Category: Mental Health

What is Logotherapy?

Published on by Andrew Marshall1 Comment

Introduction

Logotherapy was developed by neurologist and psychiatrist Viktor Frankl, on a concept based on the premise that the primary motivational force of an individual is to find a meaning in life.

Frankl describes it as “the Third Viennese School of Psychotherapy” along with Freud’s psychoanalysis and Adler’s individual psychology. Logotherapy is based on an existential analysis focusing on Kierkegaard’s will to meaning as opposed to Alfred Adler’s Nietzschean doctrine of will to power or Freud’s will to pleasure. Rather than power or pleasure, logotherapy is founded upon the belief that striving to find meaning in life is the primary, most powerful motivating and driving force in humans.

A short introduction to this system is given in Frankl’s most famous book, Man’s Search for Meaning, in which he outlines how his theories helped him to survive his Holocaust experience and how that experience further developed and reinforced his theories. Presently, there are a number of logotherapy institutes around the world.

Basic Principles

The notion of Logotherapy was created with the Greek word logos (“reason”). Frankl’s concept is based on the premise that the primary motivational force of an individual is to find a meaning in life. The following list of tenets represents basic principles of logotherapy:

  • Life has meaning under all circumstances, even the most miserable ones.
  • Our main motivation for living is our will to find meaning in life.
  • We have freedom to find meaning in what we do, and what we experience, or at least in the stance we take when faced with a situation of unchangeable suffering.

The human spirit is referred to in several of the assumptions of logotherapy, but the use of the term spirit is not “spiritual” or “religious”. In Frankl’s view, the spirit is the will of the human being. The emphasis, therefore, is on the search for meaning, which is not necessarily the search for God or any other supernatural being. Frankl also noted the barriers to humanity’s quest for meaning in life. He warns against “…affluence, hedonism, [and] materialism…” in the search for meaning.

Purpose in life and meaning in life constructs appeared in Frankl’s logotherapy writings with relation to existential vacuum and will to meaning, as well as others who have theorised about and defined positive psychological functioning. Frankl observed that it may be psychologically damaging when a person’s search for meaning is blocked. Positive life purpose and meaning was associated with strong religious beliefs, membership in groups, dedication to a cause, life values, and clear goals. Adult development and maturity theories include the purpose in life concept. Maturity emphasizes a clear comprehension of life’s purpose, directedness, and intentionality which contributes to the feeling that life is meaningful.

Frankl’s ideas were operationalized by Crumbaugh and Maholick’s Purpose in Life (PIL) test, which measures an individual’s meaning and purpose in life. With the test, investigators found that meaning in life mediated the relationships between religiosity and well-being; uncontrollable stress and substance use; depression and self-derogation. Crumbaugh found that the Seeking of Noetic Goals Test (SONG) is a complementary measure of the PIL. While the PIL measures the presence of meaning, the SONG measures orientation towards meaning. A low score in the PIL but a high score in the SONG, would predict a better outcome in the application of Logotherapy.

Discovering Meaning

According to Frankl, “We can discover this meaning in life in three different ways: (1) by creating a work or doing a deed; (2) by experiencing something or encountering someone; and (3) by the attitude we take toward unavoidable suffering” and that “everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances”. On the meaning of suffering, Frankl gives the following example:

“Once, an elderly general practitioner consulted me because of his severe depression. He could not overcome the loss of his wife who had died two years before and whom he had loved above all else. Now how could I help him? What should I tell him? I refrained from telling him anything, but instead confronted him with a question, “What would have happened, Doctor, if you had died first, and your wife would have had to survive without you?:” “Oh,” he said, “for her this would have been terrible; how she would have suffered!” Whereupon I replied, “You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now, you have to pay for it by surviving and mourning her.” He said no word but shook my hand and calmly left the office.

Frankl emphasized that realising the value of suffering is meaningful only when the first two creative possibilities are not available (for example, in a concentration camp) and only when such suffering is inevitable – he was not proposing that people suffer unnecessarily.

Philosophical Basis of Logotherapy

Frankl described the meta-clinical implications of logotherapy in his book The Will to Meaning: Foundations and Applications of Logotherapy. He believed that there is no psychotherapy apart from the theory of the individual. As an existential psychologist, he inherently disagreed with the “machine model” or “rat model”, as it undermines the human quality of humans. As a neurologist and psychiatrist, Frankl developed a unique view of determinism to coexist with the three basic pillars of logotherapy (the freedom of will). Though Frankl admitted that a person can never be free from every condition, such as, biological, sociological, or psychological determinants; based on his experience during his life in the Nazi concentration camps, he believed that a person is “capable of resisting and braving even the worst conditions”. In doing such, a person can detach from situations and themselves, choose an attitude about themselves, and determine their own determinants, thus shaping their own character and becoming responsible for themselves.

Logotherapeutic Views and Treatment

Overcoming Anxiety

By recognising the purpose of our circumstances, one can master anxiety. Anecdotes about this use of logotherapy are given by New York Times writer Tim Sanders, who explained how he uses its concept to relieve the stress of fellow airline travellers by asking them the purpose of their journey. When he does this, no matter how miserable they are, their whole demeanour changes, and they remain happy throughout the flight. Overall, Frankl believed that the anxious individual does not understand that their anxiety is the result of dealing with a sense of “unfulfilled responsibility” and ultimately a lack of meaning.

Treatment of Neurosis

Frankl cites two neurotic pathogens: hyper-intention, a forced intention toward some end which makes that end unattainable; and hyper-reflection, an excessive attention to oneself which stifles attempts to avoid the neurosis to which one thinks oneself predisposed. Frankl identified anticipatory anxiety, a fear of a given outcome which makes that outcome more likely. To relieve the anticipatory anxiety and treat the resulting neuroses, logotherapy offers paradoxical intention, wherein the patient intends to do the opposite of their hyper-intended goal.

A person, then, who fears (i.e. experiences anticipatory anxiety over) not getting a good night’s sleep may try too hard (that is, hyper-intend) to fall asleep, and this would hinder their ability to do so. A logotherapist would recommend, then, that the person go to bed and intentionally try not to fall asleep. This would relieve the anticipatory anxiety which kept the person awake in the first place, thus allowing them to fall asleep in an acceptable amount of time.

Depression

Viktor Frankl believed depression occurred at the psychological, physiological, and spiritual levels. At the psychological level, he believed that feelings of inadequacy stem from undertaking tasks beyond our abilities. At the physiological level, he recognised a “vital low”, which he defined as a “diminishment of physical energy”. Finally, Frankl believed that at the spiritual level, the depressed individual faces tension between who they actually are in relation to what they should be. Frankl refers to this as the gaping abyss. Finally Frankl suggests that if goals seem unreachable, an individual loses a sense of future and thus meaning resulting in depression. Thus logotherapy aims “to change the patient’s attitude toward their disease as well as toward their life as a task”.

Obsessive-Compulsive Disorder

Frankl believed that those suffering from obsessive-compulsive disorder lack the sense of completion that most other individuals possess. Instead of fighting the tendencies to repeat thoughts or actions, or focusing on changing the individual symptoms of the disease, the therapist should focus on “transform[ing] the neurotic’s attitude toward their neurosis”. Therefore, it is important to recognise that the patient is “not responsible for his obsessional ideas”, but that “he is certainly responsible for his attitude toward these ideas”. Frankl suggested that it is important for the patient to recognise their inclinations toward perfection as fate, and therefore, must learn to accept some degrees of uncertainty. Ultimately, following the premise of logotherapy, the patient must eventually ignore their obsessional thoughts and find meaning in their life despite such thoughts.

