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What is Fluphenazine?

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Introduction

Fluphenazine, sold under the brand names Prolixin among others, is a high-potency typical antipsychotic medication.

It is used in the treatment of chronic psychoses such as schizophrenia, and appears to be about equal in effectiveness to low-potency antipsychotics like chlorpromazine. It is given by mouth, injection into a muscle, or just under the skin. There is also a long acting injectable version that may last for up to four weeks. Fluphenazine decanoate, the depot injection form of fluphenazine, should not be used by people with severe depression.

Common side effects include movement problems, sleepiness, depression and increased weight. Serious side effects may include neuroleptic malignant syndrome, low white blood cell levels, and the potentially permanent movement disorder tardive dyskinesia. In older people with psychosis as a result of dementia it may increase the risk of dying. It may also increase prolactin levels which may result in milk production, enlarged breasts in males, impotence, and the absence of menstrual periods. It is unclear if it is safe for use in pregnancy.

Fluphenazine is a typical antipsychotic of the phenothiazine class. Its mechanism of action is not entirely clear but believed to be related to its ability to block dopamine receptors. In up to 40% of those on long term phenothiazines, liver function tests become mildly abnormal.

Fluphenazine came into use in 1959. The injectable form is on the World Health Organisation’s List of Essential Medicines. It is available as a generic medication. It was discontinued in Australia around mid 2017.

Brief History

Fluphenazine came into use in 1959.

Medical Use

A 2018 Cochrane review found that fluphenazine was an imperfect treatment and other inexpensive drugs less associated with side effects may be an equally effective choice for people with schizophrenia.

Side Effects

Discontinuation

The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotics to avoid acute withdrawal syndrome or rapid relapse. Symptoms of withdrawal commonly include nausea, vomiting, and loss of appetite. Other symptoms may include restlessness, increased sweating, and trouble sleeping. Less commonly there may be a feeling of the world spinning, numbness, or muscle pains. Symptoms generally resolve after a short period of time.

There is tentative evidence that discontinuation of antipsychotics can result in psychosis. It may also result in reoccurrence of the condition that is being treated. Rarely tardive dyskinesia can occur when the medication is stopped.

Pharmacology

Pharmacodynamics

Fluphenazine acts primarily by blocking post-synaptic D2 receptors in the basal ganglia, cortical and limbic system. It also blocks alpha-1 adrenergic receptors, muscarinic-1 receptors, and histamine-1 receptors.

Availability

The injectable form is on the World Health Organisation’s List of Essential Medicines, the safest and most effective medicines needed in a health system. It is available as a generic medication. It was discontinued in Australia around mid 2017.

Other Animals

In horses, it is sometimes given by injection as an anxiety-relieving medication, though there are many negative common side effects and it is forbidden by many equestrian competition organisations.

What is Flurazepam?

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Introduction

Flurazepam (marketed under the brand names Dalmane and Dalmadorm) is a drug which is a benzodiazepine derivative.

It possesses anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant properties. It produces a metabolite with a long half-life, which may stay in the bloodstream for days. Flurazepam was patented in 1968 and came into medical use the same year. Flurazepam, developed by Roche Pharmaceuticals was one of the first benzo hypnotics (sleeping pills) to be marketed.

Medical Uses

Flurazepam is officially indicated for mild to moderate insomnia and as such it is used for short-term treatment of patients with mild to moderate insomnia such as difficulty falling asleep, frequent awakening, early awakenings or a combination of each. Flurazepam is a long-acting benzodiazepine and is sometimes used in patients who have difficulty in maintaining sleep, though benzodiazepines with intermediate half-lives such as loprazolam, lormetazepam, and temazepam are also indicated for patients with difficulty maintaining sleep.

Flurazepam was temporarily unavailable in the United States when its sole producer, Mylan Pharmaceuticals, discontinued making it in January 2019. In October of 2019, the US Food and Drug Administration (FDA) informed pharmacies that they could expect to be resupplied by manufacturers in early to mid December 2019. As of this date, Flurazepam is now again available in the United States.

Side Effects

The most common adverse effects are dizziness, drowsiness, light-headedness, and ataxia. Flurazepam has abuse potential and should never be used with alcoholic beverages or any other substance that can cause drowsiness. Addictive and possibly fatal results may occur. Flurazepam users should only take this drug strictly as prescribed, and should only be taken directly before the user plans on sleeping a full night. Next day drowsiness is common and may increase during the initial phase of treatment as accumulation occurs until steady-state plasma levels are attained.

A 2009 meta-analysis found a 44% higher rate of mild infections, such as pharyngitis or sinusitis, in people taking hypnotic drugs compared to those taking a placebo.

In September 2020, the FDA required the boxed warning be updated for all benzodiazepine medicines to describe the risks of abuse, misuse, addiction, physical dependence, and withdrawal reactions consistently across all the medicines in the class.

Tolerance, Dependence and Withdrawal

Refer to Benzodiazepine Withdrawal Syndrome.

A review paper found that long-term use of flurazepam is associated with drug tolerance, drug dependence, rebound insomnia and central nervous system (CNS) related adverse effects. Flurazepam is best used for a short time period and at the lowest possible dose to avoid complications associated with long-term use. Non-pharmacological treatment options however, were found to have sustained improvements in sleep quality. Flurazepam and other benzodiazepines such as fosazepam, and nitrazepam lost some of their effect after seven days administration in psychogeriatric patients. Flurazepam shares cross tolerance with barbiturates and barbiturates can easily be substituted by flurazepam in those who are habituated to barbiturate sedative hypnotics.

After discontinuation of flurazepam a rebound effect or benzodiazepine withdrawal syndrome may occur about four days after discontinuation of medication.

Contraindications and Special Caution

Benzodiazepines require special precaution if used in the elderly, during pregnancy, in children, alcohol- or drug-dependent individuals and individuals with comorbid psychiatric disorders.

Elderly

Flurazepam, similar to other benzodiazepines and nonbenzodiazepine hypnotic drugs causes impairments in body balance and standing steadiness in individuals who wake up at night or the next morning. Falls and hip fractures are frequently reported. The combination with alcohol increases these impairments. Partial, but incomplete tolerance develops to these impairments. An extensive review of the medical literature regarding the management of insomnia and the elderly found that there is considerable evidence of the effectiveness and durability of non-drug treatments for insomnia in adults of all ages and that these interventions are underutilised. Compared with the benzodiazepines including flurazepam, the nonbenzodiazepine sedative-hypnotics appeared to offer few, if any, significant clinical advantages in efficacy in elderly persons. Tolerability in elderly patients, however, is improved marginally in that benzodiazepines have moderately higher risks of falls, memory problems, and disinhibition (“paradoxical agitation”) when compared to non-benzodiazepine sedatives. It was found that newer agents with novel mechanisms of action and improved safety profiles, such as the melatonin agonists, hold promise for the management of chronic insomnia in elderly people. Chronic use of sedative-hypnotic drugs for the management of insomnia does not have an evidence base and has been discouraged due to concerns including potential adverse drug effects as cognitive impairment (anterograde amnesia), daytime sedation, motor incoordination, and increased risk of motor vehicle accidents and falls. In addition, the effectiveness and safety of long-term use of sedative hypnotics has been determined to be no better than placebo after 3 months of therapy and worse than placebo after 6 months of therapy.

