Global mental health is the international perspective on different aspects of mental health. It is ‘the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide’. There is a growing body of criticism of the global mental health movement, and has been widely criticised as a neo-colonial or “missionary” project and as primarily a front for pharmaceutical companies seeking new clients for psychiatric drugs.
In theory, taking into account cultural differences and country-specific conditions, it deals with the epidemiology of mental disorders in different countries, their treatment options, mental health education, political and financial aspects, the structure of mental health care systems, human resources in mental health, and human rights issues among others.
The overall aim of the field of global mental health is to strengthen mental health all over the world by providing information about the mental health situation in all countries, and identifying mental health care needs in order to develop cost-effective interventions to meet those specific needs.
The Global Burden of Disease
Mental, neurological, and substance use disorders make a substantial contribution to the global burden of disease (GBD). This is a global measure of so-called disability-adjusted life years (DALY’s) assigned to a certain disease/disorder, which is a sum of the years lived with disability and years of life lost due to this disease within the total population. Neuropsychiatric conditions account for 14% of the global burden of disease. Among non-communicable diseases, they account for 28% of the DALY’s – more than cardiovascular disease or cancer. However, it is estimated that the real contribution of mental disorders to the global burden of disease is even higher, due to the complex interactions and co-morbidity of physical and mental illness.
Around the world, almost one million people die due to suicide every year, and it is the third leading cause of death among young people. The most important causes of disability due to health-related conditions worldwide include unipolar depression, alcoholism, schizophrenia, bipolar depression and dementia. In low- and middle-income countries, these conditions represent a total of 19.1% of all disability related to health conditions.
Mental Health by Country
The following is an outline from selected countries.
Mental illnesses and mental health disorders are widespread concerns among underdeveloped African countries, yet these issues are largely neglected, as mental health care in Africa is given statistically less attention than it is in other, westernised nations. Rising death tolls due to mental illness demonstrate the imperative need for improved mental health care policies and advances in treatment for Africans suffering from psychological disorders.
Underdeveloped African countries are so visibly troubled by physical illnesses, disease, malnutrition, and contamination that the dilemma of lacking mental health care has not been prioritised, makes it challenging to have a recognised impact on the African population. In 1988 and 1990, two original resolutions were implemented by the World Health Organisation’s (WHO) Member States in Africa. AFR/RC39/R1 and AFR/RC40/R9 attempted to improve the status of mental health care in specific African regions to combat its growing effects on the African people. However, it was found that these new policies had little impact on the status of mental health in Africa, ultimately resulting in an incline in psychological disorders instead of the desired decline, and causing this to seem like an impossible problem to manage.
In Africa, many socio-cultural and biological factors have led to heightened psychological struggles, while also masking their immediate level of importance to the African eye. Increasing rates of unemployment, violence, crime, rape, and disease are often linked to substance abuse, which can cause mental illness rates to inflate. Additionally, physical disease like HIV/AIDS, the Ebola epidemic, and malaria often have lasting psychological effects on victims that go unrecognised in African communities because of their inherent cultural beliefs. Traditional African beliefs have led to the perception of mental illness as being caused by supernatural forces, preventing helpful or rational responses to abnormal behaviour. For example, Ebola received loads of media attention when it became rampant in Africa and eventually spread to the US, however, researchers never really paid attention to its psychological effects on the African brain. Extreme anxiety, struggles with grief, feelings of rejection and incompetence, depression leading to suicide, PTSD, and much more are only some of the noted effects of diseases like Ebola. These epidemics come and go, but their lasting effects on mental health are remaining for years to come, and even ending lives because of the lack of action. There has been some effort to financially fund psychiatric support in countries like Liberia, due to its dramatic mental health crisis after warfare, but not much was benefited. Aside from financial reasons, it is so difficult to enforce mental health interventions and manage mental health in general in underdeveloped countries simply because the individuals living there do not necessarily believe in western psychiatry. It is also important to note that the socio-cultural model of psychology and abnormal behaviour is dependent on factors surrounding cultural differences. This causes mental health abnormalities to remain more hidden due to the culture’s natural behaviour, compared to westernised behaviour and cultural norms.
This relationship between mental and physical illness is an ongoing cycle that has yet to be broken. While many organisations are attempting to solve problems about physical health in Africa, as these problems are clearly visible and recognisable, there is little action taken to confront the underlying mental effects that are left on the victims. It is recognised that many of the mentally ill in Africa search for help from spiritual or religious leaders, however this is widely because many African countries are significantly lacking in mental health professionals in comparison to the rest of the world. In Ethiopia alone, there are “only 10 psychiatrists for the population of 61 million people,” studies have shown. While numbers have definitely changed since this research was done, the lack of psychological professionals throughout African continues with a current average of 1.4 mental health workers per 100,000 people compared to the global statistic of 9.0 professionals per 100,00 people. Additionally, statistics show that the “global annual rate of visits to mental health outpatient facilities is 1,051 per 100,000 population,” while “in Africa the rate is 14 per 100,000” visits. About half of Africa’s countries have some sort of mental health policy, however, these policies are highly disregarded, as Africa’s government spends “less than 1% of the total health budget on mental health”. Specifically in Sierra Leone, about 98.8% of people suffering from mental disorders remain untreated, even after the building of a well below average psychiatric hospital, further demonstrating the need for intervention.
Not only has there been little hands-on action taken to combat mental health issues in Africa, but there has also been little research done on the topic to spread its awareness and prevent deaths. The Lancet Global Health acknowledges that there are well over 1,000 published articles covering physical health in Africa, but there are still less than 50 discussing mental health. And this pressing dilemma of prioritising physical health vs. mental health is only worsening as the continent’s population is substantially growing with research showing that “Between 2000 and 2015 the continent’s population grew by 49%, yet the number of years lost to disability as a result of mental and substance use disorders increased by 52%”. The number of deaths caused by mental instability is truly competing with those caused by physical diseases: “In 2015, 17.9 million years were lost to disability as a consequence of mental health problems. Such disorders were almost as important a cause of years lost to disability as were infectious and parasitic diseases, which accounted for 18.5 million years lost to disability,”. Mental health and physical health care, while they may seem separate, are very much connected, as these two factors determine life or death for humans. As new challenges surface and old challenges still haven’t been prioritised, Africa’s mental health care policies need significant improvement in order to provide its people with the appropriate health care they deserve, hopefully preventing this problem from expanding.
A survey conducted by Australian Bureau of Statistics in 2008 regarding adults with manageable to severe neurosis reveals almost half of the population had a mental disorder at some point of their life and one in five people had a sustained disorder in the preceding 12 months. In neurotic disorders, 14% of the population experienced anxiety and comorbidity disorders were next to common mental disorder with vulnerability to substance abuse and relapses. There were distinct gender differences in disposition to mental health illness. Women were found to have high rate of mental health disorders, and Men had higher propensity of risk for substance abuse. The SMHWB survey showed families that had low socioeconomic status and high dysfunctional patterns had a greater proportional risk for mental health disorders. A 2010 survey regarding adults with psychosis revealed 5 persons per 1,000 in the population seeks professional mental health services for psychotic disorders and the most common psychotic disorder was schizophrenia.
Mental health disorder is considered a major public health concern and it constitutes about 13% of the Global Burden of disease and severe mental health disease may reduce each individual’s life expectancy by about 20%. Low and middle-income countries have a higher burden of mental health disorder as it is not considered as a health problem as other chronic diseases. Being a low-income country, in Bangladesh, mental health issues are highly stigmatised.
A community-based study in the rural area of Bangladesh in 2000-2001 estimated that the burden of mental morbidity was 16.5% among rural people and most were suffering from mainly depression and anxiety and which was one-half and one-third of total cases respectively. Furthermore, the prevalence of mental disorders was higher in women in large families aged 45 years.
Care for mental health in Bangladesh
A study conducted in 2008 stated that only 16% of patients came directly to the Mental Health Practitioner with a mean delay of 10.5 months of the onset of mental illness, which made them more vulnerable in many ways. 22% of patients went for the religious or traditional healer and 12% consulted a rural medical practitioner with the least delay of 2-2.5 weeks.
According to statistics released by the Centre of Addiction and Mental Health one in five people in Canada experience a mental health or addiction problem. Young people of ages 15 to 25 are particularly found to be vulnerable. Major depression is found to affect 8% and anxiety disorder 12% of the population. Women are 1.5 times more likely to suffer from mood and anxiety disorders. WHO points out that there are distinct gender differences in patterns of mental health and illness. The lack of power and control over their socioeconomic status, gender based violence; low social position and responsibility for the care of others render women vulnerable to mental health risks. Since more women than men seek help regarding a mental health problem, this has led to not only gender stereotyping but also reinforcing social stigma. WHO has found that this stereotyping has led doctors to diagnose depression more often in women than in men even when they display identical symptoms. Often communication between health care providers and women is authoritarian leading to either the under-treatment or over-treatment of these women.
Women’s College Hospital has a program called the “Women’s Mental Health Program” where doctors and nurses help treat and educate women regarding mental health collaboratively, individually, and online by answering questions from the public.
Another Canadian organisation serving mental health needs is the Centre for Addiction and Mental Health (CAMH). CAMH is one of Canada’s largest and most well-known health and addiction facilities, and it has received international recognitions from the Pan American Health Organisation and WHO Collaborating Centre. They do research in areas of addiction and mental health in both men and women. In order to help both men and women, CAMH provides “clinical care, research, education, policy development and health promotion to help transform the lives of people affected by mental health and addiction issues.” CAMH is different from Women’s College Hospital due to its widely known rehab centre for women who have minor addiction issues, to severe ones. This organization provides care for mental health issues by assessments, interventions, residential programs, treatments, and doctor and family support.
In Israel, a Mental Health Insurance Reform took effect in July 2015, transferring responsibility for the provision of mental health services from the Ministry of Health to the four national health plans. Physical and mental health care were united under one roof; previously they had functioned separately in terms of finance, location, and provider. Under the reform, the health plans developed new services or expanded existing ones to address mental health problems.
According to the WHO in 2004, depression is the leading cause of disability in the United States for individuals ages 15 to 44. Absence from work in the US due to depression is estimated to be in excess of $31 billion per year. Depression frequently co-occurs with a variety of medical illnesses such as heart disease, cancer, and chronic pain and is associated with poorer health status and prognosis. Each year, roughly 30,000 Americans take their lives, while hundreds of thousands make suicide attempts. In 2004, suicide was the 11th leading cause of death in the United States, third among individuals ages 15-24. Despite the increasingly availability of effectual depression treatment, the level of unmet need for treatment remains high. By way of comparison, a study conducted in Australia during 2006 to 2007 reported that one-third (34.9%) of patients diagnosed with a mental health disorder had presented to medical health services for treatment. The US has a shortage of mental healthcare workers, contributing to the unmet need for treatment. By 2025, the US will need an additional 15,400 psychiatrists and 57,490 psychologists to meet the demand for treatment.
It is estimated that one in four people in the world will be affected by mental or neurological disorders at some point in their lives. Although many effective interventions for the treatment of mental disorders are known, and awareness of the need for treatment of people with mental disorders has risen, the proportion of those who need mental health care but who do not receive it remains very high. This so-called “treatment gap” is estimated to reach between 76-85% for low- and middle-income countries, and 35-50% for high-income countries.
Despite the acknowledged need, for the most part there have not been substantial changes in mental health care delivery during the past years. Main reasons for this problem are public health priorities, lack of a mental health policy and legislation in many countries, a lack of resources – financial and human resources – as well as inefficient resource allocation.
In 2011, the WHO estimated a shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries. The annual wage bill to remove this health workforce shortage was estimated at about US$4.4 billion.
Information and evidence about cost-effective interventions to provide better mental health care are available. Although most of the research (80%) has been carried out in high-income countries, there is also strong evidence from low- and middle-income countries that pharmacological and psychosocial interventions are effective ways to treat mental disorders, with the strongest evidence for depression, schizophrenia, bipolar disorder and hazardous alcohol use.
Recommendations to strengthen mental health systems around the world have been first mentioned in the WHO’s World Health Report 2001, which focused on mental health:
Provide treatment in primary care.
Make psychotropic drugs available.
Give care in the community.
Educate the public.
Involve communities, families and consumers.
Establish national policies, programs and legislation.
Develop human resources.
Link with other sectors.
Monitor community mental health.
Support more research.
Based on the data of 12 countries, assessed by the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), the costs of scaling up mental health services by providing a core treatment package for schizophrenia, bipolar affective disorder, depressive episodes and hazardous alcohol use have been estimated. Structural changes in mental health systems according to the WHO recommendations have been taken into account.
For most countries, this model suggests an initial period of investment of US$0.30 – 0.50 per person per year. The total expenditure on mental health would have to rise at least ten-fold in low-income countries. In those countries, additional financial resources will be needed, while in middle- and high-income countries the main challenge will be the reallocation of resources within the health system to provide better mental health service.
Prevention is beginning to appear in mental health strategies, including the 2004 WHO report “Prevention of Mental Disorders”, the 2008 EU “Pact for Mental Health” and the 2011 US National Prevention Strategy. NIMH or the National Institute of Mental Health has over 400 grants.
World Health Organisation (WHO)
Two of WHO’s core programmes for mental health are WHO MIND (Mental health improvements for Nations Development) and Mental Health Gap Action Programme (mhGAP).
WHO MIND focuses on 5 areas of action to ensure concrete changes in people’s daily lives. These are:
Action in and support to countries to improve mental health, such as the WHO Pacific Island Mental Health network (PIMHnet).
Mental health policy, planning and service development.
Mental health human rights and legislation.
Mental health as a core part of human development.
The QualityRights Project which works to unite and empower people to improve the quality of care and promote human rights in mental health facilities and social care homes.
Mental Health Gap Action Programme (mhGAP) is WHO’s action plan to scale up services for mental, neurological and substance use disorders for countries especially with low and lower middle incomes. The aim of mhGAP is to build partnerships for collective action and to reinforce the commitment of governments, international organisations and other stakeholders.
The mhGAP Intervention Guide (mhGAP-IG) was launched in October 2010. It is a technical tool for the management of mental, neurological and substance use disorders in non-specialist health settings. The priority conditions included are: depression, psychosis, bipolar disorders, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm/suicide and other significant emotional or medically unexplained complaints.
This book charts the creeping of psychology and psychiatry across the borders of everyday experience and across geographical borders, as a form of colonialism that comes from within and from outside, swallowed in the form of a pill. It maps an anxious space where socio-economic crises come to be reconfigured as individual crisis – as ‘mental illness’; and how potentially violent interventions come to be seen as ‘essential’ treatment.