Schizophrenia

Though logotherapy was not intended to deal with severe disorders, Frankl believed that logotherapy could benefit even those suffering from schizophrenia. He recognised the roots of schizophrenia in physiological dysfunction. In this dysfunction, the person with schizophrenia “experiences himself as an object” rather than as a subject. Frankl suggested that a person with schizophrenia could be helped by logotherapy by first being taught to ignore voices and to end persistent self-observation. Then, during this same period, the person with schizophrenia must be led toward meaningful activity, as “even for the schizophrenic there remains that residue of freedom toward fate and toward the disease which man always possesses, no matter how ill he may be, in all situations and at every moment of life, to the very last”.

Terminally Ill Patients

In 1977, Terry Zuehlke and John Watkins conducted a study analysing the effectiveness of logotherapy in treating terminally ill patients. The study’s design used 20 male Veterans Administration volunteers who were randomly assigned to one of two possible treatments – (1) group that received 8 45-minute sessions over a 2-week period and (2) group used as control that received delayed treatment. Each group was tested on 5 scales – the MMPI K Scale, MMPI L Scale, Death Anxiety Scale, Brief Psychiatric Rating Scale, and the Purpose of Life Test. The results showed an overall significant difference between the control and treatment groups. While the univariate analyses showed that there were significant group differences in 3/5 of the dependent measures. These results confirm the idea that terminally ill patients can benefit from logotherapy in coping with death.

Forms of Treatment

Ecce Homo is a method used in logotherapy. It requires of the therapist to note the innate strengths that people have and how they have dealt with adversity and suffering in life. Despite everything a person may have gone through, they made the best of their suffering! Hence, Ecce Homo – Behold the Man!

Controversy

Authoritarianism

In 1969 Rollo May argued that logotherapy is, in essence, authoritarian. He suggested that Frankl’s therapy presents a plain solution to all of life’s problems, an assertion that would seem to undermine the complexity of human life itself. May contended that if a patient could not find their own meaning, Frankl would provide a goal for his patient. In effect, this would negate the patient’s personal responsibility, thus “diminish[ing] the patient as a person”. Frankl explicitly replied to May’s arguments through a written dialogue, sparked by Rabbi Reuven Bulka’s article “Is Logotherapy Authoritarian?”. Frankl responded that he combined the prescription of medication, if necessary, with logotherapy, to deal with the person’s psychological and emotional reaction to the illness, and highlighted areas of freedom and responsibility, where the person is free to search and to find meaning.

Religiousness

Critical views of the life of logotherapy’s founder and his work assume that Frankl’s religious background and experience of suffering guided his conception of meaning within the boundaries of the person and therefore that logotherapy is founded on Viktor Frankl’s worldview. Many researchers argue that logotherapy is not a “scientific” psychotherapeutic school in the traditional sense but a philosophy of life, a system of values, a secular religion which is not fully coherent and is based on questionable metaphysical premises.

Frankl openly spoke and wrote on religion and psychiatry, throughout his life, and specifically in his last book, Man’s Search for Ultimate Meaning (1997). He asserted that every person has a spiritual unconscious, independently of religious views or beliefs, yet Frankl’s conception of the spiritual unconscious does not necessarily entail religiosity. In Frankl’s words: “It is true, Logotherapy, deals with the Logos; it deals with Meaning. Specifically, I see Logotherapy in helping others to see meaning in life. But we cannot “give” meaning to the life of others. And if this is true of meaning per se, how much does it hold for Ultimate Meaning?” The American Psychiatric Association awarded Viktor Frankl the 1985 Oskar Pfister Award (for important contributions to religion and psychiatry).

Recent Developments

Since the 1990s, the number of institutes providing education and training in logotherapy continues to increase worldwide. Numerous logotherapeutic concepts have been integrated and applied in different fields, such as cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), and burnout prevention. The logotherapeutic concepts of noogenic neurosis and existential crisis were added to the ICD 11 under the name demoralisation crisis, i.e. a construct that features hopelessness, meaninglessness, and existential distress as first described by Frankl in the 1950s. Logotherapy has also been associated with psychosomatic and physiological health benefits. Besides Logotherapy, other meaning-centred psychotherapeutic approaches such as positive psychology and meaning therapy have emerged. Paul Wong’s meaning therapy attempts to translate logotherapy into psychological mechanisms, integrating CBT, positive psychotherapy and the positive psychology research on meaning. Logotherapy is also being applied in the field of oncology and palliative care (William Breitbart). These recent developments introduce Viktor Frankl’s logotherapy to a new generation and extend its impact to new areas of research.

What is Exercise Addiction?

Published on by Andrew Marshall2 Comments

Introduction

Exercise addiction is a state characterised by a compulsive engagement in any form of physical exercise, despite negative consequences.

Refer to Anorexia Athletica and Exercise Bulimia.

While regular exercise is generally a healthy activity, exercise addiction generally involves performing excessive amounts of exercise to the detriment of physical health, spending too much time exercising to the detriment of personal and professional life, and exercising regardless of physical injury. It may also involve a state of dependence upon regular exercise which involves the occurrence of severe withdrawal symptoms when the individual is unable to exercise. Differentiating between addictive and healthy exercise behaviours is difficult but there are key factors in determining which category a person may fall into. Exercise addiction shows a high comorbidity with eating disorders.

Exercise addiction is not listed as a disorder in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This type of addiction can be classified under a behavioural addiction in which a person’s behaviour becomes obsessive, compulsive, and/or causes dysfunction in a person’s life. The next revision of the DSM (DSM-5) will include an addictions and related disorders section; gambling is the only non-substance addiction that is likely to be included. Other non-substance addictions, such as exercise addiction, are being researched but their inclusion is undetermined.

Classification

A concrete classification of exercise addiction has proven to be difficult due to the lack of a specific and widely accepted diagnostic model. Most interpretations of addiction have traditionally been limited to drugs and alcohol, which makes it even more difficult to identify addictive tendencies in exercise. While excessive exercise is the overarching theme with exercise addiction, the term also includes a variety of symptoms like withdrawal, “exercise buzz”, and impaired physical function. Excessive exercise has been classified in different ways; sometimes as an addiction and sometimes as a more general compulsive behaviour. Psychiatric case studies have shown that exaggerated exercise could lead to negligence of work and family life. With an addiction, individuals become “hooked” to the feeling of euphoria and pleasure that exercise provides. This pleasure keeps the individual from stopping and leads to excessive exercise. With a compulsion people often do not necessarily enjoy repeating certain tasks, as they may feel like performing it will fulfil a duty that is required of them. There are many opinions on whether concrete diagnostic criteria should be created for this type of addiction. Some say preoccupation with exercise that causes significant impairment in a person’s life, not due to another disorder, may be enough criteria to label this disorder. Others say there is not enough information about exercise addiction to develop diagnostic criteria. As of 2007, the term “excessive exercise” continues to be used while the “exercise addiction” model continues to be debated.

Three main types of disorders are associated with excessive exercise:

  • Anorexia athletica (obligatory exercise):
    • When an individual feels compelled to exercise beyond the point of benefitting one’s body.
    • Individuals will participate in athletic activities regardless of pain, injury, illness, etc., and will try to arrange their lives in order to maximise workout time.
  • Exercise bulimia:
    • When an individual has binge eating sessions that are followed by periods of high-intensity exercise.
  • Body dysmorphic disorder:
    • When an individual is obsessed with parts of their body and perceive them to be different or odd.
    • These individuals will create highly regimented routines in order to improve their perception of the “flawed” body part.

