with individuals, couples, children, older adults, families, small groups, and communities.

Specialties of Clinical Psychologists

Clinical psychologists who focus on treating mental health specialises in evaluating patients and providing psychotherapy. They do not prescribe medication as this is a role of a psychiatrist (physician who specialises in psychiatry). There are a wide variety of therapeutic techniques and perspectives that guide practitioners, although most fall into the major categories of Psychodynamic, Cognitive Behavioural, Existential-Humanistic, and Systems Therapy (e.g. family or couples therapy).

In addition to therapy, clinical psychologists are also trained to administer and interpret psychological personality tests such as the MMPI and the Rorschach inkblot test, and various standardised tests of intelligence, memory, and neuropsychological functioning. Common areas of specialization include: specific disorders (e.g. trauma), neuropsychological disorders, child and adolescent, family and relationship counselling. Internationally, psychologists are generally not granted prescription privileges. In the US, prescriptive rights have been granted to appropriately trained psychologists only in the states of New Mexico and Louisiana, with some limited prescriptive rights in Indiana and the US territory of Guam.

Educational Requirements for Clinical Psychologists

Clinical psychologists, having completed an undergraduate degree usually in psychology or other social science, generally undergo specialist postgraduate training lasting at least two years (e.g. Australia), three years (e.g. UK), or four to six years depending how much research activity is included in the course (e.g. US). In countries where the course is of shorter duration, there may be an informal requirement for applicants to have undertaken prior work experience supervised by a clinical psychologist, and a proportion of applicants may also undertake a separate PhD research degree.

Today, in the US, about half of licensed psychologists are trained in the Scientist-Practitioner Model of Clinical Psychology (PhD) – a model that emphasizes both research and clinical practice and is usually housed in universities. The other half are being trained within a Practitioner-Scholar Model of Clinical Psychology (PsyD), which focuses on practice (similar to professional degrees for medicine and law). A third training model called the Clinical Scientist Model emphasizes training in clinical psychology research. Outside of coursework, graduates of both programmes generally are required to have had 2 to 3 years of supervised clinical experience, a certain amount of personal psychotherapy, and the completion of a dissertation (PhD programmes usually require original quantitative empirical research, whereas the PsyD equivalent of dissertation research often consists of literature review and qualitative research, theoretical scholarship, programme evaluation or development, critical literature analysis, or clinical application and analysis).

Continuing Education Requirements for Clinical Psychologists

Most states in the US require clinical psychologists to obtain a certain number of continuing education credits in order to renew their license. This was established to ensure that psychologists stay current with information and practices in their fields. The license renewal cycle varies, but renewal is generally required every two years.

The number of continuing education credits required for clinical psychologists varies between states. In Nebraska, psychologists are required to obtain 24 hours of approved continuing education credits in the 24 months before their license renewal. In California, the requirement is for 36 hours of credits. New York State does not have any continuing education requirements for license renewal at this time (2014).

Activities that count towards continuing education credits generally include completing courses, publishing research papers, teaching classes, home study, and attending workshops. Some states require that a certain number of the education credits be in ethics. Most states allow psychologists to self-report their credits but randomly audit individual psychologists to ensure compliance.

Counselling Psychologist or Psychotherapist

Counselling generally involves helping people with what might be considered “normal” or “moderate” psychological problems, such as the feelings of anxiety or sadness resulting from major life changes or events. As such, counselling psychologists often help people adjust to or cope with their environment or major events, although many also work with more serious problems as well.

One may practice as a counselling psychologist with a PhD or EdD, and as a counselling psychotherapist with a master’s degree. Compared with clinical psychology, there are fewer counselling psychology graduate programs (which are commonly housed in departments of education), counsellors tend to conduct more vocational assessment and less projective or objective assessment, and they are more likely to work in public service or university clinics (rather than hospitals or private practice). Despite these differences, there is considerable overlap between the two fields and distinctions between them continue to fade.

Mental health counsellors and residential counsellors are also the name for another class of counsellors or mental health professionals who may work with long-term services and supports (LTSS) clients in the community. Such counsellors may be advanced or senior staff members in a community program, and may be involved in developing skill teaching, active listening (and similar psychological and educational methods), and community participation programmes. They also are often skilled in on-site intervention, redirection and emergency techniques. Supervisory personnel often advance from this class of workers in community programmes.

Behaviour Analysts and Community/Institutional Roles

Behaviour analysts are licensed in five states to provide services for clients with substance abuse, developmental disabilities, and mental illness. This profession draws on the evidence base of applied behaviour analysis, behaviour therapy, and the philosophy of radical behaviourism. Behaviour analysts have at least a master’s degree in behaviour analysis or in a mental health related discipline as well as at least five core courses in applied behaviour analysis (narrow focus in psychological education). Many behaviour analysts have a doctorate. Most programmes have a formalised internship programme and several programmes are offered online. Most practitioners have passed the examination offered by the behaviour analysis certification board or the examination in clinical behaviour therapy by the World Association for Behaviour Analysis. The model licensing act for behaviour analysts can be found at the Association for Behaviour Analysis International’s website.

Behaviour analysts (who grew from the definition of mental health as a behavioural problem) often use community situational activities, life events, functional teaching, community “reinforcers”, family and community staff as intervenors, and structured interventions as the base in which they may be called upon to provide skilled professional assistance. Approaches that are based upon person-centred approaches have been used to update the stricter, hospital based interventions used by behaviour analysts for applicability to community environments. Behavioural approaches have often been infused with efforts at client self-determination, have been aligned with community lifestyle planning, and have been criticised as “aversive technology” which was “outlawed” in the field of severe disabilities in the 1990s.

Certified Mental Health Professional

The Certified Mental Health Professional (CMHP) certification is designed to measure an individual’s competency in performing the following job tasks. The job tasks are a sampling of job tasks with a clinical emphasis, and represents a level of line staff in community programmes reporting to a community supervisor in a small site based programme. Personnel in community housing, nursing facilities, and institutional programmes may be covered by these kinds of certifications.

  • Maintain confidentiality of records relating to clients’ treatment (and daily affairs as desired by the person).
  • Encourage clients to express their feelings, discuss what is happening in their lives, and help them to develop insight into themselves and their relationships.
  • Guide clients in the development of skills and strategies for dealing with their problems (and desired life outcomes).
  • Prepare and maintain all required treatment (and/or community service) records and reports.
  • Counsel clients and patients, individually and in group sessions, to assist in overcoming dependencies (seeking new relationships), adjusting to life, and making changes.
  • Collect information about clients through interviews, observations, and tests (and most importantly, speaking with and planning with the person).
  • Act as the client’s advocate in order to coordinate required services or to resolve emergency problems in crisis situations (often first line of emergency response).
  • Develop and implement treatment (or “person-centred”) plans based on clinical (and community) experience and knowledge.
  • Collaborate with other staff members to perform clinical assessments (and health may be contracted for specific consultations) and develop treatment (service) plans.
  • Evaluate client’s physical or mental condition (plan, not condition) based on review of client information (Evaluate outcomes as planned with the client on a “quarterly basis”).

However, these position levels have undergone decades of academic field testing and recommendations with new competencies in development in 2011-2013 by the Centres for Medicaid and Medicare (at the categorical aide levels). New professionals were recommended with a community services coordinator (commonly known as “hands on” case management), together with services and personnel management, and community development and liaison roles for community participation.

School Psychologist and Inclusion Educators

School psychologists’ primary concern is with the academic, social, and emotional well-being of children within a scholastic environment. Unlike clinical psychologists, they receive much more training in education, child development and behaviour, and the psychology of learning, often graduating with a post-master’s educational specialist degree (EdS), EdD or Doctor of Philosophy (PhD) degree. Besides offering individual and group therapy with children and their families, school psychologists also evaluate school programmes, provide cognitive assessment, help design prevention programmes (e.g. reducing drops outs), and work with teachers and administrators to help maximise teaching efficacy, both in the classroom and systemically.

In today’s world, the school psychologist remains the responsible party in “mental health” regarding children with emotional and behavioural needs, and have not always met these needs in the regular school environment. Inclusion (special) educators support participation in local school programmes and after school programmes, including new initiatives such as Achieve my Plan by the Research and Training Centre on Family Support and Children’s Mental Health at Portland State University. Referrals to residential schools and certification of the personnel involved in the residential schools and campuses have been a multi-decade concern with counties often involved in national efforts to better support these children and youth in local schools, families, homes and communities.

Psychiatric Rehabilitation

Psychiatric rehabilitation, similar to cognitive rehabilitation, is a designated field in the rehabilitation often academically prepared in either Schools of Allied Health and Sciences (near the field of Physical Medicine and Rehabilitation) and as rehabilitation counselling in the School of Education. Both have been developed specifically as preparing community personnel (at the MA and PHD levels) and to aid in the transition to professionally competent and integrated community services. Psychiatric rehabilitation personnel have a community integration-related base, support recovery and skills-based model of mental health, and may be involved with community programmes based upon normalisation and social role valourisation throughout the US. Psychiatric rehabilitation personnel have been involved in upgrading the skills of staff in institutions in order to move clients into community settings. Most common in international fields are community rehabilitation personnel which traditionally come from the rehabilitation counselling or community fields. In the new “rehabilitation centres” (new campus buildings), designed similar to hospital “rehab” (physical and occupational therapy, sports medicine), often no designated personnel in the fields of mental health (now “senior behavioural services” or “residential treatment units”). Psychiatric rehabilitation textbooks are currently on the market describing the community services their personnel were involved within community development (commonly known as deinstitutionalisation).

Psychiatric rehabilitation professionals (and psychosocial services) are the mainstay of community programs in the US, and the national service providers association itself may certify mental health staff in these areas. Psychiatric interventions which vary from behavioural ones are described in a review on their use in “residential, vocational, social or educational role functioning” as a “preferred methods for helping individuals with serious psychiatric disabilities”. Other competencies in education may involve working with families, user-directed planning methods and financing, housing and support, personal assistance services, transitional or supported employment, Americans with Disabilities Act (ADA), supported housing, integrated approaches (e.g. substance use, or intellectual disabilities), and psychosocial interventions, among others. In addition, rehabilitation counsellors (PhD, MS) may also be educated “generically” (breadth and depth) or for all diagnostic groups, and can work in these fields; other personnel may have certifications in areas such as supported employment which has been verified for use in psychiatric, neurological, traumatic brain injury, and intellectual disabilities, among others.

Social Worker

Social workers in the area of mental health may assess, treat, develop treatment plans, provide case management and/or rights advocacy to individuals with mental health problems. They can work independently or within clinics/service agencies, usually in collaboration with other health care professionals.

In the US, they are often referred to as clinical social workers; each state specifies the responsibilities and limitations of this profession. State licensing boards and national certification boards require clinical social workers to have a master’s or doctoral degree (MSW or DSW/PhD) from a university. The doctorate in social work requires submission of a major original contribution to the field in order to be awarded the degree.

In the UK there is a now a standardised three-year undergraduate social work degree, or two-year postgraduate masters for those who already have an undergraduate social sciences degree or others and relevant work experience. These courses include mandatory supervised work experience in social work, which may include mental health services. Successful completion allows an individual to register and work as a qualified social worker. There are various additional optional courses for gaining qualifications specific to mental health, for example training in psychotherapy or, in England and Wales, for the role of Approved Mental Health Professional (two years’ training for a legal role in the assessment and detention of eligible mentally disordered people under the Mental Health Act (1983) as amended in 2007).

Social workers in England and Wales are now able to become Approved Clinicians under the Mental Health Act 2007 following a period of further training (likely at postgraduate degree/diploma or doctoral level). Historically, this role was reserved for psychiatrist medical doctors, but has now extended to registered mental health professionals, such as social workers, psychologists and mental health nurses.

In general, it is the psycho-social model rather than, or in addition to, the dominant medical model, that is the underlying rationale for mental health social work. This may include a focus on social causation, labelling, critical theory and social constructiveness. Many argue social workers need to work with medical and health colleagues to provide an effective service but they also need to be at the forefront of processes that include and empower service users.

Social workers also prepare social work administration and may hold positions in human services systems as administration or Executives to Administration in the US. Social workers, similar to psychiatric rehabilitation, updates its professional education programmes based upon current developments in the fields (e.g. support services) and serve a multicultural client base.

Educational Requirements for Social Workers

In the United States, the minimum requirement for social workers is generally a bachelor’s degree in social work, though a bachelor’s degree in a related field such as sociology or psychology may qualify an applicant for certain jobs. Higher-level jobs typically require a master’s degree in social work. Master’s programs in social work usually last two years and consist of at least 900 hours of supervised instruction in the field. Regulatory boards generally require that degrees be obtained from programmes that are accredited by the Council of Social Work Education (CSWE) or another nationally recognised accrediting agency for promotion and future collaboration.

Before social workers can practice, they are required to meet the licensing, certification, or registration requirements of the state. The requirements vary depending on the state but usually involve a minimum number of supervised hours in the field and passing of an exam. All states, except California, also require pre-licensure from the Association of Social Work Boards (ASWB).

The ASWB offers four categories of social work license. The lowest level is a Bachelors, for which a bachelor’s degree in social work is required. The next level up is a Masters and a master’s degree in social work is required. The Advanced Generalist category of social worker requires a master’s degree in social work and two years of supervised post-degree experience. The highest ASWB category is a Clinical Social Worker which requires a master’s degree in social work along with two years of post-master’s direct experience in social work.

Continuing Education Requirements for Social Workers

Most states require social workers to acquire a minimum number of continuing education credits per license, certification, or registration renewal period. The purpose of these requirements is to ensure that social workers stay up-to-date with information and practices in their professions. In most states, the renewal process occurs every two or three years. The number of continuing education credits that is required varies between states but is generally 20 to 45 hours during the two- or three-year period prior to renewal.

Courses and programs that are approved as continuing education for social workers generally must be relevant to the profession and contribute to the advancement of professional competence. They often include continuing education courses, seminars, training programs, community service, research, publishing articles, or serving on a panel. Many states enforce that a minimum amount of the credits be on topics such as ethics, HIV/AIDs, or domestic violence.

Psychiatric and Mental Health Nurse

Psychiatric Nurses or Mental Health Nurse Practitioners work with people with a large variety of mental health problems, often at the time of highest distress, and usually within hospital settings. These professionals work in primary care facilities, outpatient mental health clinics, as well as in hospitals and community health centres. MHNPs evaluate and provide care for patients who have anything from psychiatric disorders, medical mental conditions, to substance abuse problems. They are licensed to provide emergency psychiatric services, assess the psycho-social and physical state of their patients, create treatment plans, and continually manage their care. They may also serve as consultants or as educators for families and staff; however, the MHNP has a greater focus on psychiatric diagnosis (typically the province of the MD or PhD), including the differential diagnosis of medical disorders with psychiatric symptoms and on medication treatment for psychiatric disorders.

Educational Requirements for Psychiatric and Mental Health Nurses

Psychiatric and mental health nurses receive specialist education to work in this area. In some countries, it is required that a full course of general nurse training be completed prior to specialising as a psychiatric nurse. In other countries, such as the UK, an individual completes a specific nurse training course that determines their area of work. As with other areas of nursing, it is becoming usual for psychiatric nurses to be educated to degree level and beyond. Psychiatric aides, now being trained by educational psychology in 2014, are part of the entry-level workforce which is projected to be needed in communities in the US in the next decades.

In order to become a nurse practitioner in the US, at least six years of college education must be obtained. After earning the bachelor’s degree (usually in nursing, although there are master’s entry level nursing graduate programs intended for individuals with a bachelor’s degree outside of nursing) the test for a license as a registered nurse (the NCLEX-RN) must be passed. Next, the candidate must complete a state-approved master’s degree advanced nursing education program which includes at least 600 clinical hours. Several schools are now also offering further education and awarding a DNP (Doctor of Nursing Practice).

Individuals who choose a master’s entry level pathway will spend an extra year at the start of the programme taking classes necessary to pass the NCLEX-RN. Some schools will issue a BSN, others will issue a certificate. The student then continues with the normal MSN programme.

Mental Health Care Navigator

A mental health care navigator is an individual who assists patients and families to find appropriate mental health caregivers, facilities and services. Individuals who are care navigators are often also trained therapists and doctors. The need for mental health care navigators arises from the fragmentation of the mental health industry, which can often leave those in need with more questions than answers. Care navigators work closely with patients through discussion and collaboration to provide information on options and referrals to healthcare professionals, facilities, and organisations specialising in the patients’ needs. The difference between other mental health professionals and a care navigator is that a care navigator provides information and directs a patient to the best help rather than offering diagnosis, prescription of medications or treatment.

Many mental health organisations use “navigator” and “navigation” to describe the service of providing guidance through the health care industry. Care navigators are also sometimes referred to as “system navigators”. One type of care navigator is an “educational consultant.”

Workforce Shortage

Behavioural health disorders are prevalent in the United States, but accessing treatment can be challenging. Nearly 1 in 5 adults experience a mental health condition for which approximately only 43% received treatment. When asked about access to mental health treatment, two-thirds of primary care physicians reported that they were unable to secure outpatient mental health treatment for their patients. This is due, in part, to the workforce shortage in behavioural health. In rural areas, 55% of US counties have no practicing psychiatrist, psychologist, or social worker. Overall, 77% of counties have a severe shortage of mental health workers and 96% of counties had some unmet need. Some of the reasons for the workforce shortage include high turnover rates, high levels of work-related stress, and inadequate compensation. Annual turnover rate is 33% for clinicians and 23% for clinical supervisors. This is compared to an annual PCP turnover rate of 7.1%. Compensation in behavioural health field is notably low. The average licensed clinical social worker, a position that requires a master’s degree and 2,000 hours of post-graduate experience, earns $45,000/year. As a point of reference, the average physical therapist earns $75,000/year. Substance abuse counsellor earnings are even lower, with an average salary of $34,000/year. Job stress is another factor that may lead to the high turnover rates and workforce shortage. It is estimated that 21-67% of mental health workers experience high levels of burnout including symptoms of emotional exhaustion, high levels of depersonalisation and a reduced sense of personal accomplishment. Researchers have offered various recommendations to reduce the critical workforce gaps in behavioural health. Some of these recommendations include the following: expanding loan repayment programmes to incentivise mental health providers to work in underserved (often rural) areas, integrating mental health into primary care, and increasing reimbursement to health care professionals.

Social workers also tend to experience competing for work and family demands, which negatively affects their job well-being and subsequently their job satisfaction, resulting in high turnover in the profession.

What is an Antidepressant?

Introduction

Antidepressants are medications used to treat major depressive disorder, some anxiety disorders, some chronic pain conditions, and to help manage some addictions. Common side-effects of antidepressants include dry mouth, weight gain, dizziness, headaches, sexual dysfunction, and emotional blunting. Most types of antidepressants are typically safe to take, but may cause increased thoughts of suicide when taken by children, adolescents, and young adults. A discontinuation syndrome can occur after stopping any antidepressant which resembles recurrent depression.

Some reviews of antidepressants for depression in adults find benefit while others do not. Evidence of benefit in children and adolescents is unclear. There is debate in the medical community about how much of the observed effects of antidepressants can be attributed to the placebo effect. Most research on whether antidepressant drugs work is done on people with very severe symptoms, so the results cannot be extrapolated to the general population.

There are methods for managing depression which do not involve medications or may be used in conjunction with medications.

Refer to Tricyclic Antidepressants (TCAs) and Tetracyclic Antidepressants (TeCAs).

Medical Uses

Antidepressants are used to treat major depressive disorder and of other conditions, including some anxiety disorders, some chronic pain conditions, and to help manage some addictions. Antidepressants are often used in combinations with one another. The proponents of the monoamine hypothesis of depression recommend choosing the antidepressant with the mechanism of action impacting the most prominent symptoms – for example, they advocate that people with major depressive disorder (MDD) who are also anxious or irritable should be treated with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), and the ones with the loss of energy and enjoyment of life – with norepinephrine and dopamine enhancing drugs.