Another prominent critic is Ethan Watters, author of Crazy Like Us: The Globalisation of the American Psyche. A more constructive approach is offered by Vincenzo Di Nicola whose article on the Global South as an emergent epistemology creates a bridge between critiques of globalisation and the initial gaps and limitations of the Global Mental Health movement.
Educational psychology is the branch of psychology concerned with the scientific study of human learning.
The study of learning processes, from both cognitive and behavioural perspectives, allows researchers to understand individual differences in intelligence, cognitive development, affect, motivation, self-regulation, and self-concept, as well as their role in learning. The field of educational psychology relies heavily on quantitative methods, including testing and measurement, to enhance educational activities related to instructional design, classroom management, and assessment, which serve to facilitate learning processes in various educational settings across the lifespan.
Educational psychology can in part be understood through its relationship with other disciplines. It is informed primarily by psychology, bearing a relationship to that discipline analogous to the relationship between medicine and biology. It is also informed by neuroscience. Educational psychology in turn informs a wide range of specialities within educational studies, including instructional design, educational technology, curriculum development, organizational learning, special education, classroom management, and student motivation. Educational psychology both draws from and contributes to cognitive science and the learning sciences. In universities, departments of educational psychology are usually housed within faculties of education, possibly accounting for the lack of representation of educational psychology content in introductory psychology textbooks.
The field of educational psychology involves the study of memory, conceptual processes, and individual differences (via cognitive psychology) in conceptualising new strategies for learning processes in humans. Educational psychology has been built upon theories of operant conditioning, functionalism, structuralism, constructivism, humanistic psychology, Gestalt psychology, and information processing.
Educational psychology has seen rapid growth and development as a profession in the last twenty years. School psychology began with the concept of intelligence testing leading to provisions for special education students, who could not follow the regular classroom curriculum in the early part of the 20th century. However, “school psychology” itself has built a fairly new profession based upon the practices and theories of several psychologists among many different fields. Educational psychologists are working side by side with psychiatrists, social workers, teachers, speech and language therapists, and counsellors in an attempt to understand the questions being raised when combining behavioural, cognitive, and social psychology in the classroom setting.
Educational psychology is a fairly new and growing field of study. Although it can date back as early as the days of Plato and Aristotle, educational psychology was not considered a specific practice. It was unknown that everyday teaching and learning in which individuals had to think about individual differences, assessment, development, the nature of a subject being taught, problem-solving, and transfer of learning was the beginning to the field of educational psychology. These topics are important to education and, as a result, they are important in understanding human cognition, learning, and social perception.
Plato and Aristotle
Educational psychology dates back to the time of Aristotle and Plato. Plato and Aristotle researched individual differences in the field of education, training of the body and the cultivation of psycho-motor skills, the formation of good character, the possibilities and limits of moral education. Some other educational topics they spoke about were the effects of music, poetry, and the other arts on the development of individual, role of teacher, and the relations between teacher and student. Plato saw knowledge acquisition as an innate ability, which evolves through experience and understanding of the world. This conception of human cognition has evolved into a continuing argument of nature vs. nurture in understanding conditioning and learning today. Aristotle observed the phenomenon of “association.” His four laws of association included succession, contiguity, similarity, and contrast. His studies examined recall and facilitated learning processes.
John Locke is considered one of the most influential philosophers in post-renaissance Europe, a time period that began around the mid-1600s. Locke is considered the “Father of English Psychology”. One of Locke’s most important works was written in 1690, named An Essay Concerning Human Understanding. In this essay, he introduced the term “tabula rasa” meaning “blank slate.” Locke explained that learning was attained through experience only and that we are all born without knowledge.
He followed by contrasting Plato’s theory of innate learning processes. Locke believed the mind was formed by experiences, not innate ideas. Locke introduced this idea as “empiricism,” or the understanding that knowledge is only built on knowledge and experience.
In the late 1600s, John Locke advanced the hypothesis that people learn primarily from external forces. He believed that the mind was like a blank tablet (tabula rasa), and that successions of simple impressions give rise to complex ideas through association and reflection. Locke is credited with establishing “empiricism” as a criterion for testing the validity of knowledge, thus providing a conceptual framework for later development of experimental methodology in the natural and social sciences.
Philosophers of education such as Juan Vives, Johann Pestalozzi, Friedrich Fröbel, and Johann Herbart had examined, classified and judged the methods of education centuries before the beginnings of psychology in the late 1800s.
Juan Vives (1493-1540) proposed induction as the method of study and believed in the direct observation and investigation of the study of nature. His studies focused on humanistic learning, which opposed scholasticism and was influenced by a variety of sources including philosophy, psychology, politics, religion, and history. He was one of the first prominent thinkers to emphasize that the location of a school is important to learning. He suggested that a school should be located away from disturbing noises; the air quality should be good and there should be plenty of food for the students and teachers. Vives emphasized the importance of understanding individual differences of the students and suggested practice as an important tool for learning.
Vives introduced his educational ideas in his writing, “De anima et vita” in 1538. In this publication, Vives explores moral philosophy as a setting for his educational ideals; with this, he explains that the different parts of the soul (similar to that of Aristotle’s ideas) are each responsible for different operations, which function distinctively. The first book covers the different “souls”: “The Vegetative Soul;” this is the soul of nutrition, growth, and reproduction, “The Sensitive Soul,” which involves the five external senses; “The Cogitative soul,” which includes internal senses and cognitive facilities. The second book involves functions of the rational soul: mind, will, and memory. Lastly, the third book explains the analysis of emotions.
Johann Pestalozzi (1746-1827), a Swiss educational reformer, emphasized the child rather than the content of the school. Pestalozzi fostered an educational reform backed by the idea that early education was crucial for children, and could be manageable for mothers. Eventually, this experience with early education would lead to a “wholesome person characterised by morality.” Pestalozzi has been acknowledged for opening institutions for education, writing books for mother’s teaching home education, and elementary books for students, mostly focusing on the kindergarten level. In his later years, he published teaching manuals and methods of teaching.
During the time of The Enlightenment, Pestalozzi’s ideals introduced “educationalisation”. This created the bridge between social issues and education by introducing the idea of social issues to be solved through education. Horlacher describes the most prominent example of this during The Enlightenment to be “improving agricultural production methods.”
Johann Herbart (1776-1841) is considered the father of educational psychology. He believed that learning was influenced by interest in the subject and the teacher. He thought that teachers should consider the students’ existing mental sets – what they already know – when presenting new information or material. Herbart came up with what are now known as the formal steps. The 5 steps that teachers should use are:
Review material that has already been learned by the student.
Prepare the student for new material by giving them an overview of what they are learning next.
Present the new material.
Relate the new material to the old material that has already been learned.
Show how the student can apply the new material and show the material they will learn next.
There were three major figures in educational psychology in this period: William James, G. Stanley Hall, and John Dewey. These three men distinguished themselves in general psychology and educational psychology, which overlapped significantly at the end of the 19th century.
William James (1842-1910)
The period of 1890-1920 is considered the golden era of educational psychology where aspirations of the new discipline rested on the application of the scientific methods of observation and experimentation to educational problems. From 1840 to 1920 37 million people immigrated to the United States. This created an expansion of elementary schools and secondary schools. The increase in immigration also provided educational psychologists the opportunity to use intelligence testing to screen immigrants at Ellis Island. Darwinism influenced the beliefs of the prominent educational psychologists. Even in the earliest years of the discipline, educational psychologists recognized the limitations of this new approach. The pioneering American psychologist William James commented that:
Psychology is a science, and teaching is an art; and sciences never generate arts directly out of themselves. An intermediate inventive mind must make that application, by using its originality”.
James is the father of psychology in America but he also made contributions to educational psychology. In his famous series of lectures Talks to Teachers on Psychology, published in 1899, James defines education as “the organization of acquired habits of conduct and tendencies to behavior”. He states that teachers should “train the pupil to behavior” so that he fits into the social and physical world. Teachers should also realise the importance of habit and instinct. They should present information that is clear and interesting and relate this new information and material to things the student already knows about. He also addresses important issues such as attention, memory, and association of ideas.
Alfred Binet published Mental Fatigue in 1898, in which he attempted to apply the experimental method to educational psychology. In this experimental method he advocated for two types of experiments, experiments done in the lab and experiments done in the classroom. In 1904 he was appointed the Minister of Public Education. This is when he began to look for a way to distinguish children with developmental disabilities. Binet strongly supported special education programs because he believed that “abnormality” could be cured. The Binet-Simon test was the first intelligence test and was the first to distinguish between “normal children” and those with developmental disabilities. Binet believed that it was important to study individual differences between age groups and children of the same age. He also believed that it was important for teachers to take into account individual students’ strengths and also the needs of the classroom as a whole when teaching and creating a good learning environment. He also believed that it was important to train teachers in observation so that they would be able to see individual differences among children and adjust the curriculum to the students. Binet also emphasized that practice of material was important. In 1916 Lewis Terman revised the Binet-Simon so that the average score was always 100. The test became known as the Stanford-Binet and was one of the most widely used tests of intelligence. Terman, unlike Binet, was interested in using intelligence test to identify gifted children who had high intelligence. In his longitudinal study of gifted children, who became known as the Termites, Terman found that gifted children become gifted adults.
Edward Thorndike (1874-1949) supported the scientific movement in education. He based teaching practices on empirical evidence and measurement. Thorndike developed the theory of instrumental conditioning or the law of effect. The law of effect states that associations are strengthened when it is followed by something pleasing and associations are weakened when followed by something not pleasing. He also found that learning is done a little at a time or in increments, learning is an automatic process and its principles apply to all mammals. Thorndike’s research with Robert Woodworth on the theory of transfer found that learning one subject will only influence your ability to learn another subject if the subjects are similar. This discovery led to less emphasis on learning the classics because they found that studying the classics does not contribute to overall general intelligence. Thorndike was one of the first to say that individual differences in cognitive tasks were due to how many stimulus-response patterns a person had rather than general intellectual ability. He contributed word dictionaries that were scientifically based to determine the words and definitions used. The dictionaries were the first to take into consideration the users’ maturity level. He also integrated pictures and easier pronunciation guide into each of the definitions. Thorndike contributed arithmetic books based on learning theory. He made all the problems more realistic and relevant to what was being studied, not just to improve the general intelligence. He developed tests that were standardized to measure performance in school-related subjects. His biggest contribution to testing was the CAVD intelligence test which used a multidimensional approach to intelligence and was the first to use a ratio scale. His later work was on programmed instruction, mastery learning, and computer-based learning:
If, by a miracle of mechanical ingenuity, a book could be so arranged that only to him who had done what was directed on page one would page two become visible, and so on, much that now requires personal instruction could be managed by print.
John Dewey (1859-1952) had a major influence on the development of progressive education in the United States. He believed that the classroom should prepare children to be good citizens and facilitate creative intelligence. He pushed for the creation of practical classes that could be applied outside of a school setting. He also thought that education should be student-oriented, not subject-oriented. For Dewey, education was a social experience that helped bring together generations of people. He stated that students learn by doing. He believed in an active mind that was able to be educated through observation, problem-solving, and enquiry. In his 1910 book How We Think, he emphasizes that material should be provided in a way that is stimulating and interesting to the student since it encourages original thought and problem-solving. He also stated that material should be relative to the student’s own experience.
“The material furnished by way of information should be relevant to a question that is vital in the students own experience”.
Jean Piaget (1896-1980) was one of the most powerful researchers in the area of developmental psychology during the 20th century. He developed the theory of cognitive development. The theory stated that intelligence developed in four different stages. The stages are the sensorimotor stage from birth to 2 years old, the preoperational state from 2 to 7 years old, the concrete operational stage from 7 to 10 years old, and the formal operational stage from 12 years old and up. He also believed that learning was constrained to the child’s cognitive development. Piaget influenced educational psychology because he was the first to believe that cognitive development was important and something that should be paid attention to in education. Most of the research on Piagetian theory was carried out by American educational psychologists.
The number of people receiving a high school and college education increased dramatically from 1920 to 1960. Because very few jobs were available to teens coming out of eighth grade, there was an increase in high school attendance in the 1930s. The progressive movement in the United States took off at this time and led to the idea of progressive education. John Flanagan, an educational psychologist, developed tests for combat trainees and instructions in combat training. In 1954 the work of Kenneth Clark and his wife on the effects of segregation on black and white children was influential in the Supreme Court case Brown v. Board of Education. From the 1960s to present day, educational psychology has switched from a behaviourist perspective to a more cognitive-based perspective because of the influence and development of cognitive psychology at this time.
Jerome Bruner is notable for integrating Piaget’s cognitive approaches into educational psychology. He advocated for discovery learning where teachers create a problem solving environment that allows the student to question, explore and experiment. In his book ‘The Process of Education’ Bruner stated that the structure of the material and the cognitive abilities of the person are important in learning. He emphasized the importance of the subject matter. He also believed that how the subject was structured was important for the student’s understanding of the subject and that it was the goal of the teacher to structure the subject in a way that was easy for the student to understand. In the early 1960s, Bruner went to Africa to teach math and science to school children, which influenced his view as schooling as a cultural institution. Bruner was also influential in the development of MACOS, Man: a Course of Study, which was an educational program that combined anthropology and science. The programme explored human evolution and social behaviour. He also helped with the development of the head start programme. He was interested in the influence of culture on education and looked at the impact of poverty on educational development.
Benjamin Bloom (1903-1999) spent over 50 years at the University of Chicago, where he worked in the department of education. He believed that all students can learn. He developed the taxonomy of educational objectives. The objectives were divided into three domains:
1. The cognitive domain deals with how we think. 2. It is divided into categories that are on a continuum from easiest to more complex. 3. The categories are knowledge or recall, comprehension, application, analysis, synthesis, and evaluation.
1. The affective domain deals with emotions and has 5 categories. 2. The categories are receiving phenomenon, responding to that phenomenon, valuing, organisation, and internalising values.
1. The psychomotor domain deals with the development of motor skills, movement, and coordination and has 7 categories that also go from simplest to most complex. 2. The 7 categories of the psychomotor domain are perception, set, guided response, mechanism, complex overt response, adaptation, and origination.
The taxonomy provided broad educational objectives that could be used to help expand the curriculum to match the ideas in the taxonomy. The taxonomy is considered to have a greater influence internationally than in the United States. Internationally, the taxonomy is used in every aspect of education from the training of the teachers to the development of testing material. Bloom believed in communicating clear learning goals and promoting an active student. He thought that teachers should provide feedback to the students on their strengths and weaknesses. Bloom also did research on college students and their problem-solving processes. He found that they differ in understanding the basis of the problem and the ideas in the problem. He also found that students differ in process of problem-solving in their approach and attitude toward the problem.