Signs and Symptoms

Five indicators of exercise addiction are:

  • An increase in exercise that may be labelled as detrimental, or becomes harmful.
  • A desire to experience euphoria; exercise may be increased as tolerance of the euphoric state increases.
  • Not participating in physical activity will cause dysfunction in one’s daily life.
  • Severe withdrawal symptoms following exercise deprivation including anxiety, restlessness, depression, guilt, tension, discomfort, loss of appetite, sleeplessness, and headaches.
  • Exercising through trauma and despite physical injuries.

Key differences between healthy and addictive levels of exercise include the presence of withdrawal symptoms when exercise is stopped as well as the addictive properties exercise may have leading to a dependence on exercise.

Those who succumb to exercise addiction may experience overtraining, which is best defined as a “condition of poor adaptation to a chronic period of excessive stress caused by a physical exertion, resulting in the development of the syndrome, compromising the health and sports performance”.

Overtraining includes one or more of the following:

  • Persistent muscle soreness.
  • Elevated resting heart rate.
  • Increased susceptibility to infections.
  • Increased incidence of injuries.
  • Insomnia.
  • Decreased appetite.
  • Weight loss.
  • Impaired performance.
  • Decreased motor coordination and force production.

Exercise addiction may also lead to mood disturbances. Those who undergo rigorous training without adequate rest are more likely to experience depression, anger, fatigue and confusion.

In addition, excessive training may cause exhaustion of the autonomic nervous system. Some symptoms include decreased total testosterone level, an imbalance between testosterone and cortisol, decreased sympathetic tone, and decreased exercise-induced lactate. These chemical balances can lead to premature osteoporosis, where the lack of testosterone accelerates bone loss, and elevated levels of cortisol alters calcium and bone metabolism by “increasing bone reabsorption and decreasing bone formation or intestinal absorption of calcium”. Calcium undernutrition may eventually occur, accelerating premature osteoporosis.

Mechanisms

As of 2016, the mechanisms involved in the development of an exercise addiction, associated with the transition from healthy committed exercise to compulsive exercise, are unknown.

Assessment

Different assessment tools can be used to determine if an individual is addicted to exercise. Most tools used to determine risk for exercise addiction are modified tools that have been used for assessing other behavioural addictions. Tools for determining eating disorders can also show a high risk for exercise addiction.

The Obligatory Exercise Questionnaire was created by Thompson and Pasman in 1991, consisting of 20 questions on exercise habits and attitudes toward exercise and body image. Patients respond to statements on a scale of 1 (never) to 4 (always). This questionnaire aided in the development of another assessment tool, the Exercise Addiction Inventory.

The Exercise Addiction Inventory was developed by Terry et al in 2004. This inventory was developed as a self-report to examine an individual’s beliefs toward exercise. The inventory is made up of six statements in relation to the perception of exercise, concerning: the importance of exercise to the individual, relationship conflicts due to exercise, how mood changes with exercise, the amount of time spent exercising, the outcome of missing a workout, and the effects of decreasing physical activity. Individuals are asked to rate each statement from 1 (strongly disagree) to 5 (strongly agree). If an individual scores above 24 they are said to be at-risk for exercise addiction.

Treatment

Behavioural addiction and substance abuse disorders are treated similarly; treatment options include exposure and response prevention. No medications have been approved for the treatment of behavioural addictions. Studies have shown promise in the use of glutamatergic altering drugs to treat addictions other than exercise. Exercise addictions comorbid in patients with an eating disorder may be treated through psychotherapy involving education, behavioural interventions, and a strengthened family support structure. In treating the eating disorder, obsessions and compulsions produced by obscured body image ideals will also be treated, this includes exercise addiction.

Epidemiology

Most research has focused on adult population or on college students, but little is known about epidemiology of behavioural addictions in adolescence. A study conducted by Villella et al looked at a group of students and the prevalence of various addictions. His results showed exercise addiction was the second most prevalent, after compulsive buying. High risk groups that appear to be addicted to exercise include athletes in sports encouraging thinness or appearance standards, young and middle-age women, and young men.

Prognosis

Individuals with exercise addiction may put exercise above family and friends, work, injuries, and other social activities. If not identified and treated, an exercise addiction may lead to a significant decline in one’s health.

Comorbidity

An addiction, by definition, includes repeated compulsive behaviours that negatively affect daily living. There are two ways to classify addictive behaviours: substance addiction and process addiction. An exercise addiction is a type of process addiction, in which an individual’s mood toward a certain event becomes dependent on addictive behaviours. Many educational, occupational, and social activities are stopped due to excessive exercising. Depression may develop if exercise is neglected or may result from reoccurring physical injuries that limit exercise. Exercise addiction is often related to obsessive-compulsive disorder as exercise addicts may have obsessions or compulsions toward physical activity. Exercise addiction is also commonly associated with eating disorders as a secondary symptom of bulimia or anorexia nervosa. Approximately 39-48% of people that have an eating disorder are also addicted to exercise. When diagnosing bulimia, exercise addiction is referred to as a compensatory behaviour and indicator of the underlying disorder. Research also shows exercise addiction influences not only the development of eating disorders but also their maintenance.

Animal Models

As with many human diseases and disorders, animal models are sometimes used to study addiction. For example, voluntary wheel running by rodents, viewed as a model of human voluntary exercise, has been used to study withdrawal symptoms, such as changes in blood pressure, when wheel access is removed from mice.

What is Exercise Bulimia?

Published on by Andrew Marshall2 Comments

Introduction

Exercise bulimia is a subset of the psychological disorder called bulimia in which a person is compelled to exercise in an effort aimed at burning the calories of food energy and fat reserves to an excessive level that negatively affects their health.

The damage normally occurs through not giving the body adequate rest for athletic recovery compared to their exercise levels, leading to increasing levels of disrepair. If the person eats a normally healthy and adequate diet but exercises in levels they know require higher levels of nutrition, this can also be seen as a form of anorexia.

Refer to Anorexia Athletica and Exercise Addiction.

Signs and Symptoms

Exercise Bulimia can sometimes go unnoticed because exercise is something that is seen as healthy, but just because a person looks healthy does not mean they are. Compulsive exercisers will often schedule their lives around exercise just as those with eating disorders schedule their lives around eating (or not eating). Other indications of compulsive exercise are:

  • Missing work, school and other important events in order to work out.
  • Working out with an injury or while sick.
  • Working out secretly or away from noticeable sight.
  • Becoming unusually depressed if unable to exercise.
  • Working out for hours at a time each day.
  • Not taking any rest or recovery days.
  • Defining self-worth in terms of performance.
  • Justifies excessive behaviour by defining self as a “special” elite athlete.
  • Depression or agitation when unable to work out.
  • Amenorrhea, the stop of a woman’s menstrual cycle.
  • Isolation from others while working out.
  • Lack of interest in friends and eating.
  • Lack of sleep.

What is Anorexia Athletica?

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Introduction

Anorexia athletica (sports anorexia), also referred to as hypergymnasia, is an eating disorder characterized by excessive and compulsive exercise.

Refer to Exercise Bulimia and Exercise Addiction.

An athlete suffering from sports anorexia tends to over exercise to give themselves a sense of having control over their body. Most often, people with the disorder tend to feel they have no control over their lives other than their control of food and exercise. In actuality, they have no control; they cannot stop exercising or regulating food intake without feeling guilty. Generally, once the activity is started, it is difficult to stop because the person is seen as being addicted to the method adopted.

Anorexia athletica is used to refer to “a disorder for athletes who engage in at least one unhealthy method of weight control”. Unlike anorexia nervosa, anorexia athletica does not have as much to do with body image as it does with performance. Athletes usually begin by eating more ‘healthy’ foods, as well as increasing their training, but when people feel like that is not enough and start working out excessively and cutting back their caloric intake until it becomes a psychological disorder.

