Category: Mental Health

What is Couples Therapy?

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Introduction

Couples therapy (aka relationship counselling, couples’ counselling, marriage counselling, or marriage therapy) attempts to improve romantic relationships and resolve interpersonal conflicts.

Refer to Counselling Psychology.

Brief History

Marriage counselling originated in Germany in the 1920s as part of the eugenics movement. The first institutes for marriage counselling in the United States began in the 1930s, partly in response to Germany’s medically directed, racial purification marriage counselling centres. It was promoted by prominent American eugenicists such as Paul Popenoe, who directed the American Institute of Family Relations until 1976, and Robert Latou Dickinson and by birth control advocates such as Abraham and Hannah Stone who wrote A Marriage Manual in 1935 and were involved with Planned Parenthood. Other founders in the United States include Lena Levine and Margaret Sanger.

It was not until the 1950s that therapists began treating psychological problems in the context of the family. Relationship counselling as a discrete, professional service is thus a recent phenomenon. Until the late 20th century, the work of relationship counselling was informally fulfilled by close friends, family members, or local religious leaders. Psychiatrists, psychologists, counsellors and social workers have historically dealt primarily with individual psychological problems in a medical and psychoanalytic framework. In many less technologically advanced cultures around the world today, the institution of family, the village or group elders fulfil the work of relationship counselling. Today marriage mentoring mirrors those cultures.

With increasing modernisation or westernisation in many parts of the world and the continuous shift towards isolated nuclear families, the trend is towards trained and accredited relationship counsellors or couple therapists. Sometimes volunteers are trained by either the government or social service institutions to help those who are in need of family or marital counselling. Many communities and government departments have their own team of trained voluntary and professional relationship counsellors. Similar services are operated by many universities and colleges, sometimes staffed by volunteers from among the student peer group. Some large companies maintain a full-time professional counselling staff to facilitate smoother interactions between corporate employees, to minimise the negative effects that personal difficulties might have on work performance.

Increasingly there is a trend toward professional certification and government registration of these services. This is in part due to the presence of duty of care issues and the consequences of the counsellor or therapist’s services being provided in a fiduciary relationship.

Refer to alienation of affection (a common law tort, abolished in many jurisdictions. Where it still exists, it is an action brought by a spouse against a third party alleged to be responsible for damaging the marriage, most often resulting in divorce).

Basic Principles

It is estimated that nearly half of all married couples get divorced and about one in five marriages experience distress at some time. Challenges with affection, communication, disagreements and fears of divorce are some of the most common reasons couples reach out for help. Couples who are dissatisfied with their relationship may turn to a variety of sources for help including online courses, self-help books, retreats, workshops, and couples counselling.

Before a relationship between individuals can begin to be understood, it is important to recognise and acknowledge that each person, including the counsellor, has a unique personality, perception, set of values and history. Individuals in the relationship may adhere to different and unexamined value systems. Institutional and societal variables (like the social, religious, group and other collective factors) which shape a person’s nature and behaviour are considered in the process of counselling and therapy. A tenet of relationship counselling is that it is intrinsically beneficial for all the participants to interact with each other and with society at large with optimal amounts of conflict. A couple’s conflict resolution skills seem to predict divorce rates.

Most relationships will get strained at some time, resulting in a failure to function optimally and produce self-reinforcing, maladaptive patterns. These patterns may be called “negative interaction cycles.” There are many possible reasons for this, including insecure attachment, ego, arrogance, jealousy, anger, greed, poor communication/understanding or problem solving, ill health, third parties and so on.

Changes in situations like financial state, physical health, and the influence of other family members can have a profound influence on the conduct, responses and actions of the individuals in a relationship.

Often it is an interaction between two or more factors, and frequently it is not just one of the people who are involved that exhibit such traits. Relationship influences are reciprocal: it takes each person involved to make and manage problems.

A viable solution to the problem and setting these relationships back on track may be to reorient the individuals’ perceptions and emotions – how one looks at or responds to situations and feels about them. Perceptions of and emotional responses to a relationship are contained within an often unexamined mental map of the relationship, also called a love map by John Gottman. These can be explored collaboratively and discussed openly. The core values they comprise can then be understood and respected or changed when no longer appropriate. This implies that each person takes equal responsibility for awareness of the problem as it arises, awareness of their own contribution to the problem and making some fundamental changes in thought and feeling.

The next step is to adopt conscious, structural changes to the inter-personal relationships and evaluate the effectiveness of those changes over time.

Indeed, “typically for those close personal relations, there is a certain degree in ‘interdependence’ – which means that the partners are alternately mutually dependent on each other. As a special aspect of such relations, something contradictory is put outside: the need for intimacy and for autonomy.”

“The common counterbalancing satisfaction these both needs, intimacy and autonomy, leads to alternately satisfaction in the relationship and stability. But it depends on the specific developing duties of each partner in every life phase and maturity”.

Basic Practices

Two methods of couples therapy focus primarily on the process of communicating. The most commonly used method is active listening, used by the late Carl Rogers and Virginia Satir, and recommended by Harville Hendrix in Getting the Love You Want. More recently, a method called “Cinematic Immersion” has been developed by Warren Farrell in Women Can’t Hear What Men Don’t Say. Each helps couples learn a method of communicating designed to create a safe environment for each partner to express and hear feelings.

When the Munich Marital Study discovered active listening to not be used in the long run, Warren Farrell observed that active listening did a better job creating a safe environment for the criticiser to criticise than for the listener to hear the criticism. The listener, often feeling overwhelmed by the criticism, tended to avoid future encounters. He hypothesized that we were biologically programmed to respond defensively to criticism, and therefore the listener needed to be trained in-depth with mental exercises and methods to interpret as love what might otherwise feel abusive. His method is Cinematic Immersion.

After 30 years of research into marriage, John Gottman has found that healthy couples almost never listen and echo each other’s feelings naturally. Whether miserable or radiantly happy, couples said what they thought about an issue, and “they got angry or sad, but their partner’s response was never anything like what we were training people to do in the listener/speaker exercise, not even close.”

Such exchanges occurred in less than 5 percent of marital interactions and they predicted nothing about whether the marriage would do well or badly. What’s more, Gottman noted, data from a 1984 Munich study demonstrated that the (reflective listening) exercise itself did not help couples to improve their marriages. To teach such interactions, whether as a daily tool for couples or as a therapeutic exercise in empathy, was a clinical dead end.

By contrast, emotionally focused therapy for couples (EFT-C) is based on attachment theory and uses emotion as the target and agent of change. Emotions bring the past alive in rigid interaction patterns, which create and reflect absorbing emotional states. As one of its founders, Sue Johnson (Hold Me Tight, 2018, p.6) says:

Forget about learning how to argue better, analysing your early childhood, making grand romantic gestures, or experimenting with new sexual positions. Instead, recognize and admit that you are emotionally attached to and dependent on your partner in much the same way that a child is on a parent for nurturing, soothing, and protection.

Research on Therapy

The most researched approach to couples therapy is behavioural couples therapy. It is a well established treatment for marital discord. This form of therapy has evolved into what is now called integrative behavioural couples therapy. Integrative behavioural couples therapy appears to be effective for 69% of couples in treatment, while the traditional model was effective for 50-60% of couples. At five-year follow-up, the marital happiness of the 134 couples who had participated in either integrative behavioural couples therapy or traditional couples therapy showed that 14% of relationships remained unchanged, 38% deteriorated, and 48% improved or recovered completely.

A review conducted in 2018 by Cochrane (organisation) states that the available evidence does not suggest that couples therapy is more or less effective than individual therapy for treating depression.

Relationship Counsellor or Couple’s Therapist

Licensed couple therapist may refer to a psychiatrist, clinical social workers, counselling psychologists, clinical psychologists, pastoral counsellors, marriage and family therapists, and psychiatric nurses. The duty and function of a relationship counsellor or couples therapist is to listen, respect, understand and facilitate better functioning between those involved.

The basic principles for a counsellor include:

  • Provide a confidential dialogue, which normalises feelings.
  • To enable each person to be heard and to hear themselves.
  • Provide a mirror with expertise to reflect the relationship’s difficulties and the potential and direction for change.
  • Empower the relationship to take control of its own destiny and make vital decisions.
  • Deliver relevant and appropriate information.
  • Changes the view of the relationship.
  • Improve communication.
  • Set clear goals and objectives.