Pharmacology

Flurazepam is a “classical” benzodiazepine; some other classical benzodiazepines include diazepam, clonazepam, oxazepam, lorazepam, nitrazepam, bromazepam, and clorazepate. Flurazepam generates an active metabolite, N-desalkylflurazepam, with a very long elimination half-life. Flurazepam could be therefore unsuitable as a sleeping medication for some individuals due to next-day sedation; however, this same effect may also provide next-day anxiety relief. Residual ‘hangover’ effects after nighttime administration of flurazepam, such as sleepiness, impaired psychomotor and cognitive functions, may persist into the next day, which may impair the ability of users to drive safely and increase risks of falls and hip fractures.

Flurazepam is lipophilic, is metabolised hepatically via oxidative pathways. The main pharmacological effect of flurazepam is to increase the effect of GABA at the GABAA receptor via binding to the benzodiazepine site on the GABAA receptor causing an increase influx of chloride ions into the GABAA neuron.

Flurazepam is contraindicated in pregnancy. It is recommended to withdraw flurazepam during breast feeding, as flurazepam is excreted in breast milk.

Society and Culture

Drug Misuse

Refer to Benzodiazepine Use Disorder.

Flurazepam is a drug with potential for misuse. Two types of drug misuse can occur, either recreational misuse where the drug is taken to achieve a high, or when the drug is continued long term against medical advice.

Flurazepam is a Schedule IV drug under the Convention on Psychotropic Substances.

What is Emotionality?

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Introduction

Emotionality is the observable behavioural and physiological component of emotion. It is a measure of a person’s emotional reactivity to a stimulus.

Most of these responses can be observed by other people, while some emotional responses can only be observed by the person experiencing them. Observable responses to emotion (i.e. smiling) do not have a single meaning. A smile can be used to express happiness or anxiety, while a frown can communicate sadness or anger. Emotionality is often used by experimental psychology researchers to operationalise emotion in research studies.

Early Theories

By the late 1800s, many high-quality contributions became interested in analysing emotion because of the works of psychologists and scientists such as Wilhelm Wundt, George Stout, William McDougall, William James, and George Herbert Mead. William James preferred to focus on the physiological aspects of emotional response, although he did not disregard the perceptual or cognitive components. William McDougall thought of emotion as the articulation of a natural response built on instinct. Other psychologists reasoned that although gestures express emotion, this is not the entirety of their function. Wundt analysed that emotion portrays both expression and communication.

As Irrational

One of the oldest views of emotion is that emotion indicates inferiority. In early psychology, it was believed that passion (emotion) was a part of the soul inherited from the animals and that it must be controlled. Solomon identified that in the Romantic movement of the eighteenth and nineteenth centuries, reason and emotion were discovered to be opposites.

As Physiological

Physiological responses to emotion originate in the central nervous system, the autonomic nervous system, and the endocrine system. Some of the responses include: heart rate, sweating, rate and depth of respiration, and electrical activity in the brain. Many researchers have attempted to find a connection between specific emotions and a corresponding pattern of physiological responses, but the results have been inconclusive.

Later Theories

The significant theories of emotion can be divided into three primary categories: physiological, neurological, and cognitive. Physiological theories imply that activity within the body can be accountable for emotions. Neurological theories suggest that activity within the brain leads to emotional responses. Lastly, cognitive theories reason that thoughts and other mental activity have a vital role in the stimulation of emotions. Common sense suggests that people first become consciously aware of their emotions and that the physiological responses follow shortly after. Theories by James-Lange, Cannon-Bard, and Schachter-Singer contradict the common-sense theory.

James-Lange

The James-Lange theory of emotion was proposed by psychologist William James and physiologist Carl Lange. This theory suggests that emotions occur as a result of physiological responses to outside stimuli or events. For example, this theory suggests that if someone is driving down the road and sees the headlights of another car heading toward them in their lane, their heart begins to race (a physiological response) and then they become afraid (fear being the emotion).

Cannon-Bard

The Cannon-Bard theory, which was conceptualized by Walter Cannon and Phillip Bard, suggests that emotions and their corresponding physiological responses are experienced simultaneously. Using the previous example, when someone sees the car coming toward them in their lane, their heart starts to race and they feel afraid at the same time.

Schachter-Singer

Stanley Schachter and Jerome Singer proposed a theory also known as the two-factor theory of emotion, which implies emotion have two factors: physical arousal and cognitive label. This suggests that if the physiological activity occurs first, then it must cognitively be distinguished as the cause of the arousal and labelled as an emotion. Using the example of someone seeing a car coming towards them in their lane, their heart would start to race and they would identify that they must be afraid if their heart is racing, and from there they would begin to feel fear.

Gender Differences

The opposition of rational thought and emotion is believed to be paralleled by the similar opposition between male and female. A traditional view is that “men are seen as rational and women as emotional, lacking rationality.” However, in spite of these ideas, and in spite of gender differences in the prevalence of mood disorders, the empirical evidence on gender differences in emotional responding is mixed.

When engaging in social interaction, studies show that women smile significantly more than men do. It is difficult to determine the exact difference between males and females to explain this disparity. It is possible that this difference in expression of emotions is due to societal influences and conformity to gender roles. However, this may not fully explain why men smile less than women do.

The male gender role involves characteristics such as strength, expert knowledge, and a competitive nature. Smiling may be stereotypically associated with weakness. Men may feel that if they engage in this perceived weakness, it may contradict their attempts to show strength and other traits of the male gender role. Another broad explanation for the contrast in male and female gender expression is that women have reported to experience greater levels of emotional intensity than men, in both positive and negative aspects, which could naturally lead to greater emotional response. It has also been reported that men are more likely to confide in female companions, revealing their emotions and intimacy, while females are typically comfortable confiding in both genders. This suggests that men are more particular about how they express the emotions they feel, potentially relating back to gender roles.

Across Cultures

There are six universal emotions which expand across all cultures. These emotions are happiness, sadness, anger, fear, surprise, and disgust. Debate exists about whether contempt should be combined with disgust. According to Ekman (1992), each of these emotions have universally corresponding facial expressions as well.

In addition to the facial expressions that are said to accompany each emotion, there is also evidence to suggest that certain autonomic nervous system (ANS) activity is associated with the three emotions of fear, anger, and disgust. Ekman theorizes that these specific emotions are associated with the universal physiological responses due to evolution. It would not be expected to observe the same physiological responses for emotions not specifically linked to survival, such as happiness or sadness.

Ekman’s theories were early challenged by James A. Russell, and have since been tested by a variety of researchers, with ambiguous results. This seems to reflect methodological problems relating to both display rules and to the components of emotion. Current thinking favours a mix of underlying universality combined with significant cultural differences in the articulation and expression of emotion. Emotions serve different functions in different cultures.