Hypergymnasia and anorexia athletica are not recognised as mental disorders in any of the medical manuals, such as the ICD-10 or the DSM-IV, nor is it part of the proposed revision of this manual, the DSM-5. If this were the case, there would be a 10-15% increase in mental disorders in sports. A study at the Anorexia Centre at Huddinge Hospital in Stockholm, Sweden showed that sports anorexia can result in mental disorders. The anxiety, stress, and pressure people with sports anorexia put on themselves (as well as the pressure parents and coaches can put on the athlete) can cause mental disorders.

Signs and Symptoms

Someone with anorexia athletica can experience numerous signs and symptoms, a few of which are listed below. The seriousness of the symptoms is dependent on the individual, and more symptoms come with the length the athlete excessively exercises. If anorexia athletica persists for long enough, the individual can become malnourished, which eventually leads to further complications in major organs such as the liver, kidney, heart and brain.

  • Excessive exercise.
  • Obsessive behaviour with calories, fat, and weight.
  • Self-worth is based on physical performance.
  • Enjoyment of sports is diminished or gone.
  • Denying the over exercising is a problem.

Causes

There is not one single cause of anorexia athletica, but many factors that are involved in the disorder. Research has shown that an area on chromosome 1 is linked to anorexia nervosa-sports anorexia. Thus, a person is more likely to have anorexia athletica if someone in their immediate family has had the disorder. Not only genetics, but also the environment a person is in, has a major impact on the disorder. Coaches and parents often suggest to their athlete/child to lose weight in order to perform better. Sports such as figure skating, ballet, and gymnastics promote both male and female athletes to have a thin figure. Females who partake in sports can suffer from a syndrome known as the triad. The media play a very significant role in pressuring athletes to have the perfect body and to be thin, which can also trigger sports anorexia.

Treatment

According to the National Eating Disorder Information Centre (NEDIC), the first step for someone going through anorexia athletica is to realise their eating and exercise habits are hurting them. Once an individual has realised they have a disorder, an appointment should be made with the family doctor. A family doctor can advise further medical attention if needed. With sports anorexia, it is important to go to a dietitian as well as a personal trainer. People with sports anorexia need to learn the balance between exercise and caloric intake.

What is a Mental Health Care Navigator?

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Introduction

A mental health care navigator is an individual who assists patients and families to find appropriate mental health caregivers, facilities and services. Individuals who are care navigators are often also trained therapists and doctors.

Background

The need for mental health care navigators arises from the fragmentation of the mental health industry, which can often leave patients with more questions than answers. Care navigators work closely with patients and families through discussion and collaboration to provide information on best options and referrals to healthcare professionals, facilities, and organisations specialising in the patients’ needs. The difference between other mental health professionals and a care navigator is that a care navigator provides information and directs a patient to the best help rather than offering treatment. Still, care navigators may provide diagnosis and treatment planning.

Mental health care navigation is also sometimes provided by self-help books. Lloyd I. Sederer, M.D.’s The Family Guide to Mental Healthcare (W. W. Norton & Company, 2013) is a resource for patients and families searching for guidance in the mental health industry. Publishers Weekly called it a “thoughtful, compassionate, and fact-packed guide for recognizing illness and getting help.” It provides information to patients and families about recognising symptoms of mental illness, how to get diagnosis and how to choose the right therapists and treatments.

Terminology

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

Models

Models for mental health care navigation can involve many scenarios from a brief consultation to an extended process with follow-up. They offer referrals, assistance with insurance and other financial matters and general support. A highly detailed method of care navigation with long-term follow up was developed in 2011 by San Francisco-based psychiatrist and mental health expert Eli Merritt, M.D. His model involves what he calls the “3 R’s” of mental health care: “Research, Resources, and Referrals.” It involves four steps:

  • Assessment & Needs Identification:
    • In this preliminary, exploratory phase, care navigators meet with the individual or family seeking help. Patient history and needs are identified.
    • Both the patient and the care navigator think through short- and long-term goals and levels of treatment sought.
  • Dialogue & Plan Formation:
    • Through discussion and collaboration, both the patient and care navigator brainstorm next steps, establishing a plan that is specific to the patient’s needs.
  • Care Coordination:
    • After information gathering and brainstorming, doctors, therapists, and other mental health options are provided to the patient.
    • Questions of affordability arise, and patients are advised toward the best solutions for their conditions and circumstances.
  • Continuity:
    • After guiding patients to healthcare providers, care navigators maintain communication and continuity with patients, offering assistance with any future obstacles that might arise.

What is Neuropsychology?

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Introduction

Neuropsychology is a branch of psychology that is concerned with how a person’s cognition and behaviour are related to the brain and the rest of the nervous system. Professionals in this branch of psychology often focus on how injuries or illnesses of the brain affect cognitive and behavioural functions.

It is both an experimental and clinical field of psychology, thus aiming to understand how behaviour and cognition are influenced by brain function and concerned with the diagnosis and treatment of behavioural and cognitive effects of neurological disorders. Whereas classical neurology focuses on the pathology of the nervous system and classical psychology is largely divorced from it, neuropsychology seeks to discover how the brain correlates with the mind through the study of neurological patients. It thus shares concepts and concerns with neuropsychiatry and with behavioural neurology in general. The term neuropsychology has been applied to lesion studies in humans and animals. It has also been applied in efforts to record electrical activity from individual cells (or groups of cells) in higher primates (including some studies of human patients).

In practice, neuropsychologists tend to work in research settings (universities, laboratories or research institutions), clinical settings (medical hospitals or rehabilitation settings, often involved in assessing or treating patients with neuropsychological problems), or forensic settings or industry (often as clinical-trial consultants where CNS function is a concern).

Brief History

Neuropsychology is a relatively new discipline within the field of psychology. The first textbook defining the field, Fundamentals of Human Neuropsychology, was initially published by Kolb and Whishaw in 1980. However, the history of its development can be traced back to the Third Dynasty in ancient Egypt, perhaps even earlier. There is much debate as to when societies started considering the functions of different organs. For many centuries, the brain was thought useless and was often discarded during burial processes and autopsies. As the field of medicine developed its understanding of human anatomy and physiology, different theories were developed as to why the body functioned the way it did. Many times, bodily functions were approached from a religious point of view and abnormalities were blamed on bad spirits and the gods. The brain has not always been considered the centre of the functioning body. It has taken hundreds of years to develop our understanding of the brain and how it affects our behaviours.

Ancient Egypt

In ancient Egypt, writings on medicine date from the time of the priest Imhotep. They took a more scientific approach to medicine and disease, describing the brain, trauma, abnormalities, and remedies for reference for future physicians. Despite this, Egyptians saw the heart, not the brain, as the seat of the soul.

Aristotle

Aristotle reinforced this focus on the heart which originated in Egypt. He believed the heart to be in control of mental processes, and looked on the brain, due to its inert nature, as a mechanism for cooling the heat generated by the heart. He drew his conclusions based on the empirical study of animals. He found that while their brains were cold to the touch and that such contact did not trigger any movements, the heart was warm and active, accelerating and slowing dependent on mood. Such beliefs were upheld by many for years to come, persisting through the Middle Ages and the Renaissance period until they began to falter in the 17th century due to further research. The influence of Aristotle in the development of neuropsychology is evident within language used in modern day, since we “follow our hearts” and “learn by the heart.”