As well as the above, the basic principles for a couples therapist also include:

  • To identify the repetitive, negative interaction cycle as a pattern.
  • To understand the source of reactive emotions that drive the pattern.
  • To expand and re-organise key emotional responses in the relationship.
  • To facilitate a shift in partners’ interaction to new patterns of interaction.
  • To create new and positively bonding emotional events in the relationship.
  • To foster a secure attachment between partners.
  • To help maintain a sense of intimacy.

Common core principles of relationship counselling and couples therapy are:

  • Respect.
  • Empathy.
  • Tact.
  • Consent.
  • Confidentiality.
  • Accountability.
  • Expertise.
  • Evidence based.
  • Certification and ongoing training.

In both methods, the practitioner evaluates the couple’s personal and relationship story as it is narrated, interrupts wisely, facilitates both de-escalation of unhelpful conflict and the development of realistic, practical solutions. The practitioner may meet each person individually at first but only if this is beneficial to both, is consensual and is unlikely to cause harm. Individualistic approaches to couple problems can cause harm. The counsellor or therapist encourages the participants to give their best efforts to reorienting their relationship with each other. One of the challenges here is for each person to change their own responses to their partner’s behaviour. Other challenges to the process are disclosing controversial or shameful events and revealing closely guarded secrets. Not all couples put all of their cards on the table at first. This can take time.

Novel Practices

A novel development in the field of couples therapy has involved the introduction of insights gained from affective neuroscience and psychopharmacology into clinical practice.

Oxytocin

There has been interest in use of the so-called love hormone – oxytocin – during therapy sessions, although this is still largely experimental and somewhat controversial. Some researchers have argued oxytocin has a general enhancing effect on all social emotions, since intranasal administration of oxytocin also increases envy and Schadenfreude. Also, oxytocin has also the potential for being abused in confidence tricks.

Popularised Methodologies

Although results are almost certainly significantly better when professional guidance is utilised (see especially family therapy), numerous attempts at making the methodologies available generally via self-help books and other media are available. In the last few years, it has become increasingly popular for these self-help books to become popularised and published as an e-book available on the web, or through content articles on blogs and websites. The challenges for individuals utilising these methods are most commonly associated with that of other self-help therapies or self-diagnosis.

Using modern technologies such as Skype VoIP conferencing to interact with practitioners are also becoming increasingly popular for their added accessibility as well as discarding any existing geographic barriers. Entrusting in the performance and privacy of these technologies may pose concerns despite the convenient structure, especially compared to the comfort of in-person meetings.

With Homosexual/Bisexual Clients

Differing psychological theories play an important role in determining how effective relationship counselling is, especially when it concerns homosexual/bisexual clients. Some experts tout cognitive behavioural therapy as the tool of choice for intervention while many rely on acceptance and commitment therapy or cognitive analytic therapy. One major progress in this area is the fact that “marital therapy” is now referred to as “couples therapy” in order to include individuals who are not married or those who are engaged in same sex relationships. Most relationship issues are shared equally among couples regardless of sexual orientation, but LGBT clients additionally have to deal with heteronormativity, homophobia and both socio-cultural and legal discrimination. Individuals may experience relational ambiguity from being in different stages of the coming out process or having an HIV serodiscordant relationship. Often, same-sex couples do not have as many role models of successful relationships as opposite-sex couples. In many jurisdictions committed LGBT couples desiring a family are denied access to assisted reproduction, adoption and fostering, leaving them childless, feeling excluded, other and bereaved. There may be issues with gender-role socialization that do not affect opposite-sex couples.

A significant number of men and women experience conflict surrounding homosexual expression within a mixed-orientation marriage. Couple therapy may include helping the clients feel more comfortable and accepting of same-sex feelings and to explore ways of incorporating same-sex and opposite-sex feelings into life patterns. Although a strong homosexual identity was associated with difficulties in marital satisfaction, viewing the same-sex activities as compulsive facilitated commitment to the marriage and to monogamy.

What is Scotomisation?

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Introduction

Scotomisation is a psychological term for the mental blocking of unwanted perceptions, analogous to the visual blindness of an actual scotoma.

Controversies

Reviving in the 1920s a term initially used by Charcot in connection with hysteria, the French analysts Rene Laforgue and Edouard Pinchon introduced the idea of scotomisation into psychoanalysis – a move initially welcomed by Freud in 1926 as a useful description of the hysterical avoidance of distressing perceptions. The following year, however, he attacked the term for suggesting that the perception was wholly blotted out (as with a retina’s blind spot), whereas his clinical experience showed that on the contrary intense psychic measures had to be taken to keep the unwanted perception out of consciousness. A debate followed between Freud and Laforgue, further illuminated by Pinchon’s 1928 article on ‘The Psychological Significance of Negation in French’, where he argued that “The French language expresses the desire for scotomisation through the forclusif.”

Decades later in the 1950s, the question of scotomisation re-emerged in a phenological context under the influence of Jacques Lacan. Lacan used scotomisation to represent the ego’s relationship to the unconscious – speaking of “everything that the ego, neglects, scotomizes, misconstrues in…reality” – as well as to challenge Sartre’s concept of the gaze. Most significantly of all, however, he developed it into his influential update of Pinchon’s concept of foreclosure, thus endowing that idea with a conflation of visual and verbal elements.

What is Applied Psychology?

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Introduction

Applied psychology is the use of psychological methods and findings of scientific psychology to solve practical problems of human and animal behaviour and experience.

Mental health, organisational psychology, business management, education, health, product design, ergonomics, and law are just a few of the areas that have been influenced by the application of psychological principles and findings. Some of the areas of applied psychology include clinical psychology, counselling psychology, evolutionary psychology, industrial and organisational psychology, legal psychology, neuropsychology, occupational health psychology, human factors, forensic psychology, engineering psychology, school psychology, sports psychology, traffic psychology, community psychology, and medical psychology. In addition, a number of specialised areas in the general field of psychology have applied branches (e.g. applied social psychology, applied cognitive psychology). However, the lines between sub-branch specialisations and major applied psychology categories are often blurred. For example, a human factors psychologist might use a cognitive psychology theory. This could be described as human factor psychology or as applied cognitive psychology.

Brief History

The founder of applied psychology was Hugo Münsterberg. He came to America (Harvard) from Germany (Berlin, Laboratory of Stern), invited by William James, and, like many aspiring psychologists during the late 19th century, originally studied philosophy. Münsterberg had many interests in the field of psychology such as purposive psychology, social psychology and forensic psychology. In 1907 he wrote several magazine articles concerning legal aspects of testimony, confessions and courtroom procedures, which eventually developed into his book, On the Witness Stand. The following year the Division of Applied Psychology was adjoined to the Harvard Psychological Laboratory. Within 9 years he had contributed eight books in English, applying psychology to education, industrial efficiency, business and teaching. Eventually Hugo Münsterberg and his contributions would define him as the creator of applied psychology. In 1920, the International Association of Applied Psychology (IAAP) was founded, as the first international scholarly society within the field of psychology.

Most professional psychologists in the US worked in an academic setting until World War II. But during the war, the armed forces and the Office of Strategic Services hired psychologists in droves to work on issues such as troop morale and propaganda design. After the war, psychologists found an expanding range of jobs outside of the academy. Since 1970, the number of college graduates with degrees in psychology has more than doubled, from 33,679 to 76,671 in 2002. The annual numbers of masters’ and PhD degrees have also increased dramatically over the same period. All the while, degrees in the related fields of economics, sociology, and political science have remained constant.

Professional organisations have organised special events and meetings to promote the idea of applied psychology. In 1990, the American Psychological Society held a Behavioural Science Summit and formed the “Human Capital Initiative”, spanning schools, workplace productivity, drugs, violence, and community health. The American Psychological Association declared 2000-2010 the Decade of Behaviour, with a similarly broad scope. Psychological methods are considered applicable to all aspects of human life and society.

Advertising

Business advertisers have long consulted psychologists in assessing what types of messages will most effectively induce a person to buy a particular product. Using the psychological research methods and the findings in human’s cognition, motivation, attitudes and decision making, those can help to design more persuasive advertisement. Their research includes the study of unconscious influences and brand loyalty. However, the effect of unconscious influences was controversial.