Major Depressive Disorder

The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicated that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor. The guidelines recommended that antidepressant treatment be considered for:

  • People with a history of moderate or severe depression;
  • Those with mild depression that has been present for a long period;
  • As a second-line treatment for mild depression that persists after other interventions; and
  • As a first-line treatment for moderate or severe depression.

The guidelines further note that antidepressant treatment should be used in combination with psychosocial interventions in most cases, should be continued for at least six months to reduce the risk of relapse, and that SSRIs are typically better tolerated than other antidepressants.

American Psychiatric Association treatment guidelines recommend that initial treatment should be individually tailored based on factors that include severity of symptoms, co-existing disorders, prior treatment experience, and the person’s preference. Options may include pharmacotherapy, psychotherapy, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS) or light therapy. They recommended antidepressant medication as an initial treatment choice in people with mild, moderate, or severe major depression, that should be given to all people with severe depression unless ECT is planned.

Some reviews of antidepressants in adults with depression find benefits while others do not.

Anxiety Disorders

Generalised Anxiety Disorder

Antidepressants are recommended by NICE for the treatment of generalised anxiety disorder (GAD) that has failed to respond to conservative measures such as education and self-help activities. GAD is a common disorder of which the central feature is excessive worry about a number of different events. Key symptoms include excessive anxiety about multiple events and issues, and difficulty controlling worrisome thoughts that persists for at least 6 months.

Antidepressants provide a modest-to-moderate reduction in anxiety in GAD. The efficacy of different antidepressants is similar.

Social Anxiety Disorder

Some antidepressants are used as a treatment for social anxiety disorder (SAD), but their efficacy is not entirely convincing, as only a small proportion of antidepressants showed some efficacy for this condition. Paroxetine was the first drug to be Food and Drug Administration (FDA)-approved for this disorder. Its efficacy is considered beneficial, although not everyone responds favourably to the drug. Sertraline and fluvoxamine extended release were later approved for it as well, while escitalopram is used off-label with acceptable efficacy. However, there is not enough evidence to support citalopram for treating social phobia, and fluoxetine was no better than placebo in clinical trials. SSRIs are used as a first-line treatment for social anxiety, but they do not work for everyone. One alternative would be venlafaxine, which is a SNRI. It showed benefits for social phobia in five clinical trials against placebo, while the other SNRIs are not considered particularly useful for this disorder as many of them didn’t undergo testing for it. As of now, it is unclear if duloxetine and desvenlafaxine can provide benefits for social anxiety sufferers. However, another class of antidepressants called MAOIs (monoamine oxidase inhibitors) are considered effective for social anxiety, but they come with many unwanted side effects and are rarely used. Phenelzine was shown to be a good treatment option, but its use is limited by dietary restrictions. Moclobemide is a RIMA (reversible inhibitors of monoamine oxidase-A) and showed mixed results but still got approval in some European countries for social anxiety disorder. TCA antidepressants (tricyclic antidepressants), such as clomipramine and imipramine, are not considered effective for this anxiety disorder in particular. This leaves out SSRIs such as paroxetine, sertraline and fluvoxamine CR as acceptable and tolerated treatment options for this disorder.

Obsessive Compulsive Disorder

SSRIs are a second-line treatment of adult obsessive compulsive disorder (OCD) with mild functional impairment and as first-line treatment for those with moderate or severe impairment. In children, SSRIs are considered as a second-line therapy in those with moderate-to-severe impairment, with close monitoring for psychiatric adverse effects. SSRIs appear useful for OCD, at least in the short term. Efficacy has been demonstrated both in short-term treatment trials of 6 to 24 weeks and in discontinuation trials of 28 to 52 weeks duration. Clomipramine, a TCA drug, is considered effective and useful for OCD, however it is used as a second line treatment because it is less well tolerated than the SSRIs. Despite this, it has not shown superiority to fluvoxamine in trials. All SSRIs can be used effectively for OCD, and in some cases, SNRIs can also be tried even though none of them is approved specifically for OCD. However, even with all these treatment options, many people remain symptomatic after initiating the medication, and less than half of them do achieve remission.

Post Traumatic Stress Disorder

Antidepressants are one of the treatment options for post traumatic stress disorder (PTSD), however their efficacy is not well established. Two antidepressants are FDA approved for it, paroxetine and sertraline, they belong to the serotonin reuptake inhibitors class. Paroxetine has slightly higher response and remission rates than sertraline for this condition, however both drugs are not considered very helpful for every person that takes them. Fluoxetine and venlafaxine are used off label, with fluoxetine producing unsatisfactory mixed results and venlafaxine, while having a response rates of 78%, which is significantly higher than what paroxetine and sertraline achieved, but it did not address all the symptoms of PTSD like the two drugs did, which is in part due to the fact the venlafaxine is an SNRI, this class of drugs inhibit the reuptake of norepinephrine too, this could cause some anxiety in some people. Fluvoxamine, escitalopram and citalopram were not well tested in this disorder. MAOIs, while some of them may be helpful, are not used much because of their unwanted side effects. This leaves paroxetine and sertraline as acceptable treatment options for some people, although more effective antidepressants are needed.

Panic Disorder

Panic disorder is relatively treated well with medications compared with other disorders, several classes of antidepressants have shown efficacy for this disorder, however SSRIs and SNRIs are used first-line. Paroxetine, sertraline, fluoxetine are FDA approved for panic disorder, although fluvoxamine, escitalopram and citalopram are considered effective for it. The SNRI venlafaxine is also approved for this condition. Unlike with social anxiety and PTSD, some TCAs antidepressants, like clomipramine and imipramine, have shown efficacy for panic disorder. Moreover, the MAOI phenelzine is considered useful too. Panic disorder has many drugs for its treatment, however, the starting dose must be lower than the one used for MDD because people, in the initiation of treatment, have reported an increase in anxiety as a result of starting the medication. In conclusion, while panic disorder’s treatment options seem acceptable and useful for this condition, many people are still symptomatic after treatment with residual symptoms.

Eating Disorders

Antidepressants are recommended as an alternative or additional first step to self-help programs in the treatment of bulimia nervosa. SSRIs (fluoxetine in particular) are preferred over other antidepressants due to their acceptability, tolerability, and superior reduction of symptoms in short-term trials. Long-term efficacy remains poorly characterised. Bupropion is not recommended for the treatment of eating disorders due to an increased risk of seizure.

Similar recommendations apply to binge eating disorder. SSRIs provide short-term reductions in binge eating behaviour, but have not been associated with significant weight loss.

Clinical trials have generated mostly negative results for the use of SSRIs in the treatment of anorexia nervosa. Treatment guidelines from NICE recommend against the use of SSRIs in this disorder. Those from the American Psychiatric Association note that SSRIs confer no advantage regarding weight gain, but that they may be used for the treatment of co-existing depressive, anxiety, or OCD.

Pain

Fibromyalgia

A 2012 meta-analysis concluded that antidepressants treatment favourably affects pain, health-related quality of life, depression, and sleep in fibromyalgia syndrome. Tricyclics appear to be the most effective class, with moderate effects on pain and sleep and small effects on fatigue and health-related quality of life. The fraction of people experiencing a 30% pain reduction on tricyclics was 48% versus 28% for placebo. For SSRIs and SNRIs the fraction of people experiencing a 30% pain reduction was 36% (20% in the placebo comparator arms) and 42% (32% in the corresponding placebo comparator arms). Discontinuation of treatment due to side effects was common. Antidepressants including amitriptyline, fluoxetine, duloxetine, milnacipran, moclobemide, and pirlindole are recommended by the European League Against Rheumatism (EULAR) for the treatment of fibromyalgia based on “limited evidence”.

Neuropathic Pain

A 2014 meta-analysis from the Cochrane Collaboration found the antidepressant duloxetine to be effective for the treatment of pain resulting from diabetic neuropathy. The same group reviewed data for amitriptyline in the treatment of neuropathic pain and found limited useful randomised clinical trial data. They concluded that the long history of successful use in the community for the treatment of fibromyalgia and neuropathic pain justified its continued use. The group was concerned about the potential for overestimating the amount of pain relief provided by amitriptyline, and highlighted that only a small number of people will experience significant pain relief by taking this medication.

Other

Antidepressants may be modestly helpful for treating people who both have depression and alcohol dependence, however the evidence supporting this association is of low quality. Buproprion is used to help people stop smoking. Antidepressants are also used to control some symptoms of narcolepsy. Antidepressants may be used to relieve pain in people with active rheumatoid arthritis however, further research is required. Antidepressants have been shown to be superior to placebo in treating depression in individuals with physical illness, although reporting bias may have exaggerated this finding.

Limitations and Strategies

Between 30% and 50% of individuals treated with a given antidepressant do not show a response. Approximately one-third of people achieve a full remission, one-third experience a response and one-third are non-responders. Partial remission is characterised by the presence of poorly defined residual symptoms. These symptoms typically include depressed mood, anxiety, sleep disturbance, fatigue and diminished interest or pleasure. It is currently unclear which factors predict partial remission. However, it is clear that residual symptoms are powerful predictors of relapse, with relapse rates 3-6 times higher in people with residual symptoms than in those who experience full remission. In addition, antidepressant drugs tend to lose efficacy over the course of treatment. According to data from the Centres for Disease Control and Prevention, less than one-third of Americans taking one antidepressant medication have seen a mental health professional in the previous year. A number of strategies are used in clinical practice to try to overcome these limits and variations. They include switching medication, augmentation, and combination.

Switching Antidepressants

The American Psychiatric Association 2000 Practice Guideline advises that where no response is achieved following six to eight weeks of treatment with an antidepressant, to switch to an antidepressant in the same class, then to a different class of antidepressant. A 2006 meta-analysis review found wide variation in the findings of prior studies; for people who had failed to respond to an SSRI antidepressant, between 12% and 86% showed a response to a new drug. However, the more antidepressants an individual had already tried, the less likely they were to benefit from a new antidepressant trial. However, a later meta-analysis found no difference between switching to a new drug and staying on the old medication; although 34% of treatment resistant people responded when switched to the new drug, 40% responded without being switched.

Augmentation and Combination

For a partial response, the American Psychiatric Association guidelines suggest augmentation, or adding a drug from a different class. These include lithium and thyroid augmentation, dopamine agonists, sex steroids, NRIs, glucocorticoid-specific agents, or the newer anticonvulsants.

A combination strategy involves adding another antidepressant, usually from a different class so as to have effect on other mechanisms. Although this may be used in clinical practice, there is little evidence for the relative efficacy or adverse effects of this strategy. Other tests conducted include the use of psychostimulants as an augmentation therapy. Several studies have shown the efficacy of combining modafinil for treatment-resistant people. It has been used to help combat SSRI-associated fatigue.

Long-Term Use

The effects of antidepressants typically do not continue once the course of medication ends. This results in a high rate of relapse. A 2003 meta-analysis found that 18% of people who had responded to an antidepressant relapsed while still taking it, compared to 41% whose antidepressant was switched for a placebo.

A gradual loss of therapeutic benefit occurs in a minority of people during the course of treatment. A strategy involving the use of pharmacotherapy in the treatment of the acute episode, followed by psychotherapy in its residual phase, has been suggested by some studies.

Adverse Effects

Difficulty tolerating adverse effects is the most common reason for antidepressant discontinuation.

Almost any medication involved with serotonin regulation has the potential to cause serotonin toxicity (also known as serotonin syndrome) – an excess of serotonin that can induce mania, restlessness, agitation, emotional lability, insomnia and confusion as its primary symptoms. Although the condition is serious, it is not particularly common, generally only appearing at high doses or while on other medications. Assuming proper medical intervention has been taken (within about 24 hours) it is rarely fatal. Antidepressants appear to increase the risk of diabetes by about 1.3 fold.

MAOIs tend to have pronounced (sometimes fatal) interactions with a wide variety of medications and over-the-counter drugs. If taken with foods that contain very high levels of tyramine (e.g. mature cheese, cured meats, or yeast extracts), they may cause a potentially lethal hypertensive crisis. At lower doses, the person may only experience a headache due to an increase in blood pressure.

In response to these adverse effects, a different type of MAOI has been developed: the reversible inhibitor of monoamine oxidase A (RIMA) class of drugs. Their primary advantage is that they do not require the person to follow a special diet, while being purportedly effective as SSRIs and tricyclics in treating depressive disorders.

Tricyclics and SSRI can cause the so-called drug-induced QT prolongation, especially in older adults; this condition can degenerate into a specific type of abnormal heart rhythm called torsades de points which can potentially lead to sudden cardiac arrest.

Pregnancy

SSRI use in pregnancy has been associated with a variety of risks with varying degrees of proof of causation. As depression is independently associated with negative pregnancy outcomes, determining the extent to which observed associations between antidepressant use and specific adverse outcomes reflects a causative relationship has been difficult in some cases. In other cases, the attribution of adverse outcomes to antidepressant exposure seems fairly clear.

SSRI use in pregnancy is associated with an increased risk of spontaneous abortion of about 1.7-fold, and is associated with preterm birth and low birth weight.

A systematic review of the risk of major birth defects in antidepressant-exposed pregnancies found a small increase (3% to 24%) in the risk of major malformations and a risk of cardiovascular birth defects that did not differ from non-exposed pregnancies. A study of fluoxetine-exposed pregnancies found a 12% increase in the risk of major malformations that just missed statistical significance. Other studies have found an increased risk of cardiovascular birth defects among depressed mothers not undergoing SSRI treatment, suggesting the possibility of ascertainment bias, e.g. that worried mothers may pursue more aggressive testing of their infants. Another study found no increase in cardiovascular birth defects and a 27% increased risk of major malformations in SSRI exposed pregnancies. The FDA advises for the risk of birth defects with the use of paroxetine and the MAOI should be avoided.

A 2013 systematic review and meta-analysis found that antidepressant use during pregnancy was statistically significantly associated with some pregnancy outcomes, such as gestational age and preterm birth, but not with other outcomes. The same review cautioned that because differences between the exposed and unexposed groups were small, it was doubtful whether they were clinically significant.

A neonate (infant less than 28 days old) may experience a withdrawal syndrome from abrupt discontinuation of the antidepressant at birth. Antidepressants have been shown to be present in varying amounts in breast milk, but their effects on infants are currently unknown.

Moreover, SSRIs inhibit nitric oxide synthesis, which plays an important role in setting vascular tone. Several studies have pointed to an increased risk of prematurity associated with SSRI use, and this association may be due to an increase risk of pre-eclampsia of pregnancy.

Antidepressant-Induced Mania

Another possible problem with antidepressants is the chance of antidepressant-induced mania or hypomania in people with or without a diagnosis of bipolar disorder. Many cases of bipolar depression are very similar to those of unipolar depression. Therefore, the person can be misdiagnosed with unipolar depression and be given antidepressants. Studies have shown that antidepressant-induced mania can occur in 20-40% of people with bipolar disorder. For bipolar depression, antidepressants (most frequently SSRIs) can exacerbate or trigger symptoms of hypomania and mania.

Suicide

Studies have shown that the use of antidepressants is correlated with an increased risk of suicidal behaviour and thinking (suicidality) in those aged under 25. This problem has been serious enough to warrant government intervention by the FDA to warn of the increased risk of suicidality during antidepressant treatment. According to the FDA, the heightened risk of suicidality occurs within the first one to two months of treatment. NICE places the excess risk in the “early stages of treatment”. A meta-analysis suggests that the relationship between antidepressant use and suicidal behaviour or thoughts is age-dependent. Compared with placebo, the use of antidepressants is associated with an increase in suicidal behaviour or thoughts among those 25 or younger (OR=1.62). There is no effect or possibly a mild protective effect among those aged 25 to 64 (OR=0.79). Antidepressant treatment has a protective effect against suicidality among those aged 65 and over (OR=0.37).

Sexual

Sexual side effects are also common with SSRIs, such as loss of sexual drive, failure to reach orgasm, and erectile dysfunction. Although usually reversible, these sexual side-effects can, in rare cases, continue after the drug has been completely withdrawn.

In a study of 1,022 outpatients, overall sexual dysfunction with all antidepressants averaged 59.1% with SSRI values between 57% and 73%, mirtazapine 24%, nefazodone 8%, amineptine 7% and moclobemide 4%. Moclobemide, a selective reversible MAO-A inhibitor, does not cause sexual dysfunction, and can actually lead to an improvement in all aspects of sexual function.

Biochemical mechanisms suggested as causative include increased serotonin, particularly affecting 5-HT2 and 5-HT3 receptors; decreased dopamine; decreased norepinephrine; blockade of cholinergic and α1adrenergic receptors; inhibition of nitric oxide synthetase; and elevation of prolactin levels. Mirtazapine is reported to have fewer sexual side effects, most likely because it antagonizes 5-HT2 and 5-HT3 receptors and may, in some cases, reverse sexual dysfunction induced by SSRIs by the same mechanism.

Bupropion, a weak NDRI and nicotinic antagonist, may be useful in treating reduced libido as a result of SSRI treatment.

Changes in Weight

Changes in appetite or weight are common among antidepressants, but are largely drug-dependent and related to which neurotransmitters they affect. Mirtazapine and paroxetine, for example, may be associated with weight gain and/or increased appetite, while others (such as bupropion and venlafaxine) achieve the opposite effect.

The antihistaminic properties of certain TCA- and TeCA-class antidepressants have been shown to contribute to the common side effects of increased appetite and weight gain associated with these classes of medication.

Discontinuation Syndrome

Antidepressant discontinuation syndrome, also called antidepressant withdrawal syndrome, is a condition that can occur following the interruption, reduction, or discontinuation of antidepressant medication. The symptoms may include flu-like symptoms, trouble sleeping, nausea, poor balance, sensory changes, and anxiety. The problem usually begins within three days and may last for several months. Rarely psychosis may occur.

A discontinuation syndrome can occur after stopping any antidepressant including SSRIs, SNRIs, and TCAs. The risk is greater among those who have taken the medication for longer and when the medication in question has a short half-life. The underlying reason for its occurrence is unclear. The diagnosis is based on the symptoms.

Methods of prevention include gradually decreasing the dose among those who wish to stop, though it is possible for symptoms to occur with tapering. Treatment may include restarting the medication and slowly decreasing the dose. People may also be switched to the long acting antidepressant fluoxetine which can then be gradually decreased.

Approximately 20-50% of people who suddenly stop an antidepressant develop an antidepressant discontinuation syndrome. The condition is generally not serious. Though about half of people with symptoms describe them as severe. Some restart antidepressants due to the severity of the symptoms.

Emotional Blunting

SSRIs appear to cause emotional blunting, or numbness in some people who take them. This is a reduction in extremes of emotion, both positive and negative. While the person may feel less depressed, they may also feel less happiness or empathy. This may be cause for a dose reduction or medication change. The mechanism is unknown.

Pharmacology

The earliest and probably most widely accepted scientific theory of antidepressant action is the monoamine hypothesis (which can be traced back to the 1950s), which states that depression is due to an imbalance (most often a deficiency) of the monoamine neurotransmitters (namely serotonin, norepinephrine and dopamine).

It was originally proposed based on the observation that certain hydrazine anti-tuberculosis agents produce antidepressant effects, which was later linked to their inhibitory effects on monoamine oxidase, the enzyme that catalyses the breakdown of the monoamine neurotransmitters. All currently marketed antidepressants have the monoamine hypothesis as their theoretical basis, with the possible exception of agomelatine which acts on a dual melatonergic-serotonergic pathway.

Despite the success of the monoamine hypothesis it has a number of limitations: for one, all monoaminergic antidepressants have a delayed onset of action of at least a week; and secondly, there are a sizeable portion (>40%) of depressed patients that do not adequately respond to monoaminergic antidepressants. A number of alternative hypotheses have been proposed, including the glutamate, neurogenic, epigenetic, cortisol hypersecretion and inflammatory hypotheses.