Hippocrates

Hippocrates viewed the brain as the seat of the soul. He drew a connection between the brain and behaviours of the body, writing: “The brain exercises the greatest power in the man.” Apart from moving the focus from the heart as the “seat of the soul” to the brain, Hippocrates did not go into much detail about its actual functioning. However, by switching the attention of the medical community to the brain, his theory led to more scientific discovery of the organ responsible for our behaviours. For years to come, scientists were inspired to explore the functions of the body and to find concrete explanations for both normal and abnormal behaviours. Scientific discovery led them to believe that there were natural and organically occurring reasons to explain various functions of the body, and it could all be traced back to the brain. Hippocrates introduced the concept of the mind – which was widely seen as a separate function apart from the actual brain organ.

René Descartes

Philosopher René Descartes expanded upon this idea and is most widely known for his work on the mind-body problem. Often Descartes’s ideas were looked upon as overly philosophical and lacking in sufficient scientific foundation. Descartes focused much of his anatomical experimentation on the brain, paying special attention to the pineal gland – which he argued was the actual “seat of the soul.” Still deeply rooted in a spiritual outlook towards the scientific world, the body was said to be mortal, and the soul immortal. The pineal gland was then thought to be the very place at which the mind would interact with the mortal and machine-like body. At the time, Descartes was convinced the mind had control over the behaviours of the body (controlling the person) – but also that the body could have influence over the mind, which is referred to as dualism. This idea that the mind essentially had control over the body, but the body could resist or even influence other behaviours, was a major turning point in the way many physiologists would look at the brain. The capabilities of the mind were observed to do much more than simply react, but also to be rational and function in organised, thoughtful ways – much more complex than he thought the animal world to be. These ideas, although disregarded by many and cast aside for years led the medical community to expand their own ideas of the brain and begin to understand in new ways just how intricate the workings of the brain really were, and the complete effects it had on daily life, as well as which treatments would be the most beneficial to helping those people living with a dysfunctional mind. The mind-body problem, spurred by René Descartes, continues to this day with many philosophical arguments both for and against his ideas. However controversial they were and remain today, the fresh and well-thought-out perspective Descartes presented has had long-lasting effects on the various disciplines of medicine, psychology and much more, especially in putting an emphasis on separating the mind from the body in order to explain observable behaviours.

Thomas Willis

It was in the mid-17th century that another major contributor to the field of neuropsychology emerged. Thomas Willis studied at Oxford University and took a physiological approach to the brain and behaviour. It was Willis who coined the words ‘hemisphere’ and ‘lobe’ when referring to the brain. He was one of the earliest to use the words ‘neurology’ and ‘psychology’. Rejecting the idea that humans were the only beings capable of rational thought, Willis looked at specialised structures of the brain. He theorised that higher structures accounted for complex functions, whereas lower structures were responsible for functions similar to those seen in other animals, consisting mostly of reactions and automatic responses. He was particularly interested in people who suffered from manic disorders and hysteria. His research constituted some of the first times that psychiatry and neurology came together to study individuals. Through his in-depth study of the brain and behaviour, Willis concluded that automated responses such as breathing, heartbeats and other various motor activities were carried out within the lower region of the brain. Although much of his work has been made obsolete, his ideas presented the brain as more complex than previously imagined, and led the way for future pioneers to understand and build upon his theories, especially when it came to looking at disorders and dysfunctions in the brain.

Franz Joseph Gall

Neuroanatomist and physiologist Franz Joseph Gall made major progress in understanding the brain. He theorized that personality was directly related to features and structures within the brain. However, Gall’s major contribution within the field of neuroscience is his invention of phrenology. This new discipline looked at the brain as an organ of the mind, where the shape of the skull could ultimately determine one’s intelligence and personality. This theory was like many circulating at the time, as many scientists were taking into account physical features of the face and body, head size, anatomical structure, and levels of intelligence; only Gall looked primarily at the brain. There was much debate over the validity of Gall’s claims however, because he was often found to be wrong in his predictions. He was once sent a cast of René Descartes’ skull, and through his method of phrenology claimed the subject must have had a limited capacity for reasoning and higher cognition. As controversial and false as many of Gall’s claims were, his contributions to understanding cortical regions of the brain and localised activity continued to advance understanding of the brain, personality, and behaviour. His work is considered crucial to having laid a firm foundation in the field of neuropsychology, which would flourish over the next few decades.

Jean-Baptiste Bouillaud

Towards the late 19th century, the belief that the size of ones skull could determine their level of intelligence was discarded as science and medicine moved forward. A physician by the name of Jean-Baptiste Bouillaud expanded upon the ideas of Gall and took a closer look at the idea of distinct cortical regions of the brain each having their own independent function. Bouillaud was specifically interested in speech and wrote many publications on the anterior region of the brain being responsible for carrying out the act of ones speech, a discovery that had stemmed from the research of Gall. He was also one of the first to use larger samples for research although it took many years for that method to be accepted. By looking at over a hundred different case studies, Bouillaud came to discover that it was through different areas of the brain that speech is completed and understood. By observing people with brain damage, his theory was made more concrete. Bouillaud, along with many other pioneers of the time made great advances within the field of neurology, especially when it came to localisation of function. There are many arguable debates as to who deserves the most credit for such discoveries, and often, people remain unmentioned, but Paul Broca is perhaps one of the most famous and well known contributors to neuropsychology – often referred to as “the father” of the discipline.

Paul Broca

Inspired by the advances being made in the area of localised function within the brain, Paul Broca committed much of his study to the phenomena of how speech is understood and produced. Through his study, it was discovered and expanded upon that we articulate via the left hemisphere. Broca’s observations and methods are widely considered to be where neuropsychology really takes form as a recognisable and respected discipline. Armed with the understanding that specific, independent areas of the brain are responsible for articulation and understanding of speech, the brains abilities were finally being acknowledged as the complex and highly intricate organ that it is. Broca was essentially the first to fully break away from the ideas of phrenology and delve deeper into a more scientific and psychological view of the brain.

Karl Spencer Lashley

Lashley’s works and theories that follow are summarised in his book Brain Mechanisms and Intelligence. Lashley’s theory of the Engram was the driving force for much of his research. An engram was believed to be a part of the brain where a specific memory was stored. He continued to use the training/ablation method that Franz had taught him. He would train a rat to learn a maze and then use systematic lesions and removed sections of cortical tissue to see if the rat forgot what it had learned.

Through his research with the rats, he learned that forgetting was dependent on the amount of tissue removed and not where it was removed from. He called this mass action and he believed that it was a general rule that governed how brain tissue would respond, independent of the type of learning. But we know now that mass action was a misinterpretation of his empirical results, because in order to run a maze the rats required multiple cortical areas. Cutting into small individual parts alone will not impair the rats’ brains much, but taking large sections removes multiple cortical areas at one time, affecting various functions such as sight, motor coordination and memory, making the animal unable to run a maze properly.

Lashley also proposed that a portion of a functional area could carry out the role of the entire area, even when the rest of the area has been removed. He called this phenomenon equipotentiality. We know now that he was seeing evidence of plasticity in the brain: within certain constraints the brain has the ability for certain areas to take over the functions of other areas if those areas should fail or be removed – although not to the extent initially argued by Lashley.

Approaches

Experimental neuropsychology is an approach that uses methods from experimental psychology to uncover the relationship between the nervous system and cognitive function. The majority of work involves studying healthy humans in a laboratory setting, although a minority of researchers may conduct animal experiments. Human work in this area often takes advantage of specific features of our nervous system (for example that visual information presented to a specific visual field is preferentially processed by the cortical hemisphere on the opposite side) to make links between neuroanatomy and psychological function.