Positive

Positive emotionality is the ability to control positive mood and emotions, people with positive emotions seek for social reward. Positive emotionality can be a preventive factor in blocking out certain types of mental illness. In a study of a sample of 1,655 youth (54% girls; 7-16 years), it found that the higher their positive emotionality was, the lower their depression would be. Depression was considered by its definition of the inability to receive positive emotions or pleasure. The youth’s temperament, adaptive emotion regulation (ER) strategies, and depressive symptoms were determined through a questionnaire. The study also reported that depressive symptoms could be reduced through emotion regulation of positive mood. A study by Charles T. Taylor et al. linked being exposed to positive emotions before a surgery to less anxiety and a decrease in having symptoms after treatment.

Negative

Negative emotionality is the opposite of positive emotionality. People are unable to control their positive mood and emotions. Everyone experiences negative emotionality in different levels, there are different factors that effect each individual in a different way. Negative emotionality effects many aspects of our lives in terms of coping and the relationship that people share with one another. Neuroticism is one of the biggest factors found in negative emotionality. Someone on the higher spectrum of neuroticism is often more anxious and enjoy the feelings of their negative emotion. Some research suggests that obese children compared to children who are not obese have higher levels of negative emotionality and the ability to control emotions.

What is Emotional Lability?

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Introduction

In medicine and psychology, emotional lability is a sign or symptom typified by exaggerated changes in mood or affect in quick succession.

Background

Sometimes the emotions expressed outwardly are very different from how the person feels on the inside. These strong emotions can be a disproportionate response to something that happened, but other times there might be no trigger at all. The person experiencing emotional lability usually feels like they do not have control over their emotions. For example, someone might cry uncontrollably in response to any strong emotion even if they do not feel sad or unhappy.

Emotional lability is seen or reported in various conditions including borderline personality disorder, histrionic personality disorder, hypomanic or manic episodes of bipolar disorder, and neurological disorders or brain injury (where it is termed pseudobulbar affect), such as after a stroke. It has sometimes been found to have been a harbinger, or early warning, of certain forms of thyroid disease. Emotional lability also results from intoxication with certain substances, such as alcohol and benzodiazepines. It can also be an associated feature of ADHD.

Children who display a high degree of emotional lability generally have low frustration tolerance and frequent crying spells or tantrums. During preschool, ADHD with emotional lability is associated with increased impairment and may be a sign of internalising problems or multiple comorbid disorders. Children who are neglected are more likely to experience emotional dysregulation, including emotional lability.

Potential triggers of emotional lability may be: excessive tiredness, stress or anxiety, over-stimulated senses (too much noise, being in large crowds, etc.), being around others exhibiting strong emotions, very sad or funny situations (such as jokes, movies, certain stories or books), death of a loved one, or other situations that elicit stress or strong emotions.

On This Day … 09 November

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People (Births)

People (Deaths)

  • 2002 – William Schutz, American psychologist and academic (b. 1925).

Paul Cameron

Paul Drummond Cameron (born 09 November 1939) is an American psychologist.

Cameron has been designated by the Southern Poverty Law Centre as an anti-gay extremist. While employed at various institutions, including the University of Nebraska, he conducted research on passive smoking, but he is best known today for his claims about homosexuality. After a successful 1982 campaign against a gay rights proposal in Lincoln, Nebraska, he established the Institute for the Scientific Investigation of Sexuality (ISIS), now known as the Family Research Institute (FRI). As FRI’s chairman, Cameron has written contentious papers asserting associations between homosexuality and the perpetration of child sexual abuse and reduced life expectancy. These have been heavily criticised by others in the field.

In 1983, the American Psychological Association expelled Cameron for non-cooperation with an ethics investigation. Position statements issued by the American Sociological Association, Canadian Psychological Association, and the Nebraska Psychological Association accuse Cameron of misrepresenting social science research.

William Schultz

William Schutz (19 December 1925 to 09 November 2002) was an American psychologist.

Schutz was born in Chicago, Illinois. He practiced at the Esalen Institute in the 1960s. He later became the president of BConWSA International. He received his Ph.D. from UCLA. In the 1950s, he was part of the peer-group at the University of Chicago’s Counselling Centre that included Carl Rogers, Thomas Gordon, Abraham Maslow and Elias Porter. He taught at Tufts University, Harvard University, University of California, Berkeley and the Albert Einstein College of Medicine, and was chairman of the holistic studies department at Antioch University until 1983.

In 1958, Schutz introduced a theory of interpersonal relations he called Fundamental Interpersonal Relations Orientation (FIRO). According to the theory three dimensions of interpersonal relations were deemed to be necessary and sufficient to explain most human interaction: Inclusion, Control and Affection. These dimensions have been used to assess group dynamics.

Schutz also created FIRO-B, a measurement instrument with scales that assess the behavioural aspects of the three dimensions. His advancement of FIRO Theory beyond the FIRO-B tool was most obvious in the change of the “Affection” scale to the “Openness” scale in the “FIRO Element-B”. This change highlighted his newer theory that behaviour comes from feelings (“FIRO Element-F”) and the self-concept (“FIRO Element-S”). “Underlying the behaviour of openness is the feeling of being likable or unlikeable, lovable or unlovable. I find you likable if I like myself in your presence, if you create an atmosphere within which I like myself.”

W. Schutz authored more than ten books and many articles. His work was influenced by Alexander Lowen, Ida Pauline Rolf and Moshe Feldenkrais. As a body therapist he led encounter group workshops focussing on the underlying causes of illnesses and developing alternative body-centred cures. His books, “Profound Simplicity” and “The Truth Option,” address this theme. He brought new approaches to body therapy that integrated truth, choice (freedom), (self) responsibility, self-esteem, self-regard and honesty into his approach.

In his books one encounters the concept of energy cycles (e.g. Schutz 1979) which a person goes through or call for completion. The single steps of the energy cycles are: motivation – prepare – act – feel.

Schutz died at his home in Muir Beach, California in 2002.

What is Dialectical Behaviour Therapy?

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Introduction

Dialectical behaviour therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders, ADHD, and interpersonal conflicts.

There is evidence that DBT can be useful in treating mood disorders, suicidal ideation, and for change in behavioural patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies, and ultimately balance and synthesize them, in a manner comparable to the philosophical dialectical process of hypothesis and antithesis, followed by synthesis.

This approach was developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviours to help avoid undesired reactions.

Linehan developed DBT as a modified form of cognitive behavioural therapy (CBT) in the late 1980s to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviours associated with spectrum mood disorders, including self-injury. Work also suggests its effectiveness with sexual-abuse survivors and chemical dependency.

DBT combines standard cognitive-behavioural techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from contemplative meditative practice. DBT is based upon the biosocial theory of mental illness and is the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. The first randomised clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalisations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.

Overview

DBT is considered part of the “third wave” of cognitive-behavioural therapy, and DBT adapts CBT to assist patients to deal with stress.

This approach was developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviours to help avoid undesired reactions.