Clinical Psychology

Clinical psychology includes the study and application of psychology for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment and psychotherapy, although clinical psychologists may also engage in research, teaching, consultation, forensic testimony, and programme development and administration. Some clinical psychologists may focus on the clinical management of patients with brain injury – this area is known as clinical neuropsychology. In many countries clinical psychology is a regulated mental health profession.

The work performed by clinical psychologists tends to be done inside various therapy models, all of which involve a formal relationship between professional and client – usually an individual, couple, family, or small group – that employs a set of procedures intended to form a therapeutic alliance, explore the nature of psychological problems, and encourage new ways of thinking, feeling, or behaving. The four major perspectives are psychodynamic, cognitive behavioural, existential-humanistic, and systems or family therapy. There has been a growing movement to integrate these various therapeutic approaches, especially with an increased understanding of issues regarding ethnicity, gender, spirituality, and sexual-orientation. With the advent of more robust research findings regarding psychotherapy, there is growing evidence that most of the major therapies are about of equal effectiveness, with the key common element being a strong therapeutic alliance. Because of this, more training programmes and psychologists are now adopting an eclectic therapeutic orientation.

Clinical psychologists do not usually prescribe medication, although there is a growing number of psychologists who do have prescribing privileges, in the field of medical psychology. In general, however, when medication is warranted many psychologists will work in cooperation with psychiatrists so that clients get therapeutic needs met. Clinical psychologists may also work as part of a team with other professionals, such as social workers and nutritionists.

Counselling Psychology

Counselling psychology is an applied specialisation within psychology, that involves both research and practice in a number of different areas or domains. According to Gelso and Fretz (2001), there are some central unifying themes among counselling psychologists. These include a focus on an individual’s strengths, relationships, their educational and career development, as well as a focus on normal personalities. Counselling psychologists help people improve their well-being, reduce and manage stress, and improve overall functioning in their lives. The interventions used by Counselling Psychologists may be either brief or long-term in duration. Often they are problem focused and goal-directed. There is a guiding philosophy which places a value on individual differences and an emphasis on “prevention, development, and adjustment across the life-span.”

Educational Psychology

Educational psychology is devoted to the study of how humans learn in educational settings, especially schools. Psychologists assess the effects of specific educational interventions: e.g. phonics versus whole language instruction in early reading attainment. They also study the question of why learning occurs differently in different situations.

Another domain of educational psychology is the psychology of teaching. In some colleges, educational psychology courses are called “the psychology of learning and teaching”. Educational psychology derives a great deal from basic-science disciplines within psychology including cognitive science and behaviourally-oriented research on learning.

Environmental Psychology

Environmental psychology is the psychological study of humans and their interactions with their environments. The types of environments studied are limitless, ranging from homes, offices, classrooms, factories, nature, and so on. However, across these different environments, there are several common themes of study that emerge within each one. Noise level and ambient temperature are clearly present in all environments and often subjects of discussion for environmental psychologists. Crowding and stressors are a few other aspects of environments studied by this sub-discipline of psychology. When examining a particular environment, environmental psychology looks at the goals and purposes of the people in the using the environment, and tries to determine how well the environment is suiting the needs of the people using it. For example, a quiet environment is necessary for a classroom of students taking a test, but would not be needed or expected on a farm full of animals. The concepts and trends learned through environmental psychology can be used when setting up or rearranging spaces so that the space will best perform its intended function. The top common, more well known areas of psychology that drive this applied field include: cognitive, perception, learning, and social psychology.

Forensic Psychology and Legal Psychology

Forensic psychology and legal psychology are the areas concerned with the application of psychological methods and principles to legal questions and issues. Most typically, forensic psychology involves a clinical analysis of a particular individual and an assessment of some specific psycho-legal question. The psycho-legal question does not have to be criminal in nature. In fact, the forensic psychologist rarely gets involved in the actual criminal investigations. Custody cases are a great example of non-criminal evaluations by forensic psychologists. The validity and upholding of eyewitness testimony is an area of forensic psychology that does veer closer to criminal investigations, though does not directly involve the psychologist in the investigation process. Psychologists are often called to testify as expert witnesses on issues such as the accuracy of memory, the reliability of police interrogation, and the appropriate course of action in child custody cases.

Legal psychology refers to any application of psychological principles, methods or understanding to legal questions or issues. In addition to the applied practices, legal psychology also includes academic or empirical research on topics involving the relationship of law to human mental processes and behaviour. However, inherent differences that arise when placing psychology in the legal context. Psychology rarely makes absolute statements. Instead, psychologists traffic in the terms like level of confidence, percentages, and significance. Legal matters, on the other hand, look for absolutes: guilty or not guilty. This makes for a sticky union between psychology and the legal system. Some universities operate dual JD/PhD programmes focusing on the intersection of these two areas.

The Committee on Legal Issues of the American Psychological Association is known to file amicus curae briefs, as applications of psychological knowledge to high-profile court cases.

A related field, police psychology, involves consultation with police departments and participation in police training.

Health and Medicine

Health psychology concerns itself with understanding how biology, behaviour, and social context influence health and illness. Health psychologists generally work alongside other medical professionals in clinical settings, although many also teach and conduct research. Although its early beginnings can be traced to the kindred field of clinical psychology, four different approaches to health psychology have been defined: clinical, public health, community and critical health psychology.

Health psychologists aim to change health behaviours for the dual purpose of helping people stay healthy and helping patients adhere to disease treatment regimens. The focus of health psychologists tend to centre on the health crisis facing the western world particularly in the US, cognitive behavioural therapy and behaviour modification are techniques often employed by health psychologists. Psychologists also study patients’ compliance with their doctors’ orders.

Health psychologists view a person’s mental condition as heavily related to their physical condition. An important concept in this field is stress, a mental phenomenon with well-known consequences for physical health.

Medical

Medical psychology involves the application of a range of psychological principles, theories and findings applied to the effective management of physical and mental disorders to improve the psychological and physical health of the patient. The American Psychological Association (APA) defines medical psychology as the branch of psychology that integrates somatic and psychotherapeutic modalities, into the management of mental illness, health rehabilitation and emotional, cognitive, behavioural and substance use disorders. According to Muse and Moore (2012), the medical psychologist’s contributions in the areas of psychopharmacology which sets it apart from other of psychotherapy and psychotherapists.

Occupational Health Psychology

Occupational health psychology (OHP) is a relatively new discipline that emerged from the confluence of health psychology, industrial and organizational psychology, and occupational health. OHP has its own journals and professional organisations. The field is concerned with identifying psychosocial characteristics of workplaces that give rise to health-related problems in people who work. These problems can involve physical health (e.g. cardiovascular disease) or mental health (e.g. depression). Examples of psychosocial characteristics of workplaces that OHP has investigated include amount of decision latitude a worker can exercise and the supportiveness of supervisors. OHP is also concerned with the development and implementation of interventions that can prevent or ameliorate work-related health problems. In addition, OHP research has important implications for the economic success of organisations. Other research areas of concern to OHP include workplace incivility and violence, work-home carryover, unemployment and downsizing, and workplace safety and accident prevention. Two important OHP journals are the Journal of Occupational Health Psychology and Work & Stress. Three important organisations closely associated with OHP are the International Commission on Occupational Health’s Scientific Committee on Work Organisation and Psychosocial Factors (ICOH-WOPS), the Society for Occupational Health Psychology, and the European Academy of Occupational Health Psychology.

Human Factors and Ergonomics

Human factors and ergonomics (HF&E) is the study of how cognitive and psychological processes affect our interaction with tools, machines, and objects in the environment. Many branches of psychology attempt to create models of and understand human behaviour. These models are usually based on data collected from experiments. Human Factor psychologists however, take the same data and use it to design or adapt processes and objects that will complement the human component of the equation. Rather than humans learning how to use and manipulate a piece of technology, human factors strives to design technology to be inline with the human behaviour models designed by general psychology. This could be accounting for physical limitations of humans, as in ergonomics, or designing systems, especially computer systems, that work intuitively with humans, as does engineering psychology.

Ergonomics is applied primarily through office work and the transportation industry. Psychologists here take into account the physical limitations of the human body and attempt to reduce fatigue and stress by designing products and systems that work within the natural limitations of the human body. From simple things like the size of buttons and design of office chairs to layout of airplane cockpits, human factor psychologists, specialising in ergonomics, attempt to de-stress our everyday lives and sometimes even save them.