Clinical neuropsychology is the application of neuropsychological knowledge to the assessment (see neuropsychological test and neuropsychological assessment), management, and rehabilitation of people who have suffered illness or injury (particularly to the brain) which has caused neurocognitive problems. In particular they bring a psychological viewpoint to treatment, to understand how such illness and injury may affect and be affected by psychological factors. They also can offer an opinion as to whether a person is demonstrating difficulties due to brain pathology or as a consequence of an emotional or another (potentially) reversible cause or both. For example, a test might show that both patients X and Y are unable to name items that they have been previously exposed to within the past 20 minutes (indicating possible dementia). If patient Y can name some of them with further prompting (e.g. given a categorical clue such as being told that the item they could not name is a fruit), this allows a more specific diagnosis than simply dementia (Y appears to have the vascular type which is due to brain pathology but is usually at least somewhat reversible). Clinical neuropsychologists often work in hospital settings in an interdisciplinary medical team; others work in private practice and may provide expert input into medico-legal proceedings.

Cognitive neuropsychology is a relatively new development and has emerged as a distillation of the complementary approaches of both experimental and clinical neuropsychology. It seeks to understand the mind and brain by studying people who have suffered brain injury or neurological illness. One model of neuropsychological functioning is known as functional localisation. This is based on the principle that if a specific cognitive problem can be found after an injury to a specific area of the brain, it is possible that this part of the brain is in some way involved. However, there may be reason to believe that the link between mental functions and neural regions is not so simple. An alternative model of the link between mind and brain, such as parallel processing, may have more explanatory power for the workings and dysfunction of the human brain. Yet another approach investigates how the pattern of errors produced by brain-damaged individuals can constrain our understanding of mental representations and processes without reference to the underlying neural structure. A more recent but related approach is cognitive neuropsychiatry which seeks to understand the normal function of mind and brain by studying psychiatric or mental illness.

Connectionism is the use of artificial neural networks to model specific cognitive processes using what are considered to be simplified but plausible models of how neurons operate. Once trained to perform a specific cognitive task these networks are often damaged or ‘lesioned’ to simulate brain injury or impairment in an attempt to understand and compare the results to the effects of brain injury in humans.

Functional neuroimaging uses specific neuroimaging technologies to take readings from the brain, usually when a person is doing a particular task, in an attempt to understand how the activation of particular brain areas is related to the task. In particular, the growth of methodologies to employ cognitive testing within established functional magnetic resonance imaging (fMRI) techniques to study brain-behaviour relations is having a notable influence on neuropsychological research.

In practice these approaches are not mutually exclusive and most neuropsychologists select the best approach or approaches for the task to be completed.

Methods and Tools

Standardised Neuropsychological Tests

These tasks have been designed so the performance on the task can be linked to specific neurocognitive processes. These tests are typically standardised, meaning that they have been administered to a specific group (or groups) of individuals before being used in individual clinical cases. The data resulting from standardisation are known as normative data. After these data have been collected and analysed, they are used as the comparative standard against which individual performances can be compared. Examples of neuropsychological tests include: the Wechsler Memory Scale (WMS), the Wechsler Adult Intelligence Scale (WAIS), Boston Naming Test, the Wisconsin Card Sorting Test, the Benton Visual Retention Test, and the Controlled Oral Word Association.

Brain Scans

The use of brain scans to investigate the structure or function of the brain is common, either as simply a way of better assessing brain injury with high resolution pictures, or by examining the relative activations of different brain areas. Such technologies may include fMRI (functional magnetic resonance imaging) and positron emission tomography (PET), which yields data related to functioning, as well as MRI (magnetic resonance imaging) and computed axial tomography (CAT or CT), which yields structural data.

Global Brain Project

Brain models based on mouse and monkey have been developed based on theoretical neuroscience involving working memory and attention, while mapping brain activity based on time constants validated by measurements of neuronal activity in various layers of the brain. These methods also map to decision states of behaviour in simple tasks that involve binary outcomes.

Electrophysiology

The use of electrophysiological measures designed to measure the activation of the brain by measuring the electrical or magnetic field produced by the nervous system. This may include electroencephalography (EEG) or magneto-encephalography (MEG).

Experimental Tasks

The use of designed experimental tasks, often controlled by computer and typically measuring reaction time and accuracy on a particular tasks thought to be related to a specific neurocognitive process. An example of this is the Cambridge Neuropsychological Test Automated Battery (CANTAB) or CNS Vital Signs (CNSVS).

What is Mentalisation-Based Treatment?

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Introduction

Mentalisation-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioural, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganised attachment and failed to develop a robust mentalisation capacity. Fonagy and Bateman define mentalisation as the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that patients with BPD increase their mentalisation capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.

More recently, a range of mentalisation-based treatments, using the “mentalising stance” defined in MBT but directed at children (MBT-C), families (MBT-F) and adolescents (MBT-A), and for chaotic multi-problem youth, AMBIT (adaptive mentalisation-based integrative treatment) has been under development by groups mainly gravitating around the Anna Freud National Centre for Children and Families.

The treatment should be distinguished from and has no connection with mindfulness-based stress reduction (MBSR) therapy developed by Jon Kabat-Zinn.

Goals

The major goals of MBT are:

  • Better behavioural control.
  • Increased affect regulation.
  • More intimate and gratifying relationships.
  • The ability to pursue life goals.

This is believed to be accomplished through increasing the patient’s capacity for mentalisation in order to stabilise the client’s sense of self and to enhance stability in emotions and relationships.

Focus of Treatment

A distinctive feature of MBT is placing the enhancement of mentalising itself as focus of treatment. The aim of therapy is not developing insight, but the recovery of mentalising. Therapy examines mainly the present moment, attending to events of the past only insofar as they affect the individual in the present. Other core aspects of treatment include a stance of curiosity, partnership with the patient rather than an ‘expert’ type role, monitoring and regulating emotional arousal, and identifying the affect focus. Transference in classical understanding of this term is not included in the MBT model. MBT does encourage consideration of the patient-therapist relationship, but without necessarily generalising to other relationships, past or present.

Treatment Procedure

MBT should be offered to patients twice per week with sessions alternating between group therapy and individual treatment. During sessions the therapist works to stimulate or nurture mentalising. Particular techniques are employed to lower or raise emotional arousal as needed, to interrupt non-mentalising and to foster flexibility in perspective-taking. Activation occurs through the elaboration of current attachment relationships, the therapist’s encouragement and regulation of the patient’s attachment bond with the therapist and the therapist’s attempts to create attachment bonds between members of the therapy group.

Mechanisms of Change

The safe attachment relationship with the therapist provides a relational context in which it is safe for the patient to explore the mind of the other. Fonagy and Bateman have recently proposed that MBT (and other evidence-based therapies) works by providing ostensive cues that stimulate epistemic trust. The increase in epistemic trust, together with a persistent focus on mentalising in therapy, appear to facilitate change by leaving people more open to learning outside of therapy, in the social interactions of their day-to-day lives.

Efficacy

Fonagy, Bateman, and colleagues have done extensive outcome research on MBT for borderline personality disorder. The first randomised, controlled trial was published in 1999, concerning MBT delivered in a partial hospital setting. The results showed real-world clinical effectiveness that compared favourably with existing treatments for BPD. A follow-up study published in 2003 demonstrated that MBT is cost-effective. Encouraging results were also found in an 18-month study, in which subjects were randomly assigned to an outpatient MBT treatment condition versus a structured clinical management (SCM) treatment. The lasting efficacy of MBT was demonstrated in an 8-year follow-up of patients from the original trial, comparing MBT versus treatment as usual. In that research, patients who had received MBT had less medication use, fewer hospitalisations and longer periods of employment compared to patients who received standard care. Replication studies have been published by other European investigators. Researchers have also demonstrated the effectiveness of MBT for adolescents as well as that of a group-only format of MBT.

What is Salutogenesis?

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Introduction

Salutogenesis is the origins of health and focuses on factors that support human health and well-being, rather than on factors that cause disease (pathogenesis).