Linehan developed DBT as a modified form of cognitive behavioural therapy (CBT) in the late 1980s to treat people with borderline personality disorder (BPD) and chronically suicidal individuals. Research on its effectiveness in treating other conditions has been fruitful; DBT has been used by practitioners to treat people with depression, drug and alcohol problems, post-traumatic stress disorder (PTSD), traumatic brain injuries (TBI), binge-eating disorder, and mood disorders. Research indicates DBT might help patients with symptoms and behaviours associated with spectrum mood disorders, including self-injury. Recent work also suggests its effectiveness with sexual-abuse survivors and chemical dependency.

DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the client’s feelings at any given time, while, nonetheless, informing the client that some feelings and behaviours are maladaptive, and showing them better alternatives. DBT focuses on the client acquiring new skills and changing their behaviours, with the ultimate goal of achieving a “life worth living”, as defined by the patient.

In DBT’s biosocial theory of BPD, clients have a biological predisposition for emotional dysregulation, and their social environment validates maladaptive behaviour.

DBT skills training alone is being used to address treatment goals in some clinical settings, and the broader goal of emotion regulation that is seen in DBT has allowed it to be used in new settings, for example, supporting parenting.

Four Modules

Mindfulness

Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations.

The concept of mindfulness and the meditative exercises used to teach it are derived from traditional contemplative religious practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one’s emotions and senses fully, yet with perspective. The practice of mindfulness can also be intended to make people more aware of their environments through their five senses: touch, smell, sight, taste, and sound. Mindfulness relies heavily on the principle of acceptance, sometimes referred to as “radical acceptance”. Acceptance skills rely on the patient’s ability to view situations with no judgment, and to accept situations and their accompanying emotions. This causes less distress overall, which can result in reduced discomfort and symptomology.

Acceptance and Change

The first few sessions of DBT introduce the dialectic of acceptance and change. The patient must first become comfortable with the idea of therapy; once the patient and therapist have established a trusting relationship, DBT techniques can flourish. An essential part of learning acceptance is to first grasp the idea of radical acceptance: radical acceptance embraces the idea that one should face situations, both positive and negative, without judgment. Acceptance also incorporates mindfulness and emotional regulation skills, which depend on the idea of radical acceptance. These skills, specifically, are what set DBT apart from other therapies.

Often, after a patient becomes familiar with the idea of acceptance, they will accompany it with change. DBT has five specific states of change which the therapist will review with the patient:

  • Precontemplation is the first stage, in which the patient is completely unaware of their problem.
  • In the second stage, contemplation, the patient realises the reality of their illness: this is not an action, but a realisation.
  • It is not until the third stage, preparation, that the patient is likely to take action, and prepares to move forward. This could be as simple as researching or contacting therapists.
  • Finally, in stage 4, the patient takes action and receives treatment.
  • In the final stage, maintenance, the patient must strengthen their change in order to prevent relapse.

After grasping acceptance and change, a patient can fully advance to mindfulness techniques.

There are six mindfulness skills used in DBT to bring the client closer to achieving a “wise mind”, the synthesis of the rational mind and emotion mind: three “what” skills (observe, describe, participate) and three “how” skills (nonjudgementally, one-mindfully, effectively).

Distress Tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances such as dealing with the death of a loved one, loss of a job, serious illness, terrorist attacks and other traumatic events. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by person-centred, psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behaviour therapy emphasizes learning to bear pain skilfully. This module outlines healthy coping behaviours intended to replace harmful ones, such as distractions, improving the moment, self-soothing, and practicing acceptance of what is.

Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and non-judgemental fashion, both oneself and the current situation. Since this is a non-judgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.

Emotion Regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. DBT skills for emotion regulation include:

  • Identify and label emotions.
  • Identify obstacles to changing emotions.
  • Reduce vulnerability to emotion mind.
  • Increase positive emotional events.
  • Increase mindfulness to current emotions.
  • Take opposite action.
  • Apply distress tolerance techniques.

Emotional regulation skills are based on the theory that intense emotions are a conditioned response to troublesome experiences, the conditioned stimulus, and therefore, are required to alter the patient’s conditioned response. These skills can be categorised into four modules: understanding and naming emotions, changing unwanted emotions, reducing vulnerability, and managing extreme conditions:

  • Learning how to understand and name emotions:
    • The patient focuses on recognising their feelings.
    • This segment relates directly to mindfulness, which also exposes a patient to their emotions.
  • Changing unwanted emotions:
    • The therapist emphasizes the use of opposite-reactions, fact-checking, and problem solving to regulate emotions.
    • While using opposite-reactions, the patient targets distressing feelings by responding with the opposite emotion.
  • Reducing vulnerability:
    • The patient learns to accumulate positive emotions and to plan coping mechanisms in advance, in order to better handle difficult experiences in the future.
  • Managing extreme conditions:
    • The patient focuses on incorporating their use of mindfulness skills to their current emotions, to remain stable and alert in a crisis.

Interpersonal Effectiveness

The three interpersonal skills focused on in DBT include self-respect, treating others “with care, interest, validation, and respect”, and assertiveness. The dialectic involved in healthy relationships involves balancing the needs of others with the needs of the self, while maintaining one’s self-respect

Tools

Specially formatted diary cards can be used to track relevant emotions and behaviours. Diary cards are most useful when they are filled out daily. The diary card is used to find the treatment priorities that guide the agenda of each therapy session. Both the client and therapist can use the diary card to see what has improved, gotten worse, or stayed the same.

Chain Analysis

Chain analysis is a form of functional analysis of behaviour but with increased focus on sequential events that form the behaviour chain. It has strong roots in behavioural psychology in particular applied behaviour analysis concept of chaining. A growing body of research supports the use of behaviour chain analysis with multiple populations.

Efficacy

Borderline Personality Disorder

DBT is the therapy that has been studied the most for treatment of borderline personality disorder, and there have been enough studies done to conclude that DBT is helpful in treating borderline personality disorder. A 2009 Canadian study compared the treatment of borderline personality disorder with dialectical behaviour therapy against general psychiatric management. A total of 180 adults, 90 in each group, were admitted to the study and treated for an average of 41 weeks. Statistically significant decreases in suicidal events and non-suicidal self-injurious events were seen overall (48% reduction, p=0.03; and 77% reduction, p=0.01; respectively). No statistically-significant difference between groups were seen for these episodes (p=.64). Emergency department visits decreased by 67% (p<0.0001) and emergency department visits for suicidal behaviour by 65% (p<0.0001), but there was also no statistically significant difference between groups.

Depression

A Duke University pilot study compared treatment of depression by antidepressant medication to treatment by antidepressants and dialectical behaviour therapy. A total of 34 chronically depressed individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically-significant differences were noted in remission rates between groups, with a greater percentage of patients treated with antidepressants and dialectical behaviour therapy in remission.

Complex Post-Traumatic Stress Disorder (CPTSD)

Exposure to complex trauma, or the experience of traumatic events, can lead to the development of complex post-traumatic stress disorder (CPTSD) in an individual. CPTSD is a concept which divides the psychological community. The American Psychological Association (APA) does not recognise it in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental illness), though some practitioners argue that CPTSD is separate from post-traumatic stress disorder (PTSD).

CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive, emotional, and biological domains, among others. CPTSD differs from PTSD in that it is believed to originate in childhood interpersonal trauma, or chronic childhood stress, and that the most common precedents are sexual traumas. Currently, the prevalence rate for CPTSD is an estimated 0.5%, while PTSD’s is 1.5%. Numerous definitions for CPTSD exist. Different versions are contributed by the World Health Organisation (WHO), The International Society for Traumatic Stress Studies (ISTSS), and individual clinicians and researchers.

Most definitions revolve around criteria for PTSD with the addition of several other domains. While The APA may not recognise CPTSD, the WHO has recognized this syndrome in its 11th edition of the International Classification of Diseases (ICD-11). The WHO defines CPTSD as a disorder following a single or multiple events which cause the individual to feel stressed or trapped, characterised by low self-esteem, interpersonal deficits, and deficits in affect regulation. These deficits in affect regulation, among other symptoms are a reason why CPTSD is sometimes compared with borderline personality disorder (BPD).

Similarities between CPTSD and Borderline Personality Disorder

In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit splitting, mood swings, and fears of abandonment. Like patients with borderline personality disorder, patients with CPTSD were traumatised frequently and/or early in their development and never learned proper coping mechanisms. These individuals may use avoidance, substances, dissociation, and other maladaptive behaviours to cope. Thus, treatment for CPTSD involves stabilising and teaching successful coping behaviours, affect regulation, and creating and maintaining interpersonal connections. In addition to sharing symptom presentations, CPTSD and BPD can share neurophysiological similarities, for example, abnormal volume of the amygdala (emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital prefrontal cortex (personality). Another shared characteristic between CPTSD and BPD is the possibility for dissociation. Further research is needed to determine the reliability of dissociation as a hallmark of CPTSD, however it is a possible symptom. Because of the two disorders’ shared symptomatology and physiological correlates, psychologists began hypothesising that a treatment which was effective for one disorder may be effective for the other as well.

DBT as a Treatment for CPTSD

DBT’s use of acceptance and goal orientation as an approach to behaviour change can help to instil empowerment and engage individuals in the therapeutic process. The focus on the future and change can help to prevent the individual from becoming overwhelmed by their history of trauma. This is a risk especially with CPTSD, as multiple traumas are common within this diagnosis. Generally, care providers address a client’s suicidality before moving on to other aspects of treatment. Because PTSD can make an individual more likely to experience suicidal ideation, DBT can be an option to stabilize suicidality and aid in other treatment modalities.

Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious behaviours (such as cutting or burning) and increases interpersonal functioning but neglects core CPTSD symptoms such as impulsivity, cognitive schemas (repetitive, negative thoughts), and emotions such as guilt and shame. The ISTSS reports that CPTSD requires treatment which differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing on traumatic memories. The recommended multiphase model consists of establishing safety, distress tolerance, and social relations.

Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT discuss the time required for the therapy to be effective. Individuals seeking DBT may not be able to commit to the individual and group sessions required, or their insurance may not cover every session.

A study co-authored by Linehan found that among women receiving outpatient care for BPD and who had attempted suicide in the previous year, 56% additionally met criteria for PTSD. Because of the correlation between borderline personality disorder traits and trauma, some settings began using DBT as a treatment for traumatic symptoms. Some providers opt to combine DBT with other PTSD interventions, such as prolonged exposure therapy (PE) (repeated, detailed description of the trauma in a psychotherapy session) or cognitive processing therapy (CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories).

For example, a regimen which combined PE and DBT would include teaching mindfulness skills and distress tolerance skills, then implementing PE. The individual with the disorder would then be taught acceptance of a trauma’s occurrence and how it may continue to affect them throughout their lives. Participants in clinical trials such as these exhibited a decrease in symptoms, and throughout the 12-week trial, no self-injurious or suicidal behaviours were reported.

Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is low. Biosocial theory posits that emotion dysregulation is caused by an individual’s heightened emotional sensitivity combined with environmental factors (such as invalidation of emotions, continued abuse/trauma), and tendency to ruminate (repeatedly think about a negative event and how the outcome could have been changed).

An individual who has these features is likely to use maladaptive coping behaviours. DBT can be appropriate in these cases because it teaches appropriate coping skills and allows the individuals to develop some degree of self-sufficiency. The first three modules of DBT increase distress tolerance and emotion regulation skills in the individual, paving the way for work on symptoms such as intrusions, self-esteem deficiency, and interpersonal relations.

Noteworthy is that DBT has often been modified based on the population being treated. For example, in veteran populations DBT is modified to include exposure exercises and accommodate the presence of traumatic brain injury (TBI), and insurance coverage (i.e. shortening treatment). Populations with comorbid BPD may need to spend longer in the “Establishing Safety” phase. In adolescent populations, the skills training aspect of DBT has elicited significant improvement in emotion regulation and ability to express emotion appropriately. In populations with comorbid substance use, adaptations may be made on a case-by-case basis.

For example, a provider may wish to incorporate elements of motivational interviewing (psychotherapy which uses empowerment to inspire behaviour change). The degree of substance use should also be considered. For some individuals, substance use is the only coping behaviour they know, and as such the provider may seek to implement skills training before target substance reduction. Inversely, a client’s substance use may be interfering with attendance or other treatment compliance and the provider may choose to address the substance use before implementing DBT for the trauma.

What is Desvenlafaxine?

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Introduction

Desvenlafaxine, sold under the brand name Pristiq among others, is a medication used to treat depression.

It is recommended that the need for further treatment be occasionally reassessed. It may be less effective than its parent compound venlafaxine, although some studies have found comparable efficacy. It is an antidepressant of the serotonin-norepinephrine reuptake inhibitor (SNRI) class and is taken by mouth.

Common side effects include dizziness, trouble sleeping, increased sweating, constipation, sleepiness, anxiety, and sexual problems. Serious side effects may include suicide in those under the age of 25, serotonin syndrome, bleeding, mania, and high blood pressure. A withdrawal syndrome may occur if the dose is rapidly decreased. It is unclear if use during pregnancy or breastfeeding is safe.

Desvenlafaxine was approved for medical use in the United States in 2008. In Europe its application for use was denied in 2009. In 2017, it was the 235th most commonly prescribed medication in the United States, with more than two million prescriptions.

Medical Uses

Desvenlafaxine is primarily used as a treatment for major depressive disorder. Use has only been studied up to 8 weeks. It may be less effective than venlafaxine, although some studies have found comparable efficacy with a lower rate of nausea.

Doses of 50-400 mg/day appear effective for major depressive disorder, although no additional benefit was demonstrated at doses greater than 50 mg/day, and adverse events and discontinuations were more frequent at higher doses.

Desvenlafaxine improves the HAM-D17 score and measures of well being such as the Sheehan Disability Scale (SDS) and 5-item World Health Organisation Well-Being Index (WHO-5).

