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What is Resignation Syndrome?

Published on by Andrew Marshall2 Comments

Introduction

Resignation syndrome (also called traumatic withdrawal syndrome or traumatic refusal; Swedish: uppgivenhetssyndrom) is a possibly factitious, dissociative syndrome that induces a catatonic state, first described in Sweden in the 1990s. The condition affects predominately psychologically traumatised children and adolescents in the midst of a strenuous and lengthy migration process.

Refer to Pervasive Refusal Syndrome (PRS).

Young people reportedly develop depressive symptoms, become socially withdrawn, and become motionless and speechless as a reaction to stress and hopelessness. In the worst cases, children reject any food or drink and have to be fed by feeding tube; the condition can persist for years. Recovery ensues within months to years and is claimed to be dependent on the restoration of hope to the family.

More recently, this phenomenon has been called into question, with two children witnessing that they were forced by their parents to act apathetic in order to increase chances of being granted residence permits. As evidenced by medical records, healthcare professionals were aware of this scam, and witnessed parents who actively refused aid for their children but remained silent at the time. Later Sveriges Television, Sweden’s national public television broadcaster, were severely critiqued by investigative journalist Janne Josefsson for failing to uncover the truth. In March 2020, a report citing the Swedish Agency for Medical and Social Evaluation, SBU, said “There are no scientific studies that answer how to diagnose abandonment syndrome, nor what treatment works.”

Signs and Symptoms

Affected individuals (predominantly children and adolescents) first exhibit symptoms of anxiety and depression (in particular apathy, lethargy), then withdraw from others and care for themselves. Eventually their condition might progress to stupor, i.e. they stop walking, eating, talking, and grow incontinent. In this stage patients are seemingly unconscious and tube feeding is life-sustaining. The condition could persist for months or even years. Remission happens after life circumstances improve and ensues with gradual return to what appears to be normal function.

Nosology

Refusal syndrome and pervasive refusal syndrome shares common features and etiologic factors; however, the former is more clearly associated with trauma and adverse life circumstances. Neither is included in the standard psychiatric classification systems.

Pervasive refusal syndrome (also called pervasive arousal withdrawal syndrome) has been conceptualised in a variety of ways, including a form of post-traumatic stress disorder, learned helplessness, ‘lethal mothering’, loss of the internal parent, apathy or the ‘giving-up’ syndrome, depressive devitalisation, primitive ‘freeze’, severe loss of activities of daily living and ‘manipulative’ illness. It was also suggested to be on the ‘refusal-withdrawal-regression spectrum’.

Acknowledging its social importance and relevance, the Swedish National Board of Health and Welfare recognised the novel diagnostic entity resignation syndrome in 2014. While others argue that already-existing diagnostic entities should be used and are sufficient in the majority of cases, i.e. severe major depressive disorder with psychotic symptoms or catatonia, or conversion/dissociation disorder.

Currently, diagnostic criteria are undetermined, pathogenesis is uncertain, and effective treatment is lacking.

Causes

Resignation syndrome appears to be a very specialised response to the trauma of refugee limbo, in which families, many of whom have escaped dangerous circumstances in their home countries, wait to be granted legal permission to stay in their new country, often undergoing numerous refusals and appeals over a period of years.

Experts proposed multifactorial explanatory models involving individual vulnerability, traumatisation, migration, culturally conditioned reaction patterns and parental dysfunction or pathological adaption to a caregiver’s expectations to interplay in pathogenesis. Severe depression or conversion/dissociation disorder has been also suggested (as best diagnostic alternatives).

However, the currently prevailing stress hypothesis fails to account for the regional distribution (see Epidemiology) and contributes little to treatment. An asserted “questioning attitude”, in particular within the health care system, it has been claimed, may constitute a “perpetuating retraumatization possibly explaining the endemic” distribution. Furthermore, Sweden’s experience raises concerns about “contagion”. Researchers argue that culture-bound psychogenesis can accommodate the endemic distribution because children may learn that dissociation is a way to deal with trauma.

A proposed neurobiological model of the disorder suggests that the impact of overwhelming negative expectations are directly causative of the down-regulation of higher order and lower order behavioural systems in particularly vulnerable individuals.

Epidemiology

Depicted as a culture-bound syndrome, it was first observed and described in Sweden among children of asylum seekers from former Soviet and Yugoslav countries. In Sweden, hundreds of migrant children, facing the possibility of deportation, have been diagnosed since the 1990s. For example, 424 cases were reported between 2003 and 2005; and 2.8% of all 6547 asylum applications submitted for children were diagnosed in 2004.

It has also been observed in refugee children transferred from Australia to the Nauru Regional Processing Centre. The Economist wrote in 2018 that Doctors without Borders (MSF) refused to say how many of the children on Nauru may be suffering from traumatic withdrawal syndrome. A report published in August 2018 suggested there were at least 30. The National Justice Project, a legal centre, has brought 35 children from Nauru this year. It estimates that seven were suffering from refusal syndrome, and three were psychotic.

What is Pervasive Refusal Syndrome?

Published on by Andrew Marshall1 Comment

Introduction

Pervasive refusal syndrome (PRS), also known as pervasive arousal withdrawal syndrome (PAWS) is a rare hypothesized paediatric mental disorder. PRS is not included in the standard psychiatric classification systems; that is, PRS is not a recognised mental disorder in the World Health Organisation’s current (ICD-10) and upcoming (ICD-11) International Classification of Diseases and the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Refer to Resignation Syndrome.

Purported Signs and Symptoms

According to some authors, PRS symptoms have common characteristics with other psychiatric disorders, but (according to these authors), current psychiatric classification schemes, such as the DSM cannot account for the full scope of symptoms seen in PRS. Purported symptoms include partial or complete refusal to eat, move, talk, or care for oneself; active and angry resistance to acts of help and support; social withdrawal; and school refusal.

Hypothesized Causes

Trauma might be a causal factor because PRS is repeatedly seen in refugees and witnesses to violence. Viral infections might be a risk factor for PRS.

Mechanism

Some authors hypothesize that learned helplessness is one of the mechanisms involved in PRS. A number of cases have been reported in the context of eating disorders.

Hypothesized Epidemiology

Epidemiological studies are lacking. Pervasive refusal syndrome is reportedly more frequent in girls than boys. The average age of onset is purported to be 7-15.

What is Couples Therapy?

Published on by Andrew Marshall1 Comment

Introduction

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

Refer to Counselling Psychology.

Brief History

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

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

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

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

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

Basic Principles

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

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

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

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

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

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

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

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

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

Basic Practices

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

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

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

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

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

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

Research on Therapy

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

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

Relationship Counsellor or Couple’s Therapist

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

The basic principles for a counsellor include:

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

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

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

Common core principles of relationship counselling and couples therapy are:

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

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

Novel Practices

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

Oxytocin

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

Popularised Methodologies

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

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

With Homosexual/Bisexual Clients

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

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

What is Scotomisation?

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Introduction

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

Controversies

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

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

What is a School Psychological Examiner?

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Introduction

In the United States education system, School Psychological Examiners assess the needs of students in schools for special education services or other interventions.

The post requires a relevant postgraduate qualification and specialist training. This role is distinct within school psychology from that of the psychiatrist, clinical psychologist and psychometrist.

Role of Psychological Examiners in Schools

School Psychological Examiners are assessors licensed by a State Department of Education to work with students from pre-kindergarten to twelfth grade in public schools, interviewing, observing, and administering and interpreting standardised testing instruments that measure cognitive and academic abilities, or describe behaviour, personality characteristics, attitude or aptitude, in order to determine eligibility for special education services, placement, or conduct re-evaluation, or occupational guidance and planning.

The work of the School Psychological Examiners is both qualitative and quantitative in nature. They prepare psychoeducational evaluation reports based on test results and interpretation. Integrated with case history, the evaluation reports should present an accurate and clear profile of a student’s level of functioning or disability, strengths and weaknesses, compare test results with the standards of the evaluation instruments, analyse potential test biases, and develop appropriate recommendations to help direct educational interventions and services in a most inclusive and least restrictive environment. Evaluation reports are framed by laws and regulations applicable to testing and assessment in special education, and must follow school district policies and the codes of ethics applicable to education, special education, and psychological assessment.

School Psychological Examiners also provide psychoeducational interventions such as consultation services, collaboration in behaviour management planning and monitoring, and devising social skills training programmes in public schools.

Unless additionally trained and licensed, School Psychological Examiners do not offer or provide psychotherapy or clinical diagnostic/treatment services, which are attributions of licensed psychiatrists and clinical psychologists, as provided by law and professional regulations.

Qualifications

School Psychological Examiners are highly trained and experienced educators who hold a master’s or higher degree in education or school counselling and at least one endorsement in special education. In addition to school district policies, School Psychological Examiners are bound by professional regulations, as well as by the ethical codes of testing and measurement. Other designations for School Psychological Examiners include ‘Educational Examiners’ or ‘Psychoeducational Examiners.’ Designation of this specialty varies among different school districts.

‘Psychometrist,’ from the term psychometrics, is an occupational designation not inclusive of the broader faculties of School Psychological Examiners. Psychometrists deal exclusively with quantitative test administration, do not require coursework beyond the bachelor’s level, or licensure by a state department of education. Training of psychometrists is primarily done on-the-job, and their services are valuable in mental health community agencies, assessment and institutional research, or test-producing companies, etc., rather than in K-12 schools.

Graduate Training and Licensure of School Psychological Examiners

Typical training includes coursework beyond the Master of Education, Master of Science in Education, or Master of Arts in Teaching degrees. Currently, School Psychological Examiners complete the courses required by their state department of education rather than by a prescribed self-contained programme of studies. The coursework is equivalent to an entire Specialist or Doctoral Degree; unfortunately just a handful of institutions of higher education offer this kind of self-standing graduate programme. Graduate courses of a psychological nature include:

  • Special Education Law.
  • Advanced Child and Adolescent Growth and Development.
  • Psychology of Students with Exceptionalities.
  • Abnormal Child and Adult Psychology.
  • Advanced Statistics and Research in Education and Psychology.
  • Tests and measurements.
  • Assessment and Evaluation of the Individual.
  • Individual Intelligence quotient.
  • Group Assessment.
  • Diagnostics and Remedial Reading.
  • Ethical issues in education and psychological measurement and evaluation reporting.
  • Methods of Instructing Students with Mild/Moderate Disabilities.
  • Methods of Instructing Students with Severe to Profound Disabilities.
  • Survey of Guidance and Counselling Techniques.
  • Practicum for School Psychological Examiners (150 supervised contact hours).

Licensure as School Psychological Examiner demands experience in a special education or school counselling setting, satisfactory completion of the required graduate coursework and practicum, plus a passing score on the ‘Praxis II Special Education: Knowledge-Based Core Principles’. Graduate school recommendation and verification of experience by the employing school district complete the requirements. In addition to the practicum, on-the-job mentoring supervision for at least two school years, sometimes four years, allows the transition from initial licensure to standard professional licensure. An annual professional development plan and ongoing performance-based evaluation ensure ‘High Quality’ professionalism as required by the No Child Left Behind law and related regulations.

Competencies

The clinical and technical skills needed to be a competent behavioural and clinical assessor include the abilities to do the following (Sattler & Hoge, 2006):

  • Establish and maintain rapport with children, parents, and teachers.
  • Use effective assessment techniques appropriate for evaluating children’s behaviour.
  • Use effective techniques for obtaining accurate and complete information from parents and teachers.
  • Evaluate the psychometric properties of tests and other measures.
  • Select an appropriate assessment battery.
  • Administer and score tests and other assessment tools by following standardised procedures.
  • Observe and evaluate behaviour objectively.
  • Perform informal assessments.
  • Interpret assessment results.
  • Use assessment findings to develop effective interventions.
  • Communicate assessment findings effectively, both orally and in writing.
  • Adhere to ethical standards.
  • Read and interpret research in behavioural and clinical assessment.
  • Keep up with laws and regulations concerning the assessment and placement of children with special needs.