Human factor psychologists specialising in engineering psychology tend to take on slightly different projects than their ergonomic centred counterparts. These psychologists look at how a human and a process interact. Often engineering psychology may be centred on computers. However at the base level, a process is simply a series of inputs and outputs between a human and a machine. The human must have a clear method to input data and be able to easily access the information in output. The inability of rapid and accurate corrections can sometimes lead to drastic consequences, as summed up by many stories in Set Phasers on Stun. The engineering psychologists wants to make the process of inputs and outputs as intuitive as possible for the user.

The goal of research in human factors is to understand the limitations and biases of human mental processes and behaviour, and design items and systems that will interact accordingly with the limitations. Some may see human factors as intuitive or a list of dos and don’ts, but in reality, human factor research strives to make sense of large piles of data to bring precise applications to product designs and systems to help people work more naturally, intuitively with the items of their surroundings.

Industrial and Organisational Psychology

Industrial and organisational psychology, or I-O psychology, focuses on the psychology of work. Relevant topics within I-O psychology include the psychology of recruitment, selecting employees from an applicant pool, training, performance appraisal, job satisfaction, work motivation. work behaviour, occupational stress, accident prevention, occupational safety and health, management, retirement planning and unemployment among many other issues related to the workplace and people’s work lives. In short, I-O psychology is the application of psychology to the workplace. One aspect of this field is job analysis, the detailed study of which behaviours a given job entails.

Though the name of the title “Industrial Organisational Psychology” implies 2 split disciplines being chained together, it is near impossible to have one half without the other. If asked to generally define the differences, Industrial psychology focuses more on the Human Resources aspects of the field, and Organisational psychology focuses more on the personal interactions of the employees. When applying these principles however, they are not easily broken apart. For example, when developing requirements for a new job position, the recruiters are looking for an applicant with strong communication skills in multiple areas. The developing of the position requirements falls under the industrial psychology, human resource type work. and the requirement of communication skills is related to how the employee with interacts with co-workers. As seen here, it is hard to separate task of developing a qualifications list from the types of qualifications on the list. This is parallel to how the I and O are nearly inseparable in practice. Therefore, I-O psychologists are generally rounded in both industrial and organisational psychology though they will have some specialisation. Other topics of interest for I-O psychologists include performance evaluation, training, and much more.

Military psychology includes research into the classification, training, and performance of soldiers.

School Psychology

School psychology is a field that applies principles of clinical psychology and educational psychology to the diagnosis and treatment of students’ behavioural and learning problems. School psychologists are educated in child and adolescent development, learning theories, psychological and psycho-educational assessment, personality theories, therapeutic interventions, special education, psychology, consultation, child and adolescent psychopathology, and the ethical, legal and administrative codes of their profession.

According to Division 16 (Division of School Psychology) of the American Psychological Association (APA), school psychologists operate according to a scientific framework. They work to promote effectiveness and efficiency in the field. School psychologists conduct psychological assessments, provide brief interventions, and develop or help develop prevention programmes. Additionally, they evaluate services with special focus on developmental processes of children within the school system, and other systems, such as families. School psychologists consult with teachers, parents, and school personnel about learning, behavioural, social, and emotional problems. They may teach lessons on parenting skills (like school counsellors), learning strategies, and other skills related to school mental health. In addition, they explain test results to parents and students. They provide individual, group, and in some cases family counselling. School psychologists are actively involved in district and school crisis intervention teams. They also supervise graduate students in school psychology. School psychologists in many districts provide professional development to teachers and other school personnel on topics such as positive behaviour intervention plans and achievement tests.

One salient application for school psychology in today’s world is responding to the unique challenges of increasingly multicultural classrooms. For example, psychologists can contribute insight about the differences between individualistic and collectivistic cultures.

School psychologists are influential within the school system and are frequently consulted to solve problems. Practitioners should be able to provide consultation and collaborate with other members of the educational community and confidently make decisions based on empirical research.

Social Change

Psychologists have been employed to promote “green” behaviour, i.e. sustainable development. In this case, their goal is behaviour modification, through strategies such as social marketing. Tactics include education, disseminating information, organising social movements, passing laws, and altering taxes to influence decisions.

Psychology has been applied on a world scale with the aim of population control. For example, one strategy towards television programming combines social models in a soap opera with informational messages during advertising time. This strategy successfully increased women’s enrolment at family planning clinics in Mexico. The programming – which has been deployed around the world by Population Communications International and the Population Media Centre – combines family planning messages with representations of female education and literacy.

Sport Psychology

Sport psychology is a specialisation within psychology that seeks to understand psychological/mental factors that affect performance in sports, physical activity and exercise and apply these to enhance individual and team performance. The sport psychology approach differs from the coaches and players perspective. Coaches tend to narrow their focus and energy towards the end-goal. They are concerned with the actions that lead to the win, as opposed to the sport psychologist who tries to focus the players thoughts on just achieving the win. Sport psychology trains players mentally to prepare them, whereas coaches tend to focus mostly on physical training. Sport psychology deals with increasing performance by managing emotions and minimizing the psychological effects of injury and poor performance. Some of the most important skills taught are goal setting, relaxation, visualization, self-talk awareness and control, concentration, using rituals, attribution training, and periodisation. The principles and theories may be applied to any human movement or performance tasks (e.g. playing a musical instrument, acting in a play, public speaking, motor skills). Usually, experts recommend that students be trained in both kinesiology (i.e. sport and exercise sciences, physical education) and counselling.

Traffic Psychology

Traffic psychology is an applied discipline within psychology that looks at the relationship between psychological processes and cognitions and the actual behaviour of road users. In general, traffic psychologists attempt to apply these principles and research findings, in order to provide solutions to problems such as traffic mobility and congestion, road accidents, speeding. Research psychologists also are involved with the education and the motivation of road users.

What is the Relationship Between Antidepressants and Suicide Risk?

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Introduction

The relationship between antidepressant use and suicide risk is a subject of medical research and has faced varying levels of debate.

This problem was thought to be serious enough to warrant intervention by the US Food and Drug Administration (FDA) to label greater likelihood of suicide as a risk of using antidepressants. Some studies have shown that the use of certain antidepressants correlate with an increased risk of suicide in some patients relative to other antidepressants. However, these conclusions have faced considerable scrutiny and disagreement: A multinational European study indicated that antidepressants decrease risk of suicide at the population level, and other reviews of antidepressant use claim that there is not enough data to indicate antidepressant use increases risk of suicide.

Youth/Young Adults

People under the age of 25 with depression antidepressants could increase the risk of suicidal thoughts and behaviour. In 2004, the FDA along with the Neuro-Psychopharmacologic Advisory Committee and the Anti-Infective Drugs Advisory Committee, concluded that there was a causal link between newer antidepressants and paediatric suicidality. Federal health officials unveiled proposed changes to the labels on antidepressant drugs in December 2006 to warn people of this danger.

A 2016 review of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) which looked at four outcomes – death, suicidality, aggressive behaviour, and agitation – found that while the data was insufficient to draw strong conclusions, adults taking these drugs did not appear to be at increased risk for any of the four outcomes, but that for children, the risks of suicidality and for aggression doubled. The authors expressed frustration with incomplete reporting and lack of access to data, and with some aspects of the clinical trial designs.

Warnings

The FDA requires “black box warnings” on all SSRIs, which state that they double suicidal ideation rates (from 2 in 1,000 to 4 in 1,000) in children and adolescents. It remains controversial whether increased risk of suicide is due to the medication (a paradoxical effect) or part of the depression itself (i.e. the antidepressant enables those who are severely depressed – who ordinarily would be paralysed by their depression – to become more alert and act out suicidal urges before being fully recovered from their depressive episode). The increased risk for suicidality and suicidal behaviour among adults under 25 approaches that seen in children and adolescents. Young patients should be closely monitored for signs of suicidal ideation or behaviours, especially in the first eight weeks of therapy. Sertraline, tricyclic agents and venlafaxine were found to increase the risk of attempted suicide in severely depressed adolescents on Medicaid.

Increased Risk for Quitting Medication

A 2009 study showed increased risk of suicide after initiation, titration, and discontinuation of medication. A study of 159,810 users of either amitriptyline, fluoxetine, paroxetine or dothiepin found that the risk of suicidal behaviour is increased in the first month after starting antidepressants, especially during the first 1 to 9 days.