More specifically, the “salutogenic model” was originally concerned with the relationship between health, stress, and coping through a study of holocaust survivors. Despite going through the dramatic tragedy of the holocaust, some survivors were able to thrive later in life. The discovery that there must be powerful health causing factors led to the development of salutogenesis. The term was coined by Aaron Antonovsky, a professor of medical sociology. The salutogenic question posed by Aaron Antonovsky is, “How can this person be helped to move toward greater health?”

Antonovsky’s theories reject the “traditional medical-model dichotomy separating health and illness”. He described the relationship as a continuous variable, what he called the “health-ease versus dis-ease continuum”. Salutogenesis now encompasses more than the origins of health and has evolved to be about multidimensional causes of higher levels of health. Models associated with salutogenesis generally include wholistic approaches related to at least the physical, social, emotional, spiritual, intellectual, vocational, and environmental dimensions. A comparison of the salutogenic model with the traditional pathogenic model is provided in the below video.

Derivation

The word “salutogenesis” comes from the Latin salus = health and the Greek genesis = origin. Antonovsky developed the term from his studies of “how people manage stress and stay well” (unlike pathogenesis which studies the causes of diseases). He observed that stress is ubiquitous, but not all individuals have negative health outcomes in response to stress. Instead, some people achieve health despite their exposure to potentially disabling stress factors.

In his 1979 book, Health, Stress and Coping, Antonovsky described a variety of influences that led him to the question of how people survive, adapt, and overcome in the face of even the most punishing life-stress experiences. In his 1987 book, Unraveling the Mysteries of Health, he focused more specifically on a study of women and aging; he found that 29% of women who had survived Nazi concentration camps had positive emotional health, compared to 51% of a control group. His insight was that 29% of the survivors were not emotionally impaired by the stress. Antonovsky wrote: “this for me was the dramatic experience that consciously set me on the road to formulating what I came to call the ‘salutogenic model’.”

In salutogenic theory, people continually battle with the effects of hardship. These ubiquitous forces are called generalised resource deficits (GRDs). On the other hand, there are generalised resistance resources (GRRs), which are all of the resources that help a person cope and are effective in avoiding or combating a range of psychosocial stressors. Examples are resources such as money, ego-strength, and social support.

Generalised resource deficits will cause the coping mechanisms to fail whenever the sense of coherence is not robust to weather the current situation. This causes illness and possibly even death. However, if the sense of coherence is high, a stressor will not necessarily be harmful. But it is the balance between generalised resource deficits and resources that determines whether a factor will be pathogenic, neutral, or salutary.

Antonovsky’s formulation was that the generalised resistance resources enabled individuals to make sense of and manage events. He argued that over time, in response to positive experiences provided by successful use of different resources, an individual would develop an attitude that was “in itself the essential tool for coping”.

Sense of Coherence

The “sense of coherence” is a theoretical formulation that provides a central explanation for the role of stress in human functioning. “Beyond the specific stress factors that one might encounter in life, and beyond your perception and response to those events, what determines whether stress will cause you harm is whether or not the stress violates your sense of coherence.” Antonovsky defined Sense of Coherence as:

“a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement.”

In his formulation, the sense of coherence has three components:

  • Comprehensibility: a belief that things happen in an orderly and predictable fashion and a sense that you can understand events in your life and reasonably predict what will happen in the future.
  • Manageability: a belief that you have the skills or ability, the support, the help, or the resources necessary to take care of things, and that things are manageable and within your control.
  • Meaningfulness: a belief that things in life are interesting and a source of satisfaction, that things are really worthwhile and that there is good reason or purpose to care about what happens.

According to Antonovsky, the third element is the most important. If a person believes there is no reason to persist and survive and confront challenges, if they have no sense of meaning, then they will have no motivation to comprehend and manage events. His essential argument is that “salutogenesis” depends on experiencing a strong “sense of coherence”. His research demonstrated that the sense of coherence predicts positive health outcomes.

Fields of Application

Health and Medicine

Antonovsky viewed his work as primarily addressed to the fields of health psychology, behavioural medicine, and the sociology of health. It has been adopted as a term to describe contemporary approaches to nursing, psychiatry, integrative medicine, and healthcare architecture. The salutogenic framework has also been adapted as a method for decision making on the fly; the method has been applied for emergency care and for healthcare architecture.

Workplace

The sense of coherence with its three components meaningfulness, manageability and understandability has also been applied to the workplace.

Meaningfulness is considered to be related to the feeling of participation and motivation and to a perceived meaning of the work. The meaningfulness component has also been linked with Job control and with task significance. Job control implies that employees have more authority to make decisions concerning their work and the working process. Task significance involves “the experience of congruence between personal values and work activities, which is accompanied by strong feelings of identification with the attitudes, values or goals of the working tasks and feelings of motivation and involvement”.

The manageability component is considered to be linked to job control as well as to access to resources. It has also been considered to be linked with social skills and trust. Social relations relate also to the meaningfulness component.

The comprehensibility component may be influenced by consistent feedback at work, for example concerning the performance appraisal.

Salutogenics perspectives are also considered in the design of offices.

What is Transference Focused Psychotherapy?

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Introduction

Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg’s object relations model of borderline personality disorder.

It views the individual with borderline personality organisation (BPO) as holding unreconciled and contradictory internalised representations of self and significant others that are affectively charged. The defence against these contradictory internalised object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.

TFP has been validated as an efficacious treatment for borderline personality disorder (BPD), though too few studies have been conducted to allow firm conclusions about its value. TFP is one of a number of treatments that may be useful in the treatment of BPD; however, in a study which compared TFP, dialectical behaviour therapy, and modified psychodynamic supportive psychotherapy, only TFP was shown to change how patients think about themselves in relationships.

Borderline Personality Disorder

TFP is a treatment for borderline personality disorder (BPD). Patients with BPD are often characterised by intense affects, stormy relationships, and impulsive behaviours. Due to their high reactivity to environmental stimuli, patients with BPD often experience dramatic and short-lived shifts in their mood, alternating between experiences of euphoria, depression, anxiety, and nervousness. Patients with BPD often experience intolerable feelings of emptiness that they attempt to fill with impulsive and self-damaging behaviours, such as substance abuse, risky sexual behaviour, uncontrolled spending, or binge eating. Further, patients with BPD often exhibit recurrent suicidal behaviours, gestures, or threats. Under intense stress patients with BPD may exhibit transient dissociative or paranoid symptoms.

Theoretical Model of Borderline Personality

According to an object relations model, in normal psychological development mental templates of oneself in relation to others, or object representations, become increasingly more differentiated and integrated. The infant’s experience, initially organised around moments of pain (“I am uncomfortable and in need of someone to care for me”) and pleasure (“I am now being soothed by someone and feel loved”), become increasingly integrated and differentiated mental templates of oneself in relation to others. These increasingly mature representations allow for the realistic blending of good and bad, such that positive and negative qualities can be integrated into a complex, multifaceted representation of an individual (“Although she is not caring for me at this moment, I know she loves me and will do so in the future”). Such integrated representations allow for the tolerance of ambivalence, difference, and contradiction in oneself and others.

For Kernberg the degree of differentiation and integration of these representations of self and other, along with their affective valence, constitutes personality organisation. In a normal personality organisation the individual has an integrated model of self and others, allowing for stability and consistency within one’s identity and in the perception of others, as well as a capacity for becoming intimate with others while maintaining one’s sense of self. For example, such an individual would be able to tolerate hateful feelings in the context of a loving relationship without internal conflict or a sense of discontinuity in the perception of the other. In contrast, in Borderline Personality Organisation (BPO), the lack of integration in representations of self and other leads to the use of primitive defence mechanisms (e.g. splitting, projective identification, dissociation), identity diffusion (inconsistent view of self and others), and unstable reality testing (inconsistent differentiation between internal and external experience). Under conditions of high stress, borderline patients may fail to appreciate the “whole” of the situation and interpret events in catastrophic and intensely personal ways. They fail to discriminate the intentions and motivations of the other and thus, perceive only threat or rejection. Thus thoughts and feelings about self and others are split into dichotomous experiences of good or bad, black or white, all or nothing.