Types of Antidepressant

Selective Serotonin Reuptake Inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are believed to increase the extracellular level of the neurotransmitter serotonin by limiting its reabsorption into the presynaptic cell, increasing the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor. They have varying degrees of selectivity for the other monoamine transporters, with pure SSRIs having only weak affinity for the norepinephrine and dopamine transporters.

SSRIs are the most widely prescribed antidepressants in many countries. The efficacy of SSRIs in mild or moderate cases of depression has been disputed.

Serotonin-Norepinephrine Reuptake Inhibitors

Serotonin-norepinephrine reuptake inhibitors (SNRIs) are potent inhibitors of the reuptake of serotonin and norepinephrine. These neurotransmitters are known to play an important role in mood. SNRIs can be contrasted with the more widely used selective serotonin reuptake inhibitors (SSRIs), which act mostly upon serotonin alone.

The human serotonin transporter (SERT) and norepinephrine transporter (NET) are membrane proteins that are responsible for the reuptake of serotonin and norepinephrine. Balanced dual inhibition of monoamine reuptake can possibly offer advantages over other antidepressants drugs by treating a wider range of symptoms.

SNRIs are sometimes also used to treat anxiety disorders, obsessive–compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), chronic neuropathic pain, and fibromyalgia syndrome (FMS), and for the relief of menopausal symptoms.

Serotonin Modulators and Stimulators

Serotonin modulator and stimulators (SMSs), sometimes referred to more simply as “serotonin modulators”, are a type of drug with a multimodal action specific to the serotonin neurotransmitter system. To be precise, SMSs simultaneously modulate one or more serotonin receptors and inhibit the reuptake of serotonin. The term was coined in reference to the mechanism of action of the serotonergic antidepressant vortioxetine, which acts as a serotonin reuptake inhibitor (SRI), partial agonist of the 5-HT1A receptor, and antagonist of the 5-HT3 and 5-HT7 receptors. However, it can also technically be applied to vilazodone, which is an antidepressant as well and acts as an SRI and 5-HT1A receptor partial agonist.

An alternative term is serotonin partial agonist/reuptake inhibitor (SPARI), which can be applied only to vilazodone.

Serotonin Antagonists and Reuptake Inhibitors

Serotonin antagonist and reuptake inhibitors (SARIs) while mainly used as antidepressants, are also anxiolytics and hypnotics. They act by antagonising serotonin receptors such as 5-HT2A and inhibiting the reuptake of serotonin, norepinephrine, and/or dopamine. Additionally, most also act as α1-adrenergic receptor antagonists. The majority of the currently marketed SARIs belong to the phenylpiperazine class of compounds. They include trazodone and nefazodone.

Norepinephrine Reuptake Inhibitors

Norepinephrine reuptake inhibitors (NRIs or NERIs) are a type of drug that acts as a reuptake inhibitor for the neurotransmitter norepinephrine (noradrenaline) by blocking the action of the norepinephrine transporter (NET). This in turn leads to increased extracellular concentrations of norepinephrine.

NRIs are commonly used in the treatment of conditions like ADHD and narcolepsy due to their psychostimulant effects and in obesity due to their appetite suppressant effects. They are also frequently used as antidepressants for the treatment of major depressive disorder, anxiety and panic disorder. Additionally, many drugs of abuse such as cocaine and methylphenidate possess NRI activity, though it is important to mention that NRIs without combined dopamine reuptake inhibitor (DRI) properties are not significantly rewarding and hence are considered to have a negligible abuse potential. However, norepinephrine has been implicated as acting synergistically with dopamine when actions on the two neurotransmitters are combined (e.g. in the case of NDRIs) to produce rewarding effects in psychostimulant drugs of abuse.

Norepinephrine-Dopamine Reuptake Inhibitors

The only drug used of this class for depression is bupropion.

Tricyclic Antidepressants

The majority of the tricyclic antidepressants (TCAs) act primarily as SNRIs by blocking the SERT and the NET, respectively, which results in an elevation of the synaptic concentrations of these neurotransmitters, and therefore an enhancement of neurotransmission. Notably, with the sole exception of amineptine, the TCAs have negligible affinity for the dopamine transporter (DAT), and therefore have no efficacy as dopamine reuptake inhibitors (DRIs).

Although TCAs are sometimes prescribed for depressive disorders, they have been largely replaced in clinical use in most parts of the world by newer antidepressants such as SSRIs, SNRIs and NRIs. Adverse effects have been found to be of a similar level between TCAs and SSRIs.

Tetracyclic Antidepressants

Tetracyclic antidepressants (TeCAs) are a class of antidepressants that were first introduced in the 1970s. They are named after their chemical structure, which contains four rings of atoms, and are closely related to the TCAs, which contain three rings of atoms.

Monoamine Oxidase Inhibitors

Monoamine oxidase inhibitors (MAOIs) are chemicals which inhibit the activity of the monoamine oxidase enzyme family. They have a long history of use as medications prescribed for the treatment of depression. They are particularly effective in treating atypical depression. They are also used in the treatment of Parkinson’s disease and several other disorders.

Because of potentially lethal dietary and drug interactions, monoamine oxidase inhibitors have historically been reserved as a last line of treatment, used only when other classes of antidepressant drugs (for example SSRIs and TCAs) have failed.

MAOIs have been found to be effective in the treatment of panic disorder with agoraphobia, social phobia, atypical depression or mixed anxiety and depression, bulimia, and PTSD, as well as borderline personality disorder. MAOIs appear to be particularly effective in the management of bipolar depression according to a retrospective-analysis. There are reports of MAOI efficacy in OCD, trichotillomania, dysmorphophobia, and avoidant personality disorder, but these reports are from uncontrolled case reports.

MAOIs can also be used in the treatment of Parkinson’s disease by targeting MAO-B in particular (therefore affecting dopaminergic neurons), as well as providing an alternative for migraine prophylaxis. Inhibition of both MAO-A and MAO-B is used in the treatment of clinical depression and anxiety disorders.

NMDA Receptor Antagonists

NMDA receptor antagonists like ketamine and esketamine are rapid-acting antidepressants and seem to work via blockade of the ionotropic glutamate NMDA receptor.

Others

See the list of antidepressants and management of depression for other drugs that are not specifically characterised.

Adjuncts

Adjunct medications are an umbrella category of substances that increase the potency or “enhance” antidepressants. They work by affecting variables very close to the antidepressant, sometimes affecting a completely different mechanism of action. This may be attempted when depression treatments have not been successful in the past.

Common types of adjunct medication techniques generally fall into the following categories:

  • Two or more antidepressants taken together.
  • From the same class (affecting the same area of the brain, often at a much higher level).
  • From different classes (affecting multiple parts of the brain not covered simultaneously by either drug alone).
  • An antipsychotic combined with an antidepressant, particularly atypical antipsychotics such as aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa), and risperidone (Risperdal).

It is unknown if undergoing psychological therapy at the same time as taking anti-depressants enhances the anti-depressive effect of the medication.

Less Common Adjuncts

Lithium has been used to augment antidepressant therapy in those who have failed to respond to antidepressants alone. Furthermore, lithium dramatically decreases the suicide risk in recurrent depression. There is some evidence for the addition of a thyroid hormone, triiodothyronine, in patients with normal thyroid function.

Psychopharmacologists have also tried adding a stimulant, in particular, d-amphetamine. However, the use of stimulants in cases of treatment-resistant depression is relatively controversial. A review article published in 2007 found psychostimulants may be effective in treatment-resistant depression with concomitant antidepressant therapy, but a more certain conclusion could not be drawn due to substantial deficiencies in the studies available for consideration, and the somewhat contradictory nature of their results.

Brief History

Before the 1950s, opioids and amphetamines were commonly used as antidepressants. Their use was later restricted due to their addictive nature and side effects. Extracts from the herb St John’s wort have been used as a “nerve tonic” to alleviate depression.

Isoniazid, Iproniazid, and Imipramine

In 1951, Irving Selikoff and Edward H. Robitzek, working out of Sea View Hospital on Staten Island, began clinical trials on two new anti-tuberculosis agents developed by Hoffman-LaRoche, isoniazid and iproniazid. Only patients with a poor prognosis were initially treated; nevertheless, their condition improved dramatically. Selikoff and Robitzek noted “a subtle general stimulation … the patients exhibited renewed vigour and indeed this occasionally served to introduce disciplinary problems.” The promise of a cure for tuberculosis in the Sea View Hospital trials was excitedly discussed in the mainstream press.

In 1952, learning of the stimulating side effects of isoniazid, the Cincinnati psychiatrist Max Lurie tried it on his patients. In the following year, he and Harry Salzer reported that isoniazid improved depression in two-thirds of their patients and coined the term antidepressant to refer to its action. A similar incident took place in Paris, where Jean Delay, head of psychiatry at Sainte-Anne Hospital, heard of this effect from his pulmonology colleagues at Cochin Hospital. In 1952 (before Lurie and Salzer), Delay, with the resident Jean-Francois Buisson, reported the positive effect of isoniazid on depressed patients. The mode of antidepressant action of isoniazid is still unclear. It is speculated that its effect is due to the inhibition of diamine oxidase, coupled with a weak inhibition of monoamine oxidase A.

Selikoff and Robitzek also experimented with another anti-tuberculosis drug, iproniazid; it showed a greater psychostimulant effect, but more pronounced toxicity. Later, Jackson Smith, Gordon Kamman, George E. Crane, and Frank Ayd, described the psychiatric applications of iproniazid. Ernst Zeller found iproniazid to be a potent monoamine oxidase inhibitor. Nevertheless, iproniazid remained relatively obscure until Nathan S. Kline, the influential head of research at Rockland State Hospital, began to popularize it in the medical and popular press as a “psychic energiser”. Roche put a significant marketing effort behind iproniazid. Its sales grew until it was recalled in 1961, due to reports of lethal hepatotoxicity.

The antidepressant effect of a tricyclic, a three ringed compound, was first discovered in 1957 by Roland Kuhn in a Swiss psychiatric hospital. Antihistamine derivatives were used to treat surgical shock and later as neuroleptics. Although in 1955 reserpine was shown to be more effective than placebo in alleviating anxious depression, neuroleptics were being developed as sedatives and antipsychotics.

Attempting to improve the effectiveness of chlorpromazine, Kuhn – in conjunction with the Geigy Pharmaceutical Company – discovered the compound “G 22355”, later renamed imipramine. Imipramine had a beneficial effect in patients with depression who showed mental and motor retardation. Kuhn described his new compound as a “thymoleptic” “taking hold of the emotions,” in contrast with neuroleptics, “taking hold of the nerves” in 1955-1956. These gradually became established, resulting in the patent and manufacture in the US in 1951 by Häfliger and SchinderA.

Second Generation Antidepressants

Antidepressants became prescription drugs in the 1950s. It was estimated that no more than 50 to 100 individuals per million suffered from the kind of depression that these new drugs would treat, and pharmaceutical companies were not enthusiastic in marketing for this small market. Sales through the 1960s remained poor compared to the sales of tranquilizers, which were being marketed for different uses. Imipramine remained in common use and numerous successors were introduced. The use of monoamine oxidase inhibitors (MAOI) increased after the development and introduction of “reversible” forms affecting only the MAO-A subtype of inhibitors, making this drug safer to use.

By the 1960s, it was thought that the mode of action of tricyclics was to inhibit norepinephrine reuptake. However, norepinephrine reuptake became associated with stimulating effects. Later tricyclics were thought to affect serotonin as proposed in 1969 by Carlsson and Lindqvist as well as Lapin and Oxenkrug.

Researchers began a process of rational drug design to isolate antihistamine-derived compounds that would selectively target these systems. The first such compound to be patented was zimelidine in 1971, while the first released clinically was indalpine. Fluoxetine was approved for commercial use by the FDA in 1988, becoming the first blockbuster SSRI. Fluoxetine was developed at Eli Lilly and Company in the early 1970s by Bryan Molloy, Klaus Schmiegel, David T. Wong and others. SSRIs became known as “novel antidepressants” along with other newer drugs such as SNRIs and NRIs with various selective effects.

St John’s wort fell out of favour in most countries through the 19th and 20th centuries, except in Germany, where Hypericum extracts were eventually licensed, packaged and prescribed. Small-scale efficacy trials were carried out in the 1970s and 1980s, and attention grew in the 1990s following a meta-analysis. It remains an over-the-counter drug (OTC) supplement in most countries. Of concern are lead contaminant; on average, lead levels in women in the United States taking St. John’s wort are elevated about 20%. Research continues to investigate its active component hyperforin, and to further understand its mode of action.

Rapid-Acting Antidepressants

Esketamine (brand name Spravato), the first rapid-acting antidepressant to be approved for clinical treatment of depression, was introduced for this indication in March 2019 in the United States.

Research

A 2016 placebo randomised controlled trial evaluated the rapid antidepressant effects of the psychedelic ayahuasca in treatment-resistant depression with positive outcome. In 2018 the FDA granted Breakthrough Therapy Designation for psilocybin-assisted therapy for treatment-resistant depression and in 2019, the FDA granted Breakthrough Therapy Designation for psilocybin therapy treating major depressive disorder.

Society and Culture

Prescription Trends

In the United States, antidepressants were the most commonly prescribed medication in 2013. Of the estimated 16 million “long term” (over 24 months) users, roughly 70% are female. As of 2017, about 16.5% of white people in the United States took antidepressants compared with 5.6% of black people in the United States.

In the UK, figures reported in 2010 indicated that the number of antidepressants prescribed by the National Health Service (NHS) almost doubled over a decade. Further analysis published in 2014 showed that number of antidepressants dispensed annually in the community went up by 25 million in the 14 years between 1998 and 2012, rising from 15 million to 40 million. Nearly 50% of this rise occurred in the four years after the 2008 banking crash, during which time the annual increase in prescriptions rose from 6.7% to 8.5%. These sources also suggest that aside from the recession, other factors that may influence changes in prescribing rates may include: improvements in diagnosis, a reduction of the stigma surrounding mental health, broader prescribing trends, GP characteristics, geographical location and housing status. Another factor that may contribute to increasing consumption of antidepressants is the fact that these medications now are used for other conditions including social anxiety and PTSD.

Adherence

As of 2003, worldwide, 30 to 60% of people did not follow their practitioner’s instructions about taking their antidepressants, and as of 2013 in the US, it appeared that around 50% of people did not take their antidepressants as directed by their practitioner.

When people fail to take their antidepressants, there is a greater risk that the drug will not help, that symptoms get worse, that they miss work or are less productive at work, and that the person may be hospitalised. This also increases costs for caring for them.

Social Science Perspective

Some academics have highlighted the need to examine the use of antidepressants and other medical treatments in cross-cultural terms, due to the fact that various cultures prescribe and observe different manifestations, symptoms, meanings and associations of depression and other medical conditions within their populations. These cross-cultural discrepancies, it has been argued, then have implications on the perceived efficacy and use of antidepressants and other strategies in the treatment of depression in these different cultures. In India, antidepressants are largely seen as tools to combat marginality, promising the individual the ability to reintegrate into society through their use – a view and association not observed in the West.

Environmental Impacts

Because most antidepressants function by inhibiting the reuptake of neurotransmitters serotonin, dopamine, and norepinepherine these drugs can interfere with natural neurotransmitter levels in other organisms impacted by indirect exposure. Antidepressants fluoxetine and sertraline have been detected in aquatic organisms residing in effluent dominated streams. The presence of antidepressants in surface waters and aquatic organisms has caused concern because ecotoxicological effects to aquatic organisms due to fluoxetine exposure have been demonstrated.

Coral reef fish have been demonstrated to modulate aggressive behaviour through serotonin. Artificially increasing serotonin levels in crustaceans can temporarily reverse social status and turn subordinates into aggressive and territorial dominant males.

Exposure to fluoxetine has been demonstrated to increase serotonergic activity in fish, subsequently reducing aggressive behaviour. Perinatal exposure to fluoxetine at relevant environmental concentrations has been shown to lead to significant modifications of memory processing in 1-month-old cuttlefish. This impairment may disadvantage cuttlefish and decrease their survival. Somewhat less than 10% of orally administered fluoxetine is excreted from humans unchanged or as glucuronide.

What is Emotion?

Introduction

Emotions are biological states associated with the nervous system brought on by neurophysiological changes variously associated with thoughts, feelings, behavioural responses, and a degree of pleasure or displeasure. There is currently no scientific consensus on a definition. Emotions are often intertwined with mood, temperament, personality, disposition, creativity, and motivation.

Research on emotion has increased significantly over the past two decades with many fields contributing including psychology, neuroscience, affective neuroscience, endocrinology, medicine, history, sociology of emotions, and computer science. The numerous theories that attempt to explain the origin, neurobiology, experience, and function of emotions have only fostered more intense research on this topic. Current areas of research in the concept of emotion include the development of materials that stimulate and elicit emotion. In addition, positron emission tomography (PET) scans and functional magnetic resonance imaging (fMRI) scans help study the affective picture processes in the brain.

From a purely mechanistic perspective, emotions can be defined as “a positive or negative experience that is associated with a particular pattern of physiological activity.” Emotions produce different physiological, behavioural and cognitive changes. The original role of emotions was to motivate adaptive behaviours that in the past would have contributed to the passing on of genes through survival, reproduction, and kin selection.

In some theories, cognition is an important aspect of emotion. For those who act primarily on emotions, they may assume that they are not thinking, but mental processes involving cognition are still essential, particularly in the interpretation of events. For example, the realisation of our believing that we are in a dangerous situation and the subsequent arousal of our body’s nervous system (rapid heartbeat and breathing, sweating, muscle tension) is integral to the experience of our feeling afraid. Other theories, however, claim that emotion is separate from and can precede cognition. Consciously experiencing an emotion is exhibiting a mental representation of that emotion from a past or hypothetical experience, which is linked back to a content state of pleasure or displeasure. The content states are established by verbal explanations of experiences, describing an internal state.

Emotions are complex. According to some theories, they are states of feeling that result in physical and psychological changes that influence our behaviour. The physiology of emotion is closely linked to arousal of the nervous system with various states and strengths of arousal relating, apparently, to particular emotions. Emotion is also linked to behavioural tendency. Extroverted people are more likely to be social and express their emotions, while introverted people are more likely to be more socially withdrawn and conceal their emotions. Emotion is often the driving force behind motivation, positive or negative. According to other theories, emotions are not causal forces but simply syndromes of components, which might include motivation, feeling, behaviour, and physiological changes, but no one of these components is the emotion. Nor is the emotion an entity that causes these components.

Emotions involve different components, such as subjective experience, cognitive processes, expressive behaviour, psychophysiological changes, and instrumental behaviour. At one time, academics attempted to identify the emotion with one of the components: William James with a subjective experience, behaviourists with instrumental behaviour, psychophysiologists with physiological changes, and so on. More recently, emotion is said to consist of all the components. The different components of emotion are categorised somewhat differently depending on the academic discipline. In psychology and philosophy, emotion typically includes a subjective, conscious experience characterised primarily by psychophysiological expressions, biological reactions, and mental states. A similar multi-componential description of emotion is found in sociology. For example, Peggy Thoits described emotions as involving physiological components, cultural or emotional labels (anger, surprise, etc.), expressive body actions, and the appraisal of situations and contexts.

Brief History

Human nature and the following bodily sensations have been always part of the interest of thinkers and philosophers. Far most extensively, this interest has been of great interest by both Western and Eastern societies. Emotional states have been associated with the divine and the enlightenment of the human mind and body. The ever changing actions of individuals and its mood variations have been of great importance by most of the Western philosophers (Aristotle, Plato, Descartes, Aquinas, Hobbes) that lead them to propose vast theories; often competing theories, that sought to explain emotion and the following motivators of human action and its consequences.