Nathaniel Gage (1917-2008) is an important figure in educational psychology as his research focused on improving teaching and understanding the processes involved in teaching. He edited the book Handbook of Research on Teaching (1963), which helped develop early research in teaching and educational psychology. Gage founded the Stanford Centre for Research and Development in Teaching, which contributed research on teaching as well as influencing the education of important educational psychologists.
Applied behaviour analysis, a research-based science utilising behavioural principles of operant conditioning, is effective in a range of educational settings. For example, teachers can alter student behaviour by systematically rewarding students who follow classroom rules with praise, stars, or tokens exchangeable for sundry items. Despite the demonstrated efficacy of awards in changing behaviour, their use in education has been criticised by proponents of self-determination theory, who claim that praise and other rewards undermine intrinsic motivation. There is evidence that tangible rewards decrease intrinsic motivation in specific situations, such as when the student already has a high level of intrinsic motivation to perform the goal behaviour. But the results showing detrimental effects are counterbalanced by evidence that, in other situations, such as when rewards are given for attaining a gradually increasing standard of performance, rewards enhance intrinsic motivation. Many effective therapies have been based on the principles of applied behaviour analysis, including pivotal response therapy which is used to treat autism spectrum disorders.
Among current educational psychologists, the cognitive perspective is more widely held than the behavioural perspective, perhaps because it admits causally related mental constructs such as traits, beliefs, memories, motivations, and emotions. Cognitive theories claim that memory structures determine how information is perceived, processed, stored, retrieved and forgotten. Among the memory structures theorised by cognitive psychologists are separate but linked visual and verbal systems described by Allan Paivio’s dual coding theory. Educational psychologists have used dual coding theory and cognitive load theory to explain how people learn from multimedia presentations.
The spaced learning effect, a cognitive phenomenon strongly supported by psychological research, has broad applicability within education. For example, students have been found to perform better on a test of knowledge about a text passage when a second reading of the passage is delayed rather than immediate. Educational psychology research has confirmed the applicability to the education of other findings from cognitive psychology, such as the benefits of using mnemonics for immediate and delayed retention of information.
Problem solving, according to prominent cognitive psychologists, is fundamental to learning. It resides as an important research topic in educational psychology. A student is thought to interpret a problem by assigning it to a schema retrieved from long-term memory. A problem students run into while reading is called “activation.” This is when the student’s representations of the text are present during working memory. This causes the student to read through the material without absorbing the information and being able to retain it. When working memory is absent from the reader’s representations of the working memory they experience something called “deactivation.” When deactivation occurs, the student has an understanding of the material and is able to retain information. If deactivation occurs during the first reading, the reader does not need to undergo deactivation in the second reading. The reader will only need to reread to get a “gist” of the text to spark their memory. When the problem is assigned to the wrong schema, the student’s attention is subsequently directed away from features of the problem that are inconsistent with the assigned schema. The critical step of finding a mapping between the problem and a pre-existing schema is often cited as supporting the centrality of analogical thinking to problem-solving.
Cognitive View of Intelligence
Each person has an individual profile of characteristics, abilities, and challenges that result from predisposition, learning, and development. These manifest as individual differences in intelligence, creativity, cognitive style, motivation, and the capacity to process information, communicate, and relate to others. The most prevalent disabilities found among school age children are attention deficit hyperactivity disorder (ADHD), learning disability, dyslexia, and speech disorder. Less common disabilities include intellectual disability, hearing impairment, cerebral palsy, epilepsy, and blindness.
Although theories of intelligence have been discussed by philosophers since Plato, intelligence testing is an invention of educational psychology, and is coincident with the development of that discipline. Continuing debates about the nature of intelligence revolve on whether it can be characterized by a single factor known as general intelligence, multiple factors (e.g. Gardner’s theory of multiple intelligences), or whether it can be measured at all. In practice, standardised instruments such as the Stanford-Binet IQ test and the WISC are widely used in economically developed countries to identify children in need of individualised educational treatment. Children classified as gifted are often provided with accelerated or enriched programs. Children with identified deficits may be provided with enhanced education in specific skills such as phonological awareness. In addition to basic abilities, the individual’s personality traits are also important, with people higher in conscientiousness and hope attaining superior academic achievements, even after controlling for intelligence and past performance.
Developmental psychology, and especially the psychology of cognitive development, opens a special perspective for educational psychology. This is so because education and the psychology of cognitive development converge on a number of crucial assumptions. First, the psychology of cognitive development defines human cognitive competence at successive phases of development. Education aims to help students acquire knowledge and develop skills that are compatible with their understanding and problem-solving capabilities at different ages. Thus, knowing the students’ level on a developmental sequence provides information on the kind and level of knowledge they can assimilate, which, in turn, can be used as a frame for organising the subject matter to be taught at different school grades. This is the reason why Piaget’s theory of cognitive development was so influential for education, especially mathematics and science education. In the same direction, the neo-Piagetian theories of cognitive development suggest that in addition to the concerns above, sequencing of concepts and skills in teaching must take account of the processing and working memory capacities that characterise successive age levels.
Second, the psychology of cognitive development involves understanding how cognitive change takes place and recognising the factors and processes which enable cognitive competence to develop. Education also capitalises on cognitive change, because the construction of knowledge presupposes effective teaching methods that would move the student from a lower to a higher level of understanding. Mechanisms such as reflection on actual or mental actions vis-à-vis alternative solutions to problems, tagging new concepts or solutions to symbols that help one recall and mentally manipulate them are just a few examples of how mechanisms of cognitive development may be used to facilitate learning.
Finally, the psychology of cognitive development is concerned with individual differences in the organization of cognitive processes and abilities, in their rate of change, and in their mechanisms of change. The principles underlying intra- and inter-individual differences could be educationally useful, because knowing how students differ in regard to the various dimensions of cognitive development, such as processing and representational capacity, self-understanding and self-regulation, and the various domains of understanding, such as mathematical, scientific, or verbal abilities, would enable the teacher to cater for the needs of the different students so that no one is left behind.
Constructivism is a category of learning theory in which emphasis is placed on the agency and prior “knowing” and experience of the learner, and often on the social and cultural determinants of the learning process. Educational psychologists distinguish individual (or psychological) constructivism, identified with Piaget’s theory of cognitive development, from social constructivism. The social constructivist paradigm views the context in which the learning occurs as central to the learning itself. It regards learning as a process of enculturation. People learn by exposure to the culture of practitioners. They observe and practice the behaviour of practitioners and ‘pick up relevant jargon, imitate behaviour, and gradually start to act in accordance with the norms of the practice’. So, a student learns to become a mathematician through exposure to mathematician using tools to solve mathematical problems. So in order to master a particular domain of knowledge it is not enough for students to learn the concepts of the domain. They should be exposed to the use of the concepts in authentic activities by the practitioners of the domain.
A dominant influence on the social constructivist paradigm is Lev Vygotsky’s work on sociocultural learning, describing how interactions with adults, more capable peers, and cognitive tools are internalized to form mental constructs. “Zone of Proximal Development” (ZPD) is a term Vygotsky used to characterize an individual’s mental development. He believed the task individuals can do on their own do not give a complete understanding of their mental development. He originally defined the ZPD as “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers.” He cited a famous example to make his case. Two children in school who originally can solve problems at an eight-year-old developmental level (that is, typical for children who were age 8), might be at different developmental levels. If each child received assistance from an adult, one was able to perform at a nine-year-old level and one was able to perform at a twelve-year-old level. He said “This difference between twelve and eight, or between nine and eight, is what we call the zone of proximal development.” He further said that the ZPD “defines those functions that have not yet matured but are in the process of maturation, functions that will mature tomorrow but are currently in an embryonic state.” The zone is bracketed by the learner’s current ability and the ability they can achieve with the aid of an instructor of some capacity.
Vygotsky viewed the ZPD as a better way to explain the relation between children’s learning and cognitive development. Prior to the ZPD, the relation between learning and development could be boiled down to the following three major positions:
Development always precedes learning (e.g. constructivism): children first need to meet a particular maturation level before learning can occur;
Learning and development cannot be separated, but instead occur simultaneously (e.g. behaviourism): essentially, learning is development; and
Learning and development are separate, but interactive processes (e.g. gestaltism): one process always prepares the other process, and vice versa.
Vygotsky rejected these three major theories because he believed that learning should always precede development in the ZPD. According to Vygotsky, through the assistance of a more knowledgeable other, a child is able to learn skills or aspects of a skill that go beyond the child’s actual developmental or maturational level. The lower limit of ZPD is the level of skill reached by the child working independently (also referred to as the child’s developmental level). The upper limit is the level of potential skill that the child is able to reach with the assistance of a more capable instructor. In this sense, the ZPD provides a prospective view of cognitive development, as opposed to a retrospective view that characterises development in terms of a child’s independent capabilities. The advancement through and attainment of the upper limit of the ZPD is limited by the instructional and scaffolding-related capabilities of the more knowledgeable other (MKO). The MKO is typically assumed to be an older, more experienced teacher or parent, but often can be a learner’s peer or someone their junior. The MKO need not even be a person, it can be a machine or book, or other source of visual and/or audio input.
Elaborating on Vygotsky’s theory, Jerome Bruner and other educational psychologists developed the important concept of instructional scaffolding, in which the social or information environment offers supports for learning that are gradually withdrawn as they become internalised.
Jean Piaget’s Cognitive Development
Jean Piaget was interested in how an organism adapts to its environment. Piaget hypothesized that infants are born with a schema operating at birth that he called “reflexes”. Piaget identified four stages in cognitive development. The four stages are:
Concrete operational stage; and
Formal operational stage.
Conditioning and learning
To understand the characteristics of learners in childhood, adolescence, adulthood, and old age, educational psychology develops and applies theories of human development. Often represented as stages through which people pass as they mature, developmental theories describe changes in mental abilities (cognition), social roles, moral reasoning, and beliefs about the nature of knowledge.
For example, educational psychologists have conducted research on the instructional applicability of Jean Piaget’s theory of development, according to which children mature through four stages of cognitive capability. Piaget hypothesized that children are not capable of abstract logical thought until they are older than about 11 years, and therefore younger children need to be taught using concrete objects and examples. Researchers have found that transitions, such as from concrete to abstract logical thought, do not occur at the same time in all domains. A child may be able to think abstractly about mathematics, but remain limited to concrete thought when reasoning about human relationships. Perhaps Piaget’s most enduring contribution is his insight that people actively construct their understanding through a self-regulatory process.
Piaget proposed a developmental theory of moral reasoning in which children progress from a naïve understanding of morality based on behaviour and outcomes to a more advanced understanding based on intentions. Piaget’s views of moral development were elaborated by Lawrence Kohlberg into a stage theory of moral development. There is evidence that the moral reasoning described in stage theories is not sufficient to account for moral behaviour. For example, other factors such as modelling (as described by the social cognitive theory of morality) are required to explain bullying.
Rudolf Steiner’s model of child development interrelates physical, emotional, cognitive, and moral development in developmental stages similar to those later described by Piaget.
Developmental theories are sometimes presented not as shifts between qualitatively different stages, but as gradual increments on separate dimensions. Development of epistemological beliefs (beliefs about knowledge) have been described in terms of gradual changes in people’s belief in: certainty and permanence of knowledge, fixedness of ability, and credibility of authorities such as teachers and experts. People develop more sophisticated beliefs about knowledge as they gain in education and maturity.
Motivation is an internal state that activates, guides and sustains behaviour. Motivation can have several impacting effects on how students learn and how they behave towards subject matter:
Provide direction towards goals.
Enhance cognitive processing abilities and performance.
Direct behaviour toward particular goals.
Lead to increased effort and energy.
Increase initiation of and persistence in activities.
Educational psychology research on motivation is concerned with the volition or will that students bring to a task, their level of interest and intrinsic motivation, the personally held goals that guide their behaviour, and their belief about the causes of their success or failure. As intrinsic motivation deals with activities that act as their own rewards, extrinsic motivation deals with motivations that are brought on by consequences or punishments. A form of attribution theory developed by Bernard Weiner describes how students’ beliefs about the causes of academic success or failure affect their emotions and motivations. For example, when students attribute failure to lack of ability, and ability is perceived as uncontrollable, they experience the emotions of shame and embarrassment and consequently decrease effort and show poorer performance. In contrast, when students attribute failure to lack of effort, and effort is perceived as controllable, they experience the emotion of guilt and consequently increase effort and show improved performance.
The self-determination theory (SDT) was developed by psychologists Edward Deci and Richard Ryan. SDT focuses on the importance of intrinsic and extrinsic motivation in driving human behaviour and posits inherent growth and development tendencies. It emphasizes the degree to which an individual’s behaviour is self-motivated and self-determined. When applied to the realm of education, the self-determination theory is concerned primarily with promoting in students an interest in learning, a value of education, and a confidence in their own capacities and attributes.
Motivational theories also explain how learners’ goals affect the way they engage with academic tasks. Those who have mastery goals strive to increase their ability and knowledge. Those who have performance approach goals strive for high grades and seek opportunities to demonstrate their abilities. Those who have performance avoidance goals are driven by fear of failure and avoid situations where their abilities are exposed. Research has found that mastery goals are associated with many positive outcomes such as persistence in the face of failure, preference for challenging tasks, creativity, and intrinsic motivation. Performance avoidance goals are associated with negative outcomes such as poor concentration while studying, disorganised studying, less self-regulation, shallow information processing, and test anxiety. Performance approach goals are associated with positive outcomes, and some negative outcomes such as an unwillingness to seek help and shallow information processing.
Locus of control is a salient factor in the successful academic performance of students. During the 1970s and ’80s, Cassandra B. Whyte did significant educational research studying locus of control as related to the academic achievement of students pursuing higher education coursework. Much of her educational research and publications focused upon the theories of Julian B. Rotter in regard to the importance of internal control and successful academic performance. Whyte reported that individuals who perceive and believe that their hard work may lead to more successful academic outcomes, instead of depending on luck or fate, persist and achieve academically at a higher level. Therefore, it is important to provide education and counselling in this regard.