Additionally, high quality School Psychological Examiners exhibit proficiency-level knowledge on:

  • The provisions of the Individuals with Disabilities Act and the Section 504 of the Civil Rights Act and related legislation.
  • State and federal laws, and all the applicable regulations, policies, and standards pertaining the provision of psychosocial and educational services to disabled individuals.
  • Children and adolescents’ advanced development and behaviour.
  • Multicultural factors in attitudes and behaviours.
  • Analysis and diagnosis of learning problems including special consideration of low incidence populations.
  • Integration of knowledge, facts, and theory on classroom environment, psychosocial principles, and test results, to plan for prescriptive instruction, management, and education of students with special needs.
  • Focused and methodical psychoeducational evaluation reporting, providing sound and accurate information and research-based remediation recommendations to improve individual student’s learning, achievement, and behavioural performance.
  • Teamwork and collaboration for the process of staffing with other school professionals and collaborative development of instructional strategies for students with special needs.
  • Provision of assistance with instructional modifications or accommodations, and programming or transition recommendations for the Individualised Education Programme (IEP).
  • Accountability for the monitoring and outcome assessment of services and interventions.

Evaluation Standards

Evaluation standards provide guidelines for designing, implementing, assessing, and reporting the psychoeducational evaluation reported by school psychological examiners. The evaluation is informed by professional codes of ethics.

  • Standards for Qualifications of Test Users.
  • Code of Fair Testing Practices in Education.
  • Standards for Multicultural Assessment.
  • Standards for Educational and Psychological Testing.

Reference

Sattler, J. M. & Hoge, R. D. (2006). Assessment of Children: Behavioral, Social, and Clinical Foundations. 5th Ed. San Diego, CA: Jerome M. Sattler Publisher, Inc. p.2.

What is a School Counsellor?

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Introduction

A school counsellor is a professional who works in primary (elementary and middle) schools or secondary schools to provide academic, career, college access/affordability/admission, and social-emotional competencies to all students through a school counselling programme.

Academic, Career, College, and Social-Emotional Interventions and Services

The four main school counselling programme interventions include school counselling curriculum classroom lessons and annual academic, career/college access/affordability/admission, and social-emotional planning for every student; and group and individual counselling for some students. School counselling is an integral part of the education system in countries representing over half of the world’s population and in other countries it is emerging as a critical support for elementary, middle, and high school learning, post-secondary options, and social-emotional/mental health.

An outdated, classist, racist term for the profession was guidance counsellor; school counsellor is used as the school counsellor’s role is advocating for every student’s academic, career, college access/affordability/attainment, and social-emotional competencies and success in all schools. In the Americas, Africa, Asia, Europe, and the Pacific, some countries with no formal school counselling programmes use teachers or psychologists to do school counselling emphasizing career development.

Countries vary in how a school counselling programme and services are provided based on economics (funding for schools and school counselling programmes), social capital (independent versus public schools), and school counsellor certification and credentialing movements in education departments, professional associations, and local, state/province, and national legislation. School counselling is established in 62 countries and emerging in another seven.

An international scoping project on school-based counselling showed school counselling is mandatory in 39 countries, 32 US states, one Australian state, 3 German states, 2 countries in the United Kingdom, and three provinces in Canada. The largest accreditation body for Counsellor Education/School Counselling programmes is the Council for the Accreditation of Counselling and Related Educational Programmes (CACREP). International Counsellor Education programmes are accredited through a CACREP affiliate, the International Registry of Counsellor Education Programmes (IRCEP).

In some countries, school counselling is provided by school counselling specialists (for example, Botswana, China, Finland, Israel, Malta, Nigeria, Romania, Taiwan, Turkey, United States). In other cases, school counselling is provided by classroom teachers who either have such duties added to their typical teaching load or teach only a limited load that also includes school counselling activities (India, Japan, Mexico, South Korea, Zambia). The IAEVG focuses on career development with some international school counselling articles and conference presentations. Both the IAEVG and the Vanguard of Counsellors promote school counselling internationally.

History, School Counsellor-to-Student Ratios, and Mandates

Armenia

After the collapse of the Soviet Union, the post-Soviet Psychologists of Armenia and the government developed the School Counsellor position in Armenian Schools.

Australia

While national policy supports school counselling, only one Australian state requires it. The school counsellor-to-student ratio ranges from 1:850 in the Australian Capital Territory to 1:18,000 in Tasmania. School counsellors play an integral part in the Australian schooling system; they provide support to teachers, parents, and students. Their roles include counselling students and assisting parents/guardians to make informed decisions about their child’s education for learning and behavioural issues. School counsellors assist schools and parents/guardians in assessing disabilities and they collaborate with outside agencies to provide the best support for schools, teachers, students, and parents.

Austria

Austria mandates school counselling at the high school level.

Bahamas

The Bahamas mandate school counselling.

Belgium

Although not mandated, some school counselling occurs in schools and community centres in three regions of the country.

Bhutan

Bhutan mandates school counselling programme for all schools. All schools have fulltime school guidance counsellors.

Botswana

Botswana mandates school counselling

Brazil

School Counsellors in Brazil have large caseloads.

Canada

The roots of school counselling stemmed from a response to the conditions created by the industrial revolution in the early 1900s. Originally, school counselling was often referred to as vocational guidance, where the goal of the profession was to help individuals find their path in a time where individuals previous ways of making a living had been displaced. As people moved towards industrialised cities, counselling was required to help students navigate these new vocations. With a great discrepancy between the rich and the poor, vocational counselling was initiated to help support disadvantaged students. After World War II, vocational guidance began to shift towards a new movement of counselling, which provided a theoretical backing. As the role of school counsellors progressed into the 1970s, there has become more uncertainty as to what the role entails. This role confusion continues into the 21st century, where there is a lack of clear consensus between counsellors, other teachers, administration, students and parents on what school counsellors should be prioritising.

Throughout Canada, the emerging trend among school counselling programmes is to provide a comprehensive and cohesive approach. These programmes address the personal, social, educational and career development of students. A comprehensive programme consists of 4 components, including developmental school counselling classroom lessons, individual student planning, responsive services, and school and community support.

  • Developmental School Counselling lessons involve small group and class presentations about valuable life skills, which is generally supported through classroom curriculum.
  • Individual student planning involves assessing students abilities, providing advice on goals and planning transitions to work and school.
  • Responsive services includes counselling with students, consulting with parents and teachers, and referrals to outside agencies.
  • Support from the school and community includes such things as professional development, community outreach and program management.

The process to become a school counsellor varies drastically across each province, with some requiring a graduate level degree in counselling while others require a teaching certification or both. Some provinces also require registration with the relevant provincial College of Registered Psychotherapists. These differences highlight the vast range of expertise required within the role of a school counsellor. Regardless of the professional requirements, all school counsellors are expected to advise students within the realm of mental health support, course choices, special education and career planning. The Canadian Counselling and Psychotherapy Association, Canada’s leading association for counselling and psychotherapy, is working towards alignment among the provinces through partnership and collaboration between provinces. Recent conferences share information on the differences and similarities within each province and how progress is being made to ensure proper regulations are in place at a national level.

In the province of Ontario, Canada, school counsellors are found in both elementary and secondary settings, to varying degrees. The Greater Toronto Area, the largest metropolis in the country, has school counsellors in 31% of elementary schools, however the remainder of the province averages 6%. Additionally, the elementary schools that have a school counsellor are scheduled for an average of 1.5 days per week. These counsellors are generally classroom teachers for the remainder of the time. In secondary schools in Ontario, Canada, the average ratio of students to school counsellors is 396:1. In 10% of Ontario schools, this average increases to 826:1. There is concern among administration that these staffing levels are not sufficient to meet the needs of students. This has been proven in recent articles appearing in the news featuring student stories of frustration as they prepare for graduation without the support they expected from school counsellors. Considering the extensive expectations placed on school counsellors, future research needs to address whether or not they can be met within one profession while effectively equipping students with support and information.

School counsellors reported in 2004 at a conference in Winnipeg on issues such as budget cuts, lack of clarity about school counsellor roles, high student-to-school counsellor ratios, especially in elementary schools, and how using a comprehensive school counselling model helped clarify school counsellor roles with teachers and administrators and strengthened the profession. More than 15 years later, the profession is continuing to evolve and meet the changing needs of 21st century students in Canada.

China

China has put substantial financial resources into school counselling with strong growth in urban areas but less than 1% of rural students receive it; China does not mandate school counselling.

In China, Thomason & Qiong discussed the main influences on school counselling as Chinese philosophers Confucius and Lao-Tzu, who provided early models of child and adult development who influenced the work of Abraham Maslow and Carl Rogers.

Only 15% of high school students are admitted to college in China, so entrance exams are fiercely competitive. Students entering university graduate at a rate of 99%. Much pressure is put on children and adolescents to study and attend college. This pressure is a central focus of school counselling in China. An additional stressor is that there are not enough places for students to attend college, and over one-third of college graduates cannot find jobs, so career and employment counselling and development are also central in school counselling.

In China, there is a stigma related to social-emotional and mental health issues; therefore, even though most universities and many (urban) primary and secondary schools have school counsellors, many students are reluctant to seek counselling for issues such as anxiety and depression. There is no national system of certifying school counsellors. Most are trained in Western-developed cognitive methods including REBT, Rogerian, Family Systems, Behaviour Modification, and Object Relations. School Counsellors also recommend Chinese methods such as qi-gong (deep breathing) and acupuncture, as well as music therapy. Chinese school counsellors work within a traditional Chinese world view of a community and family-based system that lessens the focus on the individual. In Hong Kong, Hui (2000) discussed work moving toward comprehensive school counselling programs and eliminating the older remediation-style model.

Middle school students are a priority for school counselling services in China.

Costa Rica

Costa Rica mandates school counselling.

Croatia

School counselling is only available in certain schools.

Cyprus

In 1991 Cyprus mandated school counselling with a goal of a 1:60 school counsellor-to-student ratio and one full-time school counsellor for every high school but neither of these goals has been accomplished.

Czech Republic

The Czech Republic mandates school counselling.

Denmark

Denmark mandates school counselling.

Egypt

School counselling services are delivered by elementary school psychologists with a ratio of 1 school psychologist to every 3,080 students.

Estonia

School counselling is only available in certain schools.

Finland

In Finland, legislation has been passed for a school counselling system. The Basic Education Act of 1998 stated that every student must receive school counselling services. All Finnish school counsellors must have a teaching certificate, a master’s degree in a specific academic subject, and a specialised certificate in school counselling. Finland has a school counsellor-to-student ratio of 1:245.

France

France mandates school counselling in high schools.

Gambia

Gambia mandates school counselling.

Georgia

The school counsellor-to-student ratio in Georgia is 1:615.

Germany

Two German states require school counselling at all education levels; high school counselling is established in all states.

Ghana

Ghana mandates school counselling.

Greece

There are provisions for academic and career counselling in middle and high schools but school counselling is not mandated. Social-emotional and mental-health counselling is done in community agencies. The National Guidance Resources Centre in Greece was established by researchers at Athens University of Economics & Business (ASOEE) in 1993 under the leadership of Professor Emmanuel J. Yannakoudakis. The team received funding under the European Union (PETRA II Programme): The establishment of a national occupational guidance resources centre in 1993-1994. The team organised seminars and lectures to train the first career counsellors in Greece in 1993. Further research projects at Athens University of Economics & Business were implemented as part of the European Union (LEONARDO Programme):

  • A pilot project on the use of multimedia for career analysis, 1995-1999;
  • Guidance toward the future, 1995-1999;
  • On the move to a guidance system, 1996-2001; and
  • Eurostage for guidance systems, 1996-1999.

Netherlands

School counselling is present in high schools.

Hong Kong

Hong Kong mandates school counselling.

Iceland

Iceland mandates school counselling.

India

In India, the Central Board of Secondary Education guidelines expect one school counsellor appointed for every affiliated school, but this is less than 3% of all Indian students attending public schools.

Indonesia

Indonesia mandates school counselling in middle and high school.

Iran

Middle school students are the priority for school counselling in Iran. It is mandated in high schools but there are not enough school counsellors particularly in rural areas.