Prevalence

On 06 September 2007, the US Centres for Disease Control and Prevention reported that the suicide rate in American adolescents, (especially girls, 10 to 24 years old), increased 8% (2003 to 2004), the largest jump in 15 years, to 4,599 suicides in Americans ages 10 to 24 in 2004, from 4,232 in 2003, giving a suicide rate of 7.32 per 100,000 people that age. The rate previously dropped to 6.78 per 100,000 in 2003 from 9.48 per 100,000 in 1990. Jon Jureidini, a critic of this study, says that the US “2004 suicide figures were compared simplistically with the previous year, rather than examining the change in trends over several years”. It has been noted that the pitfalls of such attempts to infer a trend using just two data points (years 2003 and 2004) are further demonstrated by the fact that, according to the new epidemiological data, the suicide rate in 2005 in children and adolescents actually declined despite the continuing decrease of SSRI prescriptions. “It is risky to draw conclusions from limited ecologic analyses of isolated year-to-year fluctuations in antidepressant prescriptions and suicides.

One promising epidemiological approach involves examining the associations between trends in psychotropic medication use and suicide over time across a large number of small geographic regions. Until the results of more detailed analyses are known, prudence dictates deferring judgment concerning the public health effects of the FDA warnings.” Subsequent follow-up studies have supported the hypothesis that antidepressant drugs reduce suicide risk.

Suicide Risk

In those under the age of 25 antidepressants appear to increase the risk of suicidal thoughts and behaviours. In the United States they contain a black box warning regarding this concern.

A 2016 review found a decreased suicidal events in older adults.

What is Behavioural Neurology?

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Introduction

Behavioural neurology is a subspecialty of neurology that studies the impact of neurological damage and disease upon behaviour, memory, and cognition, and the treatment thereof.

Refer to Behavioural Neuroscience.

Background

Two fields associated with behavioural neurology are neuropsychiatry and neuropsychology. In the United States, ‘Behavioural Neurology & Neuropsychiatry’ has been recognised as a single subspecialty by the United Council for Neurologic Subspecialties (UCNS) since 2004.

Symptoms

Syndromes and diseases commonly studied by behavioural neurology include:

  • Agraphia.
  • Agnosias.
  • Agraphesthesia.
  • Alexia (acquired dyslexia).
  • Amnesias.
  • Anosognosia.
  • Aphasias.
  • Apraxias.
  • Aprosodias.
  • Attention deficit hyperactivity disorder (ADHD).
  • Autism.
  • Dementia.
  • Dyslexia.
  • Epilepsy.
  • Hemispatial Neglect.
  • Psychosis.
  • Stroke.
  • Traumatic brain injury.

Brief History

While descriptions of behavioural syndromes go back to the ancient Greeks and Egyptians, it was during the 19th century that behavioural neurology began to arise, first with the primitive localisation theories of Franz Gall, followed in the mid 19th century by the first localisations in aphasias by Paul Broca and then Carl Wernicke. Localisationist neurology and clinical descriptions reached a peak in the late 19th and early 20th century, with work extending into the clinical descriptions of dementias by Alois Alzheimer and Arnold Pick. The work of Karl Lashley in rats for a time in the early to mid 20th century put a damper on localisation theory and lesion models of behavioural function.

In the United States, the work of Norman Geschwind led to a renaissance of behavioural neurology. He is famous for his work on disconnection syndromes, aphasia, and behavioural syndromes of limbic epilepsy, also called Geschwind syndrome. Having trained generations of behavioural neurologists (e.g. Antonio Damasio), Geschwind is considered the father of behavioural neurology.

The advent of in vivo neuroimaging starting in the 1980s led to a further strengthening of interest in the cognitive neurosciences and provided a tool that allowed for lesion, structural, and functional correlations with behavioural dysfunction in living people.

What is the Biopsychiatry Controversy?

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Introduction

The biopsychiatry controversy is a dispute over which viewpoint should predominate and form a basis of psychiatric theory and practice.

The debate is a criticism of a claimed strict biological view of psychiatric thinking. Its critics include disparate groups such as the antipsychiatry movement and some academics.

Overview of Opposition to Biopsychiatry

Biological psychiatry or biopsychiatry aims to investigate determinants of mental disorders devising remedial measures of a primarily somatic nature.

This has been criticised by Alvin Pam for being a “stilted, unidimensional, and mechanistic world-view”, so that subsequent “research in psychiatry has been geared toward discovering which aberrant genetic or neurophysiological factors underlie and cause social deviance”. According to Pam the “blame the body” approach, which typically offers medication for mental distress, shifts the focus from disturbed behaviour in the family to putative biochemical imbalances.

Research Issues

2003 Status in Biopsychiatric Research

Biopsychiatric research has produced reproducible abnormalities of brain structure and function, and a strong genetic component for a number of psychiatric disorders (although the latter has never been shown to be causative, merely correlative). It has also elucidated some of the mechanisms of action of medications that are effective in treating some of these disorders. Still, by their own admission, this research has not progressed to the stage that they can identify clear biomarkers of these disorders.

Research has shown that serious neurobiological disorders such as schizophrenia reveal reproducible abnormalities of brain structure (such as ventricular enlargement) and function. Compelling evidence exists that disorders including schizophrenia, bipolar disorder, and autism to name a few have a strong genetic component. Still, brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group. Ultimately, no gross anatomical lesion such as a tumour may ever be found; rather, mental disorders will likely be proven to represent disorders of intercellular communication; or of disrupted neural circuitry. Research already has elucidated some of the mechanisms of action of medications that are effective for depression, schizophrenia, anxiety, attention deficit, and cognitive disorders such as Alzheimer’s disease. These medications clearly exert influence on specific neurotransmitters, naturally occurring brain chemicals that effect, or regulate, communication between neurons in regions of the brain that control mood, complex reasoning, anxiety, and cognition. In 1970, The Nobel Prize was awarded to Julius Axelrod, Ph.D., of the National Institute of Mental Health, for his discovery of how anti-depressant medications regulate the availability of neurotransmitters such as norepinephrine in the synapses, or gaps, between nerve cells. (American Psychiatric Association, Statement on Diagnosis and Treatment of Mental Disorders, 26 September 2003).

Focus on Genetic Factors

Researchers have proposed that most common psychiatric and drug abuse disorders can be traced to a small number of dimensions of genetic risk and reports show significant associations between specific genomic regions and psychiatric disorders. Though, to date only a few genetic lesions have been demonstrated to be mechanistically responsible for psychiatric conditions. For example, one reported finding suggests that in persons diagnosed as schizophrenic as well as in their relatives with chronic psychiatric illnesses, the gene that encodes phosphodiesterase 4B (PDE4B) is disrupted by a balanced translocation.

The reasons for the relative lack of genetic understanding is because the links between genes and mental states defined as abnormal appear highly complex, involve extensive environmental influences and can be mediated in numerous different ways, for example by personality, temperament or life events. Therefore, while twin studies and other research suggests that personality is heritable to some extent, finding the genetic basis for particular personality or temperament traits, and their links to mental health problems, is “at least as hard as the search for genes involved in other complex disorders.” Theodore Lidz and The Gene Illusion argue that biopsychiatrists use genetic terminology in an unscientific way to reinforce their approach. Joseph maintains that biopsychiatrists disproportionately focus on understanding the genetics of those individuals with mental health problems at the expense of addressing the problems of the living in the environments of some extremely abusive families or societies.

Focus on Biochemical Factors

The chemical imbalance hypothesis states that a chemical imbalance within the brain is the main cause of psychiatric conditions and that these conditions can be improved with medication which corrects this imbalance. In that, emotions within a “normal” spectrum reflect a proper balance of neurotransmitter function, but abnormally extreme emotions which are severe enough to impact the daily functioning of patients (as seen in schizophrenia) reflect a profound imbalance. It is the goal of psychiatric intervention, therefore, to regain the homeostasis (via psychopharmacological approaches) that existed prior to the onset of disease.