Adverse Effects

Frequency of adverse effects:

  • Very common adverse effects include:
    • Nausea.
    • Headache.
    • Dizziness.
    • Dry mouth.
    • Hyperhidrosis.
    • Diarrhoea.
    • Insomnia.
    • Constipation.
    • Fatigue.
  • Common adverse effects include:
    • Tremor.
    • Blurred vision.
    • Mydriasis.
    • Decreased appetite.
    • Sexual dysfunction.
    • Insomnia.
    • Anxiety.
    • Elevated cholesterol and triglycerides.
    • Proteinuria.
    • Vertigo.
    • Feeling jittery.
    • Asthenia.
    • Nervousness.
    • Hot flush.
    • Irritability.
    • Abnormal dreams.
    • Urinary hesitation.
    • Yawning.
    • Rash.
  • Uncommon adverse effects include:
  • Rare adverse effects include:
    • Hyponatraemia (low blood sodium).
    • Seizures.
    • Extrapyramidal side effects.
    • Hallucinations.
    • Angioedema.
    • Photosensitivity reaction.
    • Stevens-Johnson syndrome.
  • Common however unknown intensity of adverse effects include:
    • Abnormal bleeding (gastrointestinal bleeds).
    • Narrow-angle glaucoma.
    • Mania.
    • Interstitial lung disease.
    • Eosinophilic pneumonia.
    • Hypertension.
    • Suicidal behaviour and thoughts.
    • Serotonin syndrome.

Pharmacology

Desvenlafaxine is a synthetic form of the isolated major active metabolite of venlafaxine, and is categorised as a serotonin-norepinephrine reuptake inhibitor (SNRI). When most normal metabolisers take venlafaxine, approximately 70% of the dose is metabolised into desvenlafaxine, so the effects of the two drugs are expected to be very similar. It works by blocking the “reuptake” transporters for key neurotransmitters affecting mood, thereby leaving more active neurotransmitters in the synapse. The neurotransmitters affected are serotonin (5-hydroxytryptamine) and norepinephrine (noradrenaline). It is approximately 10 times more potent at inhibiting serotonin uptake than norepinephrine uptake.

Approval Status

United States

Wyeth announced on 23 January 2007 that it received an approvable letter from the Food and Drug Administration (FDA) for desvenlafaxine. Final approval to sell the drug was contingent on a number of things, including:

  • A satisfactory FDA inspection of Wyeth’s Guayama, Puerto Rico facility, where the drug is to be manufactured;
  • Several postmarketing surveillance commitments, and follow-up studies on low-dose use, relapse, and use in children;
  • Clarity by Wyeth around the company’s product education plan for physicians and patients;
  • Approval of desvenlafaxine’s proprietary name, Pristiq.

The FDA approved the drug for antidepressant use in February 2008, and was to be available in US pharmacies in May 2008.

In March 2017, the generic form of the drug was made available in the US.

Canada

On 04 February 2009, Health Canada approved use of desvenlafaxine for treatment of depression.

European Union

In 2009, an application to market desvenlafaxine for major depressive disorder in the European Union was declined. In 2012, Pfizer received authorization in Spain to market desvenlafaxine for the disorder but it is not being sold.

Australia

Desvenlafaxine is classified as a schedule 4 (prescription only) drug in Australia. It was listed on the PBS (Pharmaceutical Benefits Scheme) in 2008 for the treatment of major depressive disorders.

On This Day … 08 November

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People (Births)

People (Deaths)

  • 2007 – Chad Varah, English priest, founded The Samaritans (b. 1911).

Hermann Rorschach

Hermann Rorschach (08 November 1884 to 02 April 1922) was a Swiss psychiatrist and psychoanalyst. His education in art helped to spur the development of a set of inkblots that were used experimentally to measure various unconscious parts of the subject’s personality. His method has come to be referred to as the Rorschach test, iterations of which have continued to be used over the years to help identify personality, psychotic, and neurological disorders. Rorschach continued to refine the test until his premature death at age 37.

Education and Career

Rorschach, in his early years, attended Schaffhausen Cantonal School in Schaffhausen, Switzerland. Rorschach was a bright student from the beginning, and he often tutored other students at his school. After Ernst Haeckel suggested a career in science, Rorschach attended Academie de Neuchatel in 1904 studying geology and botany. After just a single term, he transferred to the Universite de Dijon to take French classes. The same year he enrolled in medical school at the University of Zurich. While studying, Rorschach began learning Russian, and in 1906, while studying in Berlin, he travelled to Russia for a holiday.

Travel was a large part of his life after medical school. On a trip to Dijon, in France, he met a man who taught him about Russian culture. Torn by the decision whether to stay in Switzerland or move to Russia, he eventually took a job as first assistant at a Cantonal Mental Hospital. While working at the hospital, Rorschach finished his doctoral dissertation in 1912 under the psychiatrist Eugen Bleuler, who had taught Carl Jung. The excitement in intellectual circles over psychoanalysis constantly reminded Rorschach of his childhood inkblots. Wondering why different people often saw entirely different things in the same inkblots, he began, while still a medical student, showing inkblots to schoolchildren and analysing their responses. This dissertation contained the origins for his ink blot experiment.

All the while, Rorschach remained fascinated by Russian culture. In 1913, he obtained a fellowship opportunity in Russia, where he continued to study contemporary psychiatric methods. Rorschach spent some time in the village of Kryukovo outside of Moscow, and in 1914 he returned to Switzerland to work at the Waldau University Hospital in Bern. In 1915, Rorschach took the position of assistant director at the regional psychiatric hospital at Herisau, and in 1921 he wrote his book Psychodiagnostik, which was to form the basis of the inkblot test.

Chad Varah

Edward Chad Varah CH CBE (12 November 1911 to 08 November 2007) was a British Anglican priest and social activist from England. In 1953, he founded the Samaritans, the world’s first crisis hotline, to provide telephone support to those contemplating suicide.

Life

Varah was born in the town of Barton-upon-Humber, Lincolnshire, the eldest of nine children of the vicar at the Anglican church of St Peter. His father, Canon William Edward Varah, a strict Tractarian, named him after St Chad, who, according to Bede, had founded the 7th-century monastery ad Bearum (“at Barrow”), which may have occupied an Anglo-Saxon enclosure next to Barton Vicarage.

He was educated at Worksop College in north Nottinghamshire and won an exhibition to study natural sciences at Keble College, Oxford, quickly switching to Philosophy, Politics and Economics (PPE). He was involved in the university Russian and Slavonic clubs and was founder-president of the Scandinavian Club. He graduated with a third-class degree in 1933.

Clerical Career

Varah was initially reluctant to follow his father’s vocation, but his godfather persuaded him to study at Lincoln Theological College, where he was taught by the Revd Michael Ramsey, later Archbishop of Canterbury. He was ordained deacon in the Church of England in 1935 and priest in 1936. He first served as curate at St Giles, Lincoln, from 1935 to 1938, then at St Mary’s, Putney, from 1938 to 1940 and Barrow-in-Furness from 1940 to 1942. He became vicar of Holy Trinity, Blackburn, in 1942 and moved to St Paul, Battersea, in 1949. He was also chaplain of St John’s Hospital, Battersea.