Instructional design, the systematic design of materials, activities, and interactive environments for learning, is broadly informed by educational psychology theories and research. For example, in defining learning goals or objectives, instructional designers often use a taxonomy of educational objectives created by Benjamin Bloom and colleagues. Bloom also researched mastery learning, an instructional strategy in which learners only advance to a new learning objective after they have mastered its prerequisite objectives. Bloom discovered that a combination of mastery learning with one-to-one tutoring is highly effective, producing learning outcomes far exceeding those normally achieved in classroom instruction. Gagné, another psychologist, had earlier developed an influential method of task analysis in which a terminal learning goal is expanded into a hierarchy of learning objectives connected by prerequisite relationships. The following list of technological resources incorporate computer-aided instruction and intelligence for educational psychologists and their students:
Intelligent tutoring system.
Computer-supported collaborative learning.
Technology is essential to the field of educational psychology, not only for the psychologist themselves as far as testing, organisation, and resources, but also for students. Educational Psychologists who reside in the K-12 setting focus the majority of their time on Special Education students. It has been found that students with disabilities learning through technology such as iPad applications and videos are more engaged and motivated to learn in the classroom setting. Liu et al. explain that learning-based technology allows for students to be more focused, and learning is more efficient with learning technologies. The authors explain that learning technology also allows for students with social-emotional disabilities to participate in distance learning.
Research on classroom management and pedagogy is conducted to guide teaching practice and form a foundation for teacher education programmes. The goals of classroom management are to create an environment conducive to learning and to develop students’ self-management skills. More specifically, classroom management strives to create positive teacher-student and peer relationships, manage student groups to sustain on-task behaviour, and use counselling and other psychological methods to aid students who present persistent psycho-social problems.
Introductory educational psychology is a commonly required area of study in most North American teacher education programmes. When taught in that context, its content varies, but it typically emphasizes learning theories (especially cognitively oriented ones), issues about motivation, assessment of students’ learning, and classroom management. A developing Wikibook about educational psychology gives more detail about the educational psychology topics that are typically presented in preservice teacher education.
In order to become an educational psychologist, students can complete an undergraduate degree in their choice. They then must go to graduate school to study education psychology, counselling psychology, and/ or school counselling. Most students today are also receiving their doctorate degrees in order to hold the “psychologist” title. Educational psychologists work in a variety of settings. Some work in university settings where they carry out research on the cognitive and social processes of human development, learning and education. Educational psychologists may also work as consultants in designing and creating educational materials, classroom programmes and online courses. Educational psychologists who work in k–12 school settings (closely related are school psychologists in the US and Canada) are trained at the master’s and doctoral levels. In addition to conducting assessments, school psychologists provide services such as academic and behavioural intervention, counselling, teacher consultation, and crisis intervention. However, school psychologists are generally more individual-oriented towards students.
Many high schools and colleges are increasingly offering educational psychology courses, with some colleges offering it as a general education requirement. Similarly, colleges offer students opportunities to obtain a PhD. in Educational Psychology.
Within the UK, students must hold a degree that is accredited by the British Psychological Society (either undergraduate or at Masters level) before applying for a three-year doctoral course that involves further education, placement, and a research thesis.
Anticipated to grow by 18-26%, employment for psychologists in the United States is expected to grow faster than most occupations in 2014. One in four psychologists is employed in educational settings. In the United States, the median salary for psychologists in primary and secondary schools is US$58,360 as of May 2004.
In recent decades, the participation of women as professional researchers in North American educational psychology has risen dramatically.
Methods of Research
Educational psychology, as much as any other field of psychology heavily relies on a balance of pure observation and quantitative methods in psychology. The study of education generally combines the studies of history, sociology, and ethics with theoretical approaches. Smeyers and Depaepe explain that historically, the study of education and child-rearing have been associated with the interests of policymakers and practitioners within the educational field, however, the recent shift to sociology and psychology has opened the door for new findings in education as a social science. Now being its own academic discipline, educational psychology has proven to be helpful for social science researchers.
Quantitative research is the backing to most observable phenomena in psychology. This involves observing, creating, and understanding distribution of data based upon the study’s subject matter. Researchers use particular variables to interpret their data distributions from their research and employ statistics as a way of creating data tables and analysing their data. Psychology has moved from the “common sense” reputations initially posed by Thomas Reid to the methodology approach comparing independent and dependent variables through natural observation, experiments, or combinations of the two. Though results are still, with statistical methods, objectively true based upon significance variables or p- values.
Reduced affect should be distinguished from apathy and anhedonia, which explicitly refer to a lack of emotion, whereas reduced affect is a lack of emotional expression (affect display) regardless of whether emotion (underlying affect) is actually reduced or not.
A restricted or constricted affect is a reduction in an individual’s expressive range and the intensity of emotional responses.
Blunted and Flat Affect
Blunted affect is a lack of affect more severe than restricted or constricted affect, but less severe than flat or flattened affect. “The difference between flat and blunted affect is in degree. A person with flat affect has no or nearly no emotional expression. He or she may not react at all to circumstances that usually evoke strong emotions in others. A person with blunted affect, on the other hand, has a significantly reduced intensity in emotional expression”.
Shallow affect has equivalent meaning to blunted affect. Factor 1 of the Psychopathy Checklist identifies shallow affect as a common attribute of psychopathy.
Individuals with schizophrenia with blunted affect show different regional brain activity in fMRI scans when presented with emotional stimuli compared to individuals with schizophrenia without blunted affect. Individuals with schizophrenia without blunted affect show activation in the following brain areas when shown emotionally negative pictures: midbrain, pons, anterior cingulate cortex, insula, ventrolateral orbitofrontal cortex, anterior temporal pole, amygdala, medial prefrontal cortex, and extrastriate visual cortex. Individuals with schizophrenia with blunted affect show activation in the following brain regions when shown emotionally negative pictures: midbrain, pons, anterior temporal pole, and extrastriate visual cortex.
Individuals with schizophrenia with flat affect show decreased activation in the limbic system when viewing emotional stimuli. In individuals with schizophrenia with blunted affect neural processes begin in the occipitotemporal region of the brain and go through the ventral visual pathway and the limbic structures until they reach the inferior frontal areas. Damage to the amygdala of adult rhesus macaques early in life can permanently alter affective processing. Lesioning the amygdala causes blunted affect responses to both positive and negative stimuli. This effect is irreversible in the rhesus macaques; neonatal damage produces the same effect as damage that occurs later in life. The macaques’ brain cannot compensate for early amygdala damage even though significant neuronal growth may occur. There is some evidence that blunted affect symptoms in schizophrenia patients are not a result of just amygdala responsiveness, but a result of the amygdala not being integrated with other areas of the brain associated with emotional processing, particularly in amygdala-prefrontal cortex coupling. Damage in the limbic region prevents the amygdala from correctly interpreting emotional stimuli in individuals with schizophrenia by compromising the link between the amygdala and other brain regions associated with emotion.
Parts of the brainstem are responsible for passive emotional coping strategies that are characterized by disengagement or withdrawal from the external environment (quiescence, immobility, hyporeactivity), similar to what is seen in blunted affect. Individuals with schizophrenia with blunted affect show activation of the brainstem during fMRI scans, particularly the right medulla and the left pons, when shown “sad” film excerpts. The bilateral midbrain is also activated in individuals with schizophrenia diagnosed with blunted affect. Activation of the midbrain is thought to be related to autonomic responses associated with perceptual processing of emotional stimuli. This region usually becomes activated in diverse emotional states. When the connectivity between the midbrain and the medial prefrontal cortex is compromised in individuals with schizophrenia with blunted affect an absence of emotional reaction to external stimuli results.
Individuals with schizophrenia, as well as patients being successfully reconditioned with quetiapine for blunted affect, show activation of the prefrontal cortex (PFC). Failure to activate the PFC is possibly involved in impaired emotional processing in individuals with schizophrenia with blunted affect. The mesial PFC is activated in aver individuals in response to external emotional stimuli. This structure possibly receives information from the limbic structures to regulate emotional experiences and behaviour. Individuals being reconditioned with quetiapine, who show reduced symptoms, show activation in other areas of the PFC as well, including the right medial prefrontal gyrus and the left orbitofrontal gyrus.
Anterior Cingulate Cortex
A positive correlation has been found between activation of the anterior cingulate cortex and the reported magnitude of sad feelings evoked by viewing sad film excerpts. The rostral subdivision of this region is possibly involved in detecting emotional signals. This region is different in individuals with schizophrenia with blunted affect.
Patients with schizophrenia have long been recognized as showing “flat or inappropriate affect, with splitting of feelings from events … feelings seem flat instead of being in contact with what is going on”. One study of flat affect in schizophrenia found that “flat affect was more common in men, and was associated with worse current quality of life” as well as having “an adverse effect on course of illness”.
The study also reported a “dissociation between reported experience of emotion and its display” – supporting the suggestion made elsewhere that “blunted affect, including flattened facial expressiveness and lack of vocal inflection … often disguises an individual’s true feelings.” Thus, feelings may merely be unexpressed, rather than totally lacking. On the other hand, “a lack of emotions which is due not to mere repression but to a real loss of contact with the objective world gives the observer a specific impression of ‘queerness’ … the remainders of emotions or the substitutes for emotions usually refer to rage and aggressiveness”. In the most extreme cases, there is a complete “dissociation from affective states”.
Another study found that when speaking, individuals with schizophrenia with flat affect demonstrate less inflection than normal controls and appear to be less fluent. Normal subjects appear to express themselves using more complex syntax, whereas flat affect subjects speak with fewer words, and fewer words per sentence. Flat affect individuals’ use of context-appropriate words in both sad and happy narratives are similar to that of controls. It is very likely that flat affect is a result of deficits in motor expression as opposed to emotional processing. The moods of display are compromised, but subjective, autonomic, and contextual aspects of emotion are left intact.
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) was previously known to cause negative feelings, such as depressed mood, re-experiencing and hyperarousal. However, recently, psychologists have started to focus their attention on the blunted affects and also the decrease in feeling and expressing positive emotions in PTSD patients. Blunted affect, or emotional numbness, is considered one of the consequences of PTSD because it causes a diminished interest in activities that produce pleasure (anhedonia) and produces feelings of detachment from others, restricted emotional expression and a reduced tendency to express emotions behaviourally. Blunted affect is often seen in veterans as a consequence of the psychological stressful experiences that caused PTSD. Blunted affect is a response to PTSD, it is considered one of the central symptoms in post-traumatic stress disorders and it is often seen in veterans who served in combat zones. In PTSD, blunted affect can be considered a psychological response to PTSD as a way to combat overwhelming anxiety that the patients feel. In blunted affect, there are abnormalities in circuits that also include the prefrontal cortex.
In making assessments of mood and affect the clinician is cautioned that “it is important to keep in mind that demonstrative expression can be influenced by cultural differences, medication, or situational factors”; while the layperson is warned to beware of applying the criterion lightly to “friends, otherwise [he or she] is likely to make false judgments, in view of the prevalence of schizoid and cyclothymic personalities in our ‘normal’ population, and our [US] tendency to psychological hypochondriasis”.
R.D. Laing in particular stressed that “such ‘clinical’ categories as schizoid, autistic, ‘impoverished’ affect … all presuppose that there are reliable, valid impersonal criteria for making attributions about the other person’s relation to [his or her] actions. There are no such reliable or valid criteria”.
Blunted affect is very similar to anhedonia, which is the decrease or cessation of all feelings of pleasure (which thus affects enjoyment, happiness, fun, interest, and satisfaction). In the case of anhedonia, emotions relating to pleasure will not be expressed as much or at all because they are literally not experienced or are decreased. Both blunted affect and anhedonia are considered negative symptoms of schizophrenia, meaning that they are indicative of a lack of something. There are some other negative symptoms of schizophrenia which include avolition, alogia and catatonic behaviour.
Closely related is alexithymia – a condition describing people who “lack words for their feelings. They seem to lack feelings altogether, although this may actually be because of their inability to express emotion rather than from an absence of emotion altogether”. Alexithymic patients however can provide clues via assessment presentation which may be indicative of emotional arousal.
“If the amygdala is severed from the rest of the brain, the result is a striking inability to gauge the emotional significance of events; this condition is sometimes called ‘affective blindness'”. In some cases, blunted affect can fade, but there is no conclusive evidence of why this can occur.
Affect displays are the verbal and non-verbal displays of affect (emotion).
These displays can be through facial expressions, gestures and body language, volume and tone of voice, laughing, crying, etc. Affect displays can be altered or faked so one may appear one way, when they feel another (i.e. smiling when sad). Affect can be conscious or non-conscious and can be discreet or obvious. The display of positive emotions, such as smiling, laughing, etc., is termed “positive affect”, while the displays of more negative emotions, such as crying and tense gestures, is respectively termed “negative affect”.
Affect is important in psychology as well as in communication, mostly when it comes to interpersonal communication and non-verbal communication. In both psychology and communication, there are a multitude of theories that explain affect and its impact on humans and quality of life.
Affect can be taken to indicate an instinctual reaction to stimulation occurring before the typical cognitive processes considered necessary for the formation of a more complex emotion. Robert B. Zajonc asserts that this reaction to stimuli is primary for human beings and is the dominant reaction for lower organisms. Zajonc suggests affective reactions can occur without extensive perceptual and cognitive encoding, and can be made sooner and with greater confidence than cognitive judgments.
Lazarus on the other hand considers affect to be post-cognitive. That is, affect is elicited only after a certain amount of cognitive processing of information has been accomplished. In this view, an affective reaction, such as liking, disliking, evaluation, or the experience of pleasure or displeasure, is based on a prior cognitive process in which a variety of content discriminations are made and features are identified, examined for their value, and weighted for their contributions.
A divergence from a narrow reinforcement model for emotion allows for other perspectives on how affect influences emotional development. Thus, temperament, cognitive development, socialization patterns, and the idiosyncrasies of one’s family or subculture are mutually interactive in non-linear ways. As an example, the temperament of a highly reactive, low self-soothing infant may “disproportionately” affect the process of emotion regulation in the early months of life.
Non-Conscious Affect and Perception
In relation to perception, a type of non-conscious affect may be separate from the cognitive processing of environmental stimuli. A monohierarchy of perception, affect and cognition considers the roles of arousal, attentional tendencies, affective primacy, evolutionary constraints, and covert perception within the sensing and processing of preferences and discrimination. Emotions are complex chains of events triggered by certain stimuli. There is no way to completely describe an emotion by knowing only some of its components. Verbal reports of feelings are often inaccurate because people may not know exactly what they feel, or they may feel several different emotions at the same time. There are also situations that arise in which individuals attempt to hide their feelings, and there are some who believe that public and private events seldom coincide exactly, and that words for feelings are generally more ambiguous than are words for objects or events.