This conceptual framework has been debated within the scientific community, although no other demonstrably superior hypothesis has emerged. Recently, the biopsychosocial approach to mental illness has been shown to be the most comprehensive and applicable theory in understanding psychiatric disorders. However, there is still much to be discovered in this area of inquiry. As a prime example – while great strides have been made in the field of understanding certain psychiatric disorders (such as schizophrenia) others (such as major depressive disorder) operate via multiple different neurotransmitters and interact in a complex array of systems which are (as yet) not completely understood.

Reductionism

Niall McLaren emphasizes in his books Humanizing Madness and Humanizing Psychiatry that the major problem with psychiatry is that it lacks a unified model of the mind and has become entrapped in a biological reductionist paradigm. The reasons for this biological shift are intuitive as reductionism has been very effective in other fields of science and medicine. However, despite reductionism’s efficacy in explaining the smallest parts of the brain this does not explain the mind, which is where he contends the majority of psychopathology stems from. An example would be that every aspect of a computer can be understood scientifically down to the last atom; however, this does not reveal the program that drives this hardware. He also argues that the widespread acceptance of the reductionist paradigm leads to a lack of openness to self-criticism and therefore halts the very engine of scientific progress. He has proposed his own natural dualist model of the mind, the biocognitive model, which is rooted in the theories of David Chalmers and Alan Turing and does not fall into the dualist’s trap of spiritualism.

Economic Influences on Psychiatric Practice

American Psychiatric Association president Steven S. Sharfstein, M.D. has stated that when the profit motive of pharmaceutical companies and human good are aligned, the results are mutually beneficial for all. In that, “Pharmaceutical companies have developed and brought to market medications that have transformed the lives of millions of psychiatric patients. The proven effectiveness of antidepressant, mood-stabilising, and antipsychotic medications has helped sensitize the public to the reality of mental illness and taught them that treatment works[citation needed]. In this way, Big Pharma has helped reduce stigma associated with psychiatric treatment and with psychiatrists.” However, Sharfstein acknowledged that the goals of individual physicians who deliver direct patient care can be different from the pharmaceutical and medical device industry. Conflicts arising from this disparity raise natural concerns in this regard including:

  • A “broken health care system” that allows “many patients [to be] prescribed the wrong drugs or drugs they don’t need”;
  • “medical education opportunities sponsored by pharmaceutical companies [that] are often biased toward one product or another”;
  • “[d]irect marketing to consumers [that] also leads to increased demand for medications and inflates expectations about the benefits of medications”;
  • “drug companies [paying] physicians to allow company reps to sit in on patient sessions to learn more about care for patients.”

Nevertheless, Sharfstein acknowledged that without pharmaceutical companies developing and producing modern medicines – virtually every medical specialty would have few (if any) treatments for the patients that they care for.

Pharmaceutical Industry Influences in Psychiatry

Studies have shown that promotional marketing by pharmaceutical and other companies has the potential to influence physician decision making. Pharmaceutical manufacturers (and other advocates) would argue that in today’s modern world – physicians simply do not have the time to continually update their knowledge base on the status of the latest research and that by providing educational materials for both physicians and patients, they are providing an educational perspective and that it is up to the individual physician to decide what treatment is best for their patients. The idea of pure promotion (e.g. lavish dinners) is a remnant of bygone era. It has been replaced by educationally-based activities that became the basis for the legal and industry reforms involving physician gifts, influence in graduate medical education, physician disclosure of conflicts of interest, and other promotional activities.

In an essay on the effect of advertisements for marketed anti-depressants there is some evidence that both patients and physicians can be influenced by media advertisements and this has the possibility of increasing the frequency of certain medicines being prescribed over others.

What is the Body Attitudes Questionnaire?

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Introduction

The Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) is a 44 item self-report questionnaire divided into six subscales that measures a woman’s attitude towards their own body.

The BAQ is used in the assessment of eating disorders. It was devised by D.I. Ben-Tovim and M.K. Walker in 1991.

Refer to the Body Attitudes Test.

Sub-Scales

The six subscales measured by the BAQ are:

  • Overall fatness.
  • Self disparagement.
  • Strength.
  • Salience of weight.
  • Feelings of attractiveness.
  • Consciousness of lower body fat.
  • Foreign-language versions.

Portuguese Version

The BAQ was the first body attitudes scale to be translated into Portuguese. The validity of the Portuguese language version was proven in a test conducted on a cohort of Brazilian women who speak Portuguese as their native language. The test-retest reliability was 0.57 and 0.85 after a one-month interval. The test was conducted by Scagliusi et al.

Japanese Version

The BAQ was translated into Japanese and tested on 68 males and 139 females in Japan and 68 Japanese males living in Australia (Kagawa et al.) The scores were assessed against 72 Australian men using the English-language version as well as scores from previous female Australian participants. There was a significant difference between the Japanese and Australian groups (p,0.05). The BAQ was deemed adequate for use in both Japanese males and females.

References

Ben-Tovim, D.I. & Walker, M.K. (1991) The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of women’s attitudes towards their own bodies. Psychological Medicine. 21(3), pp.775-784. doi:10.1017/S0033291700022406.

Kagawa, M., Uchida, H., Uenishi, K., Binns, C.W. & Hills, A.P. (2007) Applicability of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) and the Attention to Body Shape scale (ABS) in Japanese males and females (PDF). Eating Behaviors. 8(3), pp.2772-284. doi:10.1016/j.eatbeh.2006.11.002.

Scagliusi, F.B., Polacow, V.O., Cordas, T.A., Coelho, D., Alvarenga, M., Philippi, S.T. & Lancha Jr, A.H. (2005) Psychometric testing and applications of the Body Attitudes Questionnaire translated into Portuguese. Perceptual and Motor Skills. 101(1), pp.25-41. doi:10.2466/PMS.101.5.25-41.

What is the Body Attitudes Test?

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Introduction

The Body Attitudes Test (BAT) was developed by Probst and colleagues in 1995.

Refer to Body Attitudes Questionnaire.

Background

It was designed for the assessment of eating disorders in women. The BAT measures an individual’s subjective body experience and attitudes towards one’s own body it differentiates between clinical and non-clinical subjects and between anorexics and bulimics. It is composed of twenty items which yield four factors:

  1. Negative appreciation of body size.
  2. Lack of familiarity with one’s own body.
  3. General body dissatisfaction.
  4. A rest factor.

Reference

Probst, M. Van Coppenolle, H. & Vandereycken, W. (1997) Further experience with the Body Attitude Test. Eating and Weight Disorders. 2(2), pp.100104. doi:10.1007/bf03339956.

What is Clinical Neuroscience?

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Introduction

Clinical neuroscience is a branch of neuroscience that focuses on the scientific study of fundamental mechanisms that underlie diseases and disorders of the brain and central nervous system.

It seeks to develop new ways of conceptualising and diagnosing such disorders and ultimately of developing novel treatments.

A clinical neuroscientist is a scientist who has specialised knowledge in the field. Not all clinicians are clinical neuroscientists. Clinicians and scientists – including psychiatrists, neurologists, clinical psychologists, neuroscientists, and other specialists – use basic research findings from neuroscience in general and clinical neuroscience in particular to develop diagnostic methods and ways to prevent and treat neurobiological disorders. Such disorders include addiction, Alzheimer’s disease, amyotrophic lateral sclerosis, anxiety disorders, attention deficit hyperactivity disorder, autism, bipolar disorder, brain tumours, depression, Down syndrome, dyslexia, epilepsy, Huntington’s disease, multiple sclerosis, neurological AIDS, neurological trauma, pain, obsessive-compulsive disorder, Parkinson’s disease, schizophrenia, sleep disorders, stroke and Tourette syndrome.

While neurology, neurosurgery and psychiatry are the main medical specialties that use neuroscientific information, other specialties such as cognitive neuroscience, neuroradiology, neuropathology, ophthalmology, otorhinolaryngology, anaesthesiology and rehabilitation medicine can contribute to the discipline. Integration of the neuroscience perspective alongside other traditions like psychotherapy, social psychiatry or social psychology will become increasingly important.