Ireland

In Ireland, school counselling began in County Dublin in the 1960s and went countrywide in the 1970s. However, legislation in the early 1980s severely curtailed the movement due to budget constraints. The main organization for the school counselling profession is the Institute of Guidance Counsellors (IGC), which has a code of ethics.

Israel

In Israel, a 2005 study by Erhard & Harel of 600 elementary, middle, and high school counsellors found that a third of school counsellors were delivering primarily traditional individual counselling services, about a third were delivering preventive classroom counselling curriculum lessons, and a third were delivering both individual counselling services and school counselling curriculum lessons in a comprehensive developmental school counselling programme. School counsellor roles varied due to three elements: the school counsellor’s personal preferences, school level, and the principal’s expectations. Erhard & Harel stated that the profession in Israel, like many other countries, is transforming from marginal and ancillary services to a comprehensive school counselling approach integral in the total school’s education program. In 2011-2012, Israel had a school counsellor-to-student ratio of 1:570.

Italy

School counselling is not well developed in Italy.

Japan

In Japan, school counselling is a recent phenomenon with school counsellors being introduced in the mid-1990s and often part-time focused on behavioural issues. Middle school students are the priority for school counselling in Japan and it is mandated.

Jordan

Jordan mandates school counselling with 1,950 school counsellors working in 2011-2012.

Latvia

School counselling was introduced in Latvia in 1929 but disappeared in World War II.

Lebanon

In Lebanon, the government sponsored the first training of school counsellors for public elementary and middle schools in 1996. There are now school counsellors in 1/5 of the elementary and middle schools in Lebanon but none in high schools. School counsellors have been trained in delivering preventive, developmental, and remedial services. Private schools have some school counsellors serving all grade levels but the focus is individual counselling and remedial. Challenges include regular violence and wartime strife, not enough resources, and a lack of a professional school counselling organisation, assigned school counsellors covering two or more schools, and only two school counselling graduate programmes in the country. Last, for persons trained in Western models of school counselling there are dangers of overlooking unique cultural and family aspects of Lebanese society.

Lithuania

School counselling was introduced in 1931 but disappeared during World War II.

Macau

Macau mandates school counselling.

Malaysia

Malaysia mandates school counselling in middle and high school.

Malta

In Malta, school counselling services began in 1968 in the Department of Education based on recommendations from a UNESCO consultant and used these titles: Education Officer, School Counsellor, and Guidance Teacher. Through the 1990s they included school counsellor positions in primary and trade schools in addition to secondary schools. Guidance teachers are mandated at a 1:300 teacher to student ratio. Malta mandates school counselling.

Nepal

Nepal mandates school counselling.

New Zealand

New Zealand mandates school counselling but since 1988 when education was decentralised, there has been a decline in the prevalence of school counsellors and the quality and service delivery of school counselling.

Nigeria

In Nigeria, school counselling began in 1959 in some high schools. It rarely exists at the elementary level. Where there are federally funded secondary schools, there are some professionally trained school counsellors. However, in many cases, teachers function as career educators. School counsellors often have teaching and other responsibilities that take time away from their school counselling tasks. The Counselling Association of Nigeria (CASSON) was formed in 1976 to promote the profession, but there is no code of ethics. However, a certification/licensure board has been formed. Aluede, Adomeh, & Afen-Akpaida (2004) discussed the over-reliance on textbooks from the US and the need for school counsellors in Nigeria to take a whole-school approach, lessen individual approaches, and honour the traditional African world view valuing the family and community’s roles in decision-making as paramount for effective decision-making in schools.

Norway

Norway mandates school counselling.

Oman

There are some school counselling services at the high school level.

Philippines

The Philippines mandates school counselling in middle and high school. The Congress of the Philippines passed the Guidance and Counselling Act of 2004 with a specific focus on Professional Practice, Ethics, National Certification, and the creation of a Regulatory Body, and specialists in school counselling are subject to this law.

Poland

School counselling was introduced in 1918 but disappeared during World War II.

Portugal

Portugal mandates school counselling at the high school level.

Romania

Romania mandates school counselling.

Rwanda

School counselling focuses on trauma-based counselling. It focuses on academic performance, prevention, and intervention with HIV/AIDS, and establishing peace-building clubs.

Saudi Arabia

School counselling is developing in Saudi Arabia. In 2010, 90% of high schools had some type of school counselling service.

Serbia

School counselling is available in certain schools.

Singapore

Singapore mandates school counselling.

Slovakia

Slovakia mandates school counselling.

South Korea

In South Korea, school counsellors must teach a subject besides counselling, but not all school counsellors are appointed to counselling positions, even though Korean law requires school counsellors in all middle and high schools.

Spain

Spain provides school counselling at the high school level although it is unclear if mandated. There was around one counsellor for every 1,000 primary and secondary (high school) students as of 2018.

St. Kitts

St. Kitts mandates school counselling.

Sweden

Sweden mandates school counselling. In Sweden, school counsellors’ work was divided into two work groups in the 1970s. The work groups are called “kurator” and “studie -och yrkesvägledare.” They worked with communication methodology but the kurator’s work is more therapeutic, often psychological and social-emotional issues, and the studie-och yrkesvägledare’s work is future-focused with educational and career development. Studie- och yrkesvägledaren work in primary, secondary, adult education, higher education and various training centres and most have a Bachelor of Arts degree in Study and Career Guidance.

Switzerland

School counselling is found at the high school level.

Syria

School counselling has focused on trauma-based counselling of students. Prior to the war it was done in schools but it is now found in either a school club or refugee camp sponsored and staffed by UNICEF.

Taiwan

In Taiwan, school counselling traditionally was done by “guidance teachers.” Recent advocacy by the Chinese Guidance and Counselling Association pushed for licensure for school counsellors in Taiwan’s public schools. Prior to this time, the focus had been primarily individual and group counselling, play therapy, career counselling and development, and stress related to national university examinations.

Tanzania

Tanzania mandates school counselling.

Thailand

The Thai government has put substantial funding into school counsleling but does not mandate it.

Trinidad and Tobago

Trinidad and Tobago mandate school counselling.

Turkey

Turkey mandates school counselling and it is in all schools.

Uganda

Uganda mandates school counselling.

United Arab Emirates

There is some school counselling at the high-school level in the United Arab Emirates.

United Kingdom

School counselling originated in the UK to support underachieving students and involved specialist training for teachers. Head of Year (e.g. Head of Year 7, Head of Year 8, etc.) are school staff members, usually teachers, who oversee a year group within a secondary school. These Heads of Year ensure students within the year cohort behave properly within the school, but these Heads also support students in their social and emotional well-being and course and career planning options. Wales and Northern Ireland require school counselling.

United States

In the United States, the school counselling profession began with the vocational guidance movement in the early 20th century now known as career development. Jesse B. Davis was the first to provide a systematic school counselling programme focused on career development. In 1907, he became the principal of a high school and encouraged the school English teachers to use compositions and lessons to relate career interests, develop character, and avoid behavioural problems. Many others during this time focused on what is now called career development. For example, in 1908, Frank Parsons, “Father of Career Counselling” established the Bureau of Vocational Guidance to assist young people transition from school to work.

From the 1920s to the 1930s, school counselling grew because of the rise of progressive education in schools. This movement emphasized personal, social, and moral development. Many schools reacted to this movement as anti-educational, saying that schools should teach only the fundamentals of education. Combined with the economic hardship of the Great Depression, both challenges led to a decline in school counselling. At the same time, the National Association for College Admission Counselling was established as the first professional association focused on counselling and advising high school students into college. In the early 1940s, the school counselling movement was influenced by the need for counsellors to help assess students for wartime needs. At the same time, researcher Carl Rogers’ emphasized the power of non-directive helping relationships and counselling for all ages and the profession of counselling was influenced to shift from directive “guidance” to non-directive or person-centred “counselling” as the basis for school counselling.

In the 1950s the government established the Guidance and Personnel Services Section in the Division of State and Local School Systems. In 1957, the Soviet Union launched Sputnik I. Out of concern that the Russians were winning the space race and that there were not enough scientists and mathematicians, the government passed the National Defence Education Act, spurring growth in vocational and career counselling through larger funding. In the 1950s the American School Counsellor Association (ASCA) was founded as one of the early divisions of what is now known as the American Counselling Association (ACA).

In the 1960s, new legislation and professional developments refined the school counselling profession (Schmidt,[40] 2003). The 1960s continued large amounts of federal funding for land-grant colleges and universities to establish Counsellor Education master’s and doctoral programmes. School counselling shifted from a primary focus on career development to adding social-emotional issues paralleling the rise of social justice and civil rights movements. In the early 1970s, Dr. Norm Gysbers’s research and advocacy helped the profession shift from school counsellors as solitary professionals focused on individual academic, career, and social-emotional student issues to a comprehensive developmental school counselling programme for all students K-12 that included individual and group counselling for some students and classroom lessons and annual advising/planning and activities for every student. He and his colleagues’ research evidenced strong correlations between fully implemented school counselling programmes and student academic success; a critical part of the evidence base for the school counselling profession was their work in Missouri. Dr. Chris Sink & associates showed similar evidence-based success for school counselling programmes at the elementary and middle school levels in Washington State.

School counselling in the 1980s and early 1990s was not influenced by corporate educational reform efforts. The profession had little evidence of systemic effectiveness for school counsellors and only correlational evidence of the effectiveness of school counselling programmes. In response, consulted with elementary, middle, and high school counsellors and created the American School Counsellor Association (ASCA) Student Standards with three core domains (Academic, Career, Personal/Social), nine standards, and specific competencies and indicators for K-12 students. There was no research base, however, for school counselling standards as an effective educational reform strategy. A year later, Whiston & Sexton published the first systemic meta-analysis of school counselling outcome research in academic, career, and personal/social domains and individual counselling, group counselling, classroom lessons, and parent/guardian workshop effectiveness.

In the late 1990s, former mathematics teacher, school counsellor, and administrator Pat Martin, was hired by corporate-funded educational reform group, The Education Trust, to focus the school counselling profession on equity issues by helping close achievement and opportunity gaps harming children and adolescents of colour, poor and working class children and adolescents, bilingual children and adolescents, and children and adolescents with disabilities. Martin, under considerable heat from Counsellor Educators who were not open to her equity-focused message of change, developed focus groups of K-12 students, parents, guardians, teachers, building leaders, and superintendents, and interviewed professors of School Counsellor Education. She hired Oregon State University School Counsellor Education professor emeritus Dr. Reese House, and after several years of work in the late 1990s they created, in 2003, the National Centre for Transforming School Counselling (NCTSC).

The NCTSC focused on changing school counsellor education at the graduate level and changing school counsellor practice in state and local districts to teach school counsellors how to help recognise, prevent, and close achievement and opportunity gaps. In their initial focus groups, they found what Hart & Jacobi had indicated years earlier – too many school counsellors were gatekeepers for the status quo instead of advocates for the academic success of every child and adolescent. Too many school counsellors used inequitable practices, supported inequitable school policies, and were unwilling to change.

This professional behaviour kept many students from non-dominant backgrounds (i.e. students of colour, poor and working class students, students with disabilities, and bilingual students) from receiving challenging coursework (AP, IB, and honours classes) and academic, career, and college access/affordability/admission skills needed to successfully graduate from high school and pursue post-secondary options including college. In 1998, the Education Trust received a grant from the DeWitt Wallace/Reader’s Digest to fund six $500,000 grants for Counsellor Education/School Counselling programmes, with a focus on rural and urban settings, to transform School Counsellor Education programmes to teach advocacy, leadership, teaming and collaboration, equity assessment using data, and culturally competent programme counselling and coordination skills in addition to counselling: Indiana State University, the University of Georgia, the University of West Georgia, the University of California-Northridge, the University of North Florida, and, the Ohio State University were the recipients. Over 25 additional Counsellor Education/School Counselling programmes nationwide became companion institutions in the following decade with average grants of $3000. By 2008, NCTSC consultants had worked in over 100 school districts and major cities and rural areas to transform the work of school counsellors nationwide.