Affective responses, on the other hand, are more basic and may be less problematic in terms of assessment. Brewin has proposed two experiential processes that frame non-cognitive relations between various affective experiences: those that are prewired dispositions (i.e., non-conscious processes), able to “select from the total stimulus array those stimuli that are casually relevant, using such criteria as perceptual salience, spatiotemporal cues, and predictive value in relation to data stored in memory”, and those that are automatic (i.e. subconscious processes), characterized as “rapid, relatively inflexible and difficult to modify… (requiring) minimal attention to occur and… (capable of being) activated without intention or awareness”.
Arousal is a basic physiological response to the presentation of stimuli. When this occurs, a non-conscious affective process takes the form of two control mechanisms; one mobilisation, and the other immobilisation. Within the human brain, the amygdala regulates an instinctual reaction initiating this arousal process, either freezing the individual or accelerating mobilisation.
The arousal response is illustrated in studies focused on reward systems that control food-seeking behaviour. Researchers focused on learning processes and modulatory processes that are present while encoding and retrieving goal values. When an organism seeks food, the anticipation of reward based on environmental events becomes another influence on food seeking that is separate from the reward of food itself. Therefore, earning the reward and anticipating the reward are separate processes and both create an excitatory influence of reward-related cues. Both processes are dissociated at the level of the amygdala and are functionally integrated within larger neural systems.
Affect and Mood
Mood, like emotion, is an affective state. However, an emotion tends to have a clear focus (i.e., a self-evident cause), while mood tends to be more unfocused and diffused. Mood, according to Batson, Shaw, and Oleson (1992), involves tone and intensity and a structured set of beliefs about general expectations of a future experience of pleasure or pain, or of positive or negative affect in the future. Unlike instant reactions that produce affect or emotion, and that change with expectations of future pleasure or pain, moods, being diffused and unfocused, and thus harder to cope with, can last for days, weeks, months, or even years. Moods are hypothetical constructs depicting an individual’s emotional state. Researchers typically infer the existence of moods from a variety of behavioural referents.
Positive affect and negative affect represent independent domains of emotion in the general population, and positive affect is strongly linked to social interaction. Positive and negative daily events show independent relationships to subjective well-being, and positive affect is strongly linked to social activity. Recent research suggests that “high functional support is related to higher levels of positive affect”. The exact process through which social support is linked to positive affect remains unclear. The process could derive from predictable, regularized social interaction, from leisure activities where the focus is on relaxation and positive mood, or from the enjoyment of shared activities.
Research has indicated many differences in affective displays due to gender. Gender, as opposed to sex, is one’s self-perception of being masculine or feminine (i.e. a male can perceive himself to be more feminine or a female can perceive herself to be more masculine). It can also be argued, however, that hormones (typically determined by sex) greatly affect affective displays and mood.
Affect and Child Development
According to studies done in the late ’80s and early ’90s, infants within their first year of life are not only able to begin recognising affect displays but can begin mimicking the displays and also begin developing empathy. A study in 2011 followed up on these earlier studies by testing fifteen 6-12 month old infants’ arousal, via pupil dilation, when looking at both positive and negative displays. Results showed that when presented with negative affect, an infant’s pupil will dilate and stay dilated for a longer period of time when compared to neutral affect. When presented with positive affect however, the pupil dilation is much larger, but stays dilated for shorter amount of time. While this study does not prove an infant’s ability to empathise with others, it does show that infants do recognise and acknowledge both positive and negative displays of emotion.
In the early 2000s over the period of about seven years, a study was done on about 200 children whose mother had “a history of juvenile-onset unipolar depressive disorder” or simply, depression as children themselves. In the cases of unipolar depression, a person generally displays more negative affect and less positive affect than a person without depression. Or, they are more likely to show when they are sad or upset, than when they are excited or happy. This study that was published in 2010 discovered that the children of mothers that suffer from unipolar depression, had lower levels of positive affect when compared to the control group. Even as the children grew older, while the negative affect began to stay the same, the children still showed consistently lower positive affect. This study suggests that “Reduced PA [positive affect] may be one source of developmental vulnerability to familial depression…” meaning that while having family with depression, increases the risk of children developing depression, reduced positive affect increases the risk of this development. But knowing this aspect of depression, might also be able to help prevent the onset of depression in young children well into their adulthood.
Disorders and Physical Disabilities
Refer to Reduced Affect Display.
There are some diseases, physical disabilities and mental health disorders that can change the way a person’s affect displays are conveyed. Reduced affect is when a person’s emotions cannot be properly conveyed or displayed physically. There is no actual change in how intensely they truly feel emotions, there is simply a disparity between emotions felt and how intensely they are conveyed. These disorders can greatly affect a person’s quality of life, depending on how intense the disability is.
Flat, Blunted and Restricted Affect
These are symptoms in which an affected person feels an emotion, but does not or cannot display it. Flat being the most severe in where there is very little to absolutely no show of emotions. Restricted and blunted are, respectively, less severe. Disorders involving these reduced affect displays most commonly include schizophrenia, post traumatic stress disorder, depression, autism and persons with traumatic brain injuries. One study has shown that people with schizophrenia that experience flat affect, can also experience difficulty perceiving the emotions of a healthy individual.
Facial Paralysis and Surgery
People who suffer from deformities and facial paralysis are also physically incapable of displaying emotions. This is beginning to be corrected though, through “Facial Reanimation Surgery” which is proving not only to successfully improve a patient’s affect displays, but also bettering their psychological health. There are multiple types of surgeries that can help fix facial paralysis. Some more popular types include fixing the actual nerve damage, specifically any damage to the hypoglossal nerve; facial grafts where nerves taken from a donor’s leg are transplanted into the patient’s face; or if the damage is more muscular versus actual nerves, muscle may be transferred into the patient’s face.
Refer to Psychological Manipulation.
Emotions can be displayed in order to elicit desired behaviours from others.
People have been known to display positive emotions in various settings. Service workers often engage in emotional labour, a strive to maintain positive emotional expressions despite difficulties in working conditions or rude customers, in order to conform to organisational rules. Such strategic displays are not always effective, since if they are detected, lower customer satisfaction results.
Perhaps the most notable attempt to feign negative emotion could be seen with Nixon’s madman theory. Nixon’s administration attempted to make the leaders of other countries think Nixon was mad, and that his behaviour was irrational and volatile. Fearing an unpredictable American response, leaders of hostile Communist Bloc nations would avoid provoking the United States. This diplomatic strategy was not ultimately successful.
The effectiveness of the strategic display depends on the ability of the expresser to remain undetected. It may be a risky strategy since if detected, the person’s original intent could be discovered, undermining the future relationship with the target.
According to the appraisal theory of emotions, the experience of emotions is preceded by an evaluation of an object of significance to that individual. When individuals are seen to display emotions, it serves as a signal to others of an event important to that individual. Thus, deliberately altering the emotion display toward an object could be used make the targets of the strategic emotion think and behave in ways that benefit the original expresser. For example, people attempt to hide their expressions during a poker game in order to avoid giving away information to the other players, i.e. keep a poker face.
Affective science is the scientific study of emotion or affect.
his includes the study of emotion elicitation, emotional experience and the recognition of emotions in others. Of particular relevance are the nature of feeling, mood, emotionally-driven behaviour, decision-making, attention and self-regulation, as well as the underlying physiology and neuroscience of the emotions.
An increasing interest in emotion can be seen in the behavioural, biological and social sciences. Research over the last two decades suggests that many phenomena, ranging from individual cognitive processing to social and collective behaviour, cannot be understood without taking into account affective determinants (i.e. motives, attitudes, moods, and emotions). Just as the cognitive revolution of the 1960s spawned the cognitive sciences and linked the disciplines studying cognitive functioning from different vantage points, the emerging field of affective science seeks to bring together the disciplines which study the biological, psychological, and social dimensions of affect. In particular affective science includes psychology, affective neuroscience, sociology, psychiatry, anthropology, ethology, archaeology, economics, criminology, law, political science, history, geography, education and linguistics. Research is also informed by contemporary philosophical analysis and artistic explorations of emotions. Emotions developed in human history make organisms to react to environmental stimuli and challenges.
The major challenge for this interdisciplinary domain is to integrate research focusing on the same phenomenon, emotion and similar affective processes, starting from different perspectives, theoretical backgrounds, and levels of analysis. As a result, one of the first challenges of affective science is to reach consensus on the definition of emotions. Discussion is ongoing as to whether emotions are primarily bodily responses or whether cognitive processing is central. Controversy also concerns the most effective ways to measure emotions and conceptualise how one emotion differs from another. Examples of this include the dimensional models of Russell and others, Plutchik’s wheel of emotions, and the general distinction between basic and complex emotions.
Whether scientific method is at all suited for the study of the subjective aspect of emotion, feelings, is a question for philosophy of science and epistemology. In practice, the use of self-report (i.e. questionnaires) has been widely adopted by researchers. Additionally, web-based research is being used to conduct large-scale studies on the components of happiness for example. (www.authentichappiness.com is a website run by the University of Pennsylvania, where questionnaires are routinely taken by thousands of people all over the world based on a well-being criteria devised in the book ‘Flourish.’ by Martin Seligman). Nevertheless, Seligman mentions in the book the poor reliability of using this method as it is often entirely subjective to how the individual is feeling at the time, as opposed to questionnaires which test for more long standing personal features that contribute to well-being such as meaning in life. Alongside this researchers also use functional magnetic resonance imaging, Electroencephalography and physiological measures of skin conductance, muscle tension and hormone secretion. This hybrid approach should allow researchers to gradually pinpoint the affective phenomenon. There are also a few commercial systems available that claim to measure emotions, for instance using automated video analysis or skin conductance (affectiva).
A common way to measure the emotions of others is via their emotional expressions. These include facial expression, vocal expression and bodily posture. Much work has also gone into coding expressive behaviour computer programmes that can be used to read the subject’s emotion more reliably. The model used for facial expression is the Facial Action Coding System or ‘FACS’. An influential figure in the development of this system was Paul Ekman (For criticism, refer to the conceptual-act model of emotion).
These behavioural sources can be contrasted with language descriptive of emotions. In both respects one may observe the way that affective display differs from culture to culture.
The Stanford University Psychology Department has an Affective Science area. It emphasizes basic research on emotion, culture, and psychopathology using a broad range of experimental, psychophysiological, neural, and genetic methods to test theory about psychological mechanisms underlying human behaviour. Topics include longevity, culture and emotion, reward processing, depression, social anxiety, risk for psychopathology, and emotion expression, suppression, and dysregulation.
The Texas Medication Algorithm Project (TMAP) is a controversial decision-tree medical algorithm, the design of which was based on the expert opinions of mental health specialists.
It has provided and rolled out a set of psychiatric management guidelines for doctors treating certain mental disorders within Texas’ publicly funded mental health care system, along with manuals relating to each of them. The algorithms commence after diagnosis and cover pharmacological treatment (hence “Medication Algorithm”).
TMAP was initiated in the fall (winter) of 1997 and the initial research covered around 500 patients.
TMAP arose from a collaboration that began in 1995 between the Texas Department of Mental Health and Mental Retardation (TDMHMR), pharmaceutical companies, and the University of Texas Southwestern. The research was supported by the National Institute of Mental Health, the Robert Wood Johnson Foundation, the Meadows Foundation, the Lightner-Sams Foundation, the Nanny Hogan Boyd Charitable Trust, TDMHMR, the Centre for Mental Health Services, the Department of Veterans Affairs, the Health Services Research and Development Research Career Scientist Award, the United States Pharmacopoeia Convention Inc. and Mental Health Connections.
Numerous companies that invent and develop antipsychotic medications provided use of their medications and furnished funding for the project. Companies did not participate in the production of the guidelines.
In 2004 TMAP was mentioned as an example of a successful project in a paper regarding implementing mental health screening programmes throughout the United States, by the President George W. Bush’s New Freedom Commission on Mental Health, which looks to expand the programme federally. The President had previously been Governor of Texas, in the period when TMAP was implemented. Similar programmes have been implemented in about a dozen States, according to a 2004 report in the British Medical Journal.
Similar algorithms with similar prescribing advice have been produced elsewhere, for instance at the Maudsley Hospital, London.
On November 2004, voters in the US state of California passed Proposition 63, the Mental Health Services Act (MHSA), which has been designed to expand and transform California’s county mental health service systems.
The MHSA is funded by imposing an additional one percent (1%) tax on individual, but not corporate, taxable income in excess of one million dollars. In becoming law on January 2005, the MHSA represents the latest in a Californian legislative movement, begun in the 1990s, to provide better coordinated and more comprehensive care to those with serious mental illness, particularly in underserved populations. Its claim of successes thus far, such as with the development of innovative and integrated Full Service Partnerships (FSPs), are not without detractors who highlight many problems but especially a lack of oversight, large amount of unspent funds, poor transparency, lack of engagement in some communities, and a lack of adherence to required reporting as challenges MHSA implementation must overcome to fulfil the law’s widely touted potential.
At one time, California was known for having a strong mental health system. Treatment was available for Medi-Cal recipients with few limitations on care. Legislators and voters have acknowledged the inadequacy of California’s historically underfunded mental health system to care for the state’s residents, especially those with serious mental illness, over the past few decades. In 1991, to build a more community- and county-based system of care, the California legislature instituted realignment, a delegation of the control over mental health funds and care delivery from state to county. This was followed by a succession of legislation targeted towards marginalised populations with high documented rates of mental illness, such as the homeless (AB 2034, in 1999) and the potentially violent mentally ill (Laura’s Law, in 2002). However, with the passage of Proposition 63 in 2004, California voters acted upon a widespread perception that state and county mental health systems were still in disrepair, underfunded, and requiring a systematic, organizational overhaul. This perception echoed a nationwide perspective, with the President’s New Freedom Commission on Mental Health in 2003 calling for fundamental transformation of the historically fragmented mental health system. The MHSA is California’s attempt to lead the way in accomplishing such systemic reform.
In the end, voter consciences were pricked by the well-organised and -funded campaign that displayed both the need (50,000 mentally ill homeless people, according to the National Alliance on Mental Illness) and the promise (successes of past mental health initiatives) of increased funding for the mental health system. Then-Assemblyman Darrell Steinberg and Rusty Selix, executive director of the Mental Health Association in California, led the initiative by collecting at minimum 373,816 signatures, along with financial ($4.3 million) and vocal support from stakeholders. Though Governor Arnold Schwarzenegger and the business community were opposed to Proposition 63 because of the tax it would impose on millionaires, the opposition raised only $17,500. On 02 November 2004, Proposition 63 passed with 53.8% of the vote, with 6,183,119 voting for and 5,330,052 voting against the bill.