One Mind for Research

The “One Mind for Research” forum was a convention held in Boston, Massachusetts on 23 to 25 May 2011 that produced the blueprint document A Ten-Year Plan for Neuroscience: From Molecules to Brain Health. Leading neuroscience researchers and practitioners in the United States contributed to the creation of this document, in which 17 key areas of opportunities are listed under the Clinical Neuroscience section. These include the following:

  • Rethinking curricula to break down intellectual silos.
  • Training translational neuroscientists and clinical investigators.
  • Investigating biomarkers.
  • Improving psychiatric diagnosis.
  • Developing a “Framingham Study of Brain Disorders” (i.e. longitudinal cohort for central nervous system disease).
  • Identifying developmental risk factors and producing effective interventions.
  • Discovering new treatments for pain, including neuropathic pain.
  • Treating disorders of neural signalling and pathological synchrony.
  • Treating disorders of immunity or inflammation.
  • Treating metabolic and mitochondrial disorders.
  • Developing new treatments for depression.
  • Treating addictive disorders.
  • Improving treatment of schizophrenia.
  • Preventing and treating cerebrovascular disease.
  • Achieving personalized medicine.
  • Understanding shared mechanisms of neurodegeneration.
  • Advancing anaesthesia.

In particular, it advocates for better integrated and scientifically driven curricula for practitioners, and it recommends that such curricula be shared among neurologists, psychiatrists, psychologists, neurosurgeons and neuroradiologists.

Given the various ethical, legal and societal implications for healthcare practitioners arising from advances in neuroscience, the University of Pennsylvania inaugurated the Penn Conference on Clinical Neuroscience and Society in July 2011.

What is Clinical Neuropsychology?

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Introduction

Clinical neuropsychology is a sub-field of psychology concerned with the applied science of brain-behaviour relationships.

Clinical neuropsychologists use this knowledge in the assessment, diagnosis, treatment, and or rehabilitation of patients across the lifespan with neurological, medical, neurodevelopmental and psychiatric conditions, as well as other cognitive and learning disorders. The branch of neuropsychology associated with children and young people is paediatric neuropsychology.

Clinical neuropsychology is a specialised form of clinical psychology. Strict rules are in place to maintain evidence as a focal point of treatment and research within clinical neuropsychology. The assessment and rehabilitation of neuropsychopathologies is the focus for a clinical neuropsychologist. A clinical neuropsychologist must be able to determine whether a symptom(s) may be caused by an injury to the head through interviewing a patient in order to determine what actions should be taken to best help the patient. Another duty of a clinical neuropsychologist is to find cerebral abnormalities and possible correlations. Evidence based practice in both research and treatment is paramount to appropriate clinical neuropsychological practice.

Assessment is primarily by way of neuropsychological tests, but also includes patient history, qualitative observation and may draw on findings from neuroimaging and other diagnostic medical procedures. Clinical neuropsychology requires an in-depth knowledge of: neuroanatomy, neurobiology, psychopharmacology and neuropathology.

Brief History

During the late 1800s, brain-behaviour relationships were interpreted by European physicians who observed and identified behavioural syndromes that were related with focal brain dysfunction.

Clinical neuropsychology is a fairly new practice in comparison to other specialty fields in psychology with history going back to the 1960s. The specialty focus of clinical neuropsychology evolved slowly into a more defined whole as interest grew. Threads from neurology, clinical psychology, psychiatry, cognitive psychology, and psychometrics all have been woven together to create the intricate tapestry of clinical neuropsychology, a practice which is very much so still evolving. The history of clinical neuropsychology is long and complicated due to its ties to so many older practices. Researchers like Thomas Willis (1621-1675) who has been credited with creating neurology, John Hughlings Jackson (1835-1911) who theorised that cognitive processes occurred in specific parts of the brain, Paul Broca (1824-1880) and Karl Wernicke (1848-1905) who studied the human brain in relation to psychopathology, Jean Martin Charcot (1825-1893) who apprenticed Sigmund Freud (1856-1939) who created the psychoanalytic theory all contributed to clinical medicine which later contributed to clinical neuropsychology. The field of psychometrics contributed to clinical neuropsychology through individuals such as Francis Galton (1822-1911) who collected quantitative data on physical and sensory characteristics, Karl Pearson (1857-1936) who established the statistics which psychology now relies on, Wilhelm Wundt (1832-1920) who created the first psychology lab, his student Charles Spearman (1863-1945) who furthered statistics through discoveries like factor analysis, Alfred Binet (1857-1911) and his apprentice Theodore Simon (1872-1961) who together made the Binet-Simon scale of intellectual development, and Jean Piaget (1896-1980) who studied child development. Studies in intelligence testing made by Lewis Terman (1877-1956) who updated the Binet-Simon scale to the Stanford-Binet intelligence scale, Henry Goddard (1866-1957) who developed different classification scales, and Robert Yerkes (1876-1956) who was in charge of the Army Alpha and Beta tests also all contributed to where clinical neuropsychology is today.

Clinical neuropsychology focuses on the brain and goes back to the beginning of the 20th century. As a clinician a clinical neuropsychologist offers their services by addressing three steps: assessment, diagnosis, and treatment. The term clinical neuropsychologist was first made by Sir William Osler on 16 April 1913. While clinical neuropsychology was not a focus until the 20th century evidence of brain and behaviour treatment and studies are seen as far back as the neolithic area when trephination, a crude surgery in which a piece of the skull is removed, has been observed in skulls. As a profession, clinical neuropsychology is a subspecialty beneath clinical psychology. During World War I (1914-1918) the early term shell shock was first observed in soldiers who survived the war. This was the beginning of efforts to understand traumatic events and how they affected people. During the Great Depression (1929-1941) further stressors caused shell shock like symptoms to emerge. In World War II (1939-1945) the term shell shock was changed to battle fatigue and clinical neuropsychology became even more involved with attempting to solve the puzzle of peoples’ continued signs of trauma and distress. The Veterans Administration or VA was created in 1930 which increased the call for clinical neuropsychologists and by extension the need for training. The Korean War (1950-1953) and Vietnam War (1960-1973) further solidified the need for treatment by trained clinical neuropsychologists. In 1985 the term post-traumatic stress disorder or PTSD was coined and the understanding that traumatic events of all kinds could cause PTSD started to evolve.

The relationship between human behaviour and the brain is the focus of clinical neuropsychology as defined by Meir in 1974. There are two subdivisions of clinical neuropsychology which draw much focus; organic and environmental natures. Ralph M. Reitan, Arthur L. Benton, and A.R. Luria are all past neuropsychologists whom believed and studied the organic nature of clinical neuropsychology. Alexander Luria is the Russian neuropsychologist responsible for the origination of clinical psychoneurological assessment after WWII. Building upon his original contribution connecting the voluntary and involuntary functions influencing behaviour, Luria further conjoins the methodical structures and associations of neurological processes in the brain. Luria developed the ‘combined motor method’ to measure thought processes based on the reaction times when three simultaneous tasks are appointed that require a verbal response. On the other side, environmental nature of clinical neuropsychology did not appear until more recently and is characterised by treatments such as behaviour therapy. The relationship between physical brain abnormalities and the presentation of psychopathology is not completely understood, but this is one of the questions which clinical neuropsychologists hope to answer in time. In 1861 the debate over human potentiality versus localisation began. The two sides argued over how human behaviour presented in the brain. Paul Broca postulated that cognitive problems could be caused by physical damage to specific parts of the brain based on a case study of his in which he found a lesion on the brain of a deceased patient who had presented the symptom of being unable to speak, that portion of the brain is now known as Broca’s Area. In 1874 Carl Wernicke also made a similar observation in a case study involving a patient with a brain lesion whom was unable to comprehend speech, the part of the brain with the lesion is now deemed Wernicke’s Area. Both Broca and Wernicke believed and studied the theory of localisation. On the other hand, equal potentiality theorists believed that brain function was not based on a single piece of the brain but rather on the brain as a whole. Marie J.P Flourens conducted animal studies in which he found that the amount of brain tissue damaged directly affected the amount that behaviour ability was altered or damaged. Kurt Goldstein observed the same idea as Flourens except in veterans who had fought in World War I. In the end, despite all of the disagreement, neither theory completely explains the human brains complexity. Thomas Hughlings Jackson created a theory which was thought to be a possible solution. Jackson believed that both potentiality and localisation were in part correct and that behaviour was made by multiple parts of the brain working collectively to cause behaviours, and Luria (1966-1973) furthered Jackson’s theory.