In 2002, the American School Counsellor Association released Dr. Trish Hatch and Dr. Judy Bowers’ work: the ASCA National Model: A framework for school counselling programmes comprising key school counselling components: ASCA National Standards, and the skill-based focus for closing achievement and opportunity gaps from the Education Trust’s new vision of school counselling into one document. The model drew from major theoreticians in school counselling with four key areas: Foundation (school counselling programme mission statements, vision, statements, belief statements, and annual goals); Delivery (direct services including individual and group counselling; classroom counselling lessons; planning and advising for all students); Management (use of action plans and results reports for closing gaps, small group work and classroom lessons; a school counselling programme assessment, an administrator-school counsellor annual agreement, a time-tracker tool, and a school counselling data tool; and Accountability (school counsellor annual evaluation and use of a School Counselling Programme Advisory Council to monitor data, outcomes, and effectiveness). In 2003, Dr. Jay Carey and Dr. Carey Dimmitt created the Centre for School Counselling Outcome Research and Evaluation (CSCORE) at the University of Massachusetts-Amherst as a clearinghouse for evidence-based practice with regular research briefs, original research projects, and eventual co-sponsorship of the annual Evidence-Based School Counselling conference in 2013.

In 2004, the ASCA Ethical Standards for School Counsellors was revised to focus on issues of equity, closing achievement and opportunity gaps, and ensuring all K-12 students received access to a school counselling programme. Also in 2004, an equity-focused entity on school counsellors’ role in college readiness and admission counselling, the National Office for School Counsellor Advocacy (NOSCA) emerged at The College Board led by Pat Martin and Dr. Vivian Lee. NOSCA developed scholarships for research on college counselling by K-12 school counsellors taught in School Counsellor Education programmes.

In 2008, the first NOSCA study was released by Dr. Jay Carey and colleagues focused on innovations in selected College Board “Inspiration Award” schools where school counsellors collaborated inside and outside their schools for high college-going rates and strong college-going cultures in schools with large numbers of students of non-dominant backgrounds. In 2008, ASCA released School Counselling Competencies focused on assisting school counselling programmes to effectively implement the ASCA National Model.

In 2010, the Centre for Excellence in School Counselling and Leadership (CESCAL) at San Diego State University co-sponsored the first of four school counsellor and educator conferences devoted to the needs of lesbian, bisexual, gay, and transgender students in San Diego, California. ASCA published a 5th edition of the ASCA Ethical Standards for School Counsellors.

In 2011, Counselling at the Crossroads: The perspectives and promise of school counsellors in American education, the largest survey of high school and middle school counsellors in the United States with over 5,300 interviews, was released by Pat Martin and Dr. Vivian Lee by the National Office for School Counsellor Advocacy, the National Association of Secondary School Principals, and the American School Counsellor Association. The study shared school counsellors’ views on educational policies, practices, and reform, and how many of them, especially in urban and rural school settings, were not given the chance to focus on what they were trained to do, especially career and college access and readiness counselling for all students, in part due to high caseloads and inappropriate tasks.

School counsellors suggested changes in their role to be accountable for success of all students and how school systems needed to change so school counsellors could be key advocates and leaders for every student’s success. Implications for public policy and district and school-wide change were addressed. The National Centre for Transforming School Counselling released a brief, Poised to Lead: How School Counsellors Can Drive Career and College Readiness, challenging all schools to utilise school counsellors for equity and access for challenging coursework (AP, IB, honours) for all students and ensuring college and career access skills and competencies as a major focus for school counsellors K-12.

In 2012, CSCORE assisted in evaluating and publishing six statewide research studies assessing the effectiveness of school counselling programmes based on statewide systemic use of school counselling programmes such as the ASCA National Model and published their outcomes in the American School Counsellor Association research journal Professional School Counselling. Research indicated strong correlational evidence between fully implemented school counselling programmes and low school counsellor-to-student ratios provided better student academic success, greater career and college access/readiness/admission, and reduced social-emotional issue concerns included better school safety, reduced disciplinary issues, and better attendance.

Also in 2012, the American School Counsellor Association released the third edition of the ASCA National Model.

From 2014-2016, the White House, under the Office of the First Lady Michelle Obama, partnered with key school counsellor educators and college access professionals nationwide to focus on the roles of school counsellors and college access professionals. Their collaboration resulted in a series of national Reach Higher/School Counselling and College Access convenings at Harvard University, San Diego State University, the University of North Florida, and American University. Michelle Obama and her staff also began the Reach Higher and Better Make Room programmes to focus on college access for underrepresented students, and she began hosting the American School Counsellor Association’s School Counsellor of the Year awards ceremony at the White House. The initiatives culminated in an unprecedented collaboration among multiple major professional associations focused on school counselling and college access including the American Counselling Association, the American School Counsellor Association, the National Association for College Admission Counselling, the College Board, and ACT raising the profile and prominence of the role of school counsellors collaborating on college access, affordability, and admission for all students.

In 2015, ASCA replaced the ASCA National Student Standards with the evidence-based ASCA Mindsets & Behaviours for Student Success: K-12 College and Career Readiness Standards for Every Student, created from meta-analyses done by the University of Chicago’s Consortium on Educational Reform showing key components of raising student academic success over multiple well-designed research studies. While an improvement over the lack of research in the ASCA student standards that they replaced, school counsellors shared feedback that they do not go into enough depth for career, college access/admission/affordability, and social-emotional competencies.

In 2016, ASCA published a newly revised sixth version of the ASCA Ethical Standards for School Counsellors using two rounds of feedback from practicing school counsellors in all 50 states; it also included, for the first time, a Glossary of ethical terms for heightened clarity.

In 2019, ASCA released the 4th edition of the ASCA National Model, a Framework for School Counselling Programmes. Changes included fewer templates and combined templates from the 3rd edition after school counsellor feedback that the 3rd edition had become too complex and onerous. The four outside-the-diamond skills from the first three editions: advocacy, leadership, teaming and collaboration, and systemic change were incorporated throughout the model and no longer part of the diamond graphic organiser. The four quadrants of the model were changed to verbs and action-oriented words to better clarify the key components:

  1. Define (formerly Foundation).
  2. Deliver (formerly Delivery System).
  3. Manage (formerly Management System).
  4. Assess (formerly Accountability System).

The three types of data collected by school counsellors in school counselling programmes have shifted in name to:

  1. Participation data (formerly process).
  2. Mindsets & Behaviours data (formerly perception, i.e. learning).
  3. Outcome data (results).

The 4th edition, while easier to read and use than prior editions, did not cover the history of how the model changed over time and neglected any mention of the original authors, Drs. Trish Hatch and Judy Bowers.

Venezuela

School counselling is mandated in Venezuela and it has focused on cultural competency.

Vietnam

School counselling is mandated in Vietnam.

Roles, School Counselling Programmes, Ethics, and School Counselling Professional Associations

Professional school counsellors ideally implement a school counselling programme that promotes and enhances student achievement (Hatch & Bowers, 2003, 2005; ASCA, 2012). A framework for appropriate and inappropriate school counsellor responsibilities and roles is outlined in the ASCA National Model (Hatch & Bowers, 2003, 2005; ASCA, 2012). School counsellors, in US states, have a master’s degree in school counselling from a Counsellor Education graduate programme. China requires at least three years of college experience. In Japan, school counsellors were added in the mid-1990s, part-time, primarily focused on behavioural issues. In Taiwan, they are often teachers with recent legislation requiring school counselling licensure focused on individual and group counselling for academic, career, and personal issues. In Korea, school counsellors are mandated in middle and high schools.

School counsellors are employed in elementary, middle, and high schools, in district supervisory settings, in Counsellor Education faculty positions (usually with an earned Ph.D. in Counsellor Education in the USA or related graduate doctorates abroad), and post-secondary settings doing academic, career, college access/affordability/admission, and social-emotional counselling, consultation, and programme coordination. Their work includes a focus on developmental stages of student growth, including the needs, tasks, and student interests related to those stages(Schmidt,[40] 2003).

Professional school counsellors meet the needs of student in three basic domains: academic development, career development and college access/affordability/admission, and social-emotional development (Dahir & Campbell, 1997; Hatch & Bowers, 2003, 2005; ASCA, 2012). Knowledge, understanding and skill in these domains are developed through classroom instruction, appraisal, consultation, counselling, coordination, and collaboration. For example, in appraisal, school counsellors may use a variety of personality and career assessment methods to help students explore career and college needs and interests.

Schools play a key role in assessment, access to services, and possible referral to appropriate outside support systems. They provide intervention, prevention, and services to support students’ academic, career, and post-secondary education as well as social-emotional growth. The role of school counsellors is expansive. School counsellors address mental health issues, crisis intervention, and advising for course selection. School counsellors consult with all stakeholders to support student needs and may also focus on experiential learning, cooperative education, internships, career shadowing, and entrance to specialised high school programmes.

School counsellor interventions include individual and group counselling for some students. For example, if a student’s behaviour is interfering with his or her achievement, the school counsellor may observe that student in a class, provide consultation to teachers and other stakeholders to develop (with the student) a plan to address the behavioural issue(s), and then collaborate to implement and evaluate the plan. They also provide consultation services to family members such as college access/affordability/admission, career development, parenting skills, study skills, child and adolescent development, mental health issues, and help with school-home transitions.

School counsellor interventions for all students include annual academic/career/college access/affordability/admission planning K-12 and leading classroom developmental lessons on academic, career/college, and social-emotional topics. The topics of mental health, multiculturalism (Portman, 2009), anti-racism, and school safety are important areas of focus for school counsellors. Often school counsellors will coordinate outside groups to help with student needs such as academics, or coordinate a program that teaches about child abuse or drugs, through on-stage drama.

School counsellors develop, implement, and evaluate school counselling programmes that deliver academic, career, college access/affordability/admission, and social-emotional competencies to all students in their schools. For example, the ASCA National Model (Hatch & Bowers, 2003, 2005; ASCA, 2012) includes the following four main areas:

  • Foundation (Define as of 2019) – a school counselling programme mission statement, a vision statement, a beliefs statement, SMART Goals; ASCA Mindsets & Behaviours & ASCA Code of Ethics;
  • Delivery System (Deliver as of 2019) – how school counselling core curriculum lessons, planning for every student, and individual and group counselling are delivered in direct and indirect services to students (80% of school counsellor time);
  • Management System (Manage as of 2019) – calendars; use of data tool; use of time tool; administrator-school counsellor agreement; school counselling programme advisory council; small group, school counselling core curriculum, and closing the gap action plans; and
  • Accountability System (Assess as of 2019) – school counselling program assessment; small group, school counselling core curriculum, and closing-the-gap results reports; and school counsellor performance evaluations based on school counsellor competencies.

The school counselling programme model (ASCA, 2012, 2019) is implemented using key skills from the National Centre for Transforming School Counselling’s Transforming School Counselling Initiative: Advocacy, Leadership, Teaming and Collaboration, and Systemic Change.

Many provinces in Canada offer a career pathway programme, which helps to prepare students for the employment market and support a smooth school-to-work transition.

School Counsellors are expected to follow a professional code of ethics in many countries. For example, In the US, they are the American School Counsellor Association (ASCA) School Counsellor Ethical Code, the American Counselling Association (ACA) Code of Ethics, and the National Association for College Admission Counselling (NACAC) Statement of Principles of Good Practice (SPGP).

Some school counsellors experience role confusion, given the many tasks they are expected to perform. The demands on the school counsellor to be a generalist who performs roles in leadership, advocacy, essential services, and curriculum development can be too much if there is not a clear mission, vision, and comprehensive school counselling programme in place. Additionally, some school counsellors are stretched too thin to provide mental health support on top of their other duties.

The role of a school counsellor is critical and needs to be supported by all stakeholders to ensure equity and access for all students, particularly those with the fewest resources. The roles of school counsellors are expanding and changing with time. As roles change, school counsellors help students prosper in academics, career, post-secondary, and social-emotional domains. School counsellors reduce and bridge the inequalities facing students in educational systems.

School Counsellors around the world are affiliated with various national and regional school counselling associations, and abide by their guidelines.