In the Age of Enlightenment Scottish thinker David Hume proposed a revolutionary argument that sought to explain the main motivators of human action and conduct. He proposed that actions are motivated by “fears, desires, and passions”. As he wrote in his book Treatise of Human Nature (1773): “Reason alone can never be a motive to any action of the will… it can never oppose passion in the direction of the will… Reason is, and ought to be the slave of the passions, and can never pretend to any other office than to serve and obey them”. With these lines Hume pretended to explain that reason and further action will be subjected to the desires and experience of the self. Later thinkers would propose that actions and emotions are deeply interrelated to social, political, historical, and cultural aspects of reality that would be also associated with sophisticated neurological and physiological research on the brain and other parts of the physical body.

Etymology

The word “emotion” dates back to 1579, when it was adapted from the French word émouvoir, which means “to stir up”. The term emotion was introduced into academic discussion as a catch-all term to passions, sentiments and affections. The word “emotion” was coined in the early 1800s by Thomas Brown and it is around the 1830s that the modern concept of emotion first emerged for the English language. “No one felt emotions before about 1830. Instead they felt other things – “passions”, “accidents of the soul”, “moral sentiments” – and explained them very differently from how we understand emotions today.”

Some cross-cultural studies indicate that the categorisation of “emotion” and classification of basic emotions such as “anger” and “sadness” are not universal and that the boundaries and domains of these concepts are categorised differently by all cultures. However, others argue that there are some universal bases of emotions. In psychiatry and psychology, an inability to express or perceive emotion is sometimes referred to as alexithymia.

Definitions

The Oxford Dictionaries definition of emotion is “A strong feeling deriving from one’s circumstances, mood, or relationships with others.” Emotions are responses to significant internal and external events.

Emotions can be occurrences (e.g. panic) or dispositions (e.g. hostility), and short-lived (e.g. anger) or long-lived (e.g. grief). Psychotherapist Michael C. Graham describes all emotions as existing on a continuum of intensity. Thus fear might range from mild concern to terror or shame might range from simple embarrassment to toxic shame. Emotions have been described as consisting of a coordinated set of responses, which may include verbal, physiological, behavioural, and neural mechanisms.

Emotions have been categorised, with some relationships existing between emotions and some direct opposites existing. Graham differentiates emotions as functional or dysfunctional and argues all functional emotions have benefits.

In some uses of the word, emotions are intense feelings that are directed at someone or something. On the other hand, emotion can be used to refer to states that are mild (as in annoyed or content) and to states that are not directed at anything (as in anxiety and depression). One line of research looks at the meaning of the word emotion in everyday language and finds that this usage is rather different from that in academic discourse.

In practical terms, Joseph LeDoux has defined emotions as the result of a cognitive and conscious process which occurs in response to a body system response to a trigger.

Components

According to Scherer’s Component Process Model (CPM) of emotion, there are five crucial elements of emotion. From the component process perspective, emotional experience requires that all of these processes become coordinated and synchronised for a short period of time, driven by appraisal processes. Although the inclusion of cognitive appraisal as one of the elements is slightly controversial, since some theorists make the assumption that emotion and cognition are separate but interacting systems, the CPM provides a sequence of events that effectively describes the coordination involved during an emotional episode.

  • Cognitive appraisal: provides an evaluation of events and objects.
  • Bodily symptoms: the physiological component of emotional experience.
  • Action tendencies: a motivational component for the preparation and direction of motor responses.
  • Expression: facial and vocal expression almost always accompanies an emotional state to communicate reaction and intention of actions.
  • Feelings: the subjective experience of emotional state once it has occurred.

Differentiation

Emotion can be differentiated from a number of similar constructs within the field of affective neuroscience:

  • Feeling; not all feelings include emotion, such as the feeling of knowing. In the context of emotion, feelings are best understood as a subjective representation of emotions, private to the individual experiencing them.
  • Moods are diffuse affective states that generally last for much longer durations than emotions, are also usually less intense than emotions and often appear to lack a contextual stimulus.
  • Affect is used to describe the underlying affective experience of an emotion or a mood.

Purpose and Value

One view is that emotions facilitate adaptive responses to environmental challenges. Emotions have been described as a result of evolution because they provided good solutions to ancient and recurring problems that faced our ancestors. Emotions can function as a way to communicate what’s important to us, such as values and ethics. However some emotions, such as some forms of anxiety, are sometimes regarded as part of a mental illness and thus possibly of negative value.

Classification

A distinction can be made between emotional episodes and emotional dispositions. Emotional dispositions are also comparable to character traits, where someone may be said to be generally disposed to experience certain emotions. For example, an irritable person is generally disposed to feel irritation more easily or quickly than others do. Finally, some theorists place emotions within a more general category of “affective states” where affective states can also include emotion-related phenomena such as pleasure and pain, motivational states (for example, hunger or curiosity), moods, dispositions and traits.

Basic Emotions

For more than 40 years, Paul Ekman has supported the view that emotions are discrete, measurable, and physiologically distinct. Ekman’s most influential work revolved around the finding that certain emotions appeared to be universally recognised, even in cultures that were preliterate and could not have learned associations for facial expressions through media. Another classic study found that when participants contorted their facial muscles into distinct facial expressions (for example, disgust), they reported subjective and physiological experiences that matched the distinct facial expressions. Ekman’s facial-expression research examined six basic emotions: anger, disgust, fear, happiness, sadness and surprise. Later in his career, Ekman theorised that other universal emotions may exist beyond these six. In light of this, recent cross-cultural studies led by Daniel Cordaro and Dacher Keltner, both former students of Ekman, extended the list of universal emotions. In addition to the original six, these studies provided evidence for amusement, awe, contentment, desire, embarrassment, pain, relief, and sympathy in both facial and vocal expressions. They also found evidence for boredom, confusion, interest, pride, and shame facial expressions, as well as contempt, relief, and triumph vocal expressions.

Robert Plutchik agreed with Ekman’s biologically driven perspective but developed the “wheel of emotions”, suggesting eight primary emotions grouped on a positive or negative basis: joy versus sadness; anger versus fear; trust versus disgust; and surprise versus anticipation. Some basic emotions can be modified to form complex emotions. The complex emotions could arise from cultural conditioning or association combined with the basic emotions. Alternatively, similar to the way primary colours combine, primary emotions could blend to form the full spectrum of human emotional experience. For example, interpersonal anger and disgust could blend to form contempt. Relationships exist between basic emotions, resulting in positive or negative influences.

Multi-Dimensional Analysis

Psychologists have used methods such as factor analysis to attempt to map emotion-related responses onto a more limited number of dimensions. Such methods attempt to boil emotions down to underlying dimensions that capture the similarities and differences between experiences. Often, the first two dimensions uncovered by factor analysis are valence (how negative or positive the experience feels) and arousal (how energised or enervated the experience feels). These two dimensions can be depicted on a 2D coordinate map. This two-dimensional map has been theorised to capture one important component of emotion called core affect. Core affect is not theorised to be the only component to emotion, but to give the emotion its hedonic and felt energy.

Using statistical methods to analyse emotional states elicited by short videos, Cowen and Keltner identified 27 varieties of emotional experience: admiration, adoration, aesthetic appreciation, amusement, anger, anxiety, awe, awkwardness, boredom, calmness, confusion, craving, disgust, empathic pain, entrancement, excitement, fear, horror, interest, joy, nostalgia, relief, romance, sadness, satisfaction, sexual desire and surprise.

Theories

Pre-Modern History

In Buddhism, emotions occur when an object is considered as attractive or repulsive. There is a felt tendency impelling people towards attractive objects and impelling them to move away from repulsive or harmful objects; a disposition to possess the object (greed), to destroy it (hatred), to flee from it (fear), to get obsessed or worried over it (anxiety), and so on.

In stoic theories it was seen as a hindrance to reason and therefore a hindrance to virtue. Aristotle believed that emotions were an essential component of virtue. In the Aristotelian view all emotions (called passions) corresponded to appetites or capacities. During the Middle Ages, the Aristotelian view was adopted and further developed by scholasticism and Thomas Aquinas in particular.

In Chinese antiquity, excessive emotion was believed to cause damage to qi, which in turn, damages the vital organs. The four humours theory made popular by Hippocrates contributed to the study of emotion in the same way that it did for medicine.

In the early 11th century, Avicenna theorised about the influence of emotions on health and behaviours, suggesting the need to manage emotions.

Early modern views on emotion are developed in the works of philosophers such as René Descartes, Niccolò Machiavelli, Baruch Spinoza, Thomas Hobbes and David Hume. In the 19th century emotions were considered adaptive and were studied more frequently from an empiricist psychiatric perspective.

Western Theological

Christian perspective on emotion presupposes a theistic origin to humanity. God who created humans gave humans the ability to feel emotion and interact emotionally. Biblical content expresses that God is a person who feels and expresses emotion. Though a somatic view would place the locus of emotions in the physical body, Christian theory of emotions would view the body more as a platform for the sensing and expression of emotions. Therefore emotions themselves arise from the person, or that which is “imago-dei” or image of God in humans. In Christian thought, emotions have the potential to be controlled through reasoned reflection. That reasoned reflection also mimics God who made mind. The purpose of emotions in human life are therefore summarised in God’s call to enjoy Him and creation, humans are to enjoy emotions and benefit from them and use them to energise behaviour.

Evolutionary Theories (19th Century)

Perspectives on emotions from evolutionary theory were initiated during the mid-late 19th century with Charles Darwin’s 1872 book The Expression of the Emotions in Man and Animals. Surprisingly, Darwin argued that emotions served no evolved purpose for humans, neither in communication, nor in aiding survival. Darwin largely argued that emotions evolved via the inheritance of acquired characters. He pioneered various methods for studying non-verbal expressions, from which he concluded that some expressions had cross-cultural universality. Darwin also detailed homologous expressions of emotions that occur in animals. This led the way for animal research on emotions and the eventual determination of the neural underpinnings of emotion.

Evolutionary Theories (Contemporary)

More contemporary views along the evolutionary psychology spectrum posit that both basic emotions and social emotions evolved to motivate (social) behaviours that were adaptive in the ancestral environment. Emotion is an essential part of any human decision-making and planning, and the famous distinction made between reason and emotion is not as clear as it seems. Paul D. MacLean claims that emotion competes with even more instinctive responses, on one hand, and the more abstract reasoning, on the other hand. The increased potential in neuroimaging has also allowed investigation into evolutionarily ancient parts of the brain. Important neurological advances were derived from these perspectives in the 1990s by Joseph E. LeDoux and António Damásio.

Research on social emotion also focuses on the physical displays of emotion including body language of animals and humans (see affect display). For example, spite seems to work against the individual but it can establish an individual’s reputation as someone to be feared. Shame and pride can motivate behaviours that help one maintain one’s standing in a community, and self-esteem is one’s estimate of one’s status.

Somatic Theories (General)

Somatic theories of emotion claim that bodily responses, rather than cognitive interpretations, are essential to emotions. The first modern version of such theories came from William James in the 1880s. The theory lost favour in the 20th century, but has regained popularity more recently due largely to theorists such as John Cacioppo, António Damásio, Joseph E. LeDoux and Robert Zajonc who are able to appeal to neurological evidence.

Somatic Theories (James-Lange Theory)

In his 1884 article William James argued that feelings and emotions were secondary to physiological phenomena. In his theory, James proposed that the perception of what he called an “exciting fact” directly led to a physiological response, known as “emotion.” To account for different types of emotional experiences, James proposed that stimuli trigger activity in the autonomic nervous system, which in turn produces an emotional experience in the brain. The Danish psychologist Carl Lange also proposed a similar theory at around the same time, and therefore this theory became known as the James–Lange theory. As James wrote, “the perception of bodily changes, as they occur, is the emotion.” James further claims that “we feel sad because we cry, angry because we strike, afraid because we tremble, and either we cry, strike, or tremble because we are sorry, angry, or fearful, as the case may be.”

An example of this theory in action would be as follows: An emotion-evoking stimulus (snake) triggers a pattern of physiological response (increased heart rate, faster breathing, etc.), which is interpreted as a particular emotion (fear). This theory is supported by experiments in which by manipulating the bodily state induces a desired emotional state. Some people may believe that emotions give rise to emotion-specific actions, for example, “I’m crying because I’m sad,” or “I ran away because I was scared.” The issue with the James-Lange theory is that of causation (bodily states causing emotions and being a priori), not that of the bodily influences on emotional experience (which can be argued and is still quite prevalent today in biofeedback studies and embodiment theory).

Although mostly abandoned in its original form, Tim Dalgleish argues that most contemporary neuroscientists have embraced the components of the James-Lange theory of emotions.

The James-Lange theory has remained influential. Its main contribution is the emphasis it places on the embodiment of emotions, especially the argument that changes in the bodily concomitants of emotions can alter their experienced intensity. Most contemporary neuroscientists would endorse a modified James-Lange view in which bodily feedback modulates the experience of emotion.

Somatic Theories (Cannon-Bard Theory)

Walter Bradford Cannon agreed that physiological responses played a crucial role in emotions, but did not believe that physiological responses alone could explain subjective emotional experiences. He argued that physiological responses were too slow and often imperceptible and this could not account for the relatively rapid and intense subjective awareness of emotion. He also believed that the richness, variety, and temporal course of emotional experiences could not stem from physiological reactions, that reflected fairly undifferentiated fight or flight responses. An example of this theory in action is as follows: An emotion-evoking event (snake) triggers simultaneously both a physiological response and a conscious experience of an emotion.

Phillip Bard contributed to the theory with his work on animals. Bard found that sensory, motor, and physiological information all had to pass through the diencephalon (particularly the thalamus), before being subjected to any further processing. Therefore, Cannon also argued that it was not anatomically possible for sensory events to trigger a physiological response prior to triggering conscious awareness and emotional stimuli had to trigger both physiological and experiential aspects of emotion simultaneously.

Somatic Theories (Two-Factor Theory)

Stanley Schachter formulated his theory on the earlier work of a Spanish physician, Gregorio Marañón, who injected patients with epinephrine and subsequently asked them how they felt. Marañón found that most of these patients felt something but in the absence of an actual emotion-evoking stimulus, the patients were unable to interpret their physiological arousal as an experienced emotion. Schachter did agree that physiological reactions played a big role in emotions. He suggested that physiological reactions contributed to emotional experience by facilitating a focused cognitive appraisal of a given physiologically arousing event and that this appraisal was what defined the subjective emotional experience. Emotions were thus a result of two-stage process:

  1. General physiological arousal; and
  2. Experience of emotion.

For example, the physiological arousal, heart pounding, in a response to an evoking stimulus, the sight of a bear in the kitchen. The brain then quickly scans the area, to explain the pounding, and notices the bear. Consequently, the brain interprets the pounding heart as being the result of fearing the bear. With his student, Jerome Singer, Schachter demonstrated that subjects can have different emotional reactions despite being placed into the same physiological state with an injection of epinephrine. Subjects were observed to express either anger or amusement depending on whether another person in the situation (a confederate) displayed that emotion. Hence, the combination of the appraisal of the situation (cognitive) and the participants’ reception of adrenaline or a placebo together determined the response. This experiment has been criticised in Jesse Prinz’s (2004) Gut Reactions.

Cognitive Theories (General)

With the two-factor theory now incorporating cognition, several theories began to argue that cognitive activity in the form of judgments, evaluations, or thoughts were entirely necessary for an emotion to occur. One of the main proponents of this view was Richard Lazarus who argued that emotions must have some cognitive intentionality. The cognitive activity involved in the interpretation of an emotional context may be conscious or unconscious and may or may not take the form of conceptual processing.

Lazarus’ theory is very influential; emotion is a disturbance that occurs in the following order:

  • Cognitive appraisal: The individual assesses the event cognitively, which cues the emotion.
  • Physiological changes: The cognitive reaction starts biological changes such as increased heart rate or pituitary adrenal response.
  • Action: The individual feels the emotion and chooses how to react.

For example: Jenny sees a snake.

  • Jenny cognitively assesses the snake in her presence and cognition allows her to understand it as a danger.
  • Her brain activates the adrenal glands which pump adrenaline through her blood stream, resulting in increased heartbeat.
  • Jenny screams and runs away.

Lazarus stressed that the quality and intensity of emotions are controlled through cognitive processes. These processes underline coping strategies that form the emotional reaction by altering the relationship between the person and the environment.

George Mandler provided an extensive theoretical and empirical discussion of emotion as influenced by cognition, consciousness, and the autonomic nervous system in two books (Mind and Emotion, 1975, and Mind and Body: Psychology of Emotion and Stress, 1984)

There are some theories on emotions arguing that cognitive activity in the form of judgments, evaluations, or thoughts are necessary in order for an emotion to occur. A prominent philosophical exponent is Robert C. Solomon (for example, The Passions, Emotions and the Meaning of Life, 1993). Solomon claims that emotions are judgments. He has put forward a more nuanced view which responds to what he has called the ‘standard objection’ to cognitivism, the idea that a judgment that something is fearsome can occur with or without emotion, so judgment cannot be identified with emotion. The theory proposed by Nico Frijda where appraisal leads to action tendencies is another example.

It has also been suggested that emotions (affect heuristics, feelings and gut-feeling reactions) are often used as shortcuts to process information and influence behaviour. The affect infusion model (AIM) is a theoretical model developed by Joseph Forgas in the early 1990s that attempts to explain how emotion and mood interact with one’s ability to process information.

Cognitive Theories (Perceptual Theory)

Theories dealing with perception either use one or multiples perceptions in order to find an emotion. A recent hybrid of the somatic and cognitive theories of emotion is the perceptual theory. This theory is neo-Jamesian in arguing that bodily responses are central to emotions, yet it emphasizes the meaningfulness of emotions or the idea that emotions are about something, as is recognised by cognitive theories. The novel claim of this theory is that conceptually-based cognition is unnecessary for such meaning. Rather the bodily changes themselves perceive the meaningful content of the emotion because of being causally triggered by certain situations. In this respect, emotions are held to be analogous to faculties such as vision or touch, which provide information about the relation between the subject and the world in various ways. A sophisticated defence of this view is found in philosopher Jesse Prinz’s book Gut Reactions, and psychologist James Laird’s book Feelings.

Cognitive Theories (Affective Events Theory)

Affective events theory is a communication-based theory developed by Howard M. Weiss and Russell Cropanzano (1996), that looks at the causes, structures, and consequences of emotional experience (especially in work contexts). This theory suggests that emotions are influenced and caused by events which in turn influence attitudes and behaviours. This theoretical frame also emphasizes time in that human beings experience what they call emotion episodes – a “series of emotional states extended over time and organized around an underlying theme.” This theory has been utilised by numerous researchers to better understand emotion from a communicative lens, and was reviewed further by Howard M. Weiss and Daniel J. Beal in their article, “Reflections on Affective Events Theory”, published in Research on Emotion in Organisations in 2005.

Situated Perspective on Emotion

A situated perspective on emotion, developed by Paul E. Griffiths and Andrea Scarantino, emphasizes the importance of external factors in the development and communication of emotion, drawing upon the situationism approach in psychology. This theory is markedly different from both cognitivist and neo-Jamesian theories of emotion, both of which see emotion as a purely internal process, with the environment only acting as a stimulus to the emotion. In contrast, a situationist perspective on emotion views emotion as the product of an organism investigating its environment, and observing the responses of other organisms. Emotion stimulates the evolution of social relationships, acting as a signal to mediate the behaviour of other organisms. In some contexts, the expression of emotion (both voluntary and involuntary) could be seen as strategic moves in the transactions between different organisms. The situated perspective on emotion states that conceptual thought is not an inherent part of emotion, since emotion is an action-oriented form of skilful engagement with the world. Griffiths and Scarantino suggested that this perspective on emotion could be helpful in understanding phobias, as well as the emotions of infants and animals.