The voter-approved MHSA initiative provides for developing, through an extensive stakeholder process, a comprehensive approach to providing community based mental health services and supports for California residents. Approximately 51,000 taxpayers in California will be helping to fund the MHSA through an estimated $750 million in tax revenue during fiscal year 2005-2006.
The MHSA was an unprecedented piece of legislation in California for several reasons:
Its funding source, quantity, and allocation is dedicated for mental health services, including times of budget cuts to many other public programmes
It was intended to engage communities in prioritising which service elements would be funded.
It was focused on developing preventive and innovative programmes to help transform the mental health care system in California.
To accomplish its objectives, the MHSA applies a specific portion of its funds to each of six system-building components:
Community programme planning and administration (10%).
Community services and supports (45%).
Capital (buildings) and information technology (IT) (10%).
Education and training (human resources) (10%).
Prevention and early intervention (20%).
Notably, none of the funds were to be used for programmes with existing fund allocations, unless it was for a new element or expansion in those existing programmes. 51% of the funds have to be spent on children’s service.
The MHSA stipulates that the California State Department of Mental Health (DMH) will contract with county mental health departments (plus two cities) to develop and manage the implementation of its provisions. Oversight responsibility for MHSA implementation was handed over to the sixteen member Mental Health Services Oversight and Accountability Commission (MHSOAC) on July 7, 2005, when the commission first met.
The MHSA specifies requirements for service delivery and supports for children, youths, adults and older adults with serious emotional disturbances and/or severe mental illnesses. MHSA funding will be made annually to counties to:
Define serious mental illness among children, adults and seniors as a condition deserving priority attention, including prevention and early intervention services and medical and supportive care
Reduce the long-term adverse impact on individuals, families and State and local budgets resulting from untreated serious mental illness.
Expand the kinds of successful, innovative service programs for children, adults and seniors already established in California, including culturally and linguistically competent approaches for underserved population.
Provide State and local funds to adequately meet the needs of all children and adults who can be identified and enrolled in programmes under this measure.
Ensure all funds are expended in the most cost-effective manner and services are provided in accordance with recommended best practices, subject to local and State oversight to ensure accountability to taxpayers and to the public.
Starting from enactment, implementation of the MHSA was intended to take six months; in reality, the process of obtaining stakeholder input for administrative rules extended this period by several months. By August 2005, 12 meetings and 13 conference calls involving stakeholders across the state resulted in the final draft of rules by which counties would submit their three-year plans for approval.
Counties are required to develop their own three-year plan, consistent with the requirements outlined in the act, in order to receive funding under the MHSA. Counties are obliged to collaborate with citizens and stakeholders to develop plans that will accomplish desired results through the meaningful use of time and capabilities, including things such as employment, vocational training, education, and social and community activities. Also required will be annual updates by the counties, along with a public review process. County proposals will be evaluated for their contribution to achieving the following goals:
Safe and adequate housing, including safe living environments, with family for children and youths.
Reduction in homelessness.
A network of supportive relationships.
Timely access to needed help, including times of crisis.
Reduction in incarceration in jails and juvenile halls.
Reduction in involuntary services, including reduction in institutionalisation and out-of-home placements.
MHSA specifies three stages of local funding, to fulfil initial plans, three year plans, and long term strategies. No services would be funded in the first year of implementation. The DMH approved the first county plan in January 2006. Allocations for each category of funding were planned to be granted annually, based upon detailed plans with prior approval. However, an amendment to the MHSA, AB 100, which passed in March 2011, serves to streamline the DMH approval and feedback process to the counties, ostensibly to relieve the DMH of some of its administrative burden.
Roles & Responsibilities
While the county mental health departments are involved in the actual implementation of MHSA programmes, the MHSA mandates that several entities support or oversee the counties. These include the State Department of Mental Health (DMH) and the Mental Health Services Oversight and Accountability Commission (MHSOAC).
California State Department of Mental Health (DMH)
In accordance with realignment, the DMH approves county three-year implementation plans, upon comment from the MHSOAC, and passes programmatic responsibilities to the counties. In the first few months immediately following its passage, the DMH has:
Obtained federal approvals and Medi-Cal waivers, State authority, additional resources and technical assistance in areas related to implementation.
Established detailed requirements for the content of local three year expenditure plans.
Developed criteria and procedures for reporting of county and state performance outcomes.
Defined requirements for the maintenance of current State and local efforts to protect against supplanting existing programmes and their funding streams.
Developed formulas for how funding will be divided or distributed among counties.
Determined how funding will flow to counties and set up the mechanics of distribution.
Established a 16-member Mental Health Services Oversight and Accountability Commission (MHSOAC), composed of elected State officials and Governor appointees, along with procedures for MHSOAC review of county planning efforts and oversight of DMH implementation.
Developed and published regulations and provide preliminary training to all counties on plan development and implementation requirements.
The DMH has directed all counties to develop plans incorporating five essential concepts:
Client/family-driven mental health system for older adults, adults and transition age youth and family-driven system of care for children and youth.
Wellness focus, which includes the concepts of recovery and resilience.
Integrated service experiences for clients and their families throughout their interactions with the mental health system.
The DMH, in assuming and asserting its primacy over MHSA implementation, has dictated requirements for service delivery and supports as follows:
Full Service Partnership (FSP) Funds: Funds to provide necessary services and supports for initial populations.
General System Development Funds: Funds to improve services and infrastructure.
Outreach and Engagement Funding: Funds for those populations that are currently receiving little or no service.
Mental Health Services Oversight and Accountability Commission (MHSOAC)
The authors of the MHSA created the MHSOAC to reflect the consumer-oriented focus of the law, mandating at least two appointees with severe mental illness, two other family members of individuals with severe mental illness, and various other community representatives. This diverse commission holds the responsibility of approving county implementation plans, helping develop mental illness stigma-relieving strategies, and recommending service delivery improvements to the state on an as-needed basis. Whenever the commission identifies a critical issue related to the performance of a county mental health programme, it may refer the issue to the DMH.
The first meeting of the MHSOAC was held July 7, 2005, at which time Proposition 63 author Darrell Steinberg was selected unanimously by fellow commissioners as chairman, without comment or discussion. After accepting the gavel, Steinberg was roundly praised for devising Proposition 63’s ‘creative financing’ scheme. Steinberg then said, “We must focus on the big picture,” and stated his priorities with regard to the implementation of the MHSA:
Prioritise prevention and early intervention, without falling into the trap of fail first service provision;
Address “the plight of those at risk of falling off the edge,”; and
Advocate for mental health services from his “bully pulpit.”
In accordance with MHSA requirements, the Commission shall consist of 16 voting members as follows:
The Attorney General or his or her designee.
The Superintendent of Public Instruction or his or her designee.
The Chairperson of the Senate Health and Human Services Committee or another member of the Senate selected by the President pro Tempore of the Senate.
The Chairperson of the Assembly Health Committee or another member of the Assembly selected by the Speaker of the Assembly.
Twelve appointees of the Governor, who shall seek individuals who have had personal or family experience with mental illness, to include:
Two persons with a severe mental illness.
A family member of an adult or senior with a severe mental illness.
A family member of a child who has or has had a severe mental illness.
A physician specialising in alcohol and drug treatment.
A mental health professional.
A county Sheriff.
A Superintendent of a school district.
A representative of a labour organisation.
A representative of an employer with less than 500 employees.
A representative of an employer with more than 500 employees.
A representative of a health care services plan or insurer.
State Government Appointees
The initial government officials and designee appointed:
Senator Wesley Chesbro (Democrat), of Arcata, chair of the Senate Budget and Fiscal Review Committee and the Senate Select Committee on Developmental Disabilities and Mental Health.
Assemblyman Mark Ridley-Thomas (Dem), of Los Angeles, a member of the Assembly Health committee and former L.A. city councilman.
Attorney General Bill Lockyer, of Hayward, a former State Senator and Assemblyman.
Darrell Steinberg (Dem), of Sacramento, an attorney, the author of Proposition 63, former Assemblyman. Steinberg is the appointee of the Superintendent of Public Instruction.
On 21 June 2005, then Governor Schwarzenegger announced his appointment of twelve appointees to the MHSOAC:
MHOAC Vice Chairman Linford Gayle (declined to state party), 46, of Pacifica, a mental health program specialist at San Mateo County Mental Health Services.
Karen Henry (Republican), 61, of Granite Bay, a labour attorney and a board member of California National Alliance for the Mentally Ill (NAMI). Henry is afflicted by ‘rapid cycling’ bipolar disorder, has a son who has autism, and another son with a mental illness.
William Kolender (Rep), 70, of San Diego, the San Diego County Sheriff and president of the State Sheriffs Association, a member of the State Board of Corrections, and was for three years the director of the California Youth Authority (CYA). Kolender’s wife died as a result of mental illness, and he has a son with a mental disorder.
Kelvin Lee, Ed.D. (Rep), 58, of Roseville, a superintendent of the Dry Creek Joint Elementary School District.
Andrew Poat (Rep), 45, of San Diego, former director of the government relations department for the City of San Diego, a member of the public policy committee for the San Diego Gay and Lesbian Centre, and a former deputy director of the United States Office of Consumer Affairs. Poat represented employers of more than 500 workers on the commission, and says he will use his experience building multimillion-dollar programs to bring together mental health advocates.
Darlene Prettyman (Rep), 71, of Bakersfield, is a psychiatric nurse, a board member and past president of NAMI California, and a past chairman and a member of the California Mental Health Planning Council. Her son has schizophrenia, and her stated priority is to enhance provision of housing for mental health service clients.
Carmen Diaz (Dem), 53, of Los Angeles, a family advocate coordinator with the L.A. County Department of Mental Health and a board member of United Advocates for Children of California. Diaz has a family member with a severe mental illness.
F. Jerome Doyle (Dem), 64, of Los Gatos, is chief executive officer of EMQ (a provider of mental health services for children and youth), a board member and past president of the California Council of Community Mental Health Agencies, and a board member of California Mental Health Advocates for Children.
Saul Feldman DPA, (Dem), 75, of San Francisco, is chairman and CEO of United Behavioural Health, a member of the American Psychological Association, the founder and former president of the American College of Mental Health Administration, and a former president and CEO of Health America Corporation of California. Feldman was appointed as a health care plan insurer.
Gary Jaeger, M.D. (Dem), 62, of Harbour City, is currently the chief of addiction medicine at Kaiser Foundation Hospital, South Bay, a member and former chair of the Behavioural Health Advisory Board of the California Healthcare Association, and former medical director of family recovery services at St. Joseph Hospital in Eureka. He says members of his family have an “80 percent rate of drug and alcohol abuse.”
Mary Hayashi (Dem), 38, of Castro Valley, president of the Iris Alliance Fund and a board member for Planned Parenthood Golden Gate and member of the Board of Registered Nursing. Hayashi’s concerns include transportation access for clients and paratransit services, and represents employers with 500 or fewer workers.
Patrick Henning (Dem), 32, of West Sacramento, is the legislative advocate for the California Council of Laborers. He was previously the Assistant Secretary at the Labour and Workforce Development Agency (An Agency that he helped create), deputy director for the Department of Industrial Relations and Prior to his State service Special Advisor and Congressional Liaison to President Bill Clinton. Henning is a member of the Career Technical Education Standards and Framework Advisory Group and the California Assembly Speaker’s Commission on Labour Education. He represents labour.
One unqualified success story from the MHSA thus far involves the implementation of Full Service Partnerships (FSPs) demonstrating the “whatever it takes” commitment to assist in individualised recovery – whether it is housing, “integrated services, flexible funding [such as for childcare], intensive case management, [or] 24 h access to care.” FSP interventions are based upon evidence from such programs as Assertive community treatment (ACT), which has effectively reduced homelessness and hospitalisations while bettering outcomes. But the FSP model looks more like that of the also-popular MHA Village in Long Beach, which is a centre that offers more comprehensive services besides those specifically mental health-related. Beyond these guiding principles, however, there has not been much consensus over unifying strategies to define and implement an FSP – resulting in varying FSP structures across counties.
Overall, though, the Petris Centre, funded by the DMH and California HealthCare Foundation to evaluate the MHSA, has reported quantifiable improvements in many areas:
Entry rates into the criminal justice system.
Suffering from illness.
General satisfaction with FSPs.
According to the UCLA Centre for Health Policy Research, the 2007 and 2009 California Health Interview Surveys (CHIS) demonstrate continued mental health needs of almost two million Californians, about half of which were unmet in 2011. In spite of steady tax revenue ($7.4 billion raised as of September 2011) earmarked for the MHSA, the unremittingly high numbers of mentally ill who lack treatment contrast starkly with the implementation of new programs like the FSPs, which may cost tens of thousands of dollars annually per person. The MHA Village programme, for example, averages around $18,000 annually per person. One of the major growing concerns regarding MHSA implementation is its unintentional but worrying tendency to create silos of care. As directed by the DMH, counties search for “unserved” mentally ill or at-risk individuals to enrol in their new programmes, while keeping existing and perhaps underserved clients in old programs that are usually underfunded, but cannot take MHSA funds. Ironically, while the MHSA was established in part to address racial/ethnic disparities in health care, it may be perpetuating the disparity in services delivery between underfunded and well-funded, new programmes.
A possible solution to this issue highlights another challenge for the MHSA: the need for more comprehensive evaluation, oversight, and advisory mechanisms. Though there is an accountability commission, the MHSOAC, its oversight and regulatory responsibilities are not well-defined. However, it is a relatively new entity, having been created by the MHSA in 2004, and has yet to fully delineate its role in the MHSA. With time, the MHSOAC will hopefully continue to develop towards its stated function. Objective and expert evaluation of the MHSA will also be necessary to achieve the kind of longstanding system-wide improvement that then becomes a model for others.
World Suicide Prevention Day (WSPD) is an awareness day observed on 10 September every year, in order to provide worldwide commitment and action to prevent suicides, with various activities around the world since 2003.
The International Association for Suicide Prevention (IASP) collaborates with the World Health Organisation (WHO) and the World Federation for Mental Health (WFMH) to host World Suicide Prevention Day. In 2011 an estimated 40 countries held awareness events to mark the occasion. According to WHO’s Mental Health Atlas released in 2014, no low-income country reported having a national suicide prevention strategy, while less than 100% of lower-middle income countries, and almost a third of upper-middle and high-income countries had.
On its first event in 2003, the 1999 WHO’s global suicide prevention initiative is mentioned with regards to the main strategy for its implementation, requiring:
“The organisation of global, regional and national multi-sectoral activities to increase awareness about suicidal behaviours and how to effectively prevent them.”