Elementary School Counselling

Elementary school counsellors provide academic, career, college access, and personal and social competencies and planning to all students, and individual and group counselling for some students and their families to meet the developmental needs of young children K-6. Transitions from pre-school to elementary school and from elementary school to middle school are an important focus for elementary school counsellors. Increased emphasis is placed on accountability for helping close achievement and opportunity gaps at the elementary level as more school counselling programmes move to evidence-based work with data and specific results.

School counselling programmes that deliver specific competencies to all students help to close achievement and opportunity gaps. To facilitate individual and group school counselling interventions, school counsellors use developmental, cognitive-behavioural, person-centred (Rogerian) listening and influencing skills, systemic, family, multicultural, narrative, and play therapy theories and techniques. released a research study showing the effectiveness of elementary school counselling programmes in Washington state.

Middle School Counselling

Middle school counsellors provide school counselling curriculum lessons on academic, career, college access, and personal and social competencies, advising and academic/career/college access planning to all students and individual and group counselling for some students and their families to meet the needs of older children/early adolescents in grades 7 and 8.

Middle School College Access curricula have been developed to assist students and their families before reaching high school. To facilitate the school counselling process, school counsellors use theories and techniques including developmental, cognitive-behavioural, person-centred (Rogerian) listening and influencing skills, systemic, family, multicultural, narrative, and play therapy. Transitional issues to ensure successful transitions to high school are a key area including career exploration and assessment with seventh and eighth grade students. Sink, Akos, Turnbull, & Mvududu released a study in 2008 confirming the effectiveness of middle school comprehensive school counselling programmes in Washington state.

High School Counselling

High school counsellors provide academic, career, college access, and personal and social competencies with developmental classroom lessons and planning to all students, and individual and group counselling for some students and their families to meet the developmental needs of adolescents (Hatch & Bowers, 2003, 2005, 2012). Emphasis is on college access counselling at the early high school level as more school counselling programmes move to evidence-based work with data and specific results that show how school counselling programmes help to close achievement, opportunity, and attainment gaps ensuring all students have access to school counselling programmes and early college access/affordability/admission activities. The breadth of demands high school counsellors face, from educational attainment (high school graduation and some students’ preparation for careers and college) to student social and mental health, has led to ambiguous role definition. Summarising a 2011 national survey of more than 5,330 middle school and high school counsellors, researchers argued:

“Despite the aspirations of counselors to effectively help students succeed in school and fulfill their dreams, the mission and roles of counselors in the education system must be more clearly defined; schools must create measures of accountability to track their effectiveness; and policymakers and key stakeholders must integrate counselors into reform efforts to maximize their impact in schools across America”.

Transitional issues to ensure successful transitions to college, other post-secondary educational options, and careers are a key area. The high school counsellor helps students and their families prepare for post-secondary education including college and careers (e.g. college, careers) by engaging students and their families in accessing and evaluating accurate information on what the National Office for School Counsellor Advocacy calls the 8 essential elements of college and career counselling:

  1. College Aspirations.
  2. Academic Planning for Career and College Readiness.
  3. Enrichment and Extracurricular Engagement.
  4. College and Career Exploration and Selection Processes.
  5. College and Career Assessments.
  6. College Affordability Planning.
  7. College and Career Admission Processes.
  8. Transition from High School Graduation to College Enrolment.

Some students turn to private college admissions advisors but there is no research evidence that private college admissions advisors have any effectiveness in assisting students attain selective college admissions.

Lapan, Gysbers & Sun showed correlational evidence of the effectiveness of fully implemented school counseling programs on high school students’ academic success. Carey et al.’s 2008 study showed specific best practices from high school counsel.ors raising college-going rates within a strong college-going environment in multiple USA-based high schools with large numbers of students of nondominant cultural identities.

Education Credentials, Certification, and Accreditation

The education of school counsellors around the world varies based on the laws and cultures of countries and the historical influences of their educational and credentialing systems and professional identities related to who delivers academic, career, college readiness, and personal/social information, advising, curriculum, and counselling and related services.

In Canada, the educational requirements to become a school counsellor vary by province.

In China, there is no national certification or licensure system for school counsellors.

Korea requires school counsellors in all middle and high schools.

In the Philippines, school counsellors must be licensed with a master’s degree in counselling.

Taiwan instituted school counsellor licensure for public schools.

In the US, a school counsellor is a certified educator with a master’s degree in school counselling (usually from a Counsellor Education graduate programme) with school counselling graduate training including qualifications and skills to address all students’ academic, career, college access and personal/social needs. Once you have completed your master’s degree you can take one of 2 certification options in order to become fully licensed as a professional school counsellor.

Over half of all Counsellor Education programmes that offer school counselling are accredited by the Council on the Accreditation of Counselling and Related Educational Programmes (CACREP) and all in the US with one in Canada. In 2010 one was under review in Mexico. CACREP maintains a current list of accredited programmes and programmes in the accreditation process on their website. CACREP desires to accredit more international counselling university programmes.

According to CACREP, an accredited school counselling programme offers coursework in Professional Identity and Ethics, Human Development, Counselling Theories, Group Work, Career Counselling, Multicultural Counselling, Assessment, Research and Programme Evaluation, and Clinical Coursework – a 100-hour practicum and a 600-hour internship under supervision of a school counselling faculty member and a certified school counsellor site supervisor.

When CACREP released the 2009 Standards, the accreditation process became performance-based including evidence of school counsellor candidate learning outcomes. In addition, CACREP tightened the school counselling standards with specific evidence needed for how school counselling students receive education in foundations; counselling prevention and intervention; diversity and advocacy; assessment; research and evaluation; academic development; collaboration and consultation; and leadership in K-12 school counselling contexts.

Certification practices for school counsellors vary internationally. School counsellors in the US may opt for national certification through two different boards. The National Board for Professional Teaching Standards (NBPTS) requires a two-to-three year process of performance based assessment, and demonstrate (in writing) content knowledge in human growth/development, diverse populations, school counselling programmes, theories, data, and change and collaboration. In February 2005, 30 states offered financial incentives for this certification.

Also in the US, The National Board for Certified Counsellors (NBCC) requires passing the National Certified School Counsellor Examination (NCSC), including 40 multiple choice questions and seven simulated cases assessing school counsellors’ abilities to make critical decisions. Additionally, a master’s degree and three years of supervised experience are required. NBPTS also requires three years of experience, however state certification is required (41 of 50 states require a master’s degree). At least four states offer financial incentives for the NCSC certification.

Job Growth and Earnings

The rate of job growth and earnings for school counsellors depends on the country that one is employed in and how the school is funded – public or independent. School counsellors working in international schools or “American” schools globally may find similar work environments and expectations to the US. School counsellor pay varies based on school counsellor roles, identity, expectations, and legal and certification requirements and expectations of each country. According to the Occupational Outlook Handbook (OOH), the median salary for school counsellors in the US in 2010 was (USD) $53,380 or $25.67 hourly. According to an infographic designed by Wake Forest University, the median salary of school counsellors in the US was $43,690. The US has 267,000 employees in titles such as school counsellor or related titles in education and advising and college and career counselling. The projected growth for school counsellors is 14-19% or faster than average than other occupations in the US with a predicted 94,000 job openings from 2008-2018. In Australia, a survey by the Australian Guidance and Counselling Association found that school counsellor salary ranged from (AUD) the high 50,000s to the mid 80,000s.

Among all counselling specialty areas, public elementary, middle and high school counsellors are (2009) paid the highest salary on average of all counsellors. Budget cuts, however, have affected placement of public school counsellors in Canada, Ireland, the United States, and other countries. In the United States, rural areas and urban areas traditionally have been under-served by school counsellors in public schools due to both funding shortages and often a lack of best practice models. With the expectation of school counsellors to work with data, research, and evidence-based practice, school counsellors who show and share results in assisting to close achievement, opportunity, and attainment gaps are in the best position to argue for increased school counselling resources and positions for their programmes.

Notable School Counsellors

  • Jamaal Bowman, US politician.
  • Fernando Cabrera, US politician.
  • Ern Condon, Canadian politician.
  • Derrick Dalley, Canadian politician.
  • Susie Sadlowski Garza, US politician.
  • François Gendron, Canadian politician.
  • Steve Lindberg, US politician.
  • Lillian Ortiz-Self, US politician.
  • Tony Resch, US lacrosse player.
  • Tom Tillberry, US politician.
  • Tom Villa, US politician.

On This Day … 24 June

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People (Births)

  • 1795 – Ernst Heinrich Weber, German physician and psychologist (d. 1878).

Ernst Heinrich Weber

Ernst Heinrich Weber (24 June 1795 to 26 January 1878) was a German physician who is considered one of the founders of experimental psychology. He was an influential and important figure in the areas of physiology and psychology during his lifetime and beyond. His studies on sensation and touch, along with his emphasis on good experimental techniques led to new directions and areas of study for future psychologists, physiologists, and anatomists.

Ernst Weber was born into an academic background, with his father serving as a professor at the University of Wittenberg. Weber became a doctor, specialising in anatomy and physiology. Two of his younger brothers, Wilhelm and Eduard, were also influential in academia, both as scientists with one specialising in physics and the other in anatomy. Ernst became a lecturer and a professor at the University of Leipzig and stayed there until his retirement.

What is Applied Psychology?

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Introduction

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

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

Brief History

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

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

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

Advertising

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

Clinical Psychology

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

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

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

Counselling Psychology

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

Educational Psychology

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

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

Environmental Psychology

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

Forensic Psychology and Legal Psychology

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

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

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

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

Health and Medicine

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

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

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

Medical

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

Occupational Health Psychology

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

Human Factors and Ergonomics

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

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

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

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

Industrial and Organisational Psychology

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

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

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

School Psychology

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

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

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

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

Social Change

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

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

Sport Psychology

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

Traffic Psychology

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

What is the Relationship Between Antidepressants and Suicide Risk?

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Introduction

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

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

Youth/Young Adults

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

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

Warnings

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

Increased Risk for Quitting Medication

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

Prevalence

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

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

Suicide Risk

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

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

What is an Antipsychotic?

Published on by Andrew Marshall71 Comments

Introduction

Antipsychotics, also known as neuroleptics, are a class of psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), principally in schizophrenia but also in a range of other psychotic disorders.

They are also the mainstay together with mood stabilisers in the treatment of bipolar disorder.

Recent research has shown that use of any antipsychotic results in smaller brain tissue volumes and that this brain shrinkage is dose dependent and time dependent. A review of the research has also reinforced this effect.

The use of antipsychotics may result in many unwanted side effects such as involuntary movement disorders, gynecomastia, impotence, weight gain and metabolic syndrome. Long-term use can produce adverse effects such as tardive dyskinesia.

First-generation antipsychotics, known as typical antipsychotics, were first introduced in the 1950s, and others were developed until the early 1970s. Second-generation drugs, known as atypical antipsychotics, were introduced firstly with clozapine in the early 1970s followed by others. Both generations of medication block receptors in the brain for dopamine, but atypicals tend to act on serotonin receptors as well. Neuroleptic, originating from Greek: νεῦρον (neuron) and λαμβάνω (take hold of) – thus meaning “which takes the nerve” – refers to both common neurological effects and side effects.

Brief History

The original antipsychotic drugs were happened upon largely by chance and then tested for their effectiveness. The first, chlorpromazine, was developed as a surgical anaesthetic. It was first used on psychiatric patients because of its powerful calming effect; at the time it was regarded as a non-permanent “pharmacological lobotomy”. Lobotomy at the time was used to treat many behavioural disorders, including psychosis, although its effect was to markedly reduce behaviour and mental functioning of all types. However, chlorpromazine proved to reduce the effects of psychosis in a more effective and specific manner than lobotomy, even though it was known to be capable of causing severe sedation. The underlying neurochemistry involved has since been studied in detail, and subsequent antipsychotic drugs have been discovered by an approach that incorporates this sort of information.

The discovery of chlorpromazine’s psychoactive effects in 1952 led to further research that resulted in the development of antidepressants, anxiolytics, and the majority of other drugs now used in the management of psychiatric conditions. In 1952, Henri Laborit described chlorpromazine only as inducing indifference towards what was happening around them in nonpsychotic, non-manic patients, and Jean Delay and Pierre Deniker described it as controlling manic or psychotic agitation. The former claimed to have discovered a treatment for agitation in anyone, and the latter team claimed to have discovered a treatment for psychotic illness.

Until the 1970s there was considerable debate within psychiatry on the most appropriate term to use to describe the new drugs. In the late 1950s the most widely used term was “neuroleptic”, followed by “major tranquilizer” and then “ataraxic”. The first recorded use of the term tranquilizer dates from the early nineteenth century. In 1953 Frederik F. Yonkman, a chemist at the Swiss-based Cibapharmaceutical company, first used the term tranquiliser to differentiate reserpine from the older sedatives. The word neuroleptic was coined in 1955 by Delay and Deniker after their discovery (1952) of the antipsychotic effects of chlorpromazine. It is derived from the Greek: “νεῦρον” (neuron, originally meaning “sinew” but today referring to the nerves) and “λαμβάνω” (lambanō, meaning “take hold of”). Thus, the word means taking hold of one’s nerves. It was often taken to refer also to common side effects such as reduced activity in general, as well as lethargy and impaired motor control. Although these effects are unpleasant and in some cases harmful, they were at one time, along with akathisia, considered a reliable sign that the drug was working. The term “ataraxy” was coined by the neurologist Howard Fabing and the classicist Alister Cameron to describe the observed effect of psychic indifference and detachment in patients treated with chlorpromazine. This term derived from the Greek adjective “ἀτάρακτος” (ataraktos), which means “not disturbed, not excited, without confusion, steady, calm”. In the use of the terms “tranquiliser” and “ataractic”, medical practitioners distinguished between the “major tranquilizers” or “major ataractics”, which referred to drugs used to treat psychoses, and the “minor tranquilizers” or “minor ataractics”, which referred to drugs used to treat neuroses. While popular during the 1950s, these terms are infrequently used today. They are being abandoned in favour of “antipsychotic”, which refers to the drug’s desired effects. Today, “minor tranquiliser” can refer to anxiolytic and/or hypnotic drugs such as the benzodiazepines and nonbenzodiazepines, which have some antipsychotic properties and are recommended for concurrent use with antipsychotics, and are useful for insomnia or drug-induced psychosis. They are potentially addictive sedatives.

Antipsychotics are broadly divided into two groups, the typical or first-generation antipsychotics and the atypical or second-generation antipsychotics. The difference between first- and second-generation antipsychotics is a subject of debate. The second-generation antipsychotics are generally distinguishable by the presence of 5HT2A receptor antagonism and a corresponding lower propensity for extrapyramidal side effects compared to first-generation antipsychotics.

Medical Uses

Antipsychotics are most frequently used for the following conditions:

  • Schizophrenia.
  • Schizoaffective disorder most commonly in conjunction with either an antidepressant (in the case of the depressive subtype) or a mood stabiliser (in the case of the bipolar subtype).
  • Bipolar disorder (acute mania and mixed episodes) may be treated with either typical or atypical antipsychotics, although atypical antipsychotics are usually preferred because they tend to have more favourable adverse effect profiles and, according to a recent meta-analysis, they tend to have a lower liability for causing conversion from mania to depression.
  • Psychotic depression. In this indication it is a common practice for the psychiatrist to prescribe a combination of an atypical antipsychotic and an antidepressant as this practice is best supported by the evidence.
  • Treatment resistant depression as an adjunct to standard antidepressant therapy.

Antipsychotics are generally not recommended for treating behavioural problems associated with dementia, given that the risk of use tends to be greater than the potential benefit. The same can be said for insomnia, in which they are not recommended as first-line therapy. There are evidence-based indications for using antipsychotics in children (e.g. tic disorder, bipolar disorder, psychosis), but the use of antipsychotics outside of those contexts (e.g. to treat behavioural problems) warrants significant caution.

Schizophrenia

Antipsychotic drug treatment is a key component of schizophrenia treatment recommendations by the National Institute of Health and Care Excellence (NICE), the American Psychiatric Association, and the British Society for Psychopharmacology. The main aim of treatment with antipsychotics is to reduce the positive symptoms of psychosis that include delusions and hallucinations. There is mixed evidence to support a significant impact of antipsychotic use on negative symptoms (such as apathy, lack of emotional affect, and lack of interest in social interactions) or on the cognitive symptoms (memory impairments, reduced ability to plan and execute tasks). In general, the efficacy of antipsychotic treatment in reducing both positive and negative symptoms appears to increase with increasing severity of baseline symptoms. All antipsychotic medications work relatively the same way, by antagonising D2 dopamine receptors. However, there are some differences when it comes to typical and atypical antipsychotics. For example, atypical antipsychotic medications have been seen to lower the neurocognitive impairment associated with schizophrenia more so than conventional antipsychotics, although the reasoning and mechanics of this are still unclear to researchers.

Applications of antipsychotic drugs in the treatment of schizophrenia include prophylaxis in those showing symptoms that suggest that they are at high risk of developing psychosis, treatment of first episode psychosis, maintenance therapy (a form of prophylaxis, maintenance therapy aims to maintain therapeutic benefit and prevent symptom relapse), and treatment of recurrent episodes of acute psychosis.

Prevention of Psychosis and Symptom Improvement

Test batteries such as the PACE (Personal Assessment and Crisis Evaluation Clinic) and COPS (Criteria of Prodromal Syndromes), which measure low-level psychotic symptoms and cognitive disturbances, are used to evaluate people with early, low-level symptoms of psychosis. Test results are combined with family history information to identify patients in the “high-risk” group; they are considered to have a 20-40% risk of progression to frank psychosis within two years. These patients are often treated with low doses of antipsychotic drugs with the goal of reducing their symptoms and preventing progression to frank psychosis. While generally useful for reducing symptoms, clinical trials to date show little evidence that early use of antipsychotics improves long-term outcomes in those with prodromal symptoms, either alone or in combination with cognitive behavioural therapy (CBT).

First Episode Psychosis

First episode psychosis (FEP), is the first time that psychotic symptoms are presented. NICE recommends that all persons presenting with first episode psychosis be treated with both an antipsychotic drug, and CBT. NICE further recommends that those expressing a preference for CBT alone are informed that combination treatment is more effective. A diagnosis of schizophrenia is not made at this time as it takes longer to determine by both DSM-5 and ICD-11, and only around 60% of those presenting with a first episode psychosis will later be diagnosed with schizophrenia.

The conversion rate for a first episode drug induced psychosis to bipolar disorder or schizophrenia are lower, with 30% of people converting to either bipolar disorder or schizophrenia. NICE makes no distinction between a substance-induced psychosis, and any other form of psychosis. The rate of conversion differs for different classes of drug.

Pharmacological options for the specific treatment of FEP have been discussed in recent reviews. The goals of treatment for FEP include reducing symptoms and potentially improving long-term treatment outcomes. Randomised clinical trials have provided evidence for the efficacy of antipsychotic drugs in achieving the former goal, with first-generation and second generation antipsychotics showing about equal efficacy. Evidence that early treatment has a favourable effect on long term outcomes is equivocal.

Recurrent Psychotic Episodes

Placebo controlled trials of both first and second generation antipsychotic drugs consistently demonstrate the superiority of active drug to placebo in suppressing psychotic symptoms. A large meta-analysis of 38 trials of antipsychotic drugs in schizophrenia acute psychotic episodes showed an effect size of about 0.5. There is little or no difference in efficacy among approved antipsychotic drugs, including both first- and second-generation agents. The efficacy of such drugs is suboptimal. Few patients achieve complete resolution of symptoms. Response rates, calculated using various cutoff values for symptom reduction, are low and their interpretation is complicated by high placebo response rates and selective publication of clinical trial results.

Maintenance Therapy

The majority of patients treated with an antipsychotic drug will experience a response within four weeks. The goals of continuing treatment are to maintain suppression of symptoms, prevent relapse, improve quality of life, and support engagement in psychosocial therapy.

Maintenance therapy with antipsychotic drugs is clearly superior to placebo in preventing relapse but is associated with weight gain, movement disorders, and high dropout rates. A 3-year trial following persons receiving maintenance therapy after an acute psychotic episode found that 33% obtained long-lasting symptom reduction, 13% achieved remission, and only 27% experienced satisfactory quality of life. The effect of relapse prevention on long term outcomes is uncertain, as historical studies show little difference in long term outcomes before and after the introduction of antipsychotic drugs.

While maintenance therapy clearly reduces the rate of relapses requiring hospitalization, a large observational study in Finland found that, in people that eventually discontinued antipsychotics, the risk of being hospitalized again for a mental health problem or dying increased the longer they were dispensed (and presumably took) antipsychotics prior to stopping therapy. If people did not stop taking antipsychotics, they remained at low risk for relapse and hospitalisation compared to those that stopped taking antipsychotics. The authors speculated that the difference may be because the people that discontinued treatment after a longer time had more severe mental illness than those that discontinued antipsychotic therapy sooner.

A significant challenge in the use of antipsychotic drugs for the prevention of relapse is the poor rate of adherence. In spite of the relatively high rates of adverse effects associated with these drugs, some evidence, including higher dropout rates in placebo arms compared to treatment arms in randomised clinical trials, suggest that most patients who discontinue treatment do so because of suboptimal efficacy. If someone experiences psychotic symptoms due to nonadherence, they may be compelled to treatment through a process called involuntary commitment, in which they can be forced to accept treatment (including antipsychotics). A person can also be committed to treatment outside of a hospital, called outpatient commitment.

Antipsychotics in long-acting injectable (LAI), or “depot”, form have been suggested as a method of decreasing medication nonadherence (sometimes also called non-compliance). NICE advises LAIs be offered to patients when preventing covert, intentional nonadherence is a clinical priority. LAIs are used to ensure adherence in outpatient commitment. A meta-analysis found that LAIs resulted in lower rates of rehospitalisation with a hazard ratio of 0.83, however these results were not statistically significant (the 95% confidence interval was 0.62 to 1.11).

Bipolar Disorder

Antipsychotics are routinely used, often in conjunction with mood stabilisers such as lithium/valproate, as a first-line treatment for manic and mixed episodes associated with bipolar disorder. The reason for this combination is the therapeutic delay of the aforementioned mood stabilisers (for valproate therapeutic effects are usually seen around five days after treatment is commenced whereas lithium usually takes at least a week before the full therapeutic effects are seen) and the comparatively rapid antimanic effects of antipsychotic drugs. The antipsychotics have a documented efficacy when used alone in acute mania/mixed episodes.

Three atypical antipsychotics (lurasidone, olanzapine and quetiapine) have also been found to possess efficacy in the treatment of bipolar depression as a monotherapy, whereas only olanzapine and quetiapine have been proven to be effective broad-spectrum (i.e. against all three types of relapse – manic, mixed and depressive) prophylactic (or maintenance) treatments in patients with bipolar disorder. A recent Cochrane review also found that olanzapine had a less favourable risk/benefit ratio than lithium as a maintenance treatment for bipolar disorder.

The American Psychiatric Association and the UK National Institute for Health and Care Excellence recommend antipsychotics for managing acute psychotic episodes in schizophrenia or bipolar disorder, and as a longer-term maintenance treatment for reducing the likelihood of further episodes. They state that response to any given antipsychotic can be variable so that trials may be necessary, and that lower doses are to be preferred where possible. A number of studies have looked at levels of “compliance” or “adherence” with antipsychotic regimes and found that discontinuation (stopping taking them) by patients is associated with higher rates of relapse, including hospitalisation.

Dementia

Psychosis and agitation develop in as many as 80 percent of people living in nursing homes. Despite a lack of Federal Drug Administration (FDA) approval and black-box warnings, atypical antipsychotics are often prescribed to people with dementia. An assessment for an underlying cause of behaviour is needed before prescribing antipsychotic medication for symptoms of dementia. Antipsychotics in old age dementia showed a modest benefit compared to placebo in managing aggression or psychosis, but this is combined with a fairly large increase in serious adverse events. Thus, antipsychotics should not be used routinely to treat dementia with aggression or psychosis, but may be an option in a few cases where there is severe distress or risk of physical harm to others. Psychosocial interventions may reduce the need for antipsychotics. In 2005, the FDA issued an advisory warning of an increased risk of death when atypical antipsychotics are used in dementia. In the subsequent 5 years, the use of atypical antipsychotics to treat dementia decreased by nearly 50%.

Major Depressive Disorder

A number of atypical antipsychotics have some benefits when used in addition to other treatments in major depressive disorder. Aripiprazole, quetiapine extended-release, and olanzapine (when used in conjunction with fluoxetine) have received FDA labelling for this indication. There is, however, a greater risk of side effects with their use compared to using traditional antidepressants. The greater risk of serious side effects with antipsychotics is why, e.g. quetiapine was denied approval as monotherapy for major depressive disorder or generalised anxiety disorder, and instead was only approved as an adjunctive treatment in combination with traditional antidepressants.

Other

Besides the above uses antipsychotics may be used for obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), personality disorders, Tourette syndrome, autism and agitation in those with dementia. Evidence however does not support the use of atypical antipsychotics in eating disorders or personality disorder. The atypical antipsychotic risperidone may be useful for OCD. The use of low doses of antipsychotics for insomnia, while common, is not recommended as there is little evidence of benefit and concerns regarding adverse effects. Low dose antipsychotics may also be used in treatment of impulse-behavioural and cognitive-perceptual symptoms of borderline personality disorder.

In children they may be used in those with disruptive behaviour disorders, mood disorders and pervasive developmental disorders or intellectual disability. Antipsychotics are only weakly recommended for Tourette syndrome, because although they are effective, side effects are common. The situation is similar for those on the autism spectrum. Much of the evidence for the off-label use of antipsychotics (for example, for dementia, OCD, PTSD, personality disorders, Tourette’s) was of insufficient scientific quality to support such use, especially as there was strong evidence of increased risks of stroke, tremors, significant weight gain, sedation, and gastrointestinal problems. A UK review of unlicensed usage in children and adolescents reported a similar mixture of findings and concerns. A survey of children with pervasive developmental disorder found that 16.5% were taking an antipsychotic drug, most commonly for irritability, aggression, and agitation. Both risperidone and aripiprazole have been approved by the FDA for the treatment of irritability in autistic children and adolescents.

Aggressive challenging behaviour in adults with intellectual disability is often treated with antipsychotic drugs despite lack of an evidence base. A recent randomised controlled trial, however, found no benefit over placebo and recommended that the use of antipsychotics in this way should no longer be regarded as an acceptable routine treatment.

Antipsychotics may be an option, together with stimulants, in people with ADHD and aggressive behaviour when other treatments have not worked. They have not been found to be useful for the prevention of delirium among those admitted to hospital.

Typicals vs Atypicals

It is unclear whether the atypical (second-generation) antipsychotics offer advantages over older, first generation antipsychotics. Amisulpride, olanzapine, risperidone and clozapine may be more effective but are associated with greater side effects. Typical antipsychotics have equal drop-out and symptom relapse rates to atypicals when used at low to moderate dosages.

Clozapine is an effective treatment for those who respond poorly to other drugs (“treatment-resistant” or “refractory” schizophrenia), but it has the potentially serious side effect of agranulocytosis (lowered white blood cell count) in less than 4% of people.

Due to bias in the research the accuracy of comparisons of atypical antipsychotics is a concern.

In 2005, a US government body, the National Institute of Mental Health published the results of a major independent study (the CATIE project). No other atypical studied (risperidone, quetiapine, and ziprasidone) did better than the typical perphenazine on the measures used, nor did they produce fewer adverse effects than the typical antipsychotic perphenazine, although more patients discontinued perphenazine owing to extrapyramidal effects compared to the atypical agents (8% vs. 2% to 4%).

Atypical antipsychotics do not appear to lead to improved rates of medication adherence compared to typical antipsychotics.

Many researchers question the first-line prescribing of atypicals over typicals, and some even question the distinction between the two classes. In contrast, other researchers point to the significantly higher risk of tardive dyskinesia and other extrapyramidal symptoms with the typicals and for this reason alone recommend first-line treatment with the atypicals, notwithstanding a greater propensity for metabolic adverse effects in the latter. NICE recently revised its recommendation favouring atypicals, to advise that the choice should be an individual one based on the particular profiles of the individual drug and on the patient’s preferences.

The re-evaluation of the evidence has not necessarily slowed the bias toward prescribing the atypical

Adverse Effects

Generally, more than one antipsychotic drug should not be used at a time because of increased adverse effects.

Very rarely antipsychotics may cause tardive psychosis.

By Rate

Common (≥ 1% and up to 50% incidence for most antipsychotic drugs) adverse effects of antipsychotics include:

  • Sedation (particularly common with asenapine, clozapine, olanzapine, quetiapine, chlorpromazine and zotepine).
  • Headaches.
  • Dizziness.
  • Diarrhoea.
  • Anxiety.
  • Extrapyramidal side effects (particularly common with first-generation antipsychotics), which include:
    • Akathisia, an often distressing sense of inner restlessness.
    • Dystonia, an abnormal muscle contraction.
    • Pseudoparkinsonism, symptoms that are similar to what people with Parkinson’s disease experience, including tremulousness and drooling.
  • Hyperprolactinaemia (rare for those treated with clozapine, quetiapine and aripiprazole), which can cause:
    • Galactorrhoea, the unusual secretion of breast milk.
    • Gynaecomastia, abnormal growth of breast tissue.
    • Sexual dysfunction (in both sexes).
    • Osteoporosis.
  • Orthostatic hypotension.
  • Weight gain (particularly prominent with clozapine, olanzapine, quetiapine and zotepine).
  • Anticholinergic side-effects (common for olanzapine, clozapine; less likely on risperidone) such as:
    • Blurred vision.
    • Constipation.
    • Dry mouth (although hypersalivation may also occur).
    • Reduced perspiration.
  • Tardive dyskinesia appears to be more frequent with high-potency first-generation antipsychotics, such as haloperidol, and tends to appear after chronic and not acute treatment. It is characterised by slow (hence the tardive) repetitive, involuntary and purposeless movements, most often of the face, lips, legs, or torso, which tend to resist treatment and are frequently irreversible. The rate of appearance of TD is about 5% per year of use of antipsychotic drug (whatever the drug used).

Rare/Uncommon (<1% incidence for most antipsychotic drugs) adverse effects of antipsychotics include:

  • Blood dyscrasias (e.g., agranulocytosis, leukopenia, and neutropoenia), which is more common in patients on clozapine.
  • Metabolic syndrome and other metabolic problems such as type II diabetes mellitus – particularly common with clozapine, olanzapine and zotepine. In American studies African Americans appeared to be at a heightened risk for developing type II diabetes mellitus. Evidence suggests that females are more sensitive to the metabolic side effects of first-generation antipsychotic drugs than males. Metabolic adverse effects appear to be mediated by the following mechanisms:
    • Causing weight gain by antagonising the histamine H1 and serotonin 5-HT2Creceptors] and perhaps by interacting with other neurochemical pathways in the central nervous system.
  • Neuroleptic malignant syndrome, a potentially fatal condition characterised by:
    • Autonomic instability, which can manifest with tachycardia, nausea, vomiting, diaphoresis, etc.
    • Hyperthermia – elevated body temperature.
    • Mental status change (confusion, hallucinations, coma, etc.).
    • Muscle rigidity.
    • Laboratory abnormalities (e.g. elevated creatine kinase, reduced iron plasma levels, electrolyte abnormalities, etc.).
  • Pancreatitis.
  • QT interval prolongation – more prominent in those treated with amisulpride, pimozide, sertindole, thioridazine and ziprasidone.
  • Torsades de pointes.
  • Seizures, particularly in people treated with chlorpromazine and clozapine.
  • Thromboembolism.
  • Myocardial infarction.
  • Stroke.

Long-Term Effects

Some studies have found decreased life expectancy associated with the use of antipsychotics, and argued that more studies are needed. Antipsychotics may also increase the risk of early death in individuals with dementia. Antipsychotics typically worsen symptoms in people who suffer from depersonalisation disorder. Antipsychotic polypharmacy (prescribing two or more antipsychotics at the same time for an individual) is a common practice but not evidence-based or recommended, and there are initiatives to curtail it. Similarly, the use of excessively high doses (often the result of polypharmacy) continues despite clinical guidelines and evidence indicating that it is usually no more effective but is usually more harmful.

Loss of grey matter and other brain structural changes over time are observed amongst people diagnosed with schizophrenia. Meta-analyses of the effects of antipsychotic treatment on grey matter volume and the brain’s structure have reached conflicting conclusions. A 2012 meta-analysis concluded that grey matter loss is greater in patients treated with first generation antipsychotics relative to those treated with atypicals, and hypothesized a protective effect of atypicals as one possible explanation. A second meta-analysis suggested that treatment with antipsychotics was associated with increased grey matter loss. Animal studies found that monkeys exposed to both first- and second-generation antipsychotics experience significant reduction in brain volume, resulting in an 8-11% reduction in brain volume over a 17-27 month period.

Subtle, long-lasting forms of akathisia are often overlooked or confused with post-psychotic depression, in particular when they lack the extrapyramidal aspect that psychiatrists have been taught to expect when looking for signs of akathisia.

Adverse effect on cognitive function and increased risk of death in people with dementia along with worsening of symptoms has been describe in the literature.

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 recurrence of the condition that is being treated. Rarely tardive dyskinesia can occur when the medication is stopped.

Unexpected psychotic episodes have been observed in patients withdrawing from clozapine. This is referred to as supersensitivity psychosis, not to be equated with tardive dyskinesia.

Tardive dyskinesia may abate during withdrawal from the antipsychotic agent, or it may persist.

Withdrawal effects may also occur when switching a person from one antipsychotic to another, (it is presumed due to variations of potency and receptor activity). Such withdrawal effects can include cholinergic rebound, an activation syndrome, and motor syndromes including dyskinesias. These adverse effects are more likely during rapid changes between antipsychotic agents, so making a gradual change between antipsychotics minimises these withdrawal effects. The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotic treatment to avoid acute withdrawal syndrome or rapid relapse. The process of cross-titration involves gradually increasing the dose of the new medication while gradually decreasing the dose of the old medication.

City and Hackney Clinical Commissioning Group found more than 1,000 patients in their area in July 2019 who had not had regular medication reviews or health checks because they were not registered as having serious mental illness. On average they had been taking these drugs for six years. If this is typical of practice in England more than 100,000 patients are probably in the same position.

List of Agents

Clinically used antipsychotic medications are listed below by drug group. Trade names appear in parentheses. A 2013 review has stated that the division of antipsychotics into first and second generation is perhaps not accurate.

Notes:

  • † indicates drugs that are no longer (or were never) marketed in English-speaking countries.
  • ‡ denotes drugs that are no longer (or were never to begin with) marketed in the United States. Some antipsychotics are not firmly placed in either first-generation or second-generation classes.
  • # denotes drugs that have been withdrawn worldwide.

First-Generation (Typical)

  • Butyrophenones:
    • Benperidol‡
    • Bromperidol†
    • Droperidol‡
    • Haloperidol
    • Moperone (discontinued)†
    • Pipamperone (discontinued)†
    • Timiperone †
  • Diphenylbutylpiperidines:
    • Fluspirilene ‡
    • Penfluridol ‡
    • Pimozide
  • Phenothiazines:
    • Acepromazine † – although it is mostly used in veterinary medicine.
    • Chlorpromazine
    • Cyamemazine †
    • Dixyrazine †
    • Fluphenazine
    • Levomepromazine‡
    • Mesoridazine (discontinued)†
    • Perazine
    • Pericyazine‡
    • Perphenazine
    • Pipotiazine ‡
    • Prochlorperazine
    • Promazine (discontinued)
    • Promethazine
    • Prothipendyl †
    • Thioproperazine‡ (only English-speaking country it is available in is Canada)
    • Thioridazine (discontinued)
    • Trifluoperazine
    • Triflupromazine (discontinued)†
  • Thioxanthenes:
    • Chlorprothixene †
    • Clopenthixol
    • Flupentixol ‡
    • Thiothixene
    • Zuclopenthixol ‡

Disputed/Unknown

This category is for drugs that have been called both first and second-generation, depending on the literature being used.

  • Benzamides:
    • Sulpiride ‡
    • Sultopride †
    • Veralipride †
  • Tricyclics:
    • Carpipramine †
    • Clocapramine †
    • Clorotepine †
    • Clotiapine ‡
    • Loxapine
    • Mosapramine †
  • Others:
    • Molindone #

Second-Generation (Atypical)

  • Benzamides:
    • Amisulpride ‡ – Selective dopamine antagonist. Higher doses (greater than 400 mg) act upon post-synaptic dopamine receptors resulting in a reduction in the positive symptoms of schizophrenia, such as psychosis. Lower doses, however, act upon dopamine autoreceptors, resulting in increased dopamine transmission, improving the negative symptoms of schizophrenia. Lower doses of amisulpride have also been shown to have antidepressant and anxiolytic effects in non-schizophrenic patients, leading to its use in dysthymia and social phobias.
    • Nemonapride † – Used in Japan.
    • Remoxipride # – Has a risk of causing aplastic anaemia and, hence, has been withdrawn from the market worldwide. It has also been found to possess relatively low (virtually absent) potential to induce hyperprolactinaemia and extrapyramidal symptoms, likely attributable to its comparatively weak binding to (and, hence, rapid dissociation from) the D2 receptor.
    • Sultopride – An atypical antipsychotic of the benzamide chemical class used in Europe, Japan, and Hong Kong for the treatment of schizophrenia. It was launched by Sanofi-Aventis in 1976. Sultopride acts as a selective D2 and D3 receptor antagonist.
  • Benzisoxazoles/benzisothiazoles:
    • Iloperidone – Approved by the FDA in 2009, it is fairly well tolerated, although hypotension, dizziness, and somnolence were very common side effects. Has not received regulatory approval in other countries, however.
    • Lurasidone – Approved by the FDA for schizophrenia and bipolar depression, and for use as schizophrenia treatment in Canada.
    • Paliperidone – Primary, active metabolite of risperidone that was approved in 2006.
    • Paliperidone palmitate – Long-acting version of paliperidone for once-monthly injection.
    • Perospirone † – Has a higher incidence of extrapyramidal side effects than other atypical antipsychotics.
    • Risperidone – Divided dosing is recommended until initial titration is completed, at which time the drug can be administered once daily. Used off-label to treat Tourette syndrome and anxiety disorder.
    • Ziprasidone – Approved in 2004 to treat bipolar disorder. Side-effects include a prolonged QT interval in the heart, which can be dangerous for patients with heart disease or those taking other drugs that prolong the QT interval.
  • Butyrophenones:
    • Melperone † – Only used in a few European countries. No English-speaking country has licensed it to date.
    • Lumateperone.
  • Phenylpiperazines/quinolinones:
    • Aripiprazole – Partial agonist at the D2 receptor unlike almost all other clinically-utilized antipsychotics.
    • Aripiprazole lauroxil – Long-acting version of aripiprazole for injection.
    • Brexpiprazole – Partial agonist of the D2 receptor. Successor of aripiprazole.
    • Cariprazine – A D3-preferring D2/D3 partial agonist.
  • Tricyclics:
    • Asenapine – Used for the treatment of schizophrenia and acute mania associated with bipolar disorder.
    • Clozapine – Requires routine laboratory monitoring of complete blood counts every one to four weeks due to the risk of agranulocytosis. It has unparalleled efficacy in the treatment of treatment-resistant schizophrenia.
    • Olanzapine – Used to treat psychotic disorders including schizophrenia, acute manic episodes, and maintenance of bipolar disorder. Used as an adjunct to antidepressant therapy, either alone or in combination with fluoxetine as Symbyax.
    • Quetiapine – Used primarily to treat bipolar disorder and schizophrenia. Also used and licensed in a few countries (including Australia, the United Kingdom and the United States) as an adjunct to antidepressant therapy in patients with major depressive disorder. It is the only antipsychotic that has demonstrated efficacy as a monotherapy for the treatment of major depressive disorder. It indirectly serves as a norepinephrine reuptake inhibitor by means of its active metabolite, norquetiapine.
    • Zotepine – An atypical antipsychotic indicated for acute and chronic schizophrenia. It is still used in Japan and was once used in Germany but it was discontinued.†
  • Others:
    • Blonanserin – Approved by the PMDA in 2008. Used in Japan and South Korea.
    • Pimavanserin – A selective 5-HT2A receptor antagonist approved for the treatment of Parkinson’s disease psychosis in 2016.
    • Sertindole ‡ – Developed by the Danish pharmaceutical company H. Lundbeck. Like the other atypical antipsychotics, it is believed to have antagonist activity at dopamine and serotonin receptors in the brain.

Mechanism of Action

Antipsychotic drugs such as haloperidol and chlorpromazine tend to block dopamine D2 receptors in the dopaminergic pathways of the brain. This means that dopamine released in these pathways has less effect. Excess release of dopamine in the mesolimbic pathway has been linked to psychotic experiences. Decreased dopamine release in the prefrontal cortex, and excess dopamine release in other pathways, are associated with psychotic episodes in schizophrenia and bipolar disorder. In addition to the antagonistic effects of dopamine, antipsychotics (in particular atypical neuroleptics) also antagonise 5-HT2A receptors. Different alleles of the 5-HT2A receptor have been associated with schizophrenia and other psychoses, including depression. Higher concentrations of 5-HT2A receptors in cortical and subcortical areas, in particular in the right caudate nucleus have been historically recorded.

Typical antipsychotics are not particularly selective and also block dopamine receptors in the mesocortical pathway, tuberoinfundibular pathway, and the nigrostriatal pathway. Blocking D2 receptors in these other pathways is thought to produce some unwanted side effects that the typical antipsychotics can produce (see above). They were commonly classified on a spectrum of low potency to high potency, where potency referred to the ability of the drug to bind to dopamine receptors, and not to the effectiveness of the drug. High-potency antipsychotics such as haloperidol, in general, have doses of a few milligrams and cause less sleepiness and calming effects than low-potency antipsychotics such as chlorpromazine and thioridazine, which have dosages of several hundred milligrams. The latter have a greater degree of anticholinergic and antihistaminergic activity, which can counteract dopamine-related side-effects.

Atypical antipsychotic drugs have a similar blocking effect on D2 receptors; however, most also act on serotonin receptors, especially 5-HT2A and 5-HT2C receptors. Both clozapine and quetiapine appear to bind just long enough to elicit antipsychotic effects but not long enough to induce extrapyramidal side effects and prolactin hypersecretion. 5-HT2A antagonism increases dopaminergic activity in the nigrostriatal pathway, leading to a lowered extrapyramidal side effect liability among the atypical antipsychotics.

Society and Culture

Terminology

The term major tranquiliser was used for older antipsychotic drugs. The term neuroleptic is often used as a synonym for antipsychotic, even though – strictly speaking – the two terms are not interchangeable. Antipsychotic drugs are a subgroup of neuroleptic drugs, because the latter have a wider range of effects.

Antipsychotics are a type of psychoactive or psychotropic medication.

Sales

Antipsychotics were once among the biggest selling and most profitable of all drugs, generating $22 billion in global sales in 2008. By 2003 in the US, an estimated 3.21 million patients received antipsychotics, worth an estimated $2.82 billion. Over 2/3 of prescriptions were for the newer, more expensive atypicals, each costing on average $164 per year, compared to $40 for the older types. By 2008, sales in the US reached $14.6 billion, the biggest selling drugs in the US by therapeutic class.

Overprescription

Antipsychotics in the nursing home population are often overprescribed, often for the purposes of making it easier to handle dementia patients. Federal efforts to reduce the use of antipsychotics in US nursing homes has led to a nationwide decrease in their usage in 2012.

Legal

Antipsychotics are sometimes administered as part of compulsory psychiatric treatment via inpatient (hospital) commitment or outpatient commitment.

Formulations

They may be administered orally or, in some cases, through long-acting (depot) injections administered in the dorsgluteal, ventrogluteal or deltoid muscle. Short-acting parenteral formulations also exist, which are generally reserved for emergencies or when oral administration is otherwise impossible. The oral formulations include immediate release, extended release, and orally disintegrating products (which are not sublingual, and can help ensure that medications are swallowed instead of “cheeked”). Sublingual products (e.g. asenapine) also exist, which must be held under the tongue for absorption. The first transdermal formulation of an antipsychotic (transdermal asenapine, marketed as Secuado), was FDA-approved in 2019.

Recreational Use

Certain second-generation antipsychotics are misused or abused for their sedative, tranquilising, and (paradoxically) “hallucinogenic” effects. The most commonly second-generation antipsychotic implicated is quetiapine. In case reports, quetiapine has been abused in doses taken by mouth (which is how the drug is available from the manufacturer), but also crushed and insufflated or mixed with water for injection into a vein. Olanzapine, another sedating second-generation antipsychotic, has also been misused for similar reasons. There is no standard treatment for antipsychotic abuse, though switching to a second-generation antipsychotic with less abuse potential (e.g. aripiprazole) has been used.

Controversy

Joanna Moncrieff has argued that antipsychotic drug treatment is often undertaken as a means of control rather than to treat specific symptoms experienced by the patient.

Use of this class of drugs has a history of criticism in residential care. As the drugs used can make patients calmer and more compliant, critics claim that the drugs can be overused. Outside doctors can feel under pressure from care home staff. In an official review commissioned by UK government ministers it was reported that the needless use of antipsychotic medication in dementia care was widespread and was linked to 1800 deaths per year. In the US, the government has initiated legal action against the pharmaceutical company Johnson & Johnson for allegedly paying kickbacks to Omnicare to promote its antipsychotic risperidone (Risperdal) in nursing homes.

There has also been controversy about the role of pharmaceutical companies in marketing and promoting antipsychotics, including allegations of downplaying or covering up adverse effects, expanding the number of conditions or illegally promoting off-label usage; influencing drug trials (or their publication) to try to show that the expensive and profitable newer atypicals were superior to the older cheaper typicals that were out of patent. Following charges of illegal marketing, settlements by two large pharmaceutical companies in the US set records for the largest criminal fines ever imposed on corporations. One case involved Eli Lilly and Company’s antipsychotic Zyprexa, and the other involved Bextra. In the Bextra case, the government also charged Pfizer with illegally marketing another antipsychotic, Geodon. In addition, Astrazeneca faces numerous personal-injury lawsuits from former users of Seroquel (quetiapine), amidst federal investigations of its marketing practices. By expanding the conditions for which they were indicated, Astrazeneca’s Seroquel and Eli Lilly’s Zyprexa had become the biggest selling antipsychotics in 2008 with global sales of $5.5 billion and $5.4 billion respectively.

Harvard medical professor Joseph Biederman conducted research on bipolar disorder in children that led to an increase in such diagnoses. A 2008 Senate investigation found that Biederman also received $1.6 million in speaking and consulting fees between 2000 and 2007 – some of them undisclosed to Harvard – from companies including makers of antipsychotic drugs prescribed for children with bipolar disorder. Johnson & Johnson gave more than $700,000 to a research centre that was headed by Biederman from 2002 to 2005, where research was conducted, in part, on Risperdal, the company’s antipsychotic drug. Biederman has responded saying that the money did not influence him and that he did not promote a specific diagnosis or treatment.

Pharmaceutical companies have also been accused of attempting to set the mental health agenda through activities such as funding consumer advocacy groups.

Special Populations

It is recommended that persons with dementia who exhibit behavioural and psychological symptoms should not be given antipsychotics before trying other treatments. When taking antipsychotics this population has increased risk of cerebrovascular effects, parkinsonism or extrapyramidal symptoms, sedation, confusion and other cognitive adverse effects, weight gain, and increased mortality. Physicians and caretakers of persons with dementia should try to address symptoms including agitation, aggression, apathy, anxiety, depression, irritability, and psychosis with alternative treatments whenever antipsychotic use can be replaced or reduced. Elderly persons often have their dementia treated first with antipsychotics and this is not the best management strategy.