Genetics

Emotions can motivate social interactions and relationships and therefore are directly related with basic physiology, particularly with the stress systems. This is important because emotions are related to the anti-stress complex, with an oxytocin-attachment system, which plays a major role in bonding. Emotional phenotype temperaments affect social connectedness and fitness in complex social systems. These characteristics are shared with other species and taxa and are due to the effects of genes and their continuous transmission. Information that is encoded in the DNA sequences provides the blueprint for assembling proteins that make up our cells. Zygotes require genetic information from their parental germ cells, and at every speciation event, heritable traits that have enabled its ancestor to survive and reproduce successfully are passed down along with new traits that could be potentially beneficial to the offspring.

In the five million years since the lineages leading to modern humans and chimpanzees split, only about 1.2% of their genetic material has been modified. This suggests that everything that separates us from chimpanzees must be encoded in that very small amount of DNA, including our behaviours. Students that study animal behaviours have only identified intraspecific examples of gene-dependent behavioural phenotypes. In voles (Microtus spp.) minor genetic differences have been identified in a vasopressin receptor gene that corresponds to major species differences in social organisation and the mating system. Another potential example with behavioural differences is the FOCP2 gene, which is involved in neural circuitry handling speech and language. Its present form in humans differed from that of the chimpanzees by only a few mutations and has been present for about 200,000 years, coinciding with the beginning of modern humans. Speech, language, and social organization are all part of the basis for emotions.

Formation

Neurobiological Explanation

Based on discoveries made through neural mapping of the limbic system, the neurobiological explanation of human emotion is that emotion is a pleasant or unpleasant mental state organized in the limbic system of the mammalian brain. If distinguished from reactive responses of reptiles, emotions would then be mammalian elaborations of general vertebrate arousal patterns, in which neurochemicals (for example, dopamine, noradrenaline, and serotonin) step-up or step-down the brain’s activity level, as visible in body movements, gestures and postures. Emotions can likely be mediated by pheromones (think fear).

For example, the emotion of love is proposed to be the expression of Paleocircuits of the mammalian brain (specifically, modules of the cingulate gyrus) which facilitate the care, feeding, and grooming of offspring. Paleocircuits are neural platforms for bodily expression configured before the advent of cortical circuits for speech. They consist of pre-configured pathways or networks of nerve cells in the forebrain, brain stem and spinal cord.

Other emotions like fear and anxiety long thought to be exclusively generated by the most primitive parts of the brain (stem) and more associated to the fight-or-flight responses of behaviour, have also been associated as adaptive expressions of defensive behaviour whenever a threat is encountered. Although defensive behaviours have been present in a wide variety of species, Blanchard et al. (2001) discovered a correlation of given stimuli and situation that resulted in a similar pattern of defensive behaviour towards a threat in human and non-human mammals.

Whenever, potentially dangerous stimuli is presented additional brain structures activate that previously thought (hippocampus, thalamus, etc). Thus, giving the amygdala an important role on coordinating the following behavioural input based on the presented neurotransmitters that respond to threat stimuli. These biological functions of the amygdala are not only limited to the “fear-conditioning” and “processing of aversive stimuli”, but also are present on other components of the amygdala. Therefore, it can referred the amygdala as a key structure to understand the potential responses of behaviour in danger like situations in human and non-human mammals.

The motor centres of reptiles react to sensory cues of vision, sound, touch, chemical, gravity, and motion with pre-set body movements and programmed postures. With the arrival of night-active mammals, smell replaced vision as the dominant sense, and a different way of responding arose from the olfactory sense, which is proposed to have developed into mammalian emotion and emotional memory. The mammalian brain invested heavily in olfaction to succeed at night as reptiles slept – one explanation for why olfactory lobes in mammalian brains are proportionally larger than in the reptiles. These odour pathways gradually formed the neural blueprint for what was later to become our limbic brain.

Emotions are thought to be related to certain activities in brain areas that direct our attention, motivate our behaviour, and determine the significance of what is going on around us. Pioneering work by Paul Broca (1878), James Papez (1937), and Paul D. MacLean (1952) suggested that emotion is related to a group of structures in the centre of the brain called the limbic system, which includes the hypothalamus, cingulate cortex, hippocampi, and other structures. More recent research has shown that some of these limbic structures are not as directly related to emotion as others are while some non-limbic structures have been found to be of greater emotional relevance.

Prefrontal Cortex

There is ample evidence that the left prefrontal cortex is activated by stimuli that cause positive approach. If attractive stimuli can selectively activate a region of the brain, then logically the converse should hold, that selective activation of that region of the brain should cause a stimulus to be judged more positively. This was demonstrated for moderately attractive visual stimuli and replicated and extended to include negative stimuli.

Two neurobiological models of emotion in the prefrontal cortex made opposing predictions. The valence model predicted that anger, a negative emotion, would activate the right prefrontal cortex. The direction model predicted that anger, an approach emotion, would activate the left prefrontal cortex. The second model was supported.

This still left open the question of whether the opposite of approach in the prefrontal cortex is better described as moving away (direction model), as unmoving but with strength and resistance (movement model), or as unmoving with passive yielding (action tendency model). Support for the action tendency model (passivity related to right prefrontal activity) comes from research on shyness and research on behavioural inhibition. Research that tested the competing hypotheses generated by all four models also supported the action tendency model.

Homeostatic/Primordial Emotion

Another neurological approach proposed by Bud Craig in 2003 distinguishes two classes of emotion: “classical” emotions such as love, anger and fear that are evoked by environmental stimuli, and “homeostatic emotions” – attention-demanding feelings evoked by body states, such as pain, hunger and fatigue, that motivate behaviour (withdrawal, eating or resting in these examples) aimed at maintaining the body’s internal milieu at its ideal state.

Derek Denton calls the latter “primordial emotions” and defines them as “the subjective element of the instincts, which are the genetically programmed behaviour patterns which contrive homeostasis. They include thirst, hunger for air, hunger for food, pain and hunger for specific minerals etc. There are two constituents of a primordial emotion – the specific sensation which when severe may be imperious, and the compelling intention for gratification by a consummatory act.”

Emergent Explanation

Joseph LeDoux differentiates between the human’s defence system, which has evolved over time, and emotions such as fear and anxiety. He has said that the amygdala may release hormones due to a trigger (such as an innate reaction to seeing a snake), but “then we elaborate it through cognitive and conscious processes”.

Lisa Feldman Barrett highlights differences in emotions between different cultures, and says that emotions (such as anxiety) “are not triggered; you create them. They emerge as a combination of the physical properties of your body, a flexible brain that wires itself to whatever environment it develops in, and your culture and upbringing, which provide that environment.” She has termed this approach the theory of constructed emotion.

Disciplinary Approaches

Many different disciplines have produced work on the emotions. Human sciences study the role of emotions in mental processes, disorders, and neural mechanisms. In psychiatry, emotions are examined as part of the discipline’s study and treatment of mental disorders in humans. Nursing studies emotions as part of its approach to the provision of holistic health care to humans. Psychology examines emotions from a scientific perspective by treating them as mental processes and behaviour and they explore the underlying physiological and neurological processes. In neuroscience sub-fields such as social neuroscience and affective neuroscience, scientists study the neural mechanisms of emotion by combining neuroscience with the psychological study of personality, emotion, and mood. In linguistics, the expression of emotion may change to the meaning of sounds. In education, the role of emotions in relation to learning is examined.

Social sciences often examine emotion for the role that it plays in human culture and social interactions. In sociology, emotions are examined for the role they play in human society, social patterns and interactions, and culture. In anthropology, the study of humanity, scholars use ethnography to undertake contextual analyses and cross-cultural comparisons of a range of human activities. Some anthropology studies examine the role of emotions in human activities. In the field of communication sciences, critical organisational scholars have examined the role of emotions in organisations, from the perspectives of managers, employees, and even customers. A focus on emotions in organisations can be credited to Arlie Russell Hochschild’s concept of emotional labour. The University of Queensland hosts EmoNet, an e-mail distribution list representing a network of academics that facilitates scholarly discussion of all matters relating to the study of emotion in organisational settings. The list was established in January 1997 and has over 700 members from across the globe.

In economics, the social science that studies the production, distribution, and consumption of goods and services, emotions are analysed in some sub-fields of microeconomics, in order to assess the role of emotions on purchase decision-making and risk perception. In criminology, a social science approach to the study of crime, scholars often draw on behavioural sciences, sociology, and psychology; emotions are examined in criminology issues such as anomie theory and studies of “toughness,” aggressive behaviour, and hooliganism. In law, which underpins civil obedience, politics, economics and society, evidence about people’s emotions is often raised in tort law claims for compensation and in criminal law prosecutions against alleged lawbreakers (as evidence of the defendant’s state of mind during trials, sentencing, and parole hearings). In political science, emotions are examined in a number of sub-fields, such as the analysis of voter decision-making.

In philosophy, emotions are studied in sub-fields such as ethics, the philosophy of art (for example, sensory – emotional values, and matters of taste and sentimentality), and the philosophy of music (see also music and emotion). In history, scholars examine documents and other sources to interpret and analyse past activities; speculation on the emotional state of the authors of historical documents is one of the tools of interpretation. In literature and film-making, the expression of emotion is the cornerstone of genres such as drama, melodrama, and romance. In communication studies, scholars study the role that emotion plays in the dissemination of ideas and messages. Emotion is also studied in non-human animals in ethology, a branch of zoology which focuses on the scientific study of animal behaviour. Ethology is a combination of laboratory and field science, with strong ties to ecology and evolution. Ethologists often study one type of behaviour (for example, aggression) in a number of unrelated animals.

History

The history of emotions has become an increasingly popular topic recently, with some scholars[who?] arguing that it is an essential category of analysis, not unlike class, race, or gender. Historians, like other social scientists, assume that emotions, feelings and their expressions are regulated in different ways by both different cultures and different historical times, and the constructivist school of history claims even that some sentiments and meta-emotions, for example schadenfreude, are learnt and not only regulated by culture. Historians of emotion trace and analyse the changing norms and rules of feeling, while examining emotional regimes, codes, and lexicons from social, cultural, or political history perspectives. Others focus on the history of medicine, science, or psychology. What somebody can and may feel (and show) in a given situation, towards certain people or things, depends on social norms and rules; thus historically variable and open to change. Several research centres have opened in the past few years in Germany, England, Spain, Sweden, and Australia.

Furthermore, research in historical trauma suggests that some traumatic emotions can be passed on from parents to offspring to second and even third generation, presented as examples of transgenerational trauma.

Sociology

A common way in which emotions are conceptualized in sociology is in terms of the multidimensional characteristics including cultural or emotional labels (for example, anger, pride, fear, happiness), physiological changes (for example, increased perspiration, changes in pulse rate), expressive facial and body movements (for example, smiling, frowning, baring teeth), and appraisals of situational cues. One comprehensive theory of emotional arousal in humans has been developed by Jonathan Turner (2007; 2009). Two of the key eliciting factors for the arousal of emotions within this theory are expectations states and sanctions. When people enter a situation or encounter with certain expectations for how the encounter should unfold, they will experience different emotions depending on the extent to which expectations for Self, other and situation are met or not met. People can also provide positive or negative sanctions directed at Self or other which also trigger different emotional experiences in individuals. Turner analysed a wide range of emotion theories across different fields of research including sociology, psychology, evolutionary science, and neuroscience. Based on this analysis, he identified four emotions that all researchers consider being founded on human neurology including assertive-anger, aversion-fear, satisfaction-happiness, and disappointment-sadness. These four categories are called primary emotions and there is some agreement amongst researchers that these primary emotions become combined to produce more elaborate and complex emotional experiences. These more elaborate emotions are called first-order elaborations in Turner’s theory and they include sentiments such as pride, triumph, and awe. Emotions can also be experienced at different levels of intensity so that feelings of concern are a low-intensity variation of the primary emotion aversion-fear whereas depression is a higher intensity variant.

Attempts are frequently made to regulate emotion according to the conventions of the society and the situation based on many (sometimes conflicting) demands and expectations which originate from various entities. The expression of anger is in many cultures discouraged in girls and women to a greater extent than in boys and men (the notion being that an angry man has a valid complaint that needs to be rectified, while an angry women is hysterical or oversensitive, and her anger is somehow invalid), while the expression of sadness or fear is discouraged in boys and men relative to girls and women (attitudes implicit in phrases like “man up” or “don’t be a sissy”). Expectations attached to social roles, such as “acting as man” and not as a woman, and the accompanying “feeling rules” contribute to the differences in expression of certain emotions. Some cultures encourage or discourage happiness, sadness, or jealousy, and the free expression of the emotion of disgust is considered socially unacceptable in most cultures. Some social institutions are seen as based on certain emotion, such as love in the case of contemporary institution of marriage. In advertising, such as health campaigns and political messages, emotional appeals are commonly found. Recent examples include no-smoking health campaigns and political campaigns emphasizing the fear of terrorism.

Sociological attention to emotion has varied over time. Émile Durkheim (1915/1965) wrote about the collective effervescence or emotional energy that was experienced by members of totemic rituals in Australian aborigine society. He explained how the heightened state of emotional energy achieved during totemic rituals transported individuals above themselves giving them the sense that they were in the presence of a higher power, a force, that was embedded in the sacred objects that were worshipped. These feelings of exaltation, he argued, ultimately lead people to believe that there were forces that governed sacred objects.

In the 1990s, sociologists focused on different aspects of specific emotions and how these emotions were socially relevant. For Cooley (1992), pride and shame were the most important emotions that drive people to take various social actions. During every encounter, he proposed that we monitor ourselves through the “looking glass” that the gestures and reactions of others provide. Depending on these reactions, we either experience pride or shame and this results in particular paths of action. Retzinger (1991) conducted studies of married couples who experienced cycles of rage and shame. Drawing predominantly on Goffman and Cooley’s work, Scheff (1990) developed a micro sociological theory of the social bond. The formation or disruption of social bonds is dependent on the emotions that people experience during interactions.

Subsequent to these developments, Randall Collins (2004) formulated his interaction ritual theory by drawing on Durkheim’s work on totemic rituals that was extended by Goffman (1964/2013; 1967) into everyday focused encounters. Based on interaction ritual theory, we experience different levels or intensities of emotional energy during face-to-face interactions. Emotional energy is considered to be a feeling of confidence to take action and a boldness that one experiences when they are charged up from the collective effervescence generated during group gatherings that reach high levels of intensity.

There is a growing body of research applying the sociology of emotion to understanding the learning experiences of students during classroom interactions with teachers and other students (for example, Milne & Otieno, 2007; Olitsky, 2007; Tobin, et al., 2013; Zembylas, 2002). These studies show that learning subjects like science can be understood in terms of classroom interaction rituals that generate emotional energy and collective states of emotional arousal like emotional climate.

Apart from interaction ritual traditions of the sociology of emotion, other approaches have been classed into one of six other categories:

  • Evolutionary/biological theories.
  • Symbolic interactionist theories.
  • Dramaturgical theories.
  • Ritual theories.
  • Power and status theories.
  • Stratification theories.
  • Exchange theories.

This list provides a general overview of different traditions in the sociology of emotion that sometimes conceptualise emotion in different ways and at other times in complementary ways. Many of these different approaches were synthesized by Turner (2007) in his sociological theory of human emotions in an attempt to produce one comprehensive sociological account that draws on developments from many of the above traditions.

Psychotherapy and Regulation

Emotion regulation refers to the cognitive and behavioural strategies people use to influence their own emotional experience. For example, a behavioural strategy in which one avoids a situation to avoid unwanted emotions (trying not to think about the situation, doing distracting activities, etc.). Depending on the particular school’s general emphasis on either cognitive components of emotion, physical energy discharging, or on symbolic movement and facial expression components of emotion different schools of psychotherapy approach the regulation of emotion differently. Cognitively oriented schools approach them via their cognitive components, such as rational emotive behaviour therapy. Yet others approach emotions via symbolic movement and facial expression components (like in contemporary Gestalt therapy).

Cross-Cultural Research

Research on emotions reveals the strong presence of cross-cultural differences in emotional reactions and that emotional reactions are likely to be culture-specific. In strategic settings, cross-cultural research on emotions is required for understanding the psychological situation of a given population or specific actors. This implies the need to comprehend the current emotional state, mental disposition or other behavioural motivation of a target audience located in a different culture, basically founded on its national political, social, economic, and psychological peculiarities but also subject to the influence of circumstances and events.

Computer Science

In the 2000s, research in computer science, engineering, psychology and neuroscience has been aimed at developing devices that recognise human affect display and model emotions. In computer science, affective computing is a branch of the study and development of artificial intelligence that deals with the design of systems and devices that can recognise, interpret, and process human emotions. It is an interdisciplinary field spanning computer sciences, psychology, and cognitive science. While the origins of the field may be traced as far back as to early philosophical enquiries into emotion, the more modern branch of computer science originated with Rosalind Picard’s 1995 paper on affective computing. Detecting emotional information begins with passive sensors which capture data about the user’s physical state or behaviour without interpreting the input. The data gathered is analogous to the cues humans use to perceive emotions in others. Another area within affective computing is the design of computational devices proposed to exhibit either innate emotional capabilities or that are capable of convincingly simulating emotions. Emotional speech processing recognises the user’s emotional state by analysing speech patterns. The detection and processing of facial expression or body gestures is achieved through detectors and sensors.

The Effects on Memory

Emotion affects the way autobiographical memories are encoded and retrieved. Emotional memories are reactivated more, they are remembered better and have more attention devoted to them. Through remembering our past achievements and failures, autobiographical memories affect how we perceive and feel about ourselves.

Notable Theorists

In the late 19th century, the most influential theorists were William James (1842-1910) and Carl Lange (1834-1900). James was an American psychologist and philosopher who wrote about educational psychology, psychology of religious experience/mysticism, and the philosophy of pragmatism. Lange was a Danish physician and psychologist. Working independently, they developed the James-Lange theory, a hypothesis on the origin and nature of emotions. The theory states that within human beings, as a response to experiences in the world, the autonomic nervous system creates physiological events such as muscular tension, a rise in heart rate, perspiration, and dryness of the mouth. Emotions, then, are feelings which come about as a result of these physiological changes, rather than being their cause.

Silvan Tomkins (1911-1991) developed the affect theory and script theory. The affect theory introduced the concept of basic emotions, and was based on the idea that the dominance of the emotion, which he called the affected system, was the motivating force in human life.

Some of the most influential deceased theorists on emotion from the 20th century include:

  • Magda B. Arnold (1903-2002), an American psychologist who developed the appraisal theory of emotions;
  • Richard Lazarus (1922-2002), an American psychologist who specialised in emotion and stress, especially in relation to cognition;
  • Herbert A. Simon (1916-2001), who included emotions into decision making and artificial intelligence;
  • Robert Plutchik (1928-2006), an American psychologist who developed a psychoevolutionary theory of emotion;
  • Robert Zajonc (1923-2008) a Polish-American social psychologist who specialised in social and cognitive processes such as social facilitation;
  • Robert C. Solomon (1942-2007), an American philosopher who contributed to the theories on the philosophy of emotions with books such as What Is An Emotion?: Classic and Contemporary Readings (2003);
  • Peter Goldie (1946-2011), a British philosopher who specialised in ethics, aesthetics, emotion, mood and character;
  • Nico Frijda (1927-2015), a Dutch psychologist who advanced the theory that human emotions serve to promote a tendency to undertake actions that are appropriate in the circumstances, detailed in his book The Emotions (1986); and
  • Jaak Panksepp (1943-2017), an Estonian-born American psychologist, psychobiologist, neuroscientist and pioneer in affective neuroscience.