Goals

The major goals of TFP are to reduce suicidality and self-injurious behaviours, and to facilitate better behavioural control, increased affect regulation, more gratifying relationships, and the ability to pursue life goals. This is believed to be accomplished through the development of integrated representations of self and others, the modification of primitive defensive operations, and the resolution of identity diffusion that perpetuate the fragmentation of the patient’s internal representational world.

Treatment Procedure

Contract

The treatment begins with the development of the treatment contract, which consists of general guidelines that apply for all clients and of specific items developed from problem areas of the individual client that could interfere with the therapy progress. The contract also contains therapist responsibilities. The client and the therapist must agree to the content of the treatment contract before the therapy can proceed.

Therapeutic Process

TFP consists of the following three steps:

  • Diagnostic description of a particular internalised object relation in the transference.
  • Diagnostic elaboration of the corresponding self and object representation in the transference, and of their enactment in the transference/countertransference.
  • Integration of the split-off self representations, leading to an integrated sense of self and others which resolves identity diffusion.

During the first year of treatment, TFP focuses on a hierarchy of issues:

  • Containment of suicidal and self-destructive behaviours.
  • Various ways of destroying the treatments.
  • Identification and recapitulation of dominant object relational patterns (from unintegrated and undifferentiated affects and representations of self and others to a more coherent whole).

In this treatment, the analysis of the transference is the primary vehicle for the transformation of primitive (e.g. split, polarised) to advanced (e.g. complex, differentiated and integrated) object relations. Thus, in contrast to therapies that focus on the short-term treatment of symptoms, TFP has the ambitious goal of not just changing symptoms, but changing the personality organisation, which is the context of the symptoms. To do this, the client’s affectively charged internal representations of previous relationships are consistently interpreted as the therapist becomes aware of them in the therapeutic relationship, that is, the transference. Techniques of clarification, confrontation, and interpretation are used within the evolving transference relationship between the patient and the therapist.

In the psychotherapeutic relationship, self and object representations are activated in the transference. In the course of the therapy, projection and identification are operating, i.e. devalued self-representations are projected onto the therapist whilst the client identifies with a critical object representation. These processes are usually connected to affective experiences such as anger or fear.

The information that emerges within the transference provides direct access to the individual’s internal world for two reasons. First, it is observable by both therapist and patient simultaneously so that inconsistent perceptions of the shared reality can be discussed immediately. Second, the perceptions of shared reality are accompanied by affect whereas the discussion of historical material can have an intellectualised quality and be thus less informative.

TFP emphasizes the role of interpretation within psychotherapy sessions. As the split-off representations of self and other get played out in the course of the treatment, the therapist helps the patient to understand the reasons (the fears or the anxieties) that support the continued separation of these fragmented senses of self and other. This understanding is accompanied by the experience of strong affects within the therapeutic relationship. The integration of the split and polarized concepts of self and others leads to a more complex, differentiated, and realistic sense of self and others that allows for better modulation of affects and in turn clearer thinking. Therefore, as split-off representations become integrated, patients tend to experience an increased coherence of identity, relationships that are balanced and constant over time and therefore not at risk of being overwhelmed by aggressive affect, a greater capacity for intimacy, a reduction in self-destructive behaviours, and general improvement in functioning.

Mechanisms of Change

In TFP, hypothesised mechanisms of change derive from Kernberg’s developmentally based theory of Borderline Personality Organisation, conceptualised in terms of unintegrated and undifferentiated affects and representations of self and other. Partial representations of self and other are paired and linked by an affect in mental units called object relation dyads. These dyads are elements of psychological structure. In borderline pathology, the lack of integration of the internal object relations dyads corresponds to a ‘split’ psychological structure in which totally negative representations are split off/segregated from idealised positive representations of self and other (seeing people as all good or all bad). The putative global mechanism of change in patients treated with TFP is the integration of these polarised affect states and representations of self and other into a more coherent whole.

Empirical Support

Preliminary Research

In early research studying the efficacy of a year-long TFP, suicide attempts were significantly reduced during treatment. Additionally, the physical condition of the patients was significantly improved. When the researchers compared the treatment year to the year prior, it was found that there was a significant reduction in psychiatric hospitalisations and days spent as inpatients in psychiatric hospitals. The dropout rate for the 1-year study was 19.1%, which the authors state as comparable to dropout rates in previous studies assessing the treatment of borderline individuals, including DBT research.

TFP vs. Treatment-As-Usual (TAU)

Results indicated that the TFP group experienced significant decreases in ER visits and hospitalisations during treatment year, as well as significant increases in global functioning when compared to TAU.

TFP vs. Treatment by Community Experts

A randomised clinical trial compared the outcomes of TFP or treatment by community experts for 104 borderline patients. The dropout rate was significantly higher in the community psychotherapy condition; however, the dropout rate for TFP was 38.5%, which the authors acknowledge as somewhat higher than dropout rates associated with dialectical behaviour therapy (DBT) and schema-focused therapy (SFT). The TFP group experienced significant improvement in personality organisation, psychosocial functioning, and number of suicide attempts. In this study neither group was associated with a significant change in self-harming behaviours.

TFP vs. DBT vs. Supportive Treatment

Prior to treatment and at four-month intervals during treatment, patients were assessed in the following domains: suicidal behaviour, aggression, impulsivity, anxiety, depression, and social adjustment. Results indicate that patients in all three conditions showed improvement in multiple domains at the one-year mark. Only DBT and TFP were significantly associated with improvement in suicidal behaviours; however, TFP outperformed DBT in anger and impulsivity improvement. Overall, participation in TFP predicted significant improvement in 10 of the 12 variables across the 6 domains, DBT in 5 of 12, and ST in 6 of the 12 variables.

TFP vs. Schema Focused Therapy

Significant improvements were found in both treatment groups on DSM-IV BPD criteria and on all four of the study’s outcome measures (borderline psychopathology, general psychopathology, quality of life, and TFP/SFT personality concepts) after 1-, 2-, and 3-years. Schema focused therapy (SFT, or schema therapy as it is now commonly known) was associated with a significantly higher retention rate. After three years of treatment, schema therapy patients showed greater increases in quality of life, and significantly more schema therapy patients recovered or showed clinical improvement on the BPD Severity Index, fourth version. However, the TFP cell contained more suicidal patients and showed less adherence casting doubt on a direct comparison between treatments. The schema therapy group improved significantly more than the TFP group with respect to relationships, impulsivity, and parasuicidal/suicidal behaviour although many of the alliance ratings were made after dropout. It was concluded that schema therapy was significantly more effective than TFP on all outcome measures assessed during the study. A follow-up of this study concluded that both clients and therapists rated therapeutic alliance higher in schema therapy than in TFP.

What is Applied Psychology?

Published on by Andrew Marshall1 Comment

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 program 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:

  1. Psychodynamic;
  2. Cognitive behavioural;
  3. Existential-humanistic; and
  4. 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 (someone who is not a party to a case who assists a court by offering information, expertise, or insight that has a bearing on the issues in the case), 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 organisational 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, specializing 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 minimising the psychological effects of injury and poor performance. Some of the most important skills taught are goal setting, relaxation, visualisation, 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.