The Grocers’ Company offered him the living of St Stephen Walbrook in 1953. He became rector of the church, designed by Christopher Wren, adjacent to the Mansion House in the City of London. The church was closed for structural repairs from 1978 to 1987. His son, Andrew, built chairs to replace its pews. Great controversy followed the installation of a large circular altar in travertine marble by Henry Moore, commissioned by Varah and his churchwarden Peter Palumbo. The matter was finally settled by the Court of Ecclesiastical Causes Reserved in 1987, which granted a retrospective faculty for its installation.

He was a supporter of women priests, but preferred the traditional 16th century Book of Common Prayer (1549) to the liturgical changes authorised in 1966 (Book of Common Prayer (1928). Despite the absence of a permanent congregation, the church remained popular for weddings. He officiated at the marriage of Lady Sarah Armstrong-Jones, only daughter of Princess Margaret, to actor Daniel Chatto in 1994.

He was made an honorary prebendary of St Paul’s Cathedral in 1975, becoming senior prebendary in 1997. He retired in 2003, aged 92, by which time he was the oldest incumbent in the Church of England.

Samaritans

Varah began to understand the problems facing the suicidal when he was taking a funeral as an assistant curate in 1935, his first church service, for a fourteen-year-old girl who had taken her own life because she had begun to menstruate and feared that she had a sexually transmitted disease. He later said “Little girl, I didn’t know you, but you have changed the rest of my life for good.” He vowed at that time to encourage sex education, and to help people who were contemplating suicide and had nowhere to turn.

To that end, Chad Varah founded the Samaritans in 1953 in the crypt of his church, with the stated aim that it would be an organisation “to befriend the suicidal and despairing.” The phone line, MAN 9000 (for MANsion House), received its first call on 02 November 1953, and the number of calls increased substantially after publicity in the Daily Herald on 07 December 1953.

He was director of the central London branch of Samaritans until 1974, and president from 1974 to 1986. He was also founder chairman of Befrienders Worldwide (Samaritans International) from 1974 to 1983, and then its president from 1983 to 1986.

Break with Samaritans

Later in life, Varah became disillusioned with the Samaritans organisation. He announced in 2004 that “It’s no longer what I founded. I founded an organisation to offer help to suicidal or equally desperate people. The last elected chairman re-branded the organisation. It was no longer to be an emergency service. It was to be an emotional support.”

On This Day … 07 November

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People (Births)

  • 1929 – Eric Kandel, Austrian-American neuroscientist and psychiatrist, Nobel Prize laureate.

Eric Kandel

Eric Richard Kandel (born Erich Richard Kandel, 07 November 1929) is an Austrian-born American medical doctor who specialized in psychiatry, a neuroscientist and a professor of biochemistry and biophysics at the College of Physicians and Surgeons at Columbia University.

He was a recipient of the 2000 Nobel Prize in Physiology or Medicine for his research on the physiological basis of memory storage in neurons. He shared the prize with Arvid Carlsson and Paul Greengard.

He is a Senior Investigator in the Howard Hughes Medical Institute. He was also the founding director of the Centre for Neurobiology and Behaviour, which is now the Department of Neuroscience at Columbia University. He currently serves on the Scientific Council of the Brain & Behaviour Research Foundation. Kandel’s popularised account chronicling his life and research, In Search of Memory: The Emergence of a New Science of Mind, was awarded the 2006 Los Angeles Times Book Prize for Science and Technology.

What is Career Counselling?

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Introduction

Career counselling is a type of advice-giving and support provided by career counsellors to their clients, to help the clients manage their journey through life, learning and work changes (career).

This includes career exploration, making career choices, managing career changes, lifelong career development and dealing with other career-related issues. There is no agreed definition of career counselling worldwide, mainly due to conceptual, cultural and linguistic differences. However, the terminology of ‘career counselling’ typically denotes a professional intervention which is conducted either one-on-one or in a small group. Career counselling is related to other types of counselling (e.g. marriage or clinical counselling). What unites all types of professional counselling is the role of practitioners, who combine giving advice on their topic of expertise with counselling techniques that support clients in making complex decisions and facing difficult situations.

Terminology

There is considerable variation in the terminology that is used worldwide to describe this activity. In addition to the linguistic variation between US English (counselling) and British English (counselling), there are also a range of alternate terms which are in common use. These include:

  • Career guidance;
  • Career coaching;
  • Guidance counselling;
  • Personal guidance;
  • Career consulting; and
  • A range of related terminologies.

This frequently leads writers and commentators to combine multiple terms e.g. career guidance and counselling to be inclusive. However, care should be exercised when moving from one terminology to another as each term has its own history and cultural significance. An alternate term is ‘career guidance’. This term is sometimes used as a synonym for career counselling, but can also be used to describe a broader range of interventions beyond one-to-one counselling.

Brief History and New Approaches

Career counselling has a long history going back to at least as far as the late nineteenth century. An important defining work for the field was Frank Parsons’ Choosing a Vocation which was published in 1909. Parsons was strongly rooted in the American progressive social reform movement, but as the field developed it moved away from this origin and became increasingly understood as a branch of counselling psychology.

While until the 1970s a strongly normative approach was characterised for theories (e.g. of Donald E. Super’s life-span approach) and practice of career counselling (e.g. concept of matching), new models have their starting point in the individual needs and transferable skills of the clients while managing biographical breaks and discontinuities. Career development is no longer viewed as a linear process which reflects a predictable world of work. More consideration is now placed on nonlinear, chance and unplanned influences.

This change of perspective is evident in the constructivist and social constructionist paradigms for career counselling. The constructivist/social constructionist paradigms are applied as narrative career counselling that emphasizes personal stories and the meaning individuals generate in relation to their education and work.

Postmodern career counselling is a reflective process of assisting clients in creating self through writing and revising biographical narratives taking place in a context of multiple choice from a diversity of options and constraints. The shift moves from emphasizing career choice to empowering self-affirmation and improving decision making. Recently this approach is widely applied in Australia such as in Athlete Career and Education (ACE) programme by Australian Sports Commission and Scope for artists by Ausdance.

While career counselling has its origins in the USA and the English speaking world it has now spread to become a worldwide activity that can be found to some extent in all countries.

Career counselling includes a wide variety of professional activities which help people deal with career-related challenges. Career counsellors work with adolescents seeking to explore career options, experienced professionals contemplating a career change, parents who want to return to the world of work after taking time to raise their child, or people seeking employment. Career counselling is also offered in various settings, including in groups and individually, in person or by means of digital communication.

Several approaches have been undertaken to systemize the variety of professional activities related to career guidance and counselling. In the most recent attempt, the Network for Innovation in Career Guidance and Counselling in Europe (NICE) – a consortium of 45 European institutions of higher education in the field of career counselling – has agreed on a system of professional roles for guidance counsellors. Each of these five roles is seen as an important facet of the career guidance and counselling profession. Career counsellors performing in any of these roles are expected to behave professionally, e.g. by following ethical standards in their practice. The NICE Professional Roles (NPR) are:

  • Career educators “suppor[t] people in developing their own career management competences”.
  • Career information and assessment experts “suppor[t] people in assessing their personal characteristics and needs, then connecting them with the labour market and education systems”.
  • Career counsellors “suppor[t] individuals in understanding their situations, so as to work through issues towards solutions”.
  • Programme and service managers “ensur[e] the quality and delivery of career guidance and counselling organisations’ services”.
  • Social systems intervener and developers “suppor[t] clients (even) in crisis and works to change systems for the better”.