Influential theorists who are still active include the following psychologists, neurologists, philosophers, and sociologists:

  • Lisa Feldman Barrett (born 1963): Neuroscientist and psychologist specializing in affective science and human emotion.
  • John Cacioppo (born 1951): From the University of Chicago, founding father with Gary Berntson of social neuroscience.
  • Randall Collins (born 1941): American sociologist from the University of Pennsylvania developed the interaction ritual theory which includes the emotional entrainment model.
  • Michael Apter (born 1939): British psychologist who developed reversal theory, a structural, phenomenological theory of personality, motivation, and emotion.
  • António Damásio (born 1944): Portuguese behavioural neurologist and neuroscientist who works in the US.
  • Richard Davidson (born 1951): American psychologist and neuroscientist; pioneer in affective neuroscience.
  • Paul Ekman (born 1934): Psychologist specialising in the study of emotions and their relation to facial expressions.
  • Barbara Fredrickson: Social psychologist who specialises in emotions and positive psychology.
  • Arlie Russell Hochschild (born 1940): American sociologist whose central contribution was in forging a link between the subcutaneous flow of emotion in social life and the larger trends set loose by modern capitalism within organisations.
  • Joseph E. LeDoux (born 1949): American neuroscientist who studies the biological underpinnings of memory and emotion, especially the mechanisms of fear.
  • George Mandler (born 1924): American psychologist who wrote influential books on cognition and emotion.
  • Konstantinos V. Petrides: Greek-British psychologist who specialises in emotion, personality, psychometrics, and philosophy of mind, professor of psychology and psychometrics at University College London.
  • Jesse Prinz: American philosopher who specialises in emotion, moral psychology, aesthetics and consciousness.
  • James A. Russell (born 1947): American psychologist who developed or co-developed the PAD theory of environmental impact, circumplex model of affect, prototype theory of emotion concepts, a critique of the hypothesis of universal recognition of emotion from facial expression, concept of core affect, developmental theory of differentiation of emotion concepts, and, more recently, the theory of the psychological construction of emotion.
  • Klaus Scherer (born 1943): Swiss psychologist and director of the Swiss Centre for Affective Sciences in Geneva; he specialises in the psychology of emotion.
  • Ronald de Sousa (born 1940): English-Canadian philosopher who specialises in the philosophy of emotions, philosophy of mind and philosophy of biology.
  • Jonathan H. Turner (born 1942): American sociologist from the University of California, Riverside, who is a general sociological theorist with specialty areas including the sociology of emotions, ethnic relations, social institutions, social stratification, and bio-sociology.
  • Dominique Moïsi (born 1946): Authored a book titled The Geopolitics of Emotion focusing on emotions related to globalisation.

On This Day … 12 January

People (Births)

  • 1896 – David Wechsler, Romanian-American psychologist and author (d. 1981).
  • 1914 – Mieko Kamiya, Japanese psychiatrist and psychologist (d. 1979).
  • 1941 – Fiona Caldicott, English psychiatrist and psychotherapist.

David Wechsler

David Wechsler (12 January 1896 to 02 May 1981) was a Romanian-American psychologist. He developed well-known intelligence scales, such as the Wechsler Adult Intelligence Scale (WAIS) and the Wechsler Intelligence Scale for Children (WISC). A Review of General Psychology survey, published in 2002, ranked Wechsler as the 51st most cited psychologist of the 20th century.

Biography

Wechsler was born in a Jewish family in Lespezi, Romania, and emigrated with his parents to the United States as a child. He studied at the City College of New York and Columbia University, where he earned his master’s degree in 1917 and his Ph.D. in 1925 under the direction of Robert S. Woodworth. During World War I, he worked with the United States Army to develop psychological tests to screen new draftees while studying under Charles Spearman and Karl Pearson.

After short stints at various locations (including five years in private practice), Wechsler became chief psychologist at Bellevue Psychiatric Hospital in 1932, where he stayed until 1967. He died on 02 May 1981.

Intelligence Scales

Wechsler is best known for his intelligence tests. He was one of the most influential advocates of the role of non-intellective factors in testing. He emphasized that factors other than intellectual ability are involved in intelligent behaviour. Wechsler objected to the single score offered by the 1937 Binet scale. Although his test did not directly measure non-intellective factors, it took these factors into careful account in its underlying theory. The Wechsler Adult Intelligence Scale (WAIS) was developed first in 1939 and then called the Wechsler-Bellevue Intelligence Test. From these he derived the Wechsler Intelligence Scale for Children (WISC) in 1949 and the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) in 1967. Wechsler originally created these tests to find out more about his patients at the Bellevue clinic and he found the then-current Binet IQ test unsatisfactory. The tests are still based on his philosophy that intelligence is “the global capacity to act purposefully, to think rationally, and to deal effectively with [one’s] environment” (cited in Kaplan & Saccuzzo, p. 256).

The Wechsler scales introduced many novel concepts and breakthroughs to the intelligence testing movement. First, he did away with the quotient scores of older intelligence tests (the Q in “I.Q.”). Instead, he assigned an arbitrary value of 100 to the mean intelligence and added or subtracted another 15 points for each standard deviation above or below the mean the subject was. While not rejecting the concept of general intelligence (as conceptualised by his teacher Charles Spearman), he divided the concept of intelligence into two main areas: verbal and performance (non-verbal) scales, each evaluated with different subtests.

Mieko Kamiya

Mieko Kamiya (神谷 美恵子, Kamiya Mieko, 12 January 1914 to 22 October 1979) was a Japanese psychiatrist who treated leprosy patients at Nagashima Aiseien Sanatorium. She was known for translating books on philosophy. She worked as a medical doctor in the Department of Psychiatry at Tokyo University following World War II. She was said to have greatly helped the Ministry of Education and the General Headquarters, where the Supreme Commander of the Allied Powers stayed, in her role as an English-speaking secretary, and served as an adviser to Empress Michiko. She wrote many books as a highly educated, multi-lingual person; one of her books, titled On the Meaning of Life (Ikigai Ni Tsuite in Japanese), based on her experiences with leprosy patients, attracted many readers.

Fiona Caldicott

Dame Fiona Caldicott, DBE, FMedSci (12 January 1941 to Present) is a psychiatrist and psychotherapist and, previously, Principal of Somerville College, Oxford. She is the present National Data Guardian for Health and Social Care in England.

Caldicott was born on 12 January 1941 in Troon, daughter of barrister Joseph Maurice Soesan and civil servant Elizabeth Jane (née Ransley). Her paternal grandparents were greengrocers who were unenthusiastic about education; her father left school in his mid-teens, but subsequently completed a chemistry degree at night school and a law degree by correspondence. Caldicott was educated at City of London School for Girls, then studied medicine at St Hilda’s College, Oxford, qualifying BM BCh in 1966.

Career

She was a Pro Vice-Chancellor, Personnel and Equal Opportunities, of the University of Oxford and chaired its Personnel Committee. She retired from her 10-year term as Chair at the Oxford University Hospitals NHS Trust in March 2019, and was a past President of the British Association for Counselling and Psychotherapy. She was the first woman to be President of the Royal College of Psychiatrists (1993–96) and its first woman Dean (1990-1993). From 2011 to 2013 she was Chair of the National Information Governance Board for Health and Social Care.

Caldicott Committee

A review was commissioned by the Chief Medical Officer of England and Wales owing to increasing concern about the ways in which patient information is used in the NHS of England and Wales and the need to ensure that confidentiality is not undermined. Such concern was largely due to the development of information technology in the service, and its capacity to disseminate information about patients rapidly and extensively. In 1996, guidance on “the protection and use of patient information” was promulgated and there was a need to promote awareness of it at all levels in the NHS. It did not affect Scotland originally but they have recently adopted it. A main committee was set up under Caldicott’s Chair and there were four separate working groups; the committee was known as the Caldicott Committee.

The Caldicott Committee … was [responsible] to review all patient-identifiable information, which passes from NHS organisations to other NHS or non-NHS bodies for purposes other than direct care, medical research, or where there is a statutory requirement for information. The committee was to consider each flow of patient-identifiable information and was to advise the NHS Executive whether patient identification was justified by the purpose and whether action to minimise risks of breach of confidentiality was desirable – for example, reduction, elimination, or separate storage of items of information.

The Caldicott Report was published in December 1997. Today, every NHS trust has a ‘Caldicott Guardian’, to make sure standards of patient confidentiality and the Caldicott principles are upheld.

National Data Guardian for Health and Social Care

Caldicott became the UK’s first National Data Guardian for Health and Social Care in November 2014. In December 2018 the Health and Social Care (National Data Guardian) Act 2018 passed into law, and in April 2019 she was appointed as the first statutory position holder by the Secretary of State for Health and Social Care.

Awards and Honours

  • Honorary fellow at Somerville College, Oxford.
  • Dame Commander of the Order of the British Empire, 15 June 1996..
  • Lifetime Achievement Award from the Royal College of Psychiatrists, November 2018.

What is Behaviourism?

Introduction

Behaviourism is a systematic approach to understanding the behaviour of humans and other animals. It assumes that behaviour is either a reflex evoked by the pairing of certain antecedent stimuli in the environment, or a consequence of that individual’s history, including especially reinforcement and punishment contingencies, together with the individual’s current motivational state and controlling stimuli. Although behaviourists generally accept the important role of heredity in determining behaviour, they focus primarily on environmental events.

It combines elements of philosophy, methodology, and theory. Behaviourism emerged in the early 1900s as a reaction to depth psychology and other traditional forms of psychology, which often had difficulty making predictions that could be tested experimentally, but derived from earlier research in the late nineteenth century, such as when Edward Thorndike pioneered the law of effect, a procedure that involved the use of consequences to strengthen or weaken behaviour.

During the first half of the twentieth century, John B. Watson devised methodological behaviourism, which rejected introspective methods and sought to understand behaviour by only measuring observable behaviours and events. It was not until the 1930s that B.F. Skinner suggested that covert behaviour – including cognition and emotions – subjects to the same controlling variables as observable behaviour, which became the basis for his philosophy called radical behaviourism. While Watson and Ivan Pavlov investigated how (conditioned) neutral stimuli elicit reflexes in respondent conditioning, Skinner assessed the reinforcement histories of the discriminative (antecedent) stimuli that emits behaviour; the technique became known as operant conditioning.

The application of radical behaviourism – known as applied behaviour analysis – is used in a variety of contexts, including, for example, applied animal behaviour and organisational behaviour management to treatment of mental disorders, such as autism and substance abuse. In addition, while behaviourism and cognitive schools of psychological thought do not agree theoretically, they have complemented each other in the cognitive-behaviour therapies, which have demonstrated utility in treating certain pathologies, including simple phobias, PTSD, and mood disorders.

Branches of Behaviourism

An outline of the various branches of behaviourism can be seen the table below.

BranchDescription
InterbehaviourismProposed by Jacob Robert Kantor before B. F. Skinner’s writings.
Methodological Behaviourism1. John B. Watson’s behaviourism states that only public events (motor behaviours of an individual) can be objectively observed.
2. Although it was still acknowledged that thoughts and feelings exist, they were not considered part of the science of behaviour.
3. It also laid the theoretical foundation for the early approach behaviour modification in the 1970s and early 1980s.
Psychological Behviourism1. As proposed by Arthur W. Staats, unlike the previous behaviourisms of Skinner, Hull, and Tolman, was based upon a program of human research involving various types of human behaviour.
2. Psychological behaviourism introduces new principles of human learning.
3. Humans learn not only by the animal learning principles but also by special human learning principles.
4. Those principles involve humans’ uniquely huge learning ability.
5. Humans learn repertoires that enable them to learn other things. Human learning is thus cumulative.
6. No other animal demonstrates that ability, making the human species unique.
Radical Behaviourism1. Skinner’s philosophy is an extension of Watson’s form of behaviourism by theorising that processes within the organism – particularly, private events, such as thoughts and feelings – are also part of the science of behaviour, and suggests that environmental variables control these internal events just as they control observable behaviours.
2. Although private events cannot be directly seen by others, they are later determined through the species’ overt behaviour.
3. Radical behaviourism forms the core philosophy behind behaviour analysis.
4. Willard Van Orman Quine used many of radical behaviourism’s ideas in his study of knowledge and language.
Teleological Behaviourism1. Proposed by Howard Rachlin, post-Skinnerian, purposive, close to microeconomics. Focuses on objective observation as opposed to cognitive processes.
Theoretical Behaviourism1. Proposed by J.E.R. Staddon, adds a concept of internal state to allow for the effects of context.
2. According to theoretical behaviourism, a state is a set of equivalent histories, i.e., past histories in which members of the same stimulus class produce members of the same response class (i.e., B.F. Skinner’s concept of the operant).
3. Conditioned stimuli are thus seen to control neither stimulus nor response but state.
4. Theoretical behaviourism is a logical extension of Skinner’s class-based (generic) definition of the operant.
Hullian & Post-Hullian1. A sub-type of theoretical behaviourism.
2. Theoretical, group data, not dynamic, physiological.
Purposive1. A sub-type of theoretical behaviourism.
2. Tolman’s behaviouristic anticipation of cognitive psychology

Modern-Day Theory: Radical Behaviourism

B.F. Skinner proposed radical behaviourism as the conceptual underpinning of the experimental analysis of behaviour. This viewpoint differs from other approaches to behavioural research in various ways, but, most notably here, it contrasts with methodological behaviourism in accepting feelings, states of mind and introspection as behaviours also subject to scientific investigation. Like methodological behaviourism, it rejects the reflex as a model of all behaviour, and it defends the science of behaviour as complementary to but independent of physiology. Radical behaviourism overlaps considerably with other western philosophical positions, such as American pragmatism.

Although John B. Watson mainly emphasized his position of methodological behaviourism throughout his career, Watson and Rosalie Rayner conducted the renowned Little Albert experiment (1920), a study in which Ivan Pavlov’s theory to respondent conditioning was first applied to eliciting a fearful reflex of crying in a human infant, and this became the launching point for understanding covert behaviour (or private events) in radical behaviourism. However, Skinner felt that aversive stimuli should only be experimented on with animals and spoke out against Watson for testing something so controversial on a human.

In 1959, Skinner observed the emotions of two pigeons by noting that they appeared angry because their feathers ruffled. The pigeons were placed together in an operant chamber, where they were aggressive as a consequence of previous reinforcement in the environment. Through stimulus control and subsequent discrimination training, whenever Skinner turned off the green light, the pigeons came to notice that the food reinforcer is discontinued following each peck and responded without aggression. Skinner concluded that humans also learn aggression and possess such emotions (as well as other private events) no differently than do nonhuman animals.

Experimental and Conceptual Innovations

This essentially philosophical position gained strength from the success of Skinner’s early experimental work with rats and pigeons, summarized in his books The Behaviour of Organisms and Schedules of Reinforcement. Of particular importance was his concept of the operant response, of which the canonical example was the rat’s lever-press. In contrast with the idea of a physiological or reflex response, an operant is a class of structurally distinct but functionally equivalent responses. For example, while a rat might press a lever with its left paw or its right paw or its tail, all of these responses operate on the world in the same way and have a common consequence. Operants are often thought of as species of responses, where the individuals differ but the class coheres in its function-shared consequences with operants and reproductive success with species. This is a clear distinction between Skinner’s theory and S-R theory.

Skinner’s empirical work expanded on earlier research on trial-and-error learning by researchers such as Thorndike and Guthrie with both conceptual reformulations – Thorndike’s notion of a stimulus-response “association” or “connection” was abandoned; and methodological ones – the use of the “free operant”, so called because the animal was now permitted to respond at its own rate rather than in a series of trials determined by the experimenter procedures. With this method, Skinner carried out substantial experimental work on the effects of different schedules and rates of reinforcement on the rates of operant responses made by rats and pigeons. He achieved remarkable success in training animals to perform unexpected responses, to emit large numbers of responses, and to demonstrate many empirical regularities at the purely behavioural level. This lent some credibility to his conceptual analysis. It is largely his conceptual analysis that made his work much more rigorous than his peers’, a point which can be seen clearly in his seminal work Are Theories of Learning Necessary? in which he criticizes what he viewed to be theoretical weaknesses then common in the study of psychology. An important descendant of the experimental analysis of behaviour is the Society for Quantitative Analysis of Behaviour.

Relation to Language

As Skinner turned from experimental work to concentrate on the philosophical underpinnings of a science of behaviour, his attention turned to human language with his 1957 book Verbal Behaviour and other language-related publications; Verbal Behaviour laid out a vocabulary and theory for functional analysis of verbal behaviour, and was strongly criticised in a review by Noam Chomsky.

Skinner did not respond in detail but claimed that Chomsky failed to understand his ideas, and the disagreements between the two and the theories involved have been further discussed. Innateness theory, which has been heavily critiqued, is opposed to behaviourist theory which claims that language is a set of habits that can be acquired by means of conditioning. According to some, the behaviourist account is a process which would be too slow to explain a phenomenon as complicated as language learning. What was important for a behaviourist’s analysis of human behaviour was not language acquisition so much as the interaction between language and overt behaviour. In an essay republished in his 1969 book Contingencies of Reinforcement, Skinner took the view that humans could construct linguistic stimuli that would then acquire control over their behaviour in the same way that external stimuli could. The possibility of such “instructional control” over behaviour meant that contingencies of reinforcement would not always produce the same effects on human behaviour as they reliably do in other animals. The focus of a radical behaviourist analysis of human behaviour therefore shifted to an attempt to understand the interaction between instructional control and contingency control, and also to understand the behavioural processes that determine what instructions are constructed and what control they acquire over behaviour. Recently, a new line of behavioural research on language was started under the name of relational frame theory.

Education

Behaviourism focuses on one particular view of learning: a change in external behaviour achieved through using reinforcement and repetition (Rote learning) to shape behaviour of learners. Skinner found that behaviours could be shaped when the use of reinforcement was implemented. Desired behaviour is rewarded, while the undesired behaviour is not rewarded. Incorporating behaviourism into the classroom allowed educators to assist their students in excelling both academically and personally. In the field of language learning, this type of teaching was called the audio-lingual method, characterised by the whole class using choral chanting of key phrases, dialogues and immediate correction.

Within the behaviourist view of learning, the “teacher” is the dominant person in the classroom and takes complete control, evaluation of learning comes from the teacher who decides what is right or wrong. The learner does not have any opportunity for evaluation or reflection within the learning process, they are simply told what is right or wrong. The conceptualisation of learning using this approach could be considered “superficial,” as the focus is on external changes in behaviour, i.e., not interested in the internal processes of learning leading to behaviour change and has no place for the emotions involved in the process.

Operant Conditioning

Operant conditioning was developed by B.F. Skinner in 1937 and deals with the management of environmental contingencies to change behaviour. In other words, behaviour is controlled by historical consequential contingencies, particularly reinforcement – a stimulus that increases the probability of performing behaviours, and punishment – a stimulus that decreases such probability. The core tools of consequences are either positive (presenting stimuli following a response), or negative (withdrawn stimuli following a response).

The following descriptions explain the concepts of four common types of consequences in operant conditioning.

TypeDescription
Positive Reinforcement1. Providing a stimulus that an individual desires to reinforce desired behaviours.
2. For example, a child loves playing video games.
3. His mother reinforced his tendency to provide a helping hands to other family members by providing more time for him to play video games.
Negative Reinforcement1. Removing a stimulus that an individual does not desire to reinforce desired behaviours.
3. For example, a child hates being nagged to clean his room.
3. His mother reinforces his room cleaning by removing the undesired stimulus of nagging after he has cleaned.
Positive Punishment1. Providing a stimulus that an individual does not desire to decrease undesired behaviours.
2. For example, a child hates to do chores.
3. His parents will try to reduce the undesired behaviour of failing a test by applying the undesired stimuli of having him do more chores around the house.
Negative Punishment1. Removing a stimulus that an individual desires in order to decrease undesired behaviours.
2. For example, a child loves playing video games.
3. His parents will try to reduce the undesired behaviour of failing an exam by removing the desired stimulus of video games.

Classical experiment in operant conditioning, for example the Skinner Box, “puzzle box” or operant conditioning chamber to test the effects of operant conditioning principles on rats, cats and other species. From the study of Skinner box, he discovered that the rats learned very effectively if they were rewarded frequently with food. Skinner also found that he could shape the rats’ behaviour through the use of rewards, which could, in turn, be applied to human learning as well.