“The strengthening of countries’ capabilities to develop and evaluate national policies and plans for suicide prevention.”
As of recent WHO releases, challenges represented by social stigma, the taboo to openly discuss suicide, and low availability of data are still to date obstacles leading to poor data quality for both suicide and suicide attempts: “given the sensitivity of suicide – and the illegality of suicidal behaviour in some countries – it is likely that under-reporting and misclassification are greater problems for suicide than for most other causes of death.”
Suicide has a number of complex and interrelated and underlying contributing factors … that can contribute to the feelings of pain and hopelessness. Having access to means to kill oneself – most typically firearms, medicines and poisons – is also a risk factor. Campaign release.
An estimated one million people per year die by suicide or about one person in 10,000 (1.4% of all deaths), or “a death every 40 seconds or about 3,000 every day”. As of 2004 the number of people who die by suicide is expected to reach 1.5 million per year by 2020.
On average, three male suicides are reported for every female one, consistently across different age groups and in almost every country in the world. “Conversely, rates of suicide attempts tend to be 2-3 times higher in women than in men, although the gender gap has narrowed in recent years.” More people die from suicide than from murder and war; it is the 13th leading cause of death worldwide. According to WHO there are twenty people who have a suicide attempt for every one that is fatal, at a rate approximately one every three seconds. Suicide is the “most common cause of death for people aged 15 – 24.”
According to WHO, suicide accounts for nearly half of all violent deaths in the world. Brian Mishara, IASP president, noted that, “more people kill themselves than die in all wars, terrorist acts and interpersonal violence combined.” As of 2008, the WHO refers the widest number of suicides occur in the age group 15-29, while the lowest in the 80+ although representing as well the one with the highest rate (per 100,000) of all age groups, with 27.8 suicides and 60.1 for females and males respectively. In 2015 the reported global age-standardized rate is 10.7 per 100,000.
Social norms play a significant role in the development of suicidal behaviours. Late 19th century’s sociological studies recorded first ever observations on suicide: with statistics of the time at hand, sociologists mentioned the effects of industrialisation as in relations between new urbanised communities and vulnerability to self-destructive behaviour, suggesting social pressures have effects on suicide. Today, differences in suicidal behaviour among different countries can be significant.
2003 – “Suicide Can Be Prevented!”.
2004 – “Saving Lives, Restoring Hope”.
2005 – “Prevention of Suicide is Everybody’s Business”.
2006 – “With Understanding New Hope”.
2007 – “Suicide prevention across the Life Span”.
2008 – “Think Globally, Plan Nationally, Act Locally”.
2009 – “Suicide Prevention in Different Cultures”.
2010 – “Families, Community Systems and Suicide”.
2011 – “Preventing Suicide in Multicultural Societies”.
2012 – “Suicide Prevention across the Globe: Strengthening Protective Factors and Instilling Hope”.
2013 – “Stigma: A Major Barrier to Suicide Prevention”.
2014 – “Light a candle near a Window”.
2015 – “Preventing Suicide: Reaching Out and Saving Lives”.
2016 – “Connect, Communicate, Care”.
2017 – “Take a Minute, Change a Life”.
2018 – “Working Together to Prevent Suicide”.
2019 – “Working Together to Prevent Suicide”.
2020 – “Working Together to Prevent Suicide”.
Suicide Prevention Priorities
Suicide prevention’s priorities, as declared on the 2012 World Suicide Prevention Day event, are stated below:
We need to continue to research suicide and non-fatal suicidal behaviour, addressing both risk and protective factors.
We need to develop and implement awareness campaigns, with the aim of increasing awareness of suicidal behaviours in the community, incorporating evidence on both risk and protective factors.
We need to target our efforts not only to reduce risk factors but also to strengthen protective factor, especially in childhood and adolescence.
We need to train health care professionals to better understand evidence-based risk and protective factors associated with suicidal behaviour.
We need to combine primary, secondary and tertiary prevention.
We need to increase use of and adherence to treatments shown to be effective in treating diverse conditions; and to prioritise research into effectiveness of treatments aimed at reducing self-harm and suicide risk.
We need to increase the availability of mental health resources and to reduce barriers to accessing care.
We need to disseminate research evidence about suicide prevention to policy makers at international, national and local levels.
We need to reduce stigma and promote mental health literacy among the general population and health care professionals.
We need to reach people who don’t seek help, and hence don’t receive treatment when they are in need of it.
We need to ensure sustained funding for suicide research and prevention.
We need to influence governments to develop suicide prevention strategies for all countries and to support the implementation of those strategies that have been demonstrated to save lives.
Below are two quotes on the subject of suicide:
“The main suicide triggers are poverty, unemployment, the loss of a loved one, arguments and legal or work-related problems [..] Suicide results from many complex sociocultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis (e.g. loss of a loved one, unemployment, sexual orientation, difficulties with developing one’s identity, disassociation from one’s community or other social/belief group, and honour). [..] In richer countries, three times as many men die of suicide than women do, but in low- and middle-income countries the male-to-female ratio is much lower at 1.5 men to each woman. [..] In the United States, males are four times more likely to die from suicide than are females. However, females are more likely to attempt suicide than are males. [..] The disparity in suicide rates has been partly explained by the use of more lethal means and the experience of more aggression and higher intent to die [..] in men than women.”
“In much of the world, suicide is stigmatized and condemned for religious or cultural reasons. In some countries, suicidal behavior is a criminal offence punishable by law. Suicide is therefore often a secretive act surrounded by taboo, and may be unrecognized, misclassified or deliberately hidden in official records of death. [..] Stigma, particularly surrounding mental disorders and suicide, means many people thinking of taking their own life or who have attempted suicide are not seeking help and are therefore not getting the help they need. The prevention of suicide has not been adequately addressed due to a lack of awareness of suicide as a major public health problem and the taboo in many societies to openly discuss it. [..] Raising community awareness and breaking down the taboo is important for countries to make progress in preventing suicide.”
Physical and especially mental health disabling issues such as depression, are among the most common of the long list of complex and interrelated factors, ranging from financial problems to the experience of abuse, aggression, exploitation and mistreatment, that can contribute to the feelings of pain and hopelessness underling suicide. Usually substances and alcohol abuse also play a role. Prevention strategies generally emphasize public awareness towards social stigma and suicidal behaviours.
In 1999, death by self-inflicted injuries was the fourth leading cause of death among aged 15-44, in the world. In a 2002 study it was reported the countries with the lowest rates tend to be in Latin America, “Muslim countries and a few Asian countries”, and noted a lack of information from most African countries. Data quality is to date a concern for suicide prevention policies. Incidence of suicide tends to be under-reported and misclassified due to both cultural and social pressures, and possibly completely unreported in some areas. Since data might be skewed, comparing suicide rates between nations can result in statistically unsound conclusions about suicidal behaviour in different countries. Nevertheless, the statistics are commonly used to directly influence decisions about public policy and public health strategies.
Of the 34 member countries of the OECD, a group of mostly high-income countries that uses market economy to improve the Human Development Index, South Korea had the highest suicide rate in 2009. In 2011 South Korea’s Ministry of Health and Welfare enacted legislation coinciding with WSPD to address the high rate.
In 2008 it was reported that young people 15-34 years old in China were more likely to die by suicide than by any other mean, especially young Chinese women in rural places because of “arguments about marriage”. By 2011 however, suicide rate for the same age group had been declining significantly according to official releases, mainly by late China’s urbanisation and migration from rural areas to more urbanised: since the 1990s indeed, overall national Chinese suicide rate dropped by 68%.
According to WHO, in 2009 the four countries with the highest rates of suicide were all in Eastern Europe; Slovenia had the fourth highest rate preceded by Russia, Latvia, and Belarus. This stays within findings from the start of the WSPD event in 2003 when the highest rates were also found in Eastern European countries. As of 2015 the highest suicide rates are still in Eastern Europe, Korea and the Siberian area bordering China, in Sri Lanka and the Guianas, Belgium and few Sub-Saharan countries.
According to WHO’s Mental health Atlas released in 2014, no low-income country reported having a national suicide prevention strategy, while less than 10% of lower-middle income countries, and almost a third of upper-middle and high-income countries had. Focus of the WSPD is the fundamental problem of suicide, considered a major public health issue in high-income and an emerging problem in low and middle-income countries. Among high-income countries (besides South Korea) highest rates in 2015 are found across some Eastern European countries, Belgium and France, Japan, Croatia and Austria, Uruguay and Finland.
Socioeconomic status plays an important role in suicidal behaviour, and wealth is a constant with regards to Male-Female suicide rate ratios, being that excess male mortality by suicide is generally limited or non-existent in low- and middle-income societies, whereas it is never absent in high-income countries.
Suicidal behaviour is also subject of study for economists since about the 1970s: although national costs of suicide and suicide attempts (up to 20 for every one completed suicide) are very high, suicide prevention is hampered by scarce resources for lack of interest by mental health advocates and legislators; and moreover, personal interests even financial are studied with regards to suicide attempts for example, in which insights are given that often “individuals contemplating suicide do not just choose between life and death … the resulting formula contains a somewhat paradoxical conclusion: attempting suicide can be a rational choice, but only if there is a high likelihood it will cause the attempter’s life to significantly improve.” In the United States alone, yearly costs of suicide and suicide attempts are comprised in 50-100 billion dollars.
The United Nations issued “National Policy for Suicide Prevention” in the 1990s, which some countries also use as a basis for their assisted suicide policies. Nevertheless, the UN noted that suicide bombers’ deaths are seen as secondary to their goal of killing other people or specific targets and the bombers are not otherwise typical of people committing suicide.
According to a 2006 WHO press release, one-third of worldwide suicides were committed with pesticides, “some of which were forbidden by United Nations (UN) conventions.” WHO urged the highly populated Asian countries to restrict pesticides that are commonly used in failed attempts, especially organophosphate-based pesticides that are banned by international conventions but still made in and exported by some Asian countries. WHO reports an increase in pesticide suicides in other Asian countries as well as Central and South America. It is estimated that such painful failed attempts could be reduced by legalising controlled voluntary euthanasia options, as implemented in Switzerland.
As of 2017, it is estimated that around 30% of global suicides are still due to pesticide self-poisoning, most of which occur in rural agricultural areas in low- and middle-income countries (consisting in about 80% world population). In high-income countries consisting of the remaining 20% world population most common methods are firearms, hanging and other self-poisoning.
Gender and Suicide
European and American societies report a higher male mortality by suicide than any other, while various Asian a much lower. According to most recent data provided by WHO, about 40,000 females of the global three hundred thousand female suicides and 150,000 males of the global half million male suicides, deliberately take their own life every year in Europe and the Americas (consisting of about 30% of the world’s population). As of 2015, apart from a few South and East Asian countries home to twenty percent of world population, Morocco, Lesotho, and two Caribbean countries, because of changing gender roles suicide rates are globally higher among men than women.
Even though women are more prone to suicidal thoughts than men, rates of suicide are higher among men. On average, there are about three male suicides for every female one – though in parts of Asia, the ratio is much narrower.
The disparity in suicide rates has been partly explained by the use of more lethal means and the experience of more aggression and higher intent to die, when suicidal, in men than women.
There are many potential reasons for different suicide rates in men and women: gender equality issues, differences in socially acceptable methods of dealing with stress and conflict for men and women, availability of and preference for different means of suicide, availability and patterns of alcohol consumption, and differences in care-seeking rates for mental disorders between men and women. The very wide range in the sex ratios for suicide suggests that the relative importance of these different reasons varies greatly by country and region.
In western countries men are about 300% or thrice as likely to die by suicide than females, while a few countries (counting over a hundred million residents overall) exceed the 600% figure. Most considerable difference in male–female suicide ratios is noted in countries of the former Soviet Bloc and in some of Latin America.
Globally, in 2015 women had higher suicide rates in eight countries. In China (almost a fifth of world population) women were up to 30% more likely than men to commit suicide and up to 60% in some other South Asian countries: overall South Asian (including South-Eastern Asia, a third of world population) age-adjusted ratio however, was around global average of 1.7:1 (men being around 70% more likely than women to die by suicide).
Some suicide reduction strategies do not recognize the separate needs of males and females. Researchers have recommended aggressive long-term treatments and follow up for males that show indications of suicidal thoughts. Studies have also found that because young females are at a higher risk of attempting suicide, policies tailored towards this demographic are most effective at reducing overall rates.
Shifting cultural attitudes about gender roles and social norms, and especially ideas about masculinity, may also contribute to closing the gender gap: social status and working roles are assumed to be crucial for men’s identity.
The Marchman Act, officially the “Hal S. Marchman Alcohol and Other Drug Services Act of 1993”, is a Florida law that provides a means of involuntary and voluntary assessment and stabilisation and treatment of a person allegedly abusing alcohol or drugs.
The involuntary assessment and treatment has two categories non-court and court involved admissions. The criteria for involuntary admission is:
“There is good faith reason to believe the person is substance abuse impaired and, because of such impairment:
Has lost the power of self-control with respect to substance use; AND EITHER
2a. Has inflicted, or threatened or attempted to inflict, or unless admitted is likely to inflict, physical harm on himself or herself or another; OR
b. Is in need of substance abuse services and, by reason of substance abuse impairment, his or her judgment has been so impaired that the person is incapable of appreciating his or her need for such services and of making a rational decision in regard thereto; however, mere refusal to receive such services does not constitute evidence of lack of judgment with respect to his or her need for such services. “
It is under Title XXIX – PUBLIC HEALTH Chapter 397 -SUBSTANCE ABUSE SERVICES of the Florida Statutes. The links to these paragraphs are listed below:
VOLUNTARY ADMISSIONS PROCEDURES
‘397.601 Voluntary admissions.
INVOLUNTARY ADMISSIONS PROCEDURES
A. General Provisions
B. Non-court Involved Admissions: Protective Custody
C. Non-court Involved Admissions; Emergency
D. Non-court Involved Admissions; Alternative Involuntary Assessment for Minors
E. Court Involved Admissions, Civil Involuntary Proceedings; Generally
F. Court Involved Admissions; Involuntary Assessment; Stabilization
G. Court Involved Admissions; Involuntary Treatment
397.705 Referral of substance abuse impaired offenders to service providers.
397.706 Screening, assessment, and disposition of juvenile offenders.
INMATE SUBSTANCE ABUSE PROGRAMS
397.752 Scope of part.
397.754 Duties and responsibilities of the Department of Corrections.
Criteria for involuntary admission is listed under the 397.675.