The description of the NICE professional roles (NPR) draws on a variety of prior models to define the central activities and competences of guidance counsellors. The NPR can, therefore, be understood as a state-of-the-art framework which includes all relevant aspects of career counselling. For this reason, other models have not been included here so far. Models which are reflected in the NPR include:

  • BEQU: “Kompetenzprofil für Beratende” (Germany, 2011).
  • CEDEFOP “Practitioner Competences” (2009).
  • ENTO: “National Occupational Standards for Advice and Guidance” (Great Britain, 2006).
  • IAEVG: “International Competences for Educational and Vocational Guidance” (2003).
  • Savickas, M.: “Career Counselling” (USA, 2011).

Benefits and Challenges

Benefits

Empirical research attests the effectiveness of career counselling. Professional career counsellors can support people with career-related challenges. Through their expertise in career development and labour markets, they can put a person’s qualifications, experience, strengths and weakness in a broad perspective while also considering their desired salary, personal hobbies and interests, location, job market and educational possibilities. Through their counselling and teaching abilities, career counsellors can additionally support people in gaining a better understanding of what really matters for them personally, how they can plan their careers autonomously, or help them in making tough decisions and getting through times of crisis. Finally, career counsellors are often capable of supporting their clients in finding suitable placements/ jobs, in working out conflicts with their employers, or finding the support of other helpful services. It is due to these various benefits of career counselling that policy makers in many countries publicly fund guidance services. For example, the European Union understands career guidance and counselling as an instrument to effectively combat social exclusion and increase citizens’ employability.

Challenges

One of the major challenges associated with career counselling is encouraging participants to engage in the process. For example, in the UK 70% of people under 14 say they have had no careers advice while 45% of people over 14 have had no or very poor/limited advice.

In a related issue some client groups tend to reject the interventions made by professional career counsellors preferring to rely on the advice of peers or superiors within their own profession. Jackson et al. found that 44% of doctors in training felt that senior members of their own profession were best placed to give careers advice. Furthermore, it is recognised that the giving of career advice is something that is widely spread through a range of formal and informal roles. In addition to career counsellors it is also common for psychologists, teachers, managers, trainers and Human Resources (HR) specialists to give formal support in career choices.

Similarly it is also common for people to seek informal support from friends and family around their career choices and to bypass career professionals altogether. In the 2010s, increasingly people rely on career web portals to seek advice on resume writing and handling interviews and to do research on various professions and companies. It has also possible to get a vocational assessment done online.

Training

There is no international standard qualification for professional career counsellors, although various certificates are offered nationally and internationally (e.g. by professional associations). The number of degree programmes in career guidance and/or career counselling is growing worldwide. The title “career counsellor” is unregulated, unlike engineers or psychologists whose professional titles are legally protected. At the same time, policy makers agree that the competence of career counsellors is one of the most important factors in ensuring that people receive high quality support in dealing with their career questions. Depending on the country of their education, career counsellors may have a variety of academic backgrounds. In Europe, for instance, degrees in (vocational/ industrial/ organisation) psychology and educational sciences are among the most common, but backgrounds in sociology, public administration and other sciences are also frequent. At the same time, many training programmes for career counsellors are becoming increasingly multidisciplinary.

Professional Career Guidance Centres

There are career guidance and counselling centres all over the world that give advice on higher studies, possibilities, chances and nature of courses and institutes. There are also services providing online counselling to people about their career or conducting psychometric tests to determine the person’s aptitude and interests.

Career Assessment

Assessment tools used in career counselling to help clients make realistic career decisions. These tools generally fall into three categories:

  • Interest inventories;
  • Personality inventories; and
  • Aptitude tests.

Interest inventories are usually based on the premise that if you have similar interests to people in an occupation who like their job, you will probably like that occupation also. Thus, interest inventories may suggest occupations that the client has not thought of and which have a good chance of being something that the client will be happy with. The most common interest inventory is a measure of vocational interests across six domains: Realistic, Investigative, Artistic, Social, Enterprising, Conventional. People often report a mixture of these domains, usually with one predominant domain.

Aptitude tests can predict with good odds whether a particular person will be able to be successful in a particular occupation. For example, a student who wants to be a physicist is unlikely to succeed if he cannot do the math. An aptitude test will tell him if he is likely to do well in advanced math, which is necessary for physics. There are also aptitude tests which can predict success or failure in many different occupations.

Personality inventories are sometimes used to help people with career choice. The use of these inventories for this purpose is questionable, because in any occupation there are people with many different personalities. A popular personality inventory is the Myers-Briggs Type Indicator. It is based on Carl Jung’s theory of personality, but Jung never approved it. According to Jung most people fall in the middle of each scale, but the MBTI ignores this and puts everyone in a type category. For example, according to the MBTI, everyone is either an extrovert or an introvert. According to Jung, most people are somewhere in between, and people at the extremes are rare. The validity of the MBTI for career choice is highly questionable.

Counsellors in Select Countries

In the United States

In the United States, the designation, “career counsellor” is not legally protected; that is, anyone can call themselves a career counsellor. However, CACREP, the accrediting body for counsellor education programmes requires that these programmes include one course in career counselling as a part of the coursework for a masters in counselling.

The National Career Development Association (NCDA), the credentialing body for career counsellors, provides various certifications for qualified career counsellors. For those university-trained counsellors or psychologists who have devoted a certain number of years to career counselling and taken specific coursework, it offers a Master Career Counsellor (MCC) credential. The National Career Development Association is the only professional association of career counsellors in the United States that provides certification in career counselling.

In Australia

In Australia, career counselling may be provided by professionals from various disciplines (e.g. psychology, education, guidance, and counselling). The Professional Standards for Australian Career Development Practitioners provide guidelines about appropriate qualifications and competencies for career counselling. There are a range of postgraduate degrees (e.g. Master, Doctor) that are endorsed for career development practice according to the Professional Standards. The Career Industry Council of Australia (CICA) endorses career development programmes in Australia. There are other relevant qualifications but these may necessarily not be endorsed under the provisions of the Professional Standards by CICA. A Diploma of Counselling and a Certificate IV in Career Development are offered at TAFE colleges and other registered training organisations throughout Australia.

In India

In India, career counselling is a vast area of professional service driven by factors like huge talent availability in the country and huge higher education network comprising Graduation, Post Graduation and multiple professional courses. There are many leading career guidance centres in India like. Leading bodies in India that drive policy level initiatives for students and working professionals are: Ministry of Human Resource Development (MHRD), University Grants Commission (UGC), All India Council of Technical Education (AICTE), National Skill Development Corporation (NSDC) among others.