Skinner’s model was based on the premise that reinforcement is used for the desired actions or responses while punishment was used to stop the undesired actions responses that are not. This theory proved that humans or animals will repeat any action that leads to a positive outcome, and avoiding any action that leads to a negative outcome. The experiment with the pigeons showed that a positive outcome leads to learned behaviour since the pigeon learned to peck the disc in return for the reward of food.

These historical consequential contingencies subsequently leads to (antecedent) stimulus control, but in contrast to respondent conditioning where antecedent stimuli elicits reflexive behavior, operant behavior is only emitted and therefore does not force its occurrence. It includes the following controlling stimuli:

  • Discriminative stimulus (Sd):
    • An antecedent stimulus that increases the chance of the organism engaging in a behaviour.
    • One example of this occurred in Skinner’s laboratory.
    • Whenever the green light (Sd) appeared, it signalled the pigeon to perform the behaviour of pecking because it learned in the past that each time it pecked, food was presented (the positive reinforcing stimulus).
  • Stimulus delta (S-delta):
    • An antecedent stimulus that signals the organism not to perform a behaviour since it was extinguished or punished in the past.
    • One notable instance of this occurs when a person stops their car immediately after the traffic light turns red (S-delta).
    • However, the person could decide to drive through the red light, but subsequently receive a speeding ticket (the positive punishing stimulus), so this behaviour will potentially not reoccur following the presence of the S-delta.

Respondent Conditioning

Although operant conditioning plays the largest role in discussions of behavioural mechanisms, respondent conditioning (also called Pavlovian or classical conditioning) is also an important behaviour-analytic process that need not refer to mental or other internal processes. Pavlov’s experiments with dogs provide the most familiar example of the classical conditioning procedure. At the beginning, the dog was provided a meat (unconditioned stimulus, UCS, naturally elicit a response that is not controlled) to eat, resulting in increased salivation (unconditioned response, UCR, which means that a response is naturally caused by UCS). Afterwards, a bell ring was presented together with food to the dog. Although bell ring was a neutral stimulus (NS, meaning that the stimulus did not had any effect), dog would start salivate when only hearing a bell ring after a number of pairings. Eventually, the neutral stimulus (bell ring) became conditioned. Therefore, salvation was elicited as a conditioned response (the response same as the unconditioned response), pairing up with meat – the conditioned stimulus). Although Pavlov proposed some tentative physiological processes that might be involved in classical conditioning, these have not been confirmed. The idea of classical conditioning helped behaviourist John Watson discover the key mechanism behind how humans acquire the behaviours that they do, which was to find a natural reflex that produces the response being considered.

Watson’s “Behaviourist Manifesto” has three aspects that deserve special recognition: one is that psychology should be purely objective, with any interpretation of conscious experience being removed, thus leading to psychology as the “science of behaviour”; the second one is that the goals of psychology should be to predict and control behaviour (as opposed to describe and explain conscious mental states); the third one is that there is no notable distinction between human and non-human behaviour. Following Darwin’s theory of evolution, this would simply mean that human behaviour is just a more complex version in respect to behaviour displayed by other species.

In Philosophy

Behaviourism is a psychological movement that can be contrasted with philosophy of mind. The basic premise of radical behaviourism is that the study of behaviour should be a natural science, such as chemistry or physics, without any reference to hypothetical inner states of organisms as causes for their behaviour. Behaviourism takes a functional view of behaviour. According to Edmund Fantino and colleagues: “Behaviour analysis has much to offer the study of phenomena normally dominated by cognitive and social psychologists. We hope that successful application of behavioural theory and methodology will not only shed light on central problems in judgment and choice but will also generate greater appreciation of the behavioural approach.”

Behaviourist sentiments are not uncommon within philosophy of language and analytic philosophy. It is sometimes argued that Ludwig Wittgenstein defended a logical behaviourist position (e.g. the beetle in a box argument). In logical positivism (as held, e.g. by Rudolf Carnap and Carl Hempel), the meaning of psychological statements are their verification conditions, which consist of performed overt behaviour. W.V.O. Quine made use of a type of behaviourism, influenced by some of Skinner’s ideas, in his own work on language. Quine’s work in semantics differed substantially from the empiricist semantics of Carnap which he attempted to create an alternative to, couching his semantic theory in references to physical objects rather than sensations. Gilbert Ryle defended a distinct strain of philosophical behaviourism, sketched in his book The Concept of Mind. Ryle’s central claim was that instances of dualism frequently represented “category mistakes”, and hence that they were really misunderstandings of the use of ordinary language. Daniel Dennett likewise acknowledges himself to be a type of behaviourist, though he offers extensive criticism of radical behaviourism and refutes Skinner’s rejection of the value of intentional idioms and the possibility of free will.

This is Dennett’s main point in “Skinner Skinned.” Dennett argues that there is a crucial difference between explaining and explaining away… If our explanation of apparently rational behavior turns out to be extremely simple, we may want to say that the behavior was not really rational after all. But if the explanation is very complex and intricate, we may want to say not that the behavior is not rational, but that we now have a better understanding of what rationality consists in. (Compare: if we find out how a computer program solves problems in linear algebra, we don’t say it’s not really solving them, we just say we know how it does it. On the other hand, in cases like Weizenbaum’s ELIZA program, the explanation of how the computer carries on a conversation is so simple that the right thing to say seems to be that the machine isn’t really carrying on a conversation, it’s just a trick.) (Curtis Brown, Philosophy of Mind, “Behaviorism: Skinner and Dennett”).

Law of Effect and Trace Conditioning

  • Law of Effect:
    • Although Edward Thorndike’s methodology mainly dealt with reinforcing observable behaviour, it viewed cognitive antecedents as the causes of behaviour, and was theoretically much more similar to the cognitive-behaviour therapies than classical (methodological) or modern-day (radical) behaviourism.
    • Nevertheless, Skinner’s operant conditioning was heavily influenced by the Law of Effect’s principle of reinforcement.
  • Trace conditioning:
    • Akin to B.F. Skinner’s radical behaviourism, it is a respondent conditioning technique based on Ivan Pavlov’s concept of a “memory trace” in which the observer recalls the conditioned stimulus (CS), with the memory or recall being the unconditioned response (UR).
    • There is also a time delay between the CS and unconditioned stimulus (US), causing the conditioned response (CR) – particularly the reflex – to be faded over time.

Molecular versus Molar Behaviourism

Skinner’s view of behaviour is most often characterised as a “molecular” view of behaviour; that is, behaviour can be decomposed into atomistic parts or molecules. This view is inconsistent with Skinner’s complete description of behaviour as delineated in other works, including his 1981 article “Selection by Consequences”. Skinner proposed that a complete account of behaviour requires understanding of selection history at three levels: biology (the natural selection or phylogeny of the animal); behaviour (the reinforcement history or ontogeny of the behavioual repertoire of the animal); and for some species, culture (the cultural practices of the social group to which the animal belongs). This whole organism then interacts with its environment. Molecular behaviourists use notions from melioration theory, negative power function discounting or additive versions of negative power function discounting.

Molar behaviourists, such as Howard Rachlin, Richard Herrnstein, and William Baum, argue that behaviour cannot be understood by focusing on events in the moment. That is, they argue that behaviour is best understood as the ultimate product of an organism’s history and that molecular behaviourists are committing a fallacy by inventing fictitious proximal causes for behaviour. Molar behaviourists argue that standard molecular constructs, such as “associative strength”, are better replaced by molar variables such as rate of reinforcement. Thus, a molar behaviourist would describe “loving someone” as a pattern of loving behaviour over time; there is no isolated, proximal cause of loving behaviour, only a history of behaviours (of which the current behaviour might be an example) that can be summarised as “love”.

Theoretical Behaviourism

Skinner’s radical behaviourism has been highly successful experimentally, revealing new phenomena with new methods, but Skinner’s dismissal of theory limited its development. Theoretical behaviourism recognised that a historical system, an organism, has a state as well as sensitivity to stimuli and the ability to emit responses. Indeed, Skinner himself acknowledged the possibility of what he called “latent” responses in humans, even though he neglected to extend this idea to rats and pigeons. Latent responses constitute a repertoire, from which operant reinforcement can select. Theoretical behaviourism links between the brain and the behaviour that provides a real understanding of the behaviour. Rather than a mental presumption of how brain-behaviour relates.

Behaviour Analysis and Culture

Cultural analysis has always been at the philosophical core of radical behaviourism from the early days (as seen in Skinner’s Walden Two, Science & Human Behaviour, Beyond Freedom & Dignity, and About Behaviourism).

During the 1980s, behaviour analysts, most notably Sigrid Glenn, had a productive interchange with cultural anthropologist Marvin Harris (the most notable proponent of “cultural materialism”) regarding interdisciplinary work. Very recently, behaviour analysts have produced a set of basic exploratory experiments in an effort toward this end. Behaviourism is also frequently used in game development, although this application is controversial.

Behaviour Informatics and Behaviour Computing

With the fast growth of big behavioural data and applications, behaviour analysis is ubiquitous. Understanding behaviour from the informatics and computing perspective becomes increasingly critical for in-depth understanding of what, why and how behaviours are formed, interact, evolve, change and affect business and decision. Behaviour informatics and behaviour computing deeply explore behaviour intelligence and behaviour insights from the informatics and computing perspectives.

Criticisms and Limitations

In the second half of the 20th century, behaviourism was largely eclipsed as a result of the cognitive revolution. This shift was due to radical behaviourism being highly criticised for not examining mental processes, and this led to the development of the cognitive therapy movement. In the mid-20th century, three main influences arose that would inspire and shape cognitive psychology as a formal school of thought:

  • Noam Chomsky’s 1959 critique of behaviourism, and empiricism more generally, initiated what would come to be known as the “cognitive revolution”.
  • Developments in computer science would lead to parallels being drawn between human thought and the computational functionality of computers, opening entirely new areas of psychological thought. Allen Newell and Herbert Simon spent years developing the concept of artificial intelligence (AI) and later worked with cognitive psychologists regarding the implications of AI. The effective result was more of a framework conceptualisation of mental functions with their counterparts in computers (memory, storage, retrieval, etc.)
  • Formal recognition of the field involved the establishment of research institutions such as George Mandler’s Center for Human Information Processing in 1964. Mandler described the origins of cognitive psychology in a 2002 article in the Journal of the History of the Behavioural Sciences.

In the early years of cognitive psychology, behaviourist critics held that the empiricism it pursued was incompatible with the concept of internal mental states. Cognitive neuroscience, however, continues to gather evidence of direct correlations between physiological brain activity and putative mental states, endorsing the basis for cognitive psychology.

Behaviour Therapy

Behaviour therapy is a term referring to different types of therapies that treat mental health disorders. It identifies and helps change people’s unhealthy behaviours or destructive behaviours through learning theory and conditioning. Ivan Pavlov’s classical conditioning, as well as counterconditioning are the basis for much of clinical behaviour therapy, but also includes other techniques, including operant conditioning, or contingency management, and modelling – sometimes called observational learning. A frequently noted behaviour therapy is systematic desensitisation, which was first demonstrated by Joseph Wolpe and Arnold Lazarus.

21st-Century Behaviourism (Behaviour Analysis)

Applied behaviour analysis (ABA) – also called behavioural engineering – is a scientific discipline that applies the principles of behaviour analysis to change behaviour. ABA derived from much earlier research in the Journal of the Experimental Analysis of Behaviour, which was founded by B.F. Skinner and his colleagues at Harvard University. Nearly a decade after the study “The psychiatric nurse as a behavioural engineer” (1959) was published in that journal, which demonstrated how effective the token economy was in reinforcing more adaptive behaviour for hospitalised patients with schizophrenia and intellectual disability, it led to researchers at the University of Kansas to start the Journal of Applied Behaviour Analysis in 1968.

Although ABA and behaviour modification are similar behaviour-change technologies in that the learning environment is modified through respondent and operant conditioning, behaviour modification did not initially address the causes of the behaviour (particularly, the environmental stimuli that occurred in the past), or investigate solutions that would otherwise prevent the behaviour from reoccurring. As the evolution of ABA began to unfold in the mid-1980s, functional behaviour assessments (FBAs) were developed to clarify the function of that behaviour, so that it is accurately determined which differential reinforcement contingencies will be most effective and less likely for aversive consequences to be administered. In addition, methodological behaviourism was the theory underpinning behaviour modification since private events were not conceptualised during the 1970s and early 1980s, which contrasted from the radical behaviourism of behaviour analysis. ABA – the term that replaced behaviour modification – has emerged into a thriving field.

The independent development of behaviour analysis outside the United States also continues to develop. In the US, the American Psychological Association (APA) features a subdivision for Behaviour Analysis, titled APA Division 25: Behaviour Analysis, which has been in existence since 1964, and the interests among behaviour analysts today are wide-ranging, as indicated in a review of the 30 Special Interest Groups (SIGs) within the Association for Behaviour Analysis International (ABAI). Such interests include everything from animal behaviour and environmental conservation, to classroom instruction (such as direct instruction and precision teaching), verbal behaviour, developmental disabilities and autism, clinical psychology (i.e., forensic behaviour analysis), behavioural medicine (i.e., behavioural gerontology, AIDS prevention, and fitness training), and consumer behaviour analysis.

The field of applied animal behaviour – a sub-discipline of ABA that involves training animals – is regulated by the Animal Behaviour Society, and those who practice this technique are called applied animal behaviourists. Research on applied animal behaviour has been frequently conducted in the Applied Animal Behaviour Science journal since its founding in 1974.

ABA has also been particularly well-established in the area of developmental disabilities since the 1960s, but it was not until the late 1980s that individuals diagnosed with autism spectrum disorders were beginning to grow so rapidly and groundbreaking research was being published that parent advocacy groups started demanding for services throughout the 1990s, which encouraged the formation of the Behaviour Analyst Certification Board, a credentialing program that certifies professionally trained behaviour analysts on the national level to deliver such services. Nevertheless, the certification is applicable to all human services related to the rather broad field of behaviour analysis (other than the treatment for autism), and the ABAI currently has 14 accredited MA and PhD programmes for comprehensive study in that field.

Early behavioural interventions (EBIs) based on ABA are empirically validated for teaching children with autism and has been proven as such for over the past five decades. Since the late 1990s and throughout the twenty-first century, early ABA interventions have also been identified as the treatment of choice by the US Surgeon General, American Academy of Paediatrics, and US National Research Council.

Discrete trial training – also called early intensive behavioural intervention – is the traditional EBI technique implemented for thirty to forty hours per week that instructs a child to sit in a chair, imitate fine and gross motor behaviours, as well as learn eye contact and speech, which are taught through shaping, modelling, and prompting, with such prompting being phased out as the child begins mastering each skill. When the child becomes more verbal from discrete trials, the table-based instructions are later discontinued, and another EBI procedure known as incidental teaching is introduced in the natural environment by having the child ask for desired items kept out of their direct access, as well as allowing the child to choose the play activities that will motivate them to engage with their facilitators before teaching the child how to interact with other children their own age.

A related term for incidental teaching, called pivotal response treatment (PRT), refers to EBI procedures that exclusively entail twenty-five hours per week of naturalistic teaching (without initially using discrete trials). Current research is showing that the majority of the population learn more words at a quicker pace through PRT since only a small portion of the non-verbal autistic population have lower receptive language skills – a phrase used to describe individuals who do not pay much attention to overt stimuli or others in their environment – and the latter are the children who initially require discrete trials to acquire speech.

Organizational behaviour management, which applies contingency management procedures to model and reinforce appropriate work behaviour for employees in organisations, has developed a particularly strong following within ABA, as evidenced by the formation of the OBM Network and Journal of Organisational Behaviour Management, which was rated the third highest impact journal in applied psychology by ISI JOBM rating.

Modern-day clinical behaviour analysis has also witnessed a massive resurgence in research, with the development of relational frame theory (RFT), which is described as an extension of verbal behaviour and a “post-Skinnerian account of language and cognition.” RFT also forms the empirical basis for acceptance and commitment therapy, a therapeutic approach to counselling often used to manage such conditions as anxiety and obesity that consists of acceptance and commitment, value-based living, cognitive defusion, counterconditioning (mindfulness), and contingency management (positive reinforcement). Another evidence-based counselling technique derived from RFT is the functional analytic psychotherapy known as behavioural activation that relies on the ACL model – awareness, courage, and love – to reinforce more positive moods for those struggling with depression.

Incentive-based contingency management (CM) is the standard of care for adults with substance-use disorders; it has also been shown to be highly effective for other addictions (i.e. obesity and gambling). Although it does not directly address the underlying causes of behaviour, incentive-based CM is highly behaviour analytic as it targets the function of the client’s motivational behaviour by relying on a preference assessment, which is an assessment procedure that allows the individual to select the preferred reinforcer (in this case, the monetary value of the voucher, or the use of other incentives, such as prizes). Another evidence-based CM intervention for substance abuse is community reinforcement approach and family training that uses FBAs and counterconditioning techniques – such as behavioural skills training and relapse prevention – to model and reinforce healthier lifestyle choices which promote self-management of abstinence from drugs, alcohol, or cigarette smoking during high-risk exposure when engaging with family members, friends, and co-workers.

While schoolwide positive behaviour support consists of conducting assessments and a task analysis plan to differentially reinforce curricular supports that replace students’ disruptive behaviour in the classroom, paediatric feeding therapy incorporates a liquid chaser and chin feeder to shape proper eating behaviour for children with feeding disorders. Habit reversal training, an approach firmly grounded in counterconditioning which uses contingency management procedures to reinforce alternative behaviour, is currently the only empirically validated approach for managing tic disorders.

Some studies on exposure (desensitisation) therapies – which refer to an array of interventions based on the respondent conditioning procedure known as habituation and typically infuses counterconditioning procedures, such as meditation and breathing exercises – have recently been published in behaviour analytic journals since the 1990s, as most other research are conducted from a cognitive-behaviour therapy framework. When based on a behaviour analytic research standpoint, FBAs are implemented to precisely outline how to employ the flooding form of desensitisation (also called direct exposure therapy) for those who are unsuccessful in overcoming their specific phobia through systematic desensitisation (also known as graduated exposure therapy). These studies also reveal that systematic desensitisation is more effective for children if used in conjunction with shaping, which is further termed contact desensitisation, but this comparison has yet to be substantiated with adults.

Other widely published behaviour analytic journals include Behaviour Modification, The Behaviour Analyst, Journal of Positive Behaviour Interventions, Journal of Contextual Behavioural Science, The Analysis of Verbal Behaviour, Behaviour and Philosophy, Behaviour and Social Issues, and The Psychological Record.

Cognitive Behaviour Therapy

Cognitive behaviour therapy (CBT) is a behaviour therapy discipline that often overlaps considerably with the clinical behaviour analysis subfield of ABA, but differs in that it initially incorporates cognitive restructuring and emotional regulation to alter a person’s cognition and emotions.

A popularly noted counselling intervention known as dialectical behaviour therapy (DBT) includes the use of a chain analysis, as well as cognitive restructuring, emotional regulation, distress tolerance, counterconditioning (mindfulness), and contingency management (positive reinforcement). DBT is quite similar to acceptance and commitment therapy, but contrasts in that it derives from a CBT framework. Although DBT is most widely researched for and empirically validated to reduce the risk of suicide in psychiatric patients with borderline personality disorder, it can often be applied effectively to other mental health conditions, such as substance abuse, as well as mood and eating disorders.

Most research on exposure therapies (also called desensitisation) – ranging from eye movement desensitisation and reprocessing therapy to exposure and response prevention – are conducted through a CBT framework in non-behaviour analytic journals, and these enhanced exposure therapies are well-established in the research literature for treating phobic, post-traumatic stress, and other anxiety disorders (such as obsessive compulsive disorder, or OCD).