The Role

When considering where a clinical neuropsychologist works, hospitals are a common place for practitioners to end up. There are three main variations in which a clinical neuropsychologist may work at a hospital; as an employee, consultant, or independent practitioner. As a clinical neuropsychologist working as an employee of a hospital the individual may receive a salary, benefits, and sign a contract for employment. In the case of an employee of a hospital the hospital is in charge of legal and financial responsibilities. The second option of working as a consultant implies that the clinical neuropsychologist is part of a private practice or is a member of a physicians group. In this scenario, the clinical neuropsychologist may work in the hospital like the employee of the hospital but all financial and legal responsibilities go through the group which the clinical neuropsychologist is a part of. The third option is an independent practitioner whom works alone and may even have their office outside of the hospital or rent a room in the hospital. In the third case, the clinical neuropsychologist is completely on their own and in charge of their own financial and legal responsibilities.

Assessment

Assessments are used in clinical neuropsychology to find brain psychopathologies of the cognitive, behavioural, and emotional variety. Physical evidence is not always readily visible so clinical neuropsychologists must rely on assessments to tell them the extent of the damage. The cognitive strengths and weaknesses of the patient are assessed to help narrow down the possible causes of the brain pathology. A clinical neuropsychologist is expected to help educate the patient on what is happening to them so that the patient can understand how to work with their own cognitive deficits and strengths. An assessment should accomplish many goals such as; gage consequences of impairments to quality of life, compile symptoms and the change in symptoms over time, and assess cognitive strengths and weaknesses. Accumulation of the knowledge earned from the assessment is then dedicated to developing a treatment plan based on the patient’s individual needs. An assessment can also help the clinical neuropsychologist gauge the impact of medications and neurosurgery on a patient. Behavioural neurology and neuropsychology tools can be standardised or psychometric tests and observational data collected on the patient to help build an understanding of the patient and what is happening with them. There are essential prerequisites which must be present in a patient in order for the assessment to be effective; concentration, comprehension, and motivation and effort.

Lezak lists six primary reasons neuropsychological assessments are carried out: diagnosis, patient care and its planning, treatment planning, treatment evaluation, research and forensic neuropsychology. To conduct a comprehensive assessment will typically take several hours and may need to be conducted over more than a single visit. Even the use of a screening battery covering several cognitive domains may take 1.5-2 hours. At the commencement of the assessment it is important to establish a good rapport with the patient and ensure they understand the nature and aims of the assessment.

Neuropsychological assessment can be carried out from two basic perspectives, depending on the purpose of assessment. These methods are normative or individual. Normative assessment, involves the comparison of the patient’s performance against a representative population. This method may be appropriate in investigation of an adult onset brain insult such as traumatic brain injury or stroke. Individual assessment may involve serial assessment, to establish whether declines beyond those which are expected to occur with normal aging, as with dementia or another neurodegenerative condition.

Assessment can be further subdivided into sub-sections:

History Taking

Neuropsychological assessments usually commence with a clinical interview as a means of collecting a history, which is relevant to the interpretation of any later neuropsychological tests. In addition, this interview provides qualitative information about the patient’s ability to act in a socially apt manner, organise and communicate information effectively and provide an indication as to the patient’s mood, insight and motivation. It is only within the context of a patient’s history that an accurate interpretation of their test data and thus a diagnosis can be made. The clinical interview should take place in a quiet area free from distractions. Important elements of a history include demographic information, description of presenting problem, medical history (including any childhood or developmental problems, psychiatric and psychological history), educational and occupational history (and if any legal history and military history).

Selection of Neuropsychological Tests

It is not uncommon for patients to be anxious about being tested; explaining that tests are designed so that they will challenge everyone and that no one is expected to answer all questions correctly may be helpful. An important consideration of any neuropsychological assessment is a basic coverage of all major cognitive functions. The most efficient way to achieve this is the administration of a battery of tests covering: attention, visual perception and reasoning, learning and memory, verbal function, construction, concept formation, executive function, motor abilities and emotional status. Beyond this basic battery, choices of neuropsychological tests to be administered are mainly made on the basis of which cognitive functions need to be evaluated in order to fulfil the assessment objectives.

Report Writing

Following a neuropsychological assessment it is important to complete a comprehensive report based on the assessment conducted. The report is for other clinicians, as well as the patient and their family so it is important to avoid jargon or the use of language which has different clinical and lay meanings (e.g. intellectually disabled as the correct clinical term for an IQ below 70, but offensive in lay language). The report should cover background to the referral, relevant history, reasons for assessment, neuropsychologists observations of patient’s behaviour, test administered and results for cognitive domains tested, any additional findings (e.g. questionnaires for mood) and finish the report with a summary and recommendations. In the summary it is important to comment on what the profile of results indicates regarding the referral question. The recommendations section contains practical information to assist the patient and family, or improve the management of the patient’s condition.

Educational Requirements of Different Countries

The educational requirements for becoming a clinical neuropsychologist differ between countries. In some countries it may be necessary to complete a clinical psychology degree, before specialising with further studies in clinical neuropsychology. While some countries offer clinical neuropsychology courses to students who have completed 4 years of psychology studies. All clinical neuropsychologists require a postgraduate qualification, whether it be a Masters or Doctorate (Ph.D, Psy.D. or D.Psych).

Australia

To become a clinical neuropsychologist in Australia requires the completion of a 3-year Australian Psychology Accreditation Council (APAC) approved undergraduate degree in psychology, a 1-year psychology honours, followed by a 2-year Masters or 3-year Doctorate of Psychology (D.Psych) in clinical neuropsychology. These courses involve coursework (lectures, tutorials, practicals etc.), supervised practice placements and the completion of a research thesis. Masters and D.Psych courses involve the same amount of coursework units, but differ in the amount of supervised placements undertaken and length of research thesis. Masters courses require a minimum of 1,000 hours (125 days) and D.Psych courses require a minimum of 1,500 hours (200 days), it is mandatory that these placements expose students to acute neurology/neurosurgery, rehabilitation, psychiatric, geriatric and paediatric populations.

Canada

To become a clinical neuropsychologist in Canada requires the completion of a 4-year honours degree in psychology and a 4-year doctoral degree in clinical neuropsychology. Often a 2-year master’s degree is required before commencing the doctoral degree. The doctoral degree involves coursework and practical experience (practicum and internship). Practicum is between 600 and 1,000 hours of practical application of skills acquired in the programme. At least 300 hours must be supervised, face-to-face client contact. The practicum is intended to prepare students for the internship/residency. Internships/residencies are a year long experience in which the student functions as a neuropsychologist, under supervision. Currently, there are 3 CPA-accredited Clinical Neuropsychology internships/residencies in Canada, although other unaccredited ones exist. Prior to commencing the internship students must have completed all doctoral coursework, received approval for their thesis proposal (if not completed the thesis) and the 600 hours of practicum.

United Kingdom

To become a clinical neuropsychologist in the UK, requires prior qualification as a clinical or educational psychologist as recognised by the Health Professions Council, followed by further postgraduate study in clinical neuropsychology. In its entirety, education to become a clinical neuropsychologist in the UK consists of the completion of a 3-year British Psychological Society accredited undergraduate degree in psychology, 3-year Doctorate in clinical (usually D.Clin.Psy.) or educational psychology (D.Ed.Psy.), followed by a 1-year Masters (MSc) or 9-month Postgraduate Diploma (PgDip) in Clinical Neuropsychology. The British Psychological Division of Counselling Psychology are also currently offering training to its members in order to ensure that they can apply to be registered Neuropsychologists also.

United States

In order to become a clinical neuropsychologist in the US and be compliant with Houston Conference Guidelines, the completion of a 4-year undergraduate degree in psychology and a 4 to 5-year doctoral degree (Psy.D. or Ph.D.) must be completed. After the completion of the doctoral coursework, training and dissertation, students must complete a 1-year internship, followed by an additional 2 years of supervised residency. The doctoral degree, internship and residency must all be undertaken at American Psychological Association approved institutions. After the completion of all training, students must apply to become licensed in their state to practice psychology. The American Board of Clinical Neuropsychology, The American Board of Professional Neuropsychology, and The American Board of Paediatric Neuropsychology all award board certification to neuropsychologists that demonstrate competency in specific areas of neuropsychology, by reviewing the neuropsychologist’s training, experience, submitted case samples, and successfully completing both written and oral examinations. Although these requirements are standard according to Houston Conference Guidelines, even these guidelines have stated that the completion of all of these requirements is still aspirational, and other ways of achieving clinical neuropsychologist status are possible.