Wherever you stand on it, working from home has become the norm for many over the last year.
But with lockdown finally (sort off) easing, organisations are eyeing a gradual resumption of routine business, possibly from the end of July.
Whether you are relishing or dreading the prospect, there are some steps staff across the organisation can take to make sure the process goes smoothly.
With this in mind, how should those in charge approach the return to work?
Below are some tips.
Communicate clearly
1. People need time to be able to plan and get used to the idea of when and how they will go back to work. 2. Make sure you are consistent in your messaging and that your team know you are thinking of their welfare.
Be mindful of different tensions
1. Some staff have been at work throughout and have made a safe environment that they feel happy in. 2. All of a sudden you will have an influx of people coming in from outside. 3. Meanwhile others have stayed in their bubbles at home for a long time. 4. Some might be a bit gung-ho in their approach to Covid safety measures and others are more rigid. 5. All of these areas can lead to friction.
Be open to new ways of working
1. People will have relied more on technology than face-to-face meetings. 2. Coming back together again will take some getting used to.
Ensure staff feel safe
1. Physically, everyone must feel confident of the protection measures in place to prevent them catching Covid but, mentally, there is still much uncertainty. 2. They will be wondering if this is permanent or what will happen if infection rates start to rise again. Good leaders will get everyone in and say, ‘I don’t know exactly how this is going to go, but let’s approach it together’.
Show compassion and empathy
1. Some people will be scared. Others can’t wait to get back. 2. Those with families may have additional stressors at home or ongoing childcare issues. 3. Everyone needs to adjust, and leaders should manage their own expectations and offer some leeway. 4. Even senior managers/executives/owners will be feeling anxious. 5. Have open conversations with your peers and managers and be honest if you are nervous. 6. Do things that make you calm, whether that is mindfulness or going for a run.
Take it step by step
1. Give it time, and accept there is no ‘normal’ and let everyone find their feet.
Look Out For Your Team
It can be hard to spot signs of stress in your colleagues but when you work closely with someone, you generally know when they are not themselves
Any change in their usual behaviour and performance is a red flag, for example…
An outgoing person becoming withdrawn, or the opposite.
Missing work or being late when normally punctual.
A loss of personal discipline.
Showing signs they might be drinking more than usual.
Appearing distracted or ‘not quite there’.
Uncharacteristic mistakes or procrastinating.
Negative statements such as ‘everything is against me’.
Seeming more tired than usual or mentioning sleep problems.
Low energy or mood.
Ask Twice
If you think someone is acting out of character ask “how are you feeling?” and wait to hear the answer.
If they respond with “I’m fine”, ask “are you sure?”
Three Mindful Moments to Conquer Anxiety
Mindfulness is about bringing yourself back to the present moment. If you find thoughts are overwhelming you, try the following exercises:
Have a brew:
But do not just gulp it down.
Spend a few moments feeling the warmth of the cup in your hands, smell the aromas, with your eyes open or closed.
Sip it slowly and really taste it.
Take a mindful shower:
Rather than thinking of your to-do list or things that have stressed you out, notice the feel of the water against your skin, the way the steam moves in the cubicle or perhaps follow the water droplets as they slide down the wall.
Spend time outside:
Go to a park, forest, beach or just your back garden for a little while and soak it in.
Sit and acknowledge the sights around you, the sounds of the wind in the trees, the sea against the shore, the smells of the flowers and the feel of the sun on your skin.
Ego psychology is a school of psychoanalysis rooted in Sigmund Freud’s structural id-ego-superego model of the mind.
An individual interacts with the external world as well as responds to internal forces. Many psychoanalysts use a theoretical construct called the ego to explain how that is done through various ego functions. Adherents of ego psychology focus on the ego’s normal and pathological development, its management of libidinal and aggressive impulses, and its adaptation to reality.
Brief History
Early Conceptions of the Ego
Sigmund Freud initially considered the ego to be a sense organ for perception of both external and internal stimuli. He thought of the ego as synonymous with consciousness and contrasted it with the repressed unconscious. In 1910, Freud emphasized the attention to detail when referencing psychoanalytical matters, while predicting his theory to become essential in regards to everyday tasks with the Swiss psychoanalyst, Oscar Pfister. By 1911, he referenced ego instincts for the first time in Formulations on the Two Principles of Mental Functioning and contrasted them with sexual instincts: ego instincts responded to the reality principle while sexual instincts obeyed the pleasure principle. He also introduced attention and memory as ego functions.
Freud’s Ego Psychology
Freud later argued that not all unconscious phenomena can be attributed to the id, and that the ego has unconscious aspects as well. This posed a significant problem for his topographic theory, which he resolved in The Ego and the Id (1923).
In what came to be called the structural theory, the ego was now a formal component of a three-way system that also included the id and superego. The ego was still organised around conscious perceptual capacities, yet it now had unconscious features responsible for repression and other defensive operations. Freud’s ego at this stage was relatively passive and weak; he described it as the helpless rider on the id’s horse, more or less obliged to go where the id wished to go.
In Inhibitions, Symptoms, and Anxiety (1926), Freud revised his theory of anxiety as well as delineated a more robust ego. Freud argued that instinctual drives (id), moral and value judgments (superego), and requirements of external reality all make demands upon an individual. The ego mediates among conflicting pressures and creates the best compromise. Instead of being passive and reactive to the id, the ego was now a formidable counterweight to it, responsible for regulating id impulses, as well as integrating an individual’s functioning into a coherent whole. The modifications made by Freud in Inhibitions, Symptoms, and Anxiety formed the basis of a psychoanalytic psychology interested in the nature and functions of the ego. This marked the transition of psychoanalysis from being primarily an id psychology, focused on the vicissitudes of the libidinal and aggressive drives as the determinants of both normal and psychopathological functioning, to a period in which the ego was accorded equal importance and was regarded as the prime shaper and modulator of behaviour.
Systematisation
Following Sigmund Freud, the psychoanalysts most responsible for the development of ego psychology, and its systematization as a formal school of psychoanalytic thought, were Anna Freud, Heinz Hartmann, and David Rapaport. Other important contributors included Ernst Kris, Rudolph Loewenstein, René Spitz, Margaret Mahler, Edith Jacobson, Paul Federn, and Erik Erikson.
Anna Freud
Anna Freud focused her attention on the ego’s unconscious, defensive operations and introduced many important theoretical and clinical considerations. In The Ego and the Mechanisms of Defense (1936), Anna Freud argued the ego was predisposed to supervise, regulate, and oppose the id through a variety of defences. She described the defences available to the ego, linked them to the stages of psychosexual development during which they originated, and identified various psychopathological compromise formations in which they were prominent. Clinically, Anna Freud emphasized that the psychoanalyst’s attention should always be on the defensive functions of the ego, which could be observed in the manifest presentation of the patient’s associations. The analyst needed to be attuned to the moment-by-moment process of what the patient talked about in order to identify, label, and explore defences as they appeared. For Anna Freud, direct interpretation of repressed content was less important than understanding the ego’s methods by which it kept things out of consciousness. Her work provided a bridge between Freud’s structural theory and ego psychology.
Heinz Hartmann
Heinz Hartmann (1939/1958) believed the ego included innate capacities that facilitated an individual’s ability to adapt to his or her environment. These included perception, attention, memory, concentration, motor coordination, and language. Under normal conditions, which Hartmann called “an average expectable environment,” these capacities developed into ego functions with autonomy from the libidinal and aggressive drives; that is, they were not products of frustration and conflict as Freud (1911) believed. Hartmann recognised, however, that conflicts were part of the human condition and that certain ego functions may become conflicted by aggressive and libidinal impulses, as witnessed by conversion disorders (e.g., glove paralysis), speech impediments, eating disorders, and attention-deficit disorder.
A focus on ego functions and how an individual adapts to his or her environment led Hartmann to create both a general psychology and a clinical instrument with which an analyst could evaluate an individual’s functioning and formulate appropriate therapeutic interventions. Hartmann’s propositions imply that the task of the ego psychologist was to neutralize conflicted impulses and expand the conflict-free spheres of ego functions. Through such effects, Hartmann believed, psychoanalysis facilitated an individual’s adaptation to his or her environment. He claimed, however, that his aim was to understand the mutual regulation of the ego and environment rather than to promote adjustment of the ego to the environment; additionally, he proposed that diminishing conflict in an individual’s ego would help him or her to respond actively to, and shape rather than passively react to, the environment. Mitchell and Black (p.35) stated:
“Hartmann powerfully affected the course of psychoanalysis, opening up a crucial investigation of the key processes and vicissitudes of normal development. Hartmann’s contributions broadened the scope of psychoanalytic concerns, from psychopathology to general human development, and from an isolated, self-contained treatment method to a sweeping intellectual discipline among other disciplines”
David Rapaport
David Rapaport played a prominent role in the development of ego psychology, and his work likely represented its apex. In the influential monograph The Structure of Psychoanalytic Theory (1960), Rappaport organized ego psychology into an integrated, systematic, and hierarchical theory capable of generating empirically testable hypotheses. He proposed that psychoanalytic theory – as expressed through the principles of ego psychology – was a biologically based general psychology that could explain the entire range of human behaviour. For Rapaport, this endeavour was fully consistent with Freud’s attempts to do the same (e.g. Freud’s studies of dreams, jokes, and the “psychopathology of everyday life”).
Other Contributors
While Hartmann was the principal architect of ego psychology, he collaborated closely with Ernst Kris and Rudolph Loewenstein.
Subsequent psychoanalysts interested in ego psychology emphasized the importance of early-childhood experiences and socio-cultural influences on ego development. René Spitz (1965), Margaret Mahler (1968), Edith Jacobson (1964), and Erik Erikson studied infant and child behaviour, and their observations were integrated into ego psychology. Their observational and empirical research described and explained early attachment issues, successful and faulty ego development, and psychological development through interpersonal interactions.
Spitz identified the importance of mother-infant nonverbal emotional reciprocity; Mahler refined the traditional psychosexual developmental phases by adding the separation-individuation process; and Jacobson emphasized how libidinal and aggressive impulses unfolded within the context of early relationships and environmental factors. Finally, Erik Erikson provided a bold reformulation of Freud’s biologic, epigenetic psychosexual theory through his explorations of socio-cultural influences on ego development. For Erikson, an individual was pushed by his or her own biological urges and pulled by socio-cultural forces.
Decline
In the United States, ego psychology was the predominant psychoanalytic approach from the 1940s through the 1960s. Initially, this was due to the influx of European psychoanalysts, including prominent ego psychologists like Hartmann, Kris, and Loewenstein, during and after World War II. These European analysts settled throughout the United States and trained the next generation of American psychoanalysts.
By the 1970s, several challenges to the philosophical, theoretical, and clinical tenets of ego psychology emerged. The most prominent of which were: a “rebellion” led by Rapaport’s protégés (George Klein, Robert Holt, Roy Schafer, and Merton Gill); object relations theory; and self psychology.
Contemporary
Modern Conflict Theory
Charles Brenner (1982) attempted to revive ego psychology with a concise and incisive articulation of the fundamental focus of psychoanalysis: intrapsychic conflict and the resulting compromise formations. Over time, Brenner (2002) tried to develop a more clinically based theory, what came to be called “modern conflict theory.” He distanced himself from the formal components of the structural theory and its metapsychological assumptions, and focused entirely on compromise formations.
Heinz Kohut developed self psychology, a theoretical and therapeutic model related to ego psychology, in the late 1960s. Self psychology focuses on the mental model of the self as important in pathologies.
Ego Functions
Function
Description
Reality Testing
1. The ego’s capacity to distinguish what is occurring in one’s own mind from what is occurring in the external world. 2. It is perhaps the single most important ego function because negotiating with the outside world requires accurately perceiving and understanding stimuli. 3. Reality testing is often subject to temporary, mild distortion or deterioration under stressful conditions. 4. Such impairment can result in temporary delusions and hallucination and is generally selective, clustering along specific, psychodynamic lines. 5. Chronic deficiencies suggest either psychotic or organic interference.
Impulse Control
1. The ability to manage aggressive and/or libidinal wishes without immediate discharge through behaviour or symptoms. 2. Problems with impulse control are common; for example: road rage; sexual promiscuity; excessive drug and alcohol use; and binge eating.
Affect Regulation
1. The ability to modulate feelings without being overwhelmed.
Judgement
1. The capacity to act responsibly. 2. This process includes identifying possible courses of action, anticipating and evaluating likely consequences, and making decisions as to what is appropriate in certain circumstances.
Object Relations
1. The capacity for mutually satisfying relationship. 2. The individual can perceive himself and others as whole objects with three dimensional qualities.
Thought Processes
1. The ability to have logical, coherent, and abstract thoughts. 2. In stressful situations, thought processes can become disorganised. 3. The presence of chronic or severe problems in conceptual thinking is frequently associated with schizophrenia and manic episodes.
Defensive Functioning
1. A defence is an unconscious attempt to protect the individual from some powerful, identity-threatening feeling. 2. Initial defences develop in infancy and involve the boundary between the self and the outer world; they are considered primitive defences and include projection, denial, and splitting. 3. As the child grows up, more sophisticated defences that deal with internal boundaries such as those between ego and super ego or the id develop; these defences include repression, regression, displacement, and reaction formation. 4. All adults have, and use, primitive defences, but most people also have more mature ways of coping with reality and anxiety.
Synthesis
1. The synthetic function is the ego’s capacity to organize and unify other functions within the personality. 2. It enables the individual to think, feel, and act in a coherent manner. 3. It includes the capacity to integrate potentially contradictory experiences, ideas, and feelings; for example, a child loves his or her mother yet also has angry feelings toward her at times. 4. The ability to synthesize these feelings is a pivotal developmental achievement.
Reality testing involves the individual’s capacity to understand and accept both physical and social reality as it is consensually defined within a given culture or cultural subgroup. In large measure, the function hinges on the individual’s capacity to distinguish between her own wishes or fears (internal reality) and events that occur in the real world (external reality). The ability to make distinctions that are consensually validated determines the ego’s capacity to distinguish and mediate between personal expectations, on the one hand, and social expectations or laws of nature on the other. Individuals vary considerably in how they manage this function. When the function is seriously compromised, individuals may withdraw from contact with reality for extended periods of time. This degree of withdrawal is most frequently seen in psychotic conditions. Most times, however, the function is mildly or moderately compromised for a limited period of time, with far less drastic consequences’ (Berzoff, 2011).
Judgment involves the capacity to reach “reasonable” conclusions about what is and what is not “appropriate” behaviour. Typically, arriving at a “reasonable” conclusion involves the following steps: (1) correlating wishes, feeling states, and memories about prior life experiences with current circumstances; (2) evaluating current circumstances in the context of social expectations and laws of nature (e.g. it is not possible to transport oneself instantly out of an embarrassing situation, no matter how much one wishes to do so); and (3) drawing realistic conclusions about the likely consequences of different possible courses of action. As the definition suggests, judgment is closely related to reality testing, and the two functions are usually evaluated in tandem (Berzoff, 2011).
Modulating and controlling impulses is based on the capacity to hold sexual and aggressive feelings in check with out acting on them until the ego has evaluated whether they meet the individual’s own moral standards and are acceptable in terms of social norms. Adequate functioning in this area depends on the individual’s capacity to tolerate frustration, to delay gratification, and to tolerate anxiety without immediately acting to ameliorate it. Impulse control also depends on the ability to exercise appropriate judgment in situations where the individual is strongly motivated to seek relief from psychological tension and/or to pursue some pleasurable activity (sex, power, fame, money, etc.). Problems in modulation may involve either too little or too much control over impulses (Berzoff, 2011).
Modulation of affect The ego performs this function by preventing painful or unacceptable emotional reactions from entering conscious awareness, or by managing the expression of such feelings in ways that do not disrupt either emotional equilibrium or social relationships. To adequately perform this function, the ego constantly monitors the source, intensity, and direction of feeling states, as well as the people toward whom feelings will be directed. Monitoring determines whether such states will be acknowledged or expressed and, if so, in what form. The basic principle to remember in evaluating how well the ego manages this function is that affect modulation may be problematic because of too much or too little expression. As an integral part of the monitoring process, the ego evaluates the type of expression that is most congruent with established social norms. For example, in white American culture it is assumed that individuals will contain themselves and maintain a high level of personal/vocational functioning except in extremely traumatic situations such as death of a family member, very serious illness or terrible accident. This standard is not necessarily the norm in other cultures (Berzhoff, Flanagan, & Hertz, 2011).
Object relations involves the ability to form and maintain coherent representations of others and of the self. The concept refers not only to the people one interacts with in the external world but also to significant others who are remembered and represented within the mind. Adequate functioning implies the ability to maintain a basically positive view of the other, even when one feels disappointed, frustrated, or angered by the other’s behaviour. Disturbances in object relations may manifest themselves through an inability to fall in love, emotional coldness, lack of interest in or withdrawal from interactions with others, intense dependency, and/or an excessive need to control relationships (Berzhoff, Flanagan, & Hertz, 2011).
Self-esteem regulation involves the capacity to maintain a steady and reasonable level of positive self-regard in the face of distressing or frustrating external events. Painful affective states, including anxiety, depression, shame, and guilt, as well as exhilarating emotions such as triumph, glee, and ecstasy may also undermine self-esteem. Generally speaking, in dominant American culture a measured expression of both pain and pleasure is expressed; excess in either direction is a cause for concern. White Western culture tends to assume that individuals will maintain a consistent and steadily level of self-esteem, regardless of external events or internally generated feeling states (Berzhoff, Flanagan, & Hertz, 2011).
Mastery when conceptualized as an ego function, mastery reflects the epigenetic view that individuals achieve more advanced levels of ego organization by mastering successive developmental challenges. Each stage of psychosexual development (oral, anal, phallic, genital) presents a particular challenge that must be adequately addressed before the individual can move on to the next higher stage. By mastering stage-specific challenges, the ego gains strength in relations to the other structures of the mind and thereby becomes more effective in organizing and synthesizing mental processes. Freud expressed this principle in his statement, “Where id was, shall ego be.” An undeveloped capacity for mastery can be seen, for example, in infants who have not been adequately nourished, stimulated, and protected during the first year of life, in the oral stage of development. When they enter the anal stage, such infants are not well prepared to learn socially acceptable behaviour or to control the pleasure they derive from defecating at will. As a result, some of them will experience delays in achieving bowel control and will have difficulty in controlling temper tantrums, while others will sink into a passive, joyless compliance with parental demands that compromises their ability to explore, learn, and become physically competent. Conversely, infants who have been well gratified and adequately stimulated during the oral stage enter the anal stage feeling relatively secure and confident. For the most part, they cooperate in curbing their anal desires, and are eager to win parental approval for doing so. In addition, they are physically active, free to learn and eager to explore. As they gain confidence in their increasingly autonomous physical and mental abilities, they also learn to follow the rules their parents establish and, in doing so, with parental approval. As they master the specific tasks related to the anal stage, they are well prepared to move on to the next stage of development and the next set of challenges. When adults have problems with mastery, they usually enact them in derivative or symbolic ways (Berzhoff, Flanagan, & Hertz, 2011).
Conflict, Defence and Resistance Analysis
According to Freud’s structural theory, an individual’s libidinal and aggressive impulses are continuously in conflict with his or her own conscience as well as with the limits imposed by reality. In certain circumstances, these conflicts may lead to neurotic symptoms. Thus, the goal of psychoanalytic treatment is to establish a balance between bodily needs, psychological wants, one’s own conscience, and social constraints. Ego psychologists argue that the conflict is best addressed by the psychological agency that has the closest relationship to consciousness, unconsciousness, and reality: the ego.
The clinical technique most commonly associated with ego psychology is defence analysis. Through clarifying, confronting, and interpreting the typical defence mechanisms a patient uses, ego psychologists hope to help the patient gain control over these mechanisms.
Cultural Influences
The classical scholar E. R. Dodds used ego psychology as the framework for his influential study The Greeks and the Irrational (1951).
The Sterbas relied on Hartmann’s conflict-free sphere to help explain the contradictions they found in Beethoven’s character in Beethoven and His Nephew (1954).
Criticisms
A number of authors have criticised Hartmann’s conception of a conflict-free sphere of ego functioning as both incoherent and inconsistent with Freud’s vision of psychoanalysis as a science of mental conflict. Freud believed that the ego itself takes shape as a result of the conflict between the id and the external world. The ego, therefore, is inherently a conflicting formation in the mind. To state, as Hartmann did, that the ego contains a conflict-free sphere may not be consistent with key propositions of Freud’s structural theory.
Ego psychology, and ‘Anna-Freudianism’, were together seen by Kleinians as maintaining a conformist, adaptative version of psychoanalysis inconsistent with Freud’s own views. Hartmann claimed, however, that his aim was to understand the mutual regulation of the ego and environment rather than to promote adjustment of the ego to the environment. Furthermore, an individual with a less-conflicted ego would be better able to actively respond and shape, rather than passively react to, his or her environment.
Jacques Lacan was if anything still more opposed to ego psychology, using his concept of the Imaginary to stress the role of identifications in building up the ego in the first place. Lacan saw in the “non-conflictual sphere…a down-at-heel mirage that had already been rejected as untenable by the most academic psychology of introspection’.
References
Berzoff, J., Flanagan, L.M. & Hertz, P (2011). Inside out and outside in: Psychodynamic clinical theory and psychopathology in contemporary multicultural contexts. (3rd ed. Lanham, MD: Rowman & Littlefield Publishers.
Mitchell, S.A. & Black, M.J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York: Basic Books.
The Harvard Review of Psychiatry is a peer-reviewed medical journal covering all aspects of psychiatry.
Background
The Harvard Review of Psychiatry is the authoritative source for scholarly reviews and perspectives on a diverse range of important topics in psychiatry.
Founded by the Harvard Medical School Department of Psychiatry, the journal is peer-reviewed and not industry sponsored. It is the property of the President and Fellows of Harvard College and is affiliated with all of the Departments of Psychiatry at the Harvard teaching hospitals.
Articles encompass all major issues in contemporary psychiatry, including (but not limited to) neuroscience, psychopharmacology, psychotherapy, history of psychiatry, and ethics. In addition to scholarly reviews, perspectives articles, and columns, the journal includes a Clinical Challenge section that presents a case followed by discussion and debate from a panel of experts.
Subscription includes a CME opportunity in each issue.
Logotherapy was developed by neurologist and psychiatrist Viktor Frankl, on a concept based on the premise that the primary motivational force of an individual is to find a meaning in life.
Frankl describes it as “the Third Viennese School of Psychotherapy” along with Freud’s psychoanalysis and Adler’s individual psychology. Logotherapy is based on an existential analysis focusing on Kierkegaard’s will to meaning as opposed to Alfred Adler’s Nietzschean doctrine of will to power or Freud’s will to pleasure. Rather than power or pleasure, logotherapy is founded upon the belief that striving to find meaning in life is the primary, most powerful motivating and driving force in humans.
A short introduction to this system is given in Frankl’s most famous book, Man’s Search for Meaning, in which he outlines how his theories helped him to survive his Holocaust experience and how that experience further developed and reinforced his theories. Presently, there are a number of logotherapy institutes around the world.
Basic Principles
The notion of Logotherapy was created with the Greek word logos (“reason”). Frankl’s concept is based on the premise that the primary motivational force of an individual is to find a meaning in life. The following list of tenets represents basic principles of logotherapy:
Life has meaning under all circumstances, even the most miserable ones.
Our main motivation for living is our will to find meaning in life.
We have freedom to find meaning in what we do, and what we experience, or at least in the stance we take when faced with a situation of unchangeable suffering.
The human spirit is referred to in several of the assumptions of logotherapy, but the use of the term spirit is not “spiritual” or “religious”. In Frankl’s view, the spirit is the will of the human being. The emphasis, therefore, is on the search for meaning, which is not necessarily the search for God or any other supernatural being. Frankl also noted the barriers to humanity’s quest for meaning in life. He warns against “…affluence, hedonism, [and] materialism…” in the search for meaning.
Purpose in life and meaning in life constructs appeared in Frankl’s logotherapy writings with relation to existential vacuum and will to meaning, as well as others who have theorised about and defined positive psychological functioning. Frankl observed that it may be psychologically damaging when a person’s search for meaning is blocked. Positive life purpose and meaning was associated with strong religious beliefs, membership in groups, dedication to a cause, life values, and clear goals. Adult development and maturity theories include the purpose in life concept. Maturity emphasizes a clear comprehension of life’s purpose, directedness, and intentionality which contributes to the feeling that life is meaningful.
Frankl’s ideas were operationalized by Crumbaugh and Maholick’s Purpose in Life (PIL) test, which measures an individual’s meaning and purpose in life. With the test, investigators found that meaning in life mediated the relationships between religiosity and well-being; uncontrollable stress and substance use; depression and self-derogation. Crumbaugh found that the Seeking of Noetic Goals Test (SONG) is a complementary measure of the PIL. While the PIL measures the presence of meaning, the SONG measures orientation towards meaning. A low score in the PIL but a high score in the SONG, would predict a better outcome in the application of Logotherapy.
Discovering Meaning
According to Frankl, “We can discover this meaning in life in three different ways: (1) by creating a work or doing a deed; (2) by experiencing something or encountering someone; and (3) by the attitude we take toward unavoidable suffering” and that “everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances”. On the meaning of suffering, Frankl gives the following example:
“Once, an elderly general practitioner consulted me because of his severe depression. He could not overcome the loss of his wife who had died two years before and whom he had loved above all else. Now how could I help him? What should I tell him? I refrained from telling him anything, but instead confronted him with a question, “What would have happened, Doctor, if you had died first, and your wife would have had to survive without you?:” “Oh,” he said, “for her this would have been terrible; how she would have suffered!” Whereupon I replied, “You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now, you have to pay for it by surviving and mourning her.” He said no word but shook my hand and calmly left the office.
Frankl emphasized that realising the value of suffering is meaningful only when the first two creative possibilities are not available (for example, in a concentration camp) and only when such suffering is inevitable – he was not proposing that people suffer unnecessarily.
Philosophical Basis of Logotherapy
Frankl described the meta-clinical implications of logotherapy in his book The Will to Meaning: Foundations and Applications of Logotherapy. He believed that there is no psychotherapy apart from the theory of the individual. As an existential psychologist, he inherently disagreed with the “machine model” or “rat model”, as it undermines the human quality of humans. As a neurologist and psychiatrist, Frankl developed a unique view of determinism to coexist with the three basic pillars of logotherapy (the freedom of will). Though Frankl admitted that a person can never be free from every condition, such as, biological, sociological, or psychological determinants; based on his experience during his life in the Nazi concentration camps, he believed that a person is “capable of resisting and braving even the worst conditions”. In doing such, a person can detach from situations and themselves, choose an attitude about themselves, and determine their own determinants, thus shaping their own character and becoming responsible for themselves.
Logotherapeutic Views and Treatment
Overcoming Anxiety
By recognising the purpose of our circumstances, one can master anxiety. Anecdotes about this use of logotherapy are given by New York Times writer Tim Sanders, who explained how he uses its concept to relieve the stress of fellow airline travellers by asking them the purpose of their journey. When he does this, no matter how miserable they are, their whole demeanour changes, and they remain happy throughout the flight. Overall, Frankl believed that the anxious individual does not understand that their anxiety is the result of dealing with a sense of “unfulfilled responsibility” and ultimately a lack of meaning.
Treatment of Neurosis
Frankl cites two neurotic pathogens: hyper-intention, a forced intention toward some end which makes that end unattainable; and hyper-reflection, an excessive attention to oneself which stifles attempts to avoid the neurosis to which one thinks oneself predisposed. Frankl identified anticipatory anxiety, a fear of a given outcome which makes that outcome more likely. To relieve the anticipatory anxiety and treat the resulting neuroses, logotherapy offers paradoxical intention, wherein the patient intends to do the opposite of their hyper-intended goal.
A person, then, who fears (i.e. experiences anticipatory anxiety over) not getting a good night’s sleep may try too hard (that is, hyper-intend) to fall asleep, and this would hinder their ability to do so. A logotherapist would recommend, then, that the person go to bed and intentionally try not to fall asleep. This would relieve the anticipatory anxiety which kept the person awake in the first place, thus allowing them to fall asleep in an acceptable amount of time.
Depression
Viktor Frankl believed depression occurred at the psychological, physiological, and spiritual levels. At the psychological level, he believed that feelings of inadequacy stem from undertaking tasks beyond our abilities. At the physiological level, he recognised a “vital low”, which he defined as a “diminishment of physical energy”. Finally, Frankl believed that at the spiritual level, the depressed individual faces tension between who they actually are in relation to what they should be. Frankl refers to this as the gaping abyss. Finally Frankl suggests that if goals seem unreachable, an individual loses a sense of future and thus meaning resulting in depression. Thus logotherapy aims “to change the patient’s attitude toward their disease as well as toward their life as a task”.
Obsessive-Compulsive Disorder
Frankl believed that those suffering from obsessive-compulsive disorder lack the sense of completion that most other individuals possess. Instead of fighting the tendencies to repeat thoughts or actions, or focusing on changing the individual symptoms of the disease, the therapist should focus on “transform[ing] the neurotic’s attitude toward their neurosis”. Therefore, it is important to recognise that the patient is “not responsible for his obsessional ideas”, but that “he is certainly responsible for his attitude toward these ideas”. Frankl suggested that it is important for the patient to recognise their inclinations toward perfection as fate, and therefore, must learn to accept some degrees of uncertainty. Ultimately, following the premise of logotherapy, the patient must eventually ignore their obsessional thoughts and find meaning in their life despite such thoughts.
Schizophrenia
Though logotherapy was not intended to deal with severe disorders, Frankl believed that logotherapy could benefit even those suffering from schizophrenia. He recognised the roots of schizophrenia in physiological dysfunction. In this dysfunction, the person with schizophrenia “experiences himself as an object” rather than as a subject. Frankl suggested that a person with schizophrenia could be helped by logotherapy by first being taught to ignore voices and to end persistent self-observation. Then, during this same period, the person with schizophrenia must be led toward meaningful activity, as “even for the schizophrenic there remains that residue of freedom toward fate and toward the disease which man always possesses, no matter how ill he may be, in all situations and at every moment of life, to the very last”.
Terminally Ill Patients
In 1977, Terry Zuehlke and John Watkins conducted a study analysing the effectiveness of logotherapy in treating terminally ill patients. The study’s design used 20 male Veterans Administration volunteers who were randomly assigned to one of two possible treatments – (1) group that received 8 45-minute sessions over a 2-week period and (2) group used as control that received delayed treatment. Each group was tested on 5 scales – the MMPI K Scale, MMPI L Scale, Death Anxiety Scale, Brief Psychiatric Rating Scale, and the Purpose of Life Test. The results showed an overall significant difference between the control and treatment groups. While the univariate analyses showed that there were significant group differences in 3/5 of the dependent measures. These results confirm the idea that terminally ill patients can benefit from logotherapy in coping with death.
Forms of Treatment
Ecce Homo is a method used in logotherapy. It requires of the therapist to note the innate strengths that people have and how they have dealt with adversity and suffering in life. Despite everything a person may have gone through, they made the best of their suffering! Hence, Ecce Homo – Behold the Man!
Controversy
Authoritarianism
In 1969 Rollo May argued that logotherapy is, in essence, authoritarian. He suggested that Frankl’s therapy presents a plain solution to all of life’s problems, an assertion that would seem to undermine the complexity of human life itself. May contended that if a patient could not find their own meaning, Frankl would provide a goal for his patient. In effect, this would negate the patient’s personal responsibility, thus “diminish[ing] the patient as a person”. Frankl explicitly replied to May’s arguments through a written dialogue, sparked by Rabbi Reuven Bulka’s article “Is Logotherapy Authoritarian?”. Frankl responded that he combined the prescription of medication, if necessary, with logotherapy, to deal with the person’s psychological and emotional reaction to the illness, and highlighted areas of freedom and responsibility, where the person is free to search and to find meaning.
Religiousness
Critical views of the life of logotherapy’s founder and his work assume that Frankl’s religious background and experience of suffering guided his conception of meaning within the boundaries of the person and therefore that logotherapy is founded on Viktor Frankl’s worldview. Many researchers argue that logotherapy is not a “scientific” psychotherapeutic school in the traditional sense but a philosophy of life, a system of values, a secular religion which is not fully coherent and is based on questionable metaphysical premises.
Frankl openly spoke and wrote on religion and psychiatry, throughout his life, and specifically in his last book, Man’s Search for Ultimate Meaning (1997). He asserted that every person has a spiritual unconscious, independently of religious views or beliefs, yet Frankl’s conception of the spiritual unconscious does not necessarily entail religiosity. In Frankl’s words: “It is true, Logotherapy, deals with the Logos; it deals with Meaning. Specifically, I see Logotherapy in helping others to see meaning in life. But we cannot “give” meaning to the life of others. And if this is true of meaning per se, how much does it hold for Ultimate Meaning?” The American Psychiatric Association awarded Viktor Frankl the 1985 Oskar Pfister Award (for important contributions to religion and psychiatry).
Recent Developments
Since the 1990s, the number of institutes providing education and training in logotherapy continues to increase worldwide. Numerous logotherapeutic concepts have been integrated and applied in different fields, such as cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), and burnout prevention. The logotherapeutic concepts of noogenic neurosis and existential crisis were added to the ICD 11 under the name demoralisation crisis, i.e. a construct that features hopelessness, meaninglessness, and existential distress as first described by Frankl in the 1950s. Logotherapy has also been associated with psychosomatic and physiological health benefits. Besides Logotherapy, other meaning-centred psychotherapeutic approaches such as positive psychology and meaning therapy have emerged. Paul Wong’s meaning therapy attempts to translate logotherapy into psychological mechanisms, integrating CBT, positive psychotherapy and the positive psychology research on meaning. Logotherapy is also being applied in the field of oncology and palliative care (William Breitbart). These recent developments introduce Viktor Frankl’s logotherapy to a new generation and extend its impact to new areas of research.
While regular exercise is generally a healthy activity, exercise addiction generally involves performing excessive amounts of exercise to the detriment of physical health, spending too much time exercising to the detriment of personal and professional life, and exercising regardless of physical injury. It may also involve a state of dependence upon regular exercise which involves the occurrence of severe withdrawal symptoms when the individual is unable to exercise. Differentiating between addictive and healthy exercise behaviours is difficult but there are key factors in determining which category a person may fall into. Exercise addiction shows a high comorbidity with eating disorders.
Exercise addiction is not listed as a disorder in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This type of addiction can be classified under a behavioural addiction in which a person’s behaviour becomes obsessive, compulsive, and/or causes dysfunction in a person’s life. The next revision of the DSM (DSM-5) will include an addictions and related disorders section; gambling is the only non-substance addiction that is likely to be included. Other non-substance addictions, such as exercise addiction, are being researched but their inclusion is undetermined.
Classification
A concrete classification of exercise addiction has proven to be difficult due to the lack of a specific and widely accepted diagnostic model. Most interpretations of addiction have traditionally been limited to drugs and alcohol, which makes it even more difficult to identify addictive tendencies in exercise. While excessive exercise is the overarching theme with exercise addiction, the term also includes a variety of symptoms like withdrawal, “exercise buzz”, and impaired physical function. Excessive exercise has been classified in different ways; sometimes as an addiction and sometimes as a more general compulsive behaviour. Psychiatric case studies have shown that exaggerated exercise could lead to negligence of work and family life. With an addiction, individuals become “hooked” to the feeling of euphoria and pleasure that exercise provides. This pleasure keeps the individual from stopping and leads to excessive exercise. With a compulsion people often do not necessarily enjoy repeating certain tasks, as they may feel like performing it will fulfil a duty that is required of them. There are many opinions on whether concrete diagnostic criteria should be created for this type of addiction. Some say preoccupation with exercise that causes significant impairment in a person’s life, not due to another disorder, may be enough criteria to label this disorder. Others say there is not enough information about exercise addiction to develop diagnostic criteria. As of 2007, the term “excessive exercise” continues to be used while the “exercise addiction” model continues to be debated.
Three main types of disorders are associated with excessive exercise:
When an individual feels compelled to exercise beyond the point of benefitting one’s body.
Individuals will participate in athletic activities regardless of pain, injury, illness, etc., and will try to arrange their lives in order to maximise workout time.
When an individual is obsessed with parts of their body and perceive them to be different or odd.
These individuals will create highly regimented routines in order to improve their perception of the “flawed” body part.
Signs and Symptoms
Five indicators of exercise addiction are:
An increase in exercise that may be labelled as detrimental, or becomes harmful.
A desire to experience euphoria; exercise may be increased as tolerance of the euphoric state increases.
Not participating in physical activity will cause dysfunction in one’s daily life.
Severe withdrawal symptoms following exercise deprivation including anxiety, restlessness, depression, guilt, tension, discomfort, loss of appetite, sleeplessness, and headaches.
Exercising through trauma and despite physical injuries.
Key differences between healthy and addictive levels of exercise include the presence of withdrawal symptoms when exercise is stopped as well as the addictive properties exercise may have leading to a dependence on exercise.
Those who succumb to exercise addiction may experience overtraining, which is best defined as a “condition of poor adaptation to a chronic period of excessive stress caused by a physical exertion, resulting in the development of the syndrome, compromising the health and sports performance”.
Overtraining includes one or more of the following:
Persistent muscle soreness.
Elevated resting heart rate.
Increased susceptibility to infections.
Increased incidence of injuries.
Insomnia.
Decreased appetite.
Weight loss.
Impaired performance.
Decreased motor coordination and force production.
Exercise addiction may also lead to mood disturbances. Those who undergo rigorous training without adequate rest are more likely to experience depression, anger, fatigue and confusion.
In addition, excessive training may cause exhaustion of the autonomic nervous system. Some symptoms include decreased total testosterone level, an imbalance between testosterone and cortisol, decreased sympathetic tone, and decreased exercise-induced lactate. These chemical balances can lead to premature osteoporosis, where the lack of testosterone accelerates bone loss, and elevated levels of cortisol alters calcium and bone metabolism by “increasing bone reabsorption and decreasing bone formation or intestinal absorption of calcium”. Calcium undernutrition may eventually occur, accelerating premature osteoporosis.
Mechanisms
As of 2016, the mechanisms involved in the development of an exercise addiction, associated with the transition from healthy committed exercise to compulsive exercise, are unknown.
Assessment
Different assessment tools can be used to determine if an individual is addicted to exercise. Most tools used to determine risk for exercise addiction are modified tools that have been used for assessing other behavioural addictions. Tools for determining eating disorders can also show a high risk for exercise addiction.
The Obligatory Exercise Questionnaire was created by Thompson and Pasman in 1991, consisting of 20 questions on exercise habits and attitudes toward exercise and body image. Patients respond to statements on a scale of 1 (never) to 4 (always). This questionnaire aided in the development of another assessment tool, the Exercise Addiction Inventory.
The Exercise Addiction Inventory was developed by Terry et al in 2004. This inventory was developed as a self-report to examine an individual’s beliefs toward exercise. The inventory is made up of six statements in relation to the perception of exercise, concerning: the importance of exercise to the individual, relationship conflicts due to exercise, how mood changes with exercise, the amount of time spent exercising, the outcome of missing a workout, and the effects of decreasing physical activity. Individuals are asked to rate each statement from 1 (strongly disagree) to 5 (strongly agree). If an individual scores above 24 they are said to be at-risk for exercise addiction.
Treatment
Behavioural addiction and substance abuse disorders are treated similarly; treatment options include exposure and response prevention. No medications have been approved for the treatment of behavioural addictions. Studies have shown promise in the use of glutamatergic altering drugs to treat addictions other than exercise. Exercise addictions comorbid in patients with an eating disorder may be treated through psychotherapy involving education, behavioural interventions, and a strengthened family support structure. In treating the eating disorder, obsessions and compulsions produced by obscured body image ideals will also be treated, this includes exercise addiction.
Epidemiology
Most research has focused on adult population or on college students, but little is known about epidemiology of behavioural addictions in adolescence. A study conducted by Villella et al looked at a group of students and the prevalence of various addictions. His results showed exercise addiction was the second most prevalent, after compulsive buying. High risk groups that appear to be addicted to exercise include athletes in sports encouraging thinness or appearance standards, young and middle-age women, and young men.
Prognosis
Individuals with exercise addiction may put exercise above family and friends, work, injuries, and other social activities. If not identified and treated, an exercise addiction may lead to a significant decline in one’s health.
Comorbidity
An addiction, by definition, includes repeated compulsive behaviours that negatively affect daily living. There are two ways to classify addictive behaviours: substance addiction and process addiction. An exercise addiction is a type of process addiction, in which an individual’s mood toward a certain event becomes dependent on addictive behaviours. Many educational, occupational, and social activities are stopped due to excessive exercising. Depression may develop if exercise is neglected or may result from reoccurring physical injuries that limit exercise. Exercise addiction is often related to obsessive-compulsive disorder as exercise addicts may have obsessions or compulsions toward physical activity. Exercise addiction is also commonly associated with eating disorders as a secondary symptom of bulimia or anorexia nervosa. Approximately 39-48% of people that have an eating disorder are also addicted to exercise. When diagnosing bulimia, exercise addiction is referred to as a compensatory behaviour and indicator of the underlying disorder. Research also shows exercise addiction influences not only the development of eating disorders but also their maintenance.
Animal Models
As with many human diseases and disorders, animal models are sometimes used to study addiction. For example, voluntary wheel running by rodents, viewed as a model of human voluntary exercise, has been used to study withdrawal symptoms, such as changes in blood pressure, when wheel access is removed from mice.
Exercise bulimia is a subset of the psychological disorder called bulimia in which a person is compelled to exercise in an effort aimed at burning the calories of food energy and fat reserves to an excessive level that negatively affects their health.
The damage normally occurs through not giving the body adequate rest for athletic recovery compared to their exercise levels, leading to increasing levels of disrepair. If the person eats a normally healthy and adequate diet but exercises in levels they know require higher levels of nutrition, this can also be seen as a form of anorexia.
Exercise Bulimia can sometimes go unnoticed because exercise is something that is seen as healthy, but just because a person looks healthy does not mean they are. Compulsive exercisers will often schedule their lives around exercise just as those with eating disorders schedule their lives around eating (or not eating). Other indications of compulsive exercise are:
Missing work, school and other important events in order to work out.
Working out with an injury or while sick.
Working out secretly or away from noticeable sight.
Becoming unusually depressed if unable to exercise.
Working out for hours at a time each day.
Not taking any rest or recovery days.
Defining self-worth in terms of performance.
Justifies excessive behaviour by defining self as a “special” elite athlete.
Depression or agitation when unable to work out.
Amenorrhea, the stop of a woman’s menstrual cycle.
An athlete suffering from sports anorexia tends to over exercise to give themselves a sense of having control over their body. Most often, people with the disorder tend to feel they have no control over their lives other than their control of food and exercise. In actuality, they have no control; they cannot stop exercising or regulating food intake without feeling guilty. Generally, once the activity is started, it is difficult to stop because the person is seen as being addicted to the method adopted.
Anorexia athletica is used to refer to “a disorder for athletes who engage in at least one unhealthy method of weight control”. Unlike anorexia nervosa, anorexia athletica does not have as much to do with body image as it does with performance. Athletes usually begin by eating more ‘healthy’ foods, as well as increasing their training, but when people feel like that is not enough and start working out excessively and cutting back their caloric intake until it becomes a psychological disorder.
Hypergymnasia and anorexia athletica are not recognised as mental disorders in any of the medical manuals, such as the ICD-10 or the DSM-IV, nor is it part of the proposed revision of this manual, the DSM-5. If this were the case, there would be a 10-15% increase in mental disorders in sports. A study at the Anorexia Centre at Huddinge Hospital in Stockholm, Sweden showed that sports anorexia can result in mental disorders. The anxiety, stress, and pressure people with sports anorexia put on themselves (as well as the pressure parents and coaches can put on the athlete) can cause mental disorders.
Signs and Symptoms
Someone with anorexia athletica can experience numerous signs and symptoms, a few of which are listed below. The seriousness of the symptoms is dependent on the individual, and more symptoms come with the length the athlete excessively exercises. If anorexia athletica persists for long enough, the individual can become malnourished, which eventually leads to further complications in major organs such as the liver, kidney, heart and brain.
Excessive exercise.
Obsessive behaviour with calories, fat, and weight.
Self-worth is based on physical performance.
Enjoyment of sports is diminished or gone.
Denying the over exercising is a problem.
Causes
There is not one single cause of anorexia athletica, but many factors that are involved in the disorder. Research has shown that an area on chromosome 1 is linked to anorexia nervosa-sports anorexia. Thus, a person is more likely to have anorexia athletica if someone in their immediate family has had the disorder. Not only genetics, but also the environment a person is in, has a major impact on the disorder. Coaches and parents often suggest to their athlete/child to lose weight in order to perform better. Sports such as figure skating, ballet, and gymnastics promote both male and female athletes to have a thin figure. Females who partake in sports can suffer from a syndrome known as the triad. The media play a very significant role in pressuring athletes to have the perfect body and to be thin, which can also trigger sports anorexia.
Treatment
According to the National Eating Disorder Information Centre (NEDIC), the first step for someone going through anorexia athletica is to realise their eating and exercise habits are hurting them. Once an individual has realised they have a disorder, an appointment should be made with the family doctor. A family doctor can advise further medical attention if needed. With sports anorexia, it is important to go to a dietitian as well as a personal trainer. People with sports anorexia need to learn the balance between exercise and caloric intake.
A mental health care navigator is an individual who assists patients and families to find appropriate mental health caregivers, facilities and services. Individuals who are care navigators are often also trained therapists and doctors.
Background
The need for mental health care navigators arises from the fragmentation of the mental health industry, which can often leave patients with more questions than answers. Care navigators work closely with patients and families through discussion and collaboration to provide information on best options and referrals to healthcare professionals, facilities, and organisations specialising in the patients’ needs. The difference between other mental health professionals and a care navigator is that a care navigator provides information and directs a patient to the best help rather than offering treatment. Still, care navigators may provide diagnosis and treatment planning.
Mental health care navigation is also sometimes provided by self-help books. Lloyd I. Sederer, M.D.’s The Family Guide to Mental Healthcare (W. W. Norton & Company, 2013) is a resource for patients and families searching for guidance in the mental health industry. Publishers Weekly called it a “thoughtful, compassionate, and fact-packed guide for recognizing illness and getting help.” It provides information to patients and families about recognising symptoms of mental illness, how to get diagnosis and how to choose the right therapists and treatments.
Terminology
Many mental health organisations use “navigator” and “navigation” to describe the service of providing guidance through the health care industry. Care navigators are also sometimes referred to as “system navigators.”. One type of care navigator is an “educational consultant.”
Models
Models for mental health care navigation can involve many scenarios from a brief consultation to an extended process with follow-up. They offer referrals, assistance with insurance and other financial matters and general support. A highly detailed method of care navigation with long-term follow up was developed in 2011 by San Francisco-based psychiatrist and mental health expert Eli Merritt, M.D. His model involves what he calls the “3 R’s” of mental health care: “Research, Resources, and Referrals.” It involves four steps:
Assessment & Needs Identification:
In this preliminary, exploratory phase, care navigators meet with the individual or family seeking help. Patient history and needs are identified.
Both the patient and the care navigator think through short- and long-term goals and levels of treatment sought.
Dialogue & Plan Formation:
Through discussion and collaboration, both the patient and care navigator brainstorm next steps, establishing a plan that is specific to the patient’s needs.
Care Coordination:
After information gathering and brainstorming, doctors, therapists, and other mental health options are provided to the patient.
Questions of affordability arise, and patients are advised toward the best solutions for their conditions and circumstances.
Continuity:
After guiding patients to healthcare providers, care navigators maintain communication and continuity with patients, offering assistance with any future obstacles that might arise.
Neuropsychology is a branch of psychology that is concerned with how a person’s cognition and behaviour are related to the brain and the rest of the nervous system. Professionals in this branch of psychology often focus on how injuries or illnesses of the brain affect cognitive and behavioural functions.
It is both an experimental and clinical field of psychology, thus aiming to understand how behaviour and cognition are influenced by brain function and concerned with the diagnosis and treatment of behavioural and cognitive effects of neurological disorders. Whereas classical neurology focuses on the pathology of the nervous system and classical psychology is largely divorced from it, neuropsychology seeks to discover how the brain correlates with the mind through the study of neurological patients. It thus shares concepts and concerns with neuropsychiatry and with behavioural neurology in general. The term neuropsychology has been applied to lesion studies in humans and animals. It has also been applied in efforts to record electrical activity from individual cells (or groups of cells) in higher primates (including some studies of human patients).
In practice, neuropsychologists tend to work in research settings (universities, laboratories or research institutions), clinical settings (medical hospitals or rehabilitation settings, often involved in assessing or treating patients with neuropsychological problems), or forensic settings or industry (often as clinical-trial consultants where CNS function is a concern).
Brief History
Neuropsychology is a relatively new discipline within the field of psychology. The first textbook defining the field, Fundamentals of Human Neuropsychology, was initially published by Kolb and Whishaw in 1980. However, the history of its development can be traced back to the Third Dynasty in ancient Egypt, perhaps even earlier. There is much debate as to when societies started considering the functions of different organs. For many centuries, the brain was thought useless and was often discarded during burial processes and autopsies. As the field of medicine developed its understanding of human anatomy and physiology, different theories were developed as to why the body functioned the way it did. Many times, bodily functions were approached from a religious point of view and abnormalities were blamed on bad spirits and the gods. The brain has not always been considered the centre of the functioning body. It has taken hundreds of years to develop our understanding of the brain and how it affects our behaviours.
Ancient Egypt
In ancient Egypt, writings on medicine date from the time of the priest Imhotep. They took a more scientific approach to medicine and disease, describing the brain, trauma, abnormalities, and remedies for reference for future physicians. Despite this, Egyptians saw the heart, not the brain, as the seat of the soul.
Aristotle
Aristotle reinforced this focus on the heart which originated in Egypt. He believed the heart to be in control of mental processes, and looked on the brain, due to its inert nature, as a mechanism for cooling the heat generated by the heart. He drew his conclusions based on the empirical study of animals. He found that while their brains were cold to the touch and that such contact did not trigger any movements, the heart was warm and active, accelerating and slowing dependent on mood. Such beliefs were upheld by many for years to come, persisting through the Middle Ages and the Renaissance period until they began to falter in the 17th century due to further research. The influence of Aristotle in the development of neuropsychology is evident within language used in modern day, since we “follow our hearts” and “learn by the heart.”
Hippocrates
Hippocrates viewed the brain as the seat of the soul. He drew a connection between the brain and behaviours of the body, writing: “The brain exercises the greatest power in the man.” Apart from moving the focus from the heart as the “seat of the soul” to the brain, Hippocrates did not go into much detail about its actual functioning. However, by switching the attention of the medical community to the brain, his theory led to more scientific discovery of the organ responsible for our behaviours. For years to come, scientists were inspired to explore the functions of the body and to find concrete explanations for both normal and abnormal behaviours. Scientific discovery led them to believe that there were natural and organically occurring reasons to explain various functions of the body, and it could all be traced back to the brain. Hippocrates introduced the concept of the mind – which was widely seen as a separate function apart from the actual brain organ.
René Descartes
Philosopher René Descartes expanded upon this idea and is most widely known for his work on the mind-body problem. Often Descartes’s ideas were looked upon as overly philosophical and lacking in sufficient scientific foundation. Descartes focused much of his anatomical experimentation on the brain, paying special attention to the pineal gland – which he argued was the actual “seat of the soul.” Still deeply rooted in a spiritual outlook towards the scientific world, the body was said to be mortal, and the soul immortal. The pineal gland was then thought to be the very place at which the mind would interact with the mortal and machine-like body. At the time, Descartes was convinced the mind had control over the behaviours of the body (controlling the person) – but also that the body could have influence over the mind, which is referred to as dualism. This idea that the mind essentially had control over the body, but the body could resist or even influence other behaviours, was a major turning point in the way many physiologists would look at the brain. The capabilities of the mind were observed to do much more than simply react, but also to be rational and function in organised, thoughtful ways – much more complex than he thought the animal world to be. These ideas, although disregarded by many and cast aside for years led the medical community to expand their own ideas of the brain and begin to understand in new ways just how intricate the workings of the brain really were, and the complete effects it had on daily life, as well as which treatments would be the most beneficial to helping those people living with a dysfunctional mind. The mind-body problem, spurred by René Descartes, continues to this day with many philosophical arguments both for and against his ideas. However controversial they were and remain today, the fresh and well-thought-out perspective Descartes presented has had long-lasting effects on the various disciplines of medicine, psychology and much more, especially in putting an emphasis on separating the mind from the body in order to explain observable behaviours.
Thomas Willis
It was in the mid-17th century that another major contributor to the field of neuropsychology emerged. Thomas Willis studied at Oxford University and took a physiological approach to the brain and behaviour. It was Willis who coined the words ‘hemisphere’ and ‘lobe’ when referring to the brain. He was one of the earliest to use the words ‘neurology’ and ‘psychology’. Rejecting the idea that humans were the only beings capable of rational thought, Willis looked at specialised structures of the brain. He theorised that higher structures accounted for complex functions, whereas lower structures were responsible for functions similar to those seen in other animals, consisting mostly of reactions and automatic responses. He was particularly interested in people who suffered from manic disorders and hysteria. His research constituted some of the first times that psychiatry and neurology came together to study individuals. Through his in-depth study of the brain and behaviour, Willis concluded that automated responses such as breathing, heartbeats and other various motor activities were carried out within the lower region of the brain. Although much of his work has been made obsolete, his ideas presented the brain as more complex than previously imagined, and led the way for future pioneers to understand and build upon his theories, especially when it came to looking at disorders and dysfunctions in the brain.
Franz Joseph Gall
Neuroanatomist and physiologist Franz Joseph Gall made major progress in understanding the brain. He theorized that personality was directly related to features and structures within the brain. However, Gall’s major contribution within the field of neuroscience is his invention of phrenology. This new discipline looked at the brain as an organ of the mind, where the shape of the skull could ultimately determine one’s intelligence and personality. This theory was like many circulating at the time, as many scientists were taking into account physical features of the face and body, head size, anatomical structure, and levels of intelligence; only Gall looked primarily at the brain. There was much debate over the validity of Gall’s claims however, because he was often found to be wrong in his predictions. He was once sent a cast of René Descartes’ skull, and through his method of phrenology claimed the subject must have had a limited capacity for reasoning and higher cognition. As controversial and false as many of Gall’s claims were, his contributions to understanding cortical regions of the brain and localised activity continued to advance understanding of the brain, personality, and behaviour. His work is considered crucial to having laid a firm foundation in the field of neuropsychology, which would flourish over the next few decades.
Jean-Baptiste Bouillaud
Towards the late 19th century, the belief that the size of ones skull could determine their level of intelligence was discarded as science and medicine moved forward. A physician by the name of Jean-Baptiste Bouillaud expanded upon the ideas of Gall and took a closer look at the idea of distinct cortical regions of the brain each having their own independent function. Bouillaud was specifically interested in speech and wrote many publications on the anterior region of the brain being responsible for carrying out the act of ones speech, a discovery that had stemmed from the research of Gall. He was also one of the first to use larger samples for research although it took many years for that method to be accepted. By looking at over a hundred different case studies, Bouillaud came to discover that it was through different areas of the brain that speech is completed and understood. By observing people with brain damage, his theory was made more concrete. Bouillaud, along with many other pioneers of the time made great advances within the field of neurology, especially when it came to localisation of function. There are many arguable debates as to who deserves the most credit for such discoveries, and often, people remain unmentioned, but Paul Broca is perhaps one of the most famous and well known contributors to neuropsychology – often referred to as “the father” of the discipline.
Paul Broca
Inspired by the advances being made in the area of localised function within the brain, Paul Broca committed much of his study to the phenomena of how speech is understood and produced. Through his study, it was discovered and expanded upon that we articulate via the left hemisphere. Broca’s observations and methods are widely considered to be where neuropsychology really takes form as a recognisable and respected discipline. Armed with the understanding that specific, independent areas of the brain are responsible for articulation and understanding of speech, the brains abilities were finally being acknowledged as the complex and highly intricate organ that it is. Broca was essentially the first to fully break away from the ideas of phrenology and delve deeper into a more scientific and psychological view of the brain.
Karl Spencer Lashley
Lashley’s works and theories that follow are summarised in his book Brain Mechanisms and Intelligence. Lashley’s theory of the Engram was the driving force for much of his research. An engram was believed to be a part of the brain where a specific memory was stored. He continued to use the training/ablation method that Franz had taught him. He would train a rat to learn a maze and then use systematic lesions and removed sections of cortical tissue to see if the rat forgot what it had learned.
Through his research with the rats, he learned that forgetting was dependent on the amount of tissue removed and not where it was removed from. He called this mass action and he believed that it was a general rule that governed how brain tissue would respond, independent of the type of learning. But we know now that mass action was a misinterpretation of his empirical results, because in order to run a maze the rats required multiple cortical areas. Cutting into small individual parts alone will not impair the rats’ brains much, but taking large sections removes multiple cortical areas at one time, affecting various functions such as sight, motor coordination and memory, making the animal unable to run a maze properly.
Lashley also proposed that a portion of a functional area could carry out the role of the entire area, even when the rest of the area has been removed. He called this phenomenon equipotentiality. We know now that he was seeing evidence of plasticity in the brain: within certain constraints the brain has the ability for certain areas to take over the functions of other areas if those areas should fail or be removed – although not to the extent initially argued by Lashley.