Cognitive-based behavioural activation (BA) – the psychotherapeutic approach used for depression – is shown to be highly effective and is widely used in clinical practice. Some large randomised control trials have indicated that cognitive-based BA is as beneficial as antidepressant medications but more efficacious than traditional cognitive therapy. Other commonly used clinical treatments derived from behavioural learning principles that are often implemented through a CBT model include community reinforcement approach and family training, and habit reversal training for substance abuse and tics, respectively.

Related Therapies

  • Acceptance and commitment therapy (ACT).
  • Applied animal behaviour.
  • Behavioural activation.
  • Behaviour modification.
  • Behaviour therapy.
  • Biofeedback.
  • Clinical behaviour analysis.
  • Contingency management.
  • Desensitization.
  • Dialectical behaviour therapy.
  • Direct instruction.
  • Discrete trial training.
  • Exposure and response prevention.
  • Exposure therapy.
  • Eye movement desensitisation and reprocessing.
  • Flooding.
  • Functional analytic psychotherapy.
  • Habit reversal training.
  • Organisational behaviour management.
  • Pivotal response treatment.
  • Positive behaviour support.
  • Prolonged exposure therapy.
  • Social skills training.
  • Systematic desensitisation.

On This Day .. 11 January

People (Births)

  • 1842 – William James, American psychologist and philosopher (d. 1910).
  • 1867 – Edward B. Titchener, English psychologist and academic (d. 1927).

People (Deaths)

  • 2007 – Robert Anton Wilson, American psychologist, author, poet, and playwright (b. 1932).

William James

William James (11 January 1842 to 26 August 1910) was an American philosopher and psychologist, and the first educator to offer a psychology course in the United States. James is considered to be a leading thinker of the late nineteenth century, one of the most influential philosophers of the United States, and the “Father of American psychology”.

Along with Charles Sanders Peirce, James established the philosophical school known as pragmatism, and is also cited as one of the founders of functional psychology. A Review of General Psychology analysis, published in 2002, ranked James as the 14th most eminent psychologist of the 20th century. A survey published in American Psychologist in 1991 ranked James’s reputation in second place, after Wilhelm Wundt, who is widely regarded as the founder of experimental psychology. James also developed the philosophical perspective known as radical empiricism. James’s work has influenced philosophers and academics such as Émile Durkheim, W.E.B. Du Bois, Edmund Husserl, Bertrand Russell, Ludwig Wittgenstein, Hilary Putnam, Richard Rorty, and Marilynne Robinson.

Born into a wealthy family, James was the son of the Swedenborgian theologian Henry James Sr. and the brother of both the prominent novelist Henry James and the diarist Alice James. James trained as a physician and taught anatomy at Harvard, but never practiced medicine. Instead he pursued his interests in psychology and then philosophy. James wrote widely on many topics, including epistemology, education, metaphysics, psychology, religion, and mysticism. Among his most influential books are The Principles of Psychology, a ground-breaking text in the field of psychology; Essays in Radical Empiricism, an important text in philosophy; and The Varieties of Religious Experience, an investigation of different forms of religious experience, including theories on mind-cure.

Edward B. Titchener

Edward Bradford Titchener (11 January 1867 to 03 August 1927) was an English psychologist who studied under Wilhelm Wundt for several years. Titchener is best known for creating his version of psychology that described the structure of the mind: structuralism. He created the largest doctoral program in the United States (at the time) after becoming a professor at Cornell University, and his first graduate student, Margaret Floy Washburn, became the first woman to be granted a PhD in psychology (1894).

Robert Anton Wilson

Robert Anton Wilson (born Robert Edward Wilson; 18 January 1932 to 11 January 2007) was an American author, futurist and self-described agnostic mystic. Recognised by Discordianism as a Pope and saint, Wilson helped publicise the group through his writings and interviews.

Wilson described his work as an “attempt to break down conditioned associations, to look at the world in a new way, with many models recognised as models or maps, and no one model elevated to the truth”. His goal being “to try to get people into a state of generalised agnosticism, not agnosticism about God alone but agnosticism about everything.”

Following a journalistic career, Wilson emerged as a major countercultural figure in the mid-1970s, comparable to one of his co-authors, Timothy Leary, as well as Terence McKenna.

He received a B.A., M.A. (1978) and Ph.D. (1981) in psychology from Paideia University, an unaccredited institution that has since closed. Wilson reworked his dissertation, and it found publication in 1983 as Prometheus Rising.

On This Day … 09 January

People (Births)

  • 1879 – John B. Watson, American psychologist and academic (d. 1958).

People (Deaths)

  • 2012 – William G. Roll, German-American psychologist and parapsychologist (b. 1926).

John B. Watson

John Broadus Watson (09 January 1878 to 25 September 1958) was an American psychologist who popularized the scientific theory of behaviourism, establishing it as a psychological school. Watson advanced this change in the psychological discipline through his 1913 address at Columbia University, titled Psychology as the Behaviourist Views It. Through his behaviourist approach, Watson conducted research on animal behaviour, child rearing, and advertising, as well as conducting the controversial “Little Albert” experiment and the Kerplunk experiment. He was also the editor of Psychological Review from 1910 to 1915. A Review of General Psychology survey, published in 2002, ranked Watson as the 17th most cited psychologist of the 20th century.

William G. Roll

William G. Roll (03 July 1926 to 09 January 2012) was an American psychologist and parapsychologist on the faculty of the Psychology Department of the University of West Georgia in Carrollton, Georgia. Roll is most notable for his belief in poltergeist activity. He coined the term “recurrent spontaneous psychokinesis” (RSPK) to explain poltergeist cases. However, RSPK was never accepted by mainstream science and sceptics have described Roll as a credulous investigator.

What is a Community Mental Health Service?

Introduction

Centre for Mental Health Services, also known as community mental health teams (CMHT) in the United Kingdom, support or treat people with mental disorders (mental illness or mental health difficulties) in a domiciliary setting, instead of a psychiatric hospital (asylum). The array of community mental health services vary depending on the country in which the services are provided. It refers to a system of care in which the patient’s community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment.

Community services include supported housing with full or partial supervision (including halfway houses), psychiatric wards of general hospitals (including partial hospitalisation), local primary care medical services, day centres or clubhouses, community mental health centres, and self-help groups for mental health.

The services may be provided by government organisations and mental health professionals, including specialised teams providing services across a geographical area, such as assertive community treatment and early psychosis teams. They may also be provided by private or charitable organisations. They may be based on peer support and the consumer/survivor/ex-patient movement.

The World Health Organisation (WHO) states that community mental health services are more accessible and effective, lessen social exclusion, and are likely to have fewer possibilities for the neglect and violations of human rights that were often encountered in mental hospitals. However, WHO notes that in many countries, the closing of mental hospitals has not been accompanied by the development of community services, leaving a service vacuum with far too many not receiving any care.

New legal powers have developed in some countries, such as the United States, to supervise and ensure compliance with treatment of individuals living in the community, known as outpatient commitment or assisted outpatient treatment or community treatment orders.

Brief History

Origins

Community mental health services began as an effort to contain those who were “mad” or considered “lunatics”. Understanding the history of mental disorders is crucial in understanding the development of community mental health services. As medical psychology developed as a science and shifted toward the treatment of the mentally ill, psychiatric institutions began to develop around the world, and laid the groundwork for modern day community mental health services.

Pre-Deinstitutionalisation

On 03 July 1946, US President Harry Truman signed the National Mental Health Act which, for the first time in the history of the United States, generated a large amount of federal funding for both psychiatric education and research. The passing of this Act eventually led to the founding of the National Institute of Mental Health (NIMH) in 1949. At the end of the 1940s and moving into the beginning of the 1950s, the governor of Minnesota Luther Youngdahl initiated the development of numerous community-based mental health services. He also advocated for the humane treatment of people in state institutions.

Deinstitutionalisation

Philippe Pinel played a large role in the ethical and humane treatment of patients and greatly influenced Dorothea Dix. Dix advocated the expansion of state psychiatric hospitals for patients who were at the time being housed in jails and poor houses. Despite her good intentions, rapid urbanisation and increased immigration led to a gross overwhelming of the state’s mental health systems and because of this, as the 19th century ended and the 20th century began, a shift in focus from treatment to custodial care was seen. As quality of care declined and psychotropic drugs were introduced, those with mental illnesses were reintroduced to the community, where community mental health services were designated as primary care providers.

Mental Health Movements

Reform MovementEraSettingFocus of Reform
Moral Treatment1800-1850AsylumHumane, restorative treatment
Mental Hygiene1890-1920Mental hospital or clinicPrevention, scientific orientation
Community Mental Health1955-1970Community mental health centreDeinstitutionalisation, social integration
Community Support1975-PresentCommunitiesMental illness as a social welfare problem (e.g. treatment housing, employment, etc.)

Post-Deinstitutionalisation

Following deinstitutionalisation, many of the mentally ill ended up in jails, nursing homes, and on the streets as homeless individuals. It was at this point in history that modern community mental health services started to grow and become influential. In 1955, following a major period of deinstitutionalisation, the Mental Health Study Act was passed. With the passing of this Act, the US Congress called for “an objective, thorough, nationwide analysis and re-evaluation of the human and economic problems of mental health.” Following Congress’ mandate, the Joint Commission on Mental Illness conducted numerous studies. For the next four years this Commission made recommendations to establish community mental health centres across the country. In 1963, the Community Mental Health Centres Act was passed, essentially kick-starting the community mental health revolution. This Act contributed further to deinstitutionalisation by moving mental patients into their “least restrictive” environments. The Community Mental Health Centres Act funded three main initiatives:

  • Professional training for those working in community mental health centres;
  • Improvement of research in the methodology utilised by community mental health centres; and
  • Improving the quality of care of existing programmes until newer community mental health centres could be developed.

That same year the Mental Retardation Facilities and Community Mental Health Centres Construction Act was passed. President John F. Kennedy ran part of his campaign on a platform strongly supporting community mental health in the United States. Kennedy’s ultimate goal was to reduce custodial care of mental health patients by 50% in ten to twenty years. In 1965, the Community Mental Health Act was amended to ensure a long list of provisions. First, construction and staffing grants were extended to include centres that served patients with substance abuse disorders. Secondly, grants were provided to bolster the initiation and progression of community mental health services in low-SES areas. Lastly, new grants were established to support mental health services aimed at helping children. As the 20th century progressed, even more political influence was exerted on community mental health. In 1965, with the passing of Medicare and Medicaid, there was an intense growth of skilled nursing homes and intermediate-care facilities that alleviated the burden felt by the large-scale public psychiatric hospitals.

20th Century

From 1965 to 1969, $260 million was authorised for community mental health centres. Compared to other government organisations and programmes, this number is strikingly low. The funding drops even further under Richard Nixon from 1970-1973 with a total of $50.3 million authorised. Even though the funding for community mental health centres was on a steady decline, deinstitutionalisation continued into the 1960s and 1970s. The number of state and county mental hospital resident patients in 1950 was 512,501 and by 1989 had decreased to 101,402. This continuing process of deinstitutionalisation without adequate alternative resources led the mentally ill into homelessness, jails, and self-medication through the use of drugs or alcohol. In 1975, Congress passed an Act requiring community mental health centres to provide aftercare services to all patients in the hopes of improving recovery rates. In 1980, just five years later, Congress passed the Mental Health Systems Act of 1980, which provided federal funding for ongoing support and development of community mental health programmes. This Act strengthened the connection between federal, state, and local governments with regards to funding for community mental health services. It was the final result of a long series of recommendations by Jimmy Carter’s Mental Health Commission. Despite this apparent progress, just a year after the Mental Health Systems Act was passed, the Omnibus Budget Reconciliation Act of 1981 was passed. The Omnibus Act was passed by the efforts of the Reagan administration as an effort to reduce domestic spending. The Act rescinded a large amount of the legislation just passed, and the legislation that was not rescinded was almost entirely revamped. It effectively ended federal funding of community treatment for the mentally ill, shifting the burden entirely to individual state governments. Federal funding was now replaced by granting smaller amounts of money to the individual states. In 1977, the National Institute of Mental Health (NIMH) initiated its Community Support Program (C.S.P.). The C.S.P.’s goal was to shift the focus from psychiatric institutions and the services they offer to networks of support for individual clients. The C.S.P. established the ten elements of a community support system listed below:

  • Responsible team.
  • Residential care.
  • Emergency care.
  • Medicare care.
  • Halfway house.
  • Supervised (supported) apartments.
  • Outpatient therapy.
  • Vocational training and opportunities.
  • Social and recreational opportunities.
  • Family and network attention.

This conceptualisation of what makes a good community programme has come to serve as a theoretical guideline for community mental health service development throughout the modern-day United States psychological community. In 1986, Congress passed the Mental Health Planning Act of 1986, which was a Federal law requiring that at the state government level, all states must have plans for establishing case management under Medicaid, improving mental health coverage of community mental health services, adding rehabilitative services, and expanding clinical services to the homeless population. More specifically, community mental health providers could now receive reimbursement for services from Medicare and Medicaid, which allowed for many of the centres to expand their range of treatment options and services. As the 1990s began, many positive changes occurred for people with mental illnesses through the development of larger networks of community-based providers and added innovations with regards to payment options from Medicare and Medicaid. Despite these advancements, there were many issues associated with the increasing cost of health care. Community mental health services moved toward a system more similar to managed care as the 1990s progressed. Managed care as a system focuses on limiting costs by one of two means: either keeping the total number of patients using services low or reducing the cost of the service itself. Despite the drive for community mental health, many physicians, mental health specialists, and even patients have come to question its effectiveness as a treatment. The underlying assumptions of community mental health require that patients who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation. These assumptions are in fact often wrong. Many people with mental illnesses, upon discharge, have no family to return to and end up homeless. While there is much to be said for the benefits that community mental health offers, many communities as a whole often harbour negative attitudes toward those with mental illnesses. Historically, people with mental illnesses have been portrayed as violent or criminal and because of this, “many American jails have become housing for persons with severe mental illnesses arrested for various crimes.” In 1999 the Supreme Court ruled on the case Olmstead v. L.C. The Court ruled that it was a violation of the Americans with Disabilities Act of 1990 to keep an individual in a more restrictive inpatient setting, such as a hospital, when a more appropriate and less restrictive community service was available to the individual.

21st Century and Modern Trends

In 2002, President George W. Bush increased funding for community health centres. The funding aided in the construction of additional centres and increased the number of services offered at these centres, which included healthcare benefits. In 2003, the New Freedom Commission on Mental Health, established by President Bush, issued a report. The report was in place to “conduct a comprehensive study of the United States mental health delivery system…” Its objectives included assessing the efficiency and quality of both public and private mental health providers and identifying possible new technologies that could aid in treatment. As the 20th century came to a close and the 21st century began, the number of patients diagnosed with a mental health or substance abuse disorder receiving services at community mental health centres grew from 210,000 to approximately 800,000. This nearly four-fold increase shows just how important community mental health centres are becoming to the general population’s wellbeing. Unfortunately, this drastic rise in the number of patients was not mirrored by a concomitant rise in the number of clinicians serving this population. The staggering new numbers of patients then are being forced to seek specialised treatment from their primary care providers or hospital emergency rooms. The unfortunate result of this trend is that when a patient is working with their primary care provider, they are more likely for a number of reasons to receive less care than with a specialised clinician. Politics and funding have always been and continue to be a topic of contention when it comes to funding of community health centres. Political views aside, it is clear that these community mental health centres exist largely to aid areas painfully under resourced with psychiatric care. In 2008, over 17 million people utilised community mental health centres with 35% being insured through Medicaid, and 38% being uninsured. As the 2000s continued, the rate of increase of patients receiving mental health treatment in community mental health centres stayed steady.

Purpose and Examples

Cultural knowledge and attitude is passed from generation to generation. For example, the stigma with therapy may be passed from mother to daughter. San Diego county has a diverse range of ethnicities. Thus, the population diversity in San Diego include many groups with historical trauma and trans-generational trauma within those populations. For example, witnesses of war can pass down certain actions and patterns of survival mechanism to generations. Refugee groups have trans-generational trauma around war and PTSD. Providing services and therapy to these communities is important because it affects their day-to-day lives, where their experiences lead to trauma or the experiences are traumatic themselves. Knowledge and access to mental health resources are limited in these multicultural communities. Government agencies fund community groups that provide services to these communities. Therefore, this creates a power hierarchy. If their missions do not align with each other, it will be hard to provide benefits for the community, even though the services are imperative to the wellbeing of its residents.

The combination of a mental illness as a clinical diagnosis, functional impairment with one or more major life activities, and distress is highest in ages 18-25 years old. Despite the research showing the necessity of therapy for this age group, only one fifth of emerging adults receive treatment. Psychosocial interventions that encourage self-exploration and self-awareness, such as acceptance and mindfulness-based therapies, is useful in preventing and treating mental health concerns. At the Centre for Community Counselling and Engagement, 39% of their clients are ages 1-25 years old and 40% are in ages 26-40 years old as well as historically underrepresented people of colour. The centre serves a wide range of ethnicities and socio-economic statuses in the City Heights community with counsellors who are graduate student therapists getting their Master’s in Marriage and Family Therapy or Community Counselling from San Diego State University, as well as post-graduate interns with their master’s degree, who are preparing to be licensed by the state of California. Counselling fees are based on household incomes, which 69% of the client’s annual income is $1-$25,000 essentially meeting the community’s needs. Taking into account of San Diego’s population, the clinic serves as an example of how resources can be helpful for multicultural communities that have a lot of trauma in their populations.

Future

On one hand, despite the field’s movement toward community mental health services, currently “insufficient empirical research exists regarding the effectiveness of community treatment programmes, and the evidence that does exist does not generalise to all types of community treatment.” In addition to the fact that community mental health’s overall success must be further evaluated, in the times when it has proved effective, very little research exists to help in understanding what exact aspects make it effective. Effective and insightful research will be crucial in not only evaluating, but also improving the techniques community mental health utilises. On the other hand, the demand for and necessity of community mental health is driving it into the future. With this seemingly unrelenting increase in the number of people experiencing mental health illnesses and the number of people reporting these problems, the question becomes what role community mental health services will play. In 2007, almost 5% of adults in the United States reported at least one unmet need for mental health care. Funding has historically been and continues to be an issue for both the organisations attempting to provide mental health services to a community and the citizens of the community who are so desperately in need of treatment. The community mental health system’s goal is an extremely difficult one and it continues to struggle against changing social priorities, funding deficits, and increasing need. Community mental health services would ideally provide quality care at a low cost to those who need it most. In the case of deinstitutionalisation, as the number of patients treated increased, the quality and availability of care went down. With the case of small, private treatment homes, as the quality of the care went up their ability to handle large numbers of patients decreased. This unending battle for the middle ground is a difficult one but there seems to be hope. For example, the 2009 Federal Stimulus Package and Health Reform Act have increased the funding for community health centres substantially. Undoubtedly as community mental health moves forward, there will continue to be a juggling act between clinical needs and standards, political agendas, and funding.

On This Day … 08 January

People (Births)

  • 1902 – Carl Rogers, American psychologist and academic (d. 1987).

Carl Rogers

Carl Ransom Rogers (08 January 1902 to 04 February 1987) was an American psychologist and among the founders of the humanistic approach (or client-centred approach) to psychology. Rogers is widely considered to be one of the founding fathers of psychotherapy research and was honoured for his pioneering research with the Award for Distinguished Scientific Contributions by the American Psychological Association (APA) in 1956.

The person-centred approach, his own unique approach to understanding personality and human relationships, found wide application in various domains such as psychotherapy and counselling (client-centred therapy), education (student-centred learning), organisations, and other group settings. For his professional work he was bestowed the Award for Distinguished Professional Contributions to Psychology by the APA in 1972. In a study by Steven J. Haggbloom and colleagues using six criteria such as citations and recognition, Rogers was found to be the sixth most eminent psychologist of the 20th century and second, among clinicians, only to Sigmund Freud. Based on a 1982 survey among 422 respondents of US and Canadian psychologists, he was considered the first most influential psychotherapist in history (Sigmund Freud was ranked third).