3-5 days for assessment under special conditions (minors or emergency admissions).
Non-Court protective custody is limited to 3 days (72 hours). The court can order involuntary treatment at a licensed service provider for a period not to exceed 60 days.
A sworn affidavit is signed at the local county courthouse or clerk’s office.
A hearing is set before the court after a Petition for Involuntary Assessment and Stabilisation is filed.
Following the hearing, the individual is held for up to five days for medical stabilisation and assessment.
A Petition for Treatment must be filed with the court and a second hearing is held for the court to review the assessment.
Based on the assessment and the recommendation that the individual needs extended help, the judge can then order a 60-day treatment period with a possible 90-day extension, if necessary.
If the addict exits treatment in violation of the judge’s order, the addict must return to court and answer to the court as to why they did not comply with treatment. Then the individual is returned immediately for involuntary care.
If the addict refuses, they are held in civil contempt of court for not following treatment order and are ordered to either return to treatment or be incarcerated.
It is an unfunded state requirement and each community must allocate funds for it.
Additionally, there are filing fees with the court.
Kendra’s Law, effective since November 1999, is a New York State law concerning involuntary outpatient commitment also known as assisted outpatient treatment.
It grants judges the authority to issue orders that require people who meet certain criteria to regularly undergo psychiatric treatment. Failure to comply could result in commitment for up to 72 hours. Kendra’s Law does not mandate that patients be forced to take medication.
It was originally proposed by members of the National Alliance on Mental Illness, the Alliance on Mental Illness of New York State, and many local NAMI chapters throughout the state. They were concerned that laws were preventing individuals with serious mental illness from receiving care until after they became “dangerous to self or others”. They viewed outpatient commitment as a less expensive, less restrictive and more humane alternative to inpatient commitment.
The members of NAMI, working with NYS Assemblywoman Elizabeth Connelly, NYC Department of Mental Health Commissioner Doctor Luis Marcos, and Doctor Howard Telson were successful in getting a three-year pilot commitment program started at Bellevue Hospital. When the Bellevue outpatient commitment programme came to an end, Attorney General Eliot Spitzer, the Treatment Advocacy Centre and DJ Jaffe put together a coalition to pass a statewide law. It was based on the same concept as the Bellevue Outpatient Commitment Programme but with important differences.
In 1999, there was a series of incidents involving individuals with untreated mental illness becoming violent. In one assault in the New York City Subway, Andrew Goldstein, then 29 and diagnosed with schizophrenia but off medication, pushed Kendra Webdale into the path of an oncoming N train at the 23rd Street station. Goldstein had recently attempted to get treatment but had been turned away. Kendra’s family joined a coalition led by Governor Pataki, the Treatment Advocacy Centre and DJ Jaffe, and the family played a significant role in getting the law passed. Subsequently, in a similar incident, Julio Perez, age 43, pushed Edgar Rivera in front of an uptown 6 train at 51st Street. Rivera lost his legs and became a strong supporter of the law. Kendra’s Law, introduced by Governor George E. Pataki, was created as a response to these incidents. In 2005, the law was extended for 5 years.
As a result of these incidents, involuntary outpatient commitment moved from being seen as a program to help people with mental illness to a program that could increase public safety. Public safety advocates joined advocates in trying to take the Bellevue Pilot Program statewide. What was formerly known as involuntary outpatient commitment was re-named euphemistically as “assisted outpatient treatment”, in an attempt to imply a positive intent of the law.
Kendra’s Law allows courts to order certain people diagnosed with mental illness to attend treatment as a condition for living in the community. The law is aimed at those who have a pattern of not following treatment recommendations which has resulted in re-hospitalisation, and/or violent behaviour placing the patient or others as serious risk of physical harm.
In order to be admitted to Kendra’s Law, individuals must meet the following criteria established in Section 9.60 of NYS Mental Health Law. A patient may be ordered to obtain assisted outpatient treatment if the court finds by clear and convincing evidence that:
The patient is eighteen years of age or older; and
The patient is suffering from a mental illness; and
The patient is unlikely to survive safely in the community without supervision, based on a clinical determination; and
The patient has a history of lack of compliance with treatment for mental illness that has:
At least twice within the last thirty-six months been a significant factor in necessitating hospitalisation in a hospital, or receipt of services in a forensic or other mental health unit of a correctional facility or a local correctional facility, not including any period during which the person was hospitalised or incarcerated immediately preceding the filing of the petition or;
Resulted in one or more acts of serious violent behaviour toward self or others or threats of, or attempts at, serious physical harm to self or others within the last forty-eight months, not including any period in which the person was hospitalised or incarcerated immediately preceding the filing of the petition; and
The patient is, as a result of his or her mental illness, unlikely to voluntarily participate in the recommended treatment pursuant to the treatment plan; and
In view of the patient’s treatment history and current behaviour, the patient is in need of assisted outpatient treatment in order to prevent a relapse or deterioration which would be likely to result in serious harm to the patient or others as defined in section 9.01 of this article; and
It is likely that the patient will benefit from assisted outpatient treatment; and
If the patient has executed a health care proxy as defined in article 29-C of the public health law, that any directions included in such proxy shall be taken into account by the court in determining the written treatment plan; and
The treatment plan set forth is the least restrictive plan that is most likely to benefit the patient.
A patient can only be ordered to Assisted Outpatient Treatment for a maximum 12-month period. The Assisted Outpatient Treatment may be renewed by petition filed prior to the current order’s expiration. Where the petition is for a renewal, the 36-month limit for re-hospitalisations and the 48-month limit for violent behaviour do not apply.
The New York Times reported:
“a study has found that a controversial program that orders these patients to receive treatment when they are not hospitalized has had positive results. Patients were much less likely to end up back in psychiatric hospitals and were arrested less often. Use of outpatient treatment significantly increased, as did refills of medication. Costs to the mental health system and Medicaid of caring for these patients dropped by half or more.”
According to the Treatment Advocacy Centre, the following organisations (in part or in full) support the law:
Treatment Advocacy Center (TAC).
American Psychiatric Nurses Association.
American Psychiatric Association.
National Alliance on Mental Illness (NAMI).
National Sheriffs Association.
National Crime Prevention Council.
National Alliance on Mental Illness New York State (NAMI NYS).
NYS Association of Chiefs of Police (NYSCOP).
AMI-Friends of NYS Psychiatric Institute, NYC.
NAMI/Familya of Rockland County.
NAMI Chautauqua County.
NAMI of Buffalo and Erie County.
NAMI of NYC/Staten Island.
NAMI Orange County.
NAMI Champlain Valley.
Harlem Alliance for the Mentally Ill.
NAMI of Montgomery, Fulton, Hamilton Counties.
NAMI North Country.
Albany County Forensic Task Force.
Westchester County Chiefs of Police Association.
Orange County Police Chiefs Association.
Town of New Windsor, Police Department.
Town of Chester, NY Police Department.
Town of Mechanicville, Police Department.
West Seneca, NY Police Department.
Broome County District Attorney.
Selected individual supporters:
Dr. Xavier Amador – author, I am Not Sick, I Don’t Need Help!
Pete Early – author, Crazy: A Father’s Search Through America’s Mental Health Madness.
Rael Jean Isaac – co-author, Madness in the Streets.
Dr. Richard Lamb – Dept. of Psychiatry, USC.
Edgar Rivera – lost legs in subway pushing.
E. Fuller Torrey – author, Surviving Schizophrenia.
Pat Webdale – mother of Kendra Webdale.
Dr. Robert Yolken – Director of Developmental Neurovirology Johns Hopkins Univ.
DJ Jaffe, Executive Dir. Mental Illness Policy Org.
Media editorial supporters:
New York Times.
New York Post.
Albany Times Union.
Office of the Attorney General.
NYS Public Employees Federation.
Greater NY Hospital Association.
Citizens Crime Commission.
Victim Services Agency.
Visiting Nurses Service.
Justice for All.
St. Francis Residence.
Moreover, research (outlined in the “Studies” section below) specifically on Kendra’s Law in New York State shows lower rates of violence, homelessness, arrest, incarceration, and cost. It shows that shows those who support Kendra’s Law say it helps them get well and stay well. Research in other states that have Assisted Outpatient Treatment programs have also shown positive results.
Courts have ruled that Assisted Outpatient Treatment (Kendra’s Law) does not violate rights citing the narrow criteria, the fact that the law does not provide for medication over objection (“force”) and the government interest in reducing violence.
Supporters note that the system in the United States is so different from that in the UK that studies that aggregate community treatment orders (CTOs) used in the UK and elsewhere overseas with Kendra’s Law as practiced in the US do not give as accurate a picture as studies exclusively on Kendra’s Law. They note that the Cochrane Study quoted by opponents of Assisted Outpatient Treatment did not include any of the studies on Kendra’s Law, or Assisted Outpatient Treatment as practiced in other states, and only included a pilot program, the Bellevue Outpatient Commitment Program, that was never taken statewide.
In addition, the New York Times reported on Kendra’s Law:
The “program that orders these patients to receive treatment when they are not hospitalized has had positive results. Patients were much less likely to end up back in psychiatric hospitals and were arrested less often. Use of outpatient treatment significantly increased, as did refills of medication. Costs to the mental health system and Medicaid of caring for these patients dropped by half or more.”
Kendra’s Law is opposed for different reasons by many groups, most notably the anti-psychiatry movement and the New York Civil Liberties Union. Opponents say that the law has harmed the mental health system, because it can deter people from seeking treatment. The implementation of the law is also criticised as being racially and socioeconomically biased.
A 2017 Cochrane systematic review of the literature, that included three relatively small randomized controlled trials, did not find significant differences in the use of services, social functioning, or quality of life when comparing compulsory community treatment with standard voluntary care or brief supervised discharge. The systematic review did report that people who receive compulsory community treatment may be less likely to be victims of crime, both violent and non-violent.
A randomised, controlled trial published in The Lancet concluded, “the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty.”
Of 442 patients assessed, 336 patients were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients). One patient withdrew directly after randomisation and two were ineligible, giving a total sample of 333 patients (166 in the CTO group and 167 in the Section 17 group). At 12 months, despite the fact that the length of initial compulsory outpatient treatment differed significantly between the two groups (median 183 days CTO group vs 8 days Section 17 group, p<0·001) the number of patients readmitted did not differ between groups (59 [36%] of 166 patients in the CTO group vs 60 [36%] of 167 patients in the Section 17 group; adjusted relative risk 1·0 [95% CI 0·75—1·33]).
A 2005 study, “Kendra’s Law: A Final Report on the Status of Assisted Outpatient Treatment”, done by New York State’s Office of Mental Health, concluded, “Over a three year period prior to their AOT order, almost all (97%) had been hospitalised (with an average of three hospitalisations per recipient), and many experienced homelessness, arrest, and incarceration. During participation in the AOT programme, rates for hospitalisations, homelessness, arrests, and incarcerations have declined significantly, and programme participants have experienced a lessening of the stress associated with these events.”
The same study found 55% fewer recipients engaged in suicide attempts or physical harm to self; 47% fewer physically harmed others; 46% fewer damaged or destroyed property; 43% fewer threatened physical harm to others and the average decrease in harmful behaviour was 44%. 74% fewer participants experienced homelessness; 77% fewer experienced psychiatric hospitalisation; there was a 56% reduction in length of hospitalization; 83% fewer experienced arrest; 87% fewer experienced incarceration; 49% fewer abused alcohol and 48% fewer abused drugs. The number of individuals exhibiting good adherence to meds increased 51%; The number of individuals exhibiting good service engagement increased 103%.
The study found that of those subjects included in the sample, 75% reported that AOT helped them gain control over their lives; 81% said AOT helped them get and stay well; 90% said AOT made them more likely to keep appointments and take medications; 87% of participants said they were confident in their case manager’s ability, and 88% said they and their case manager agreed on the issues to be addressed.
The study reported the following effects on the mental health system. “Improved access to services. AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers.” “Improved treatment plan development, discharge planning, and coordination of service planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past.” “Improved collaboration between mental health and court systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources.” “There is now an organized process to prioritize and monitor individuals with the greatest need …” AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve. …” “There is now increased collaboration between inpatient and community-based providers.”
A 2009 study, New York State Assisted Outpatient Treatment Evaluation done by Duke University, Policy Research Associates, University of Virginia, concluded that New York State’s programme had the following effects on the mental health system:
…improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients. The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes. It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.
The authors said that the evaluation reflected not just the compulsory aspects of the programme, but the additional resources provided for recipients, particularly in New York City.
The same study found “No evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings.” “AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.” “After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone.” “Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT.”
One study found Kendra’s Law has lowered risk of violent behaviour, reduced thoughts about suicide, and enhanced capacity to function despite problems with mental illness. Patients given mandatory outpatient treatment were four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. Patients who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem.
Another study found, “For those who received AOT, the odds of any arrest were 2.66 times greater (p<.01) and the odds of arrest for a violent offense 8.61 times greater (p<.05) before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds (1.91, p<.05) of arrest compared with the AOT group in the period during and shortly after assignment.”
Another study found, “The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (OR=.39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement.”
A study previously cited also found, “The likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order … and by over one-third during a subsequent six-month renewal of the order…. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals…. Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services.”
A peer-reviewed study that included an analysis on the costs of Assisted Outpatient Treatment found that in New York City net costs declined 50% in the first year after Assisted Outpatient Treatment began and an additional 13% in the second year. In non-NYC counties, costs declined 62% in the first year and an additional 27% in the second year. This was in spite of the fact that psychotropic drug costs increased during the first year after initiation of Assisted Outpatient Treatment, by 40 percent and 44 percent in the city and five-county samples, respectively. The increased community-based mental health costs were more than offset by the reduction in inpatient and incarceration costs. Cost declines associated with Assisted Outpatient Treatment were about twice as large as those seen for voluntary services.
Another study found that “In all three regions, for all three groups, the predicted probability of a M(edication) P(ossession) R(atio) ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and ‘neither treatment,’ improving 8–19 points).”
Another peer review study on the effect of AOT on the mental health system found that “In tandem with New York’s AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.”
Finally, a study found individuals in AOT stay in treatment after AOT ends. “When the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services.”
On 15 January 2013, then New York Governor Andrew Cuomo signed into law a new measure that extended Kendra’s Law through 2017.
47 states have adopted laws allowing for assisted outpatient treatment.
In February 2021, Governor Cuomo suggested that state lawmakers should revisit or expand Kendra’s law, after New York City experienced a spate of violent attacks committed by people with untreated mental illness.