Approaches
Experimental neuropsychology is an approach that uses methods from experimental psychology to uncover the relationship between the nervous system and cognitive function. The majority of work involves studying healthy humans in a laboratory setting, although a minority of researchers may conduct animal experiments. Human work in this area often takes advantage of specific features of our nervous system (for example that visual information presented to a specific visual field is preferentially processed by the cortical hemisphere on the opposite side) to make links between neuroanatomy and psychological function.
Clinical neuropsychology is the application of neuropsychological knowledge to the assessment (see neuropsychological test and neuropsychological assessment), management, and rehabilitation of people who have suffered illness or injury (particularly to the brain) which has caused neurocognitive problems. In particular they bring a psychological viewpoint to treatment, to understand how such illness and injury may affect and be affected by psychological factors. They also can offer an opinion as to whether a person is demonstrating difficulties due to brain pathology or as a consequence of an emotional or another (potentially) reversible cause or both. For example, a test might show that both patients X and Y are unable to name items that they have been previously exposed to within the past 20 minutes (indicating possible dementia). If patient Y can name some of them with further prompting (e.g. given a categorical clue such as being told that the item they could not name is a fruit), this allows a more specific diagnosis than simply dementia (Y appears to have the vascular type which is due to brain pathology but is usually at least somewhat reversible). Clinical neuropsychologists often work in hospital settings in an interdisciplinary medical team; others work in private practice and may provide expert input into medico-legal proceedings.
Cognitive neuropsychology is a relatively new development and has emerged as a distillation of the complementary approaches of both experimental and clinical neuropsychology. It seeks to understand the mind and brain by studying people who have suffered brain injury or neurological illness. One model of neuropsychological functioning is known as functional localisation. This is based on the principle that if a specific cognitive problem can be found after an injury to a specific area of the brain, it is possible that this part of the brain is in some way involved. However, there may be reason to believe that the link between mental functions and neural regions is not so simple. An alternative model of the link between mind and brain, such as parallel processing, may have more explanatory power for the workings and dysfunction of the human brain. Yet another approach investigates how the pattern of errors produced by brain-damaged individuals can constrain our understanding of mental representations and processes without reference to the underlying neural structure. A more recent but related approach is cognitive neuropsychiatry which seeks to understand the normal function of mind and brain by studying psychiatric or mental illness.
Connectionism is the use of artificial neural networks to model specific cognitive processes using what are considered to be simplified but plausible models of how neurons operate. Once trained to perform a specific cognitive task these networks are often damaged or ‘lesioned’ to simulate brain injury or impairment in an attempt to understand and compare the results to the effects of brain injury in humans.
Functional neuroimaging uses specific neuroimaging technologies to take readings from the brain, usually when a person is doing a particular task, in an attempt to understand how the activation of particular brain areas is related to the task. In particular, the growth of methodologies to employ cognitive testing within established functional magnetic resonance imaging (fMRI) techniques to study brain-behaviour relations is having a notable influence on neuropsychological research.
In practice these approaches are not mutually exclusive and most neuropsychologists select the best approach or approaches for the task to be completed.
Methods and Tools
Standardised Neuropsychological Tests
These tasks have been designed so the performance on the task can be linked to specific neurocognitive processes. These tests are typically standardised, meaning that they have been administered to a specific group (or groups) of individuals before being used in individual clinical cases. The data resulting from standardisation are known as normative data. After these data have been collected and analysed, they are used as the comparative standard against which individual performances can be compared. Examples of neuropsychological tests include: the Wechsler Memory Scale (WMS), the Wechsler Adult Intelligence Scale (WAIS), Boston Naming Test, the Wisconsin Card Sorting Test, the Benton Visual Retention Test, and the Controlled Oral Word Association.
Brain Scans
The use of brain scans to investigate the structure or function of the brain is common, either as simply a way of better assessing brain injury with high resolution pictures, or by examining the relative activations of different brain areas. Such technologies may include fMRI (functional magnetic resonance imaging) and positron emission tomography (PET), which yields data related to functioning, as well as MRI (magnetic resonance imaging) and computed axial tomography (CAT or CT), which yields structural data.
Global Brain Project
Brain models based on mouse and monkey have been developed based on theoretical neuroscience involving working memory and attention, while mapping brain activity based on time constants validated by measurements of neuronal activity in various layers of the brain. These methods also map to decision states of behaviour in simple tasks that involve binary outcomes.
Electrophysiology
The use of electrophysiological measures designed to measure the activation of the brain by measuring the electrical or magnetic field produced by the nervous system. This may include electroencephalography (EEG) or magneto-encephalography (MEG).
Experimental Tasks
The use of designed experimental tasks, often controlled by computer and typically measuring reaction time and accuracy on a particular tasks thought to be related to a specific neurocognitive process. An example of this is the Cambridge Neuropsychological Test Automated Battery (CANTAB) or CNS Vital Signs (CNSVS).
Mentalisation-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioural, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganised attachment and failed to develop a robust mentalisation capacity. Fonagy and Bateman define mentalisation as the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that patients with BPD increase their mentalisation capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.
More recently, a range of mentalisation-based treatments, using the “mentalising stance” defined in MBT but directed at children (MBT-C), families (MBT-F) and adolescents (MBT-A), and for chaotic multi-problem youth, AMBIT (adaptive mentalisation-based integrative treatment) has been under development by groups mainly gravitating around the Anna Freud National Centre for Children and Families.
The treatment should be distinguished from and has no connection with mindfulness-based stress reduction (MBSR) therapy developed by Jon Kabat-Zinn.
Goals
The major goals of MBT are:
Better behavioural control.
Increased affect regulation.
More intimate and gratifying relationships.
The ability to pursue life goals.
This is believed to be accomplished through increasing the patient’s capacity for mentalisation in order to stabilise the client’s sense of self and to enhance stability in emotions and relationships.
Focus of Treatment
A distinctive feature of MBT is placing the enhancement of mentalising itself as focus of treatment. The aim of therapy is not developing insight, but the recovery of mentalising. Therapy examines mainly the present moment, attending to events of the past only insofar as they affect the individual in the present. Other core aspects of treatment include a stance of curiosity, partnership with the patient rather than an ‘expert’ type role, monitoring and regulating emotional arousal, and identifying the affect focus. Transference in classical understanding of this term is not included in the MBT model. MBT does encourage consideration of the patient-therapist relationship, but without necessarily generalising to other relationships, past or present.
Treatment Procedure
MBT should be offered to patients twice per week with sessions alternating between group therapy and individual treatment. During sessions the therapist works to stimulate or nurture mentalising. Particular techniques are employed to lower or raise emotional arousal as needed, to interrupt non-mentalising and to foster flexibility in perspective-taking. Activation occurs through the elaboration of current attachment relationships, the therapist’s encouragement and regulation of the patient’s attachment bond with the therapist and the therapist’s attempts to create attachment bonds between members of the therapy group.
Mechanisms of Change
The safe attachment relationship with the therapist provides a relational context in which it is safe for the patient to explore the mind of the other. Fonagy and Bateman have recently proposed that MBT (and other evidence-based therapies) works by providing ostensive cues that stimulate epistemic trust. The increase in epistemic trust, together with a persistent focus on mentalising in therapy, appear to facilitate change by leaving people more open to learning outside of therapy, in the social interactions of their day-to-day lives.
Efficacy
Fonagy, Bateman, and colleagues have done extensive outcome research on MBT for borderline personality disorder. The first randomised, controlled trial was published in 1999, concerning MBT delivered in a partial hospital setting. The results showed real-world clinical effectiveness that compared favourably with existing treatments for BPD. A follow-up study published in 2003 demonstrated that MBT is cost-effective. Encouraging results were also found in an 18-month study, in which subjects were randomly assigned to an outpatient MBT treatment condition versus a structured clinical management (SCM) treatment. The lasting efficacy of MBT was demonstrated in an 8-year follow-up of patients from the original trial, comparing MBT versus treatment as usual. In that research, patients who had received MBT had less medication use, fewer hospitalisations and longer periods of employment compared to patients who received standard care. Replication studies have been published by other European investigators. Researchers have also demonstrated the effectiveness of MBT for adolescents as well as that of a group-only format of MBT.
Mental Health Matters 
You must be logged in to post a comment.