Mental Health Matters

What is Therapy?

Published on 01/04/202101/04/2021 by Andrew Marshall28 Comments

Introduction

A therapy or medical treatment (often abbreviated tx, Tx, or Tx) is the attempted remediation of a health problem, usually following a medical diagnosis.

As a rule, each therapy has indications and contraindications. There are many different types of therapy. Not all therapies are effective. Many therapies can produce unwanted adverse effects.

Treatment and therapy are generally considered synonyms. However, in the context of mental health, the term therapy may refer specifically to psychotherapy.

Semantic Field

The words care, therapy, treatment, and intervention overlap in a semantic field, and thus they can be synonymous depending on context. Moving rightward through that order, the connotative level of holism decreases and the level of specificity (to concrete instances) increases. Thus, in health care contexts (where its senses are always noncount), the word care tends to imply a broad idea of everything done to protect or improve someone’s health (for example, as in the terms preventive care and primary care, which connote ongoing action), although it sometimes implies a narrower idea (for example, in the simplest cases of wound care or post-anaesthesia care, a few particular steps are sufficient, and the patient’s interaction with that provider is soon finished).

In contrast, the word intervention tends to be specific and concrete, and thus the word is often countable; for example, one instance of cardiac catheterisation is one intervention performed, and coronary care (noncount) can require a series of interventions (count). At the extreme, the piling on of such countable interventions amounts to interventionism, a flawed model of care lacking holistic circumspection – merely treating discrete problems (in billable increments) rather than maintaining health. Therapy and treatment, in the middle of the semantic field, can connote either the holism of care or the discreteness of intervention, with context conveying the intent in each use. Accordingly, they can be used in both noncount and count senses (for example, therapy for chronic kidney disease can involve several dialysis treatments per week).

The words aceology and iamatology are obscure and obsolete synonyms referring to the study of therapies.

The English word therapy comes via Latin therapīa from Greek: θεραπεία and literally means “curing” or “healing”.

Types of Therapies

By Chronology, Priority, or Intensity

Levels of Care

Levels of care classify health care into categories of chronology, priority, or intensity, as follows:

Emergency care handles medical emergencies and is a first point of contact or intake for less serious problems, which can be referred to other levels of care as appropriate.
Intensive care, also called critical care, is care for extremely ill or injured patients.
- It thus requires high resource intensity, knowledge, and skill, as well as quick decision making.
Ambulatory care is care provided on an outpatient basis.
- Typically patients can walk into and out of the clinic under their own power (hence “ambulatory”), usually on the same day.
Home care is care at home, including care from providers (such as physicians, nurses, and home health aides) making house calls, care from caregivers such as family members, and patient self-care.
Primary care is meant to be the main kind of care in general, and ideally a medical home that unifies care across referred providers.
Secondary care is care provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, cardiologists, urologists and dermatologists.
- A patient reaches secondary care as a next step from primary care, typically by provider referral although sometimes by patient self-initiative.
Tertiary care is specialised consultative care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital.
Follow-up care is additional care during or after convalescence.
- Aftercare is generally synonymous with follow-up care.
End-of-life care is care near the end of one’s life. It often includes the following:
- Palliative care is supportive care, most especially (but not necessarily) near the end of life.
- Hospice care is palliative care very near the end of life when cure is very unlikely.
  - Its main goal is comfort, both physical and mental.

Lines of Therapy

Treatment decisions often follow formal or informal algorithmic guidelines. Treatment options can often be ranked or prioritised into lines of therapy: first-line therapy, second-line therapy, third-line therapy, and so on.

First-line therapy (sometimes called induction therapy, primary therapy, or front-line therapy) is the first therapy that will be tried. Its priority over other options is usually either:

Formally recommended on the basis of clinical trial evidence for its best-available combination of efficacy, safety, and tolerability; or
Chosen based on the clinical experience of the physician.

If a first-line therapy either fails to resolve the issue or produces intolerable side effects, additional (second-line) therapies may be substituted or added to the treatment regimen, followed by third-line therapies, and so on.

An example of a context in which the formalisation of treatment algorithms and the ranking of lines of therapy is very extensive is chemotherapy regimens. Because of the great difficulty in successfully treating some forms of cancer, one line after another may be tried. In oncology the count of therapy lines may reach 10 or even 20.

Often multiple therapies may be tried simultaneously (combination therapy or polytherapy). Thus combination chemotherapy is also called polychemotherapy, whereas chemotherapy with one agent at a time is called single-agent therapy or monotherapy.

Adjuvant therapy is therapy given in addition to the primary, main, or initial treatment, but simultaneously (as opposed to second-line therapy). Neoadjuvant therapy is therapy that is begun before the main therapy. Thus one can consider surgical excision of a tumour as the first-line therapy for a certain type and stage of cancer even though radiotherapy is used before it; the radiotherapy is neoadjuvant (chronologically first but not primary in the sense of the main event). Premedication is conceptually not far from this, but the words are not interchangeable; cytotoxic drugs to put a tumour “on the ropes” before surgery delivers the “knockout punch” are called neoadjuvant chemotherapy, not premedication, whereas things like anaesthetics or prophylactic antibiotics before dental surgery are called premedication.

Step therapy or stepladder therapy is a specific type of prioritisation by lines of therapy. It is controversial in American health care because unlike conventional decision-making about what constitutes first-line, second-line, and third-line therapy, which in the US reflects safety and efficacy first and cost only according to the patient’s wishes, step therapy attempts to mix cost containment by someone other than the patient (third-party payers) into the algorithm. Therapy freedom and the negotiation between individual and group rights are involved.

By Intent

Therapy Type	Description
Abortive Therapy	1. A therapy that is intended to stop a medical condition from progressing any further. 2. A medication taken at the earliest signs of a disease, such as an analgesic taken at the very first symptoms of a migraine headache to prevent it from getting worse, is an abortive therapy. 3. Compare abortifacients, which abort a pregnancy.
Bridge Therapy	1. A therapy that figuratively provides a bridge to another step or phase, crossing over some immediate chasm (challenge). 2. In contrast with destination therapy (see below), which is the final therapy in cases where clinically appropriate.
Consolidation Therapy	1. A therapy given to consolidate the gains from induction therapy. In cancer, this means chasing after any malignant cells that may be left.
Curative Therapy	1. A therapy with curative intent, that is, one that seeks to cure the root cause of a disorder. 2. Also known as etiotropic therapy.
Definitive Therapy	1. A therapy that may be final, superior to others, curative, or all of those.
Destination Therapy	1. A therapy that is the final destination rather than a bridge to another therapy. 2. Usually refers to ventricular assist devices to keep the existing heart going, not just until a heart transplant can occur, but for the rest of the patient’s life expectancy.
Empiric Therapy	1. A therapy given on an empiric basis; that is, one given according to a clinician’s educated guess despite uncertainty about the illness’s causative factors. 2. For example, empiric antibiotic therapy administers a broad-spectrum antibiotic immediately on the basis of a good chance (given the history, physical examination findings, and risk factors present) that the illness is bacterial and will respond to that drug (even though the bacterial species or variant is not yet known).
Gold Standard Therapy	1. A therapy that is definitive, just as a gold standard diagnostic test is a definitive test.
Investigational Therapy	1. An experimental therapy. Use of experimental therapies must be ethically justified, because by definition they raise the question of standard of care. 2. Physicians have autonomy to provide empirical care (such as off-label care) according to their experience and clinical judgment, but the autonomy has limits that preclude quackery. 3. Thus it may be necessary to design a clinical trial around the new therapy and to use the therapy only per a formal protocol. 4. Sometimes shorthand phrases such as “treated on protocol” imply not just “treated according to a plan” but specifically “treated with investigational therapy”.
Maintenance Therapy	1. A therapy taken during disease remission to prevent relapse.
Palliative Therapy	See supportive therapy (below) for connotative distinctions.
Preventive Therapy (Prophylactic Therapy)	1. A therapy that is intended to prevent a medical condition from occurring (also known as prophylaxis). 2. For example, many vaccines prevent infectious diseases.
Salvage Therapy (Rescue Therapy)	1. A therapy tried after others have failed; it may be a “last-line” therapy.
Stepdown Therapy	1. Therapy that tapers the dosage gradually rather than abruptly cutting it off. 2. For example, a switch from intravenous to oral antibiotics as an infection is brought under control steps down the intensity of therapy.
Supportive Therapy	1. A therapy that does not treat or improve the underlying condition, but instead increases the patient’s comfort, also called symptomatic treatment (see there for more information). 2. For example, supportive care for flu, colds, or gastrointestinal upset can include rest, fluids, and over the counter pain relievers; those things do not treat the cause, but they treat the symptoms and thus provide relief. 3. Supportive therapy may be palliative therapy (palliative care). 4. The two terms are sometimes synonymous, but palliative care often specifically refers to serious illness and end-of-life care. 5. Therapy may be categorised as having curative intent (when it is possible to eliminate the disease) or palliative intent (when eliminating the disease is impossible and the focus shifts to minimizing the distress that it causes). 6. The two are often contradistinguished (mutually exclusive) in some contexts (such as the management of some cancers), but they are not inherently mutually exclusive; often a therapy can be both curative and palliative simultaneously. 7. Supportive psychotherapy aims to support the patient by alleviating the worst of the symptoms, with the expectation that definitive therapy can follow later if possible.
Systemic Therapy	1. A therapy that is systemic. 2. In the physiological sense, this means affecting the whole body (rather than being local or locoregional), whether via systemic administration, systemic effect, or both. 3. Systemic therapy in the psychotherapeutic sense seeks to address people not only on the individual level but also as people in relationships, dealing with the interactions of groups.

By Therapy Composition

Treatments can be classified according to the method of treatment:

By Matter:
- By drugs: pharmacotherapy, chemotherapy (also, medical therapy often means specifically pharmacotherapy).
- By medical devices: implantation.
  - Cardiac resynchronisation therapy.
- By specific molecules: molecular therapy (although most drugs are specific molecules, molecular medicine refers in particular to medicine relying on molecular biology).
  - By specific biomolecular targets: targeted therapy.
    - Molecular chaperone therapy.
  - By chelation: chelation therapy
- By specific chemical elements:
  - By metals:
    - By heavy metals:
    - By gold: chrysotherapy (aurotherapy).
    - By platinum-containing drugs: platin therapy.
    - By biometals:
      - By lithium: lithium therapy.
      - By potassium: potassium supplementation.
      - By magnesium: magnesium supplementation.
      - By chromium: chromium supplementation; phonemic neurological hypochromium therapy.
      - By copper: copper supplementation.
  - By non-metals:
    - By diatomic oxygen: oxygen therapy, hyperbaric oxygen therapy (hyperbaric medicine).
    - Transdermal continuous oxygen therapy.
    - By triatomic oxygen (ozone): ozone therapy.
    - By fluoride: fluoride therapy.
    - By other gases: medical gas therapy.
- By water:
  - Hydrotherapy.
  - Aquatic therapy.
  - Rehydration therapy.
    - Oral rehydration therapy.
  - Water cure (therapy).
- By biological materials (biogenic substances, biomolecules, biotic materials, natural products), including their synthetic equivalents: biotherapy.
  - By whole organisms.
    - By viruses: virotherapy.
    - By bacteriophages: phage therapy.
    - By animal interaction: see animal interaction section.
  - By constituents or products of organisms.
    - By plant parts or extracts (but many drugs are derived from plants, even when the term phytotherapy is not used).
      - Scientific type: phytotherapy.
      - Traditional (prescientific) type: herbalism.
    - By animal parts: quackery involving shark fins, tiger parts, and so on, often driving threat or endangerment of species.
    - By genes: gene therapy.
      - Gene therapy for epilepsy.
      - Gene therapy for osteoarthritis.
      - Gene therapy for colour blindness.
      - Gene therapy of the human retina.
      - Gene therapy in Parkinson’s disease.
    - By epigenetics: epigenetic therapy.
    - By proteins: protein therapy (but many drugs are proteins despite not being called protein therapy).
    - By enzymes: enzyme replacement therapy.
    - By hormones: hormone therapy.
      - Hormonal therapy (oncology).
      - Hormone replacement therapy.
        Oestrogen replacement therapy.
        Androgen replacement therapy.
        Hormone replacement therapy (menopause).
        Hormone replacement therapy (transgender).
        Hormone replacement therapy (male-to-female).
        Hormone replacement therapy (female-to-male).
      - Antihormone therapy.
        Androgen deprivation therapy.
    - By whole cells: cell therapy (cytotherapy).
      - By stem cells: stem cell therapy.
      - By immune cells: see immune system products below.
    - By immune system products: immunotherapy, host modulatory therapy.
      - By immune cells:
        T-cell vaccination.
        Cell transfer therapy.
        Autologous immune enhancement therapy.
        TK cell therapy.
      - By humoral immune factors: antibody therapy.
        By whole serum: serotherapy, including antiserum therapy.
        By immunoglobulins: immunoglobulin therapy.
        By monoclonal antibodies: monoclonal antibody therapy.
  - By urine: urine therapy (some scientific forms; many prescientific or pseudoscientific forms).
  - By food and dietary choices:
    - Medical nutrition therapy.
    - Grape therapy (quackery).
- By salts (but many drugs are the salts of organic acids, even when drug therapy is not called by names reflecting that).
  - By salts in the air.
    - By natural dry salt air: “taking the cure” in desert locales (especially common in prescientific medicine; for example, one 19th-century way to treat tuberculosis).
    - By artificial dry salt air:
      - Low-humidity forms of speleotherapy.
      - Negative air ionisation therapy.
    - By moist salt air:
      - By natural moist salt air: seaside cure (especially common in prescientific medicine).
      - By artificial moist salt air: water vapor forms of speleotherapy.
    - By salts in the water.
      - By mineral water: spa cure (“taking the waters”) (especially common in prescientific medicine).
      - By seawater: seaside cure (especially common in prescientific medicine).
- By aroma: aromatherapy.
- By other materials with mechanism of action unknown.
  - By occlusion with duct tape: duct tape occlusion therapy.

By Energy:
- By electric energy as electric current: electrotherapy, electroconvulsive therapy:
  - Transcranial magnetic stimulation.
- By magnetic energy:
  - Magnet therapy.
  - Pulsed electromagnetic field therapy.
  - Magnetic resonance therapy.
- By electromagnetic radiation (EMR):
  - By light: light therapy (phototherapy).
    - Ultraviolet light therapy.
      - PUVA therapy.
    - Photodynamic therapy.
      - Photothermal therapy.
      - Cytoluminescent therapy.
    - Blood irradiation therapy.
    - By darkness: dark therapy.
    - By lasers: laser therapy.
      - Low level laser therapy.
  - By gamma rays: radiosurgery.
    - Gamma Knife radiosurgery.
    - Stereotactic radiation therapy.
    - Cobalt therapy.
  - By radiation generally: radiation therapy (radiotherapy).
    - Intraoperative radiation therapy.
    - By EMR particles:
      - Particle therapy.
        Proton therapy.
        Electron therapy.
        Intraoperative electron radiation therapy.
        Auger therapy.
        Neutron therapy.
        Fast neutron therapy.
        Neutron capture therapy of cancer.
    - By radioisotopes emitting EMR:
      - By nuclear medicine.
      - By brachytherapy.
  - Quackery type: electromagnetic therapy (alternative medicine).
- By mechanical: manual therapy as massotherapy and therapy by exercise as in physiotherapy and exercise therapy.
  - Inversion therapy.
- By sound:
  - By ultrasound:
    - Ultrasonic lithotripsy.
      - Extracorporeal shock wave lithotripsy.
      - Extracorporeal shockwave therapy.
    - Sonodynamic therapy.
  - By music: music therapy.
    - Neurologic music therapy.
- By temperature.
  - By heat: heat therapy (thermotherapy).
    - By moderately elevated ambient temperatures: hyperthermia therapy.
      - By dry warm surroundings: Waon therapy.
      - By dry or humid warm surroundings: sauna, including infrared sauna, for sweat therapy
  - By cold:
    - By extreme cold to specific tissue volumes: cryotherapy.
    - By ice and compression: cold compression therapy.
    - By ambient cold: hypothermia therapy for neonatal encephalopathy.
  - By hot and cold alternation: contrast bath therapy.

By Procedure and Human Interaction:
- Surgery.
- By counselling, such as psychotherapy (refer to list of psychotherapies).
  - Systemic therapy.
  - By group psychotherapy.
- By cognitive behavioural therapy.
  - By cognitive therapy.
  - By behaviour therapy.
    - By dialectical behaviour therapy.
  - By cognitive emotional behavioural therapy.
- By cognitive rehabilitation therapy.
- By family therapy.
- By education.
  - By psychoeducation.
  - By information therapy.
- By physical therapy/occupational therapy, vision therapy, massage therapy, chiropractic or acupuncture.
- By lifestyle modifications, such as avoiding unhealthy food or maintaining a predictable sleep schedule.
- By coaching.

By Animal Interaction:
- By pets, assistance animals, or working animals: animal-assisted therapy.
  - By horses: equine therapy, hippotherapy.
  - By dogs: pet therapy with therapy dogs, including grief therapy dogs.
  - By cats: pet therapy with therapy cats.
- By fish: ichthyotherapy (wading with fish), aquarium therapy (watching fish).
- By maggots: maggot therapy.
- By worms:
  - By internal worms: helminthic therapy.
  - By leeches: leech therapy.
- By immersion: animal bath.

By Meditation:
- By mindfulness: mindfulness-based cognitive therapy.

By Reading:
- By bibliotherapy.

By Creativity:
- By expression: expressive therapy.
  - By writing: writing therapy.
    - Journal therapy.
- By play: play therapy.
- By art: art therapy.
  - Sensory art therapy.
  - Comic book therapy.
- By gardening: horticultural therapy.
- By dance: dance therapy.
- By drama: drama therapy.
- By recreation: recreational therapy.
- By music: music therapy.

By Sleeping and Waking:
- By deep sleep: deep sleep therapy.
- By waking: wake therapy.

What is the Impact of Military Service Exposures & Psychological Resilience on the Mental Health Trajectories of Older Male Veterans?

Published on 01/04/202101/04/2021 by Andrew MarshallLeave a comment

Research Paper Title

The Impact of Military Service Exposures and Psychological Resilience on the Mental Health Trajectories of Older Male Veterans.

Background

The researchers examine the impact of exposure to the dead, dying, and wounded (DDW) during military service on the later-life depressive symptom trajectories of male United States veterans, using psychological resilience as an internal resource that potentially moderates negative consequences.

Methods

The Health and Retirement Study (2006-2014) and linked Veteran Mail Survey were used to estimate latent growth curve models of depressive symptom trajectories, beginning at respondents’ first report of resilience.

Results

Veterans with higher levels of resilience do not have increased depressive symptoms in later life, despite previous exposure to DDW. Those with lower levels of resilience and previous exposure to DDW experience poorer mental health in later life.

Conclusions

Psychological resilience is important for later-life mental health, particularly for veterans who endured potentially traumatic experiences. The researches discuss the importance acknowledging the role individual resources play in shaping adaptation to adverse life events and implications for mental health service needs.

Reference

Urena, S., Taylor, M.G. & Carr, D.C. (2020) The Impact of Military Service Exposures and Psychological Resilience on the Mental Health Trajectories of Older Male Veterans. Journal of Aging and Health. doi: 10.1177/0898264320975231. Online ahead of print.

What is a Psychiatrist?

Published on 01/04/202101/04/2021 by Andrew Marshall291 Comments

Introduction

A psychiatrist is a physician who specialises in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders.

Psychiatrists are medical doctors and evaluate patients to determine whether their symptoms are the result of a physical illness, a combination of physical and mental ailments or strictly mental issues. A psychiatrist usually works within a multi-disciplinary team, which may comprise clinical psychologists, social workers, occupational therapists, and nursing staff. Psychiatrists have broad training in a bio-psycho-social approach to assessment and management of mental illness.

As part of the clinical assessment process, psychiatrists may employ a mental status examination; a physical examination; brain imaging such as a computerised tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) scan; and blood testing. Psychiatrists prescribe medicine, and may also use psychotherapy, although they could also primarily concentrate on medical management and refer to a psychologist or other specialised therapist for weekly to bi-monthly psychotherapy.

Subspecialties

The field of psychiatry (in the US) has many subspecialties (also known as fellowships) that require additional training which are certified by the American Board of Psychiatry and Neurology (ABPN) and require Maintenance of Certification Programme (MOC) to continue. These include the following:

Clinical neurophysiology.
Forensic psychiatry.
Addiction psychiatry.
Child and adolescent psychiatry.
Geriatric psychiatry.
Hospice and palliative medicine.
Pain management.
Psychosomatic medicine (also known as consultation-liaison psychiatry).
Sleep medicine.
Brain injury medicine.
Further, other specialties that exist include:
- Cross-cultural psychiatry.
- Emergency psychiatry.
- Learning disability.
- Neurodevelopmental disorder.
- Cognition diseases as in various forms of dementia.
- Biological psychiatry.
- Community psychiatry.
- Global mental health.
- Military psychiatry.
- Social psychiatry.
- Sports psychiatry.

The United Council for Neurologic Subspecialties in the US offers certification and fellowship programme accreditation in the subspecialty ‘Behavioural Neurology and Neuropsychiatry’ (BNNP) – which is open to both neurologists and psychiatrists.

Some psychiatrists specialise in helping certain age groups. Paediatric psychiatry is the area of the profession working with children in addressing psychological problems. Psychiatrists specialising in geriatric psychiatry work with the elderly and are called geriatric psychiatrists or geropsychiatrists. Those who practice psychiatry in the workplace are called occupational psychiatrists in the US and occupational psychology is the name used for the most similar discipline in the UK. Psychiatrists working in the courtroom and reporting to the judge and jury, in both criminal and civil court cases, are called forensic psychiatrists, who also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

Other psychiatrists and mental health professionals in the field of psychiatry may also specialise in psychopharmacology, psychotherapy, psychiatric genetics, neuroimaging, dementia-related disorders such as Alzheimer’s disease, attention deficit hyperactivity disorder (ADHD), sleep medicine, pain medicine, palliative medicine, eating disorders, sexual disorders, women’s health, global mental health, early psychosis intervention, mood disorders, and anxiety disorders such as obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).

Psychiatrists work in a wide variety of settings. Some are full-time medical researchers, many see patients in private medical practices, consult liaison psychiatrists see patients in hospital settings where psychiatric and other medical conditions interact.

Professional Requirements

While requirements to become a psychiatrist differ from country to country, all require a medical degree.

US and Canada

In the US and Canada one must first attain the degree of M.D. or D.O., followed by practice as a psychiatric resident for another four years (five years in Canada). This extended period involves comprehensive training in psychiatric diagnosis, psychopharmacology, medical care issues, and psychotherapies. All accredited psychiatry residencies in the United States require proficiency in cognitive-behavioural, brief, psychodynamic, and supportive psychotherapies. Psychiatry residents are required to complete at least four post-graduate months of internal medicine or paediatrics, plus a minimum of two months of neurology during their first year of residency, referred to as an “internship”. After completing their training, psychiatrists are eligible to take a specialty board examination to become board-certified. The total amount of time required to complete educational and training requirements in the field of psychiatry in the US is twelve years after high school. Subspecialists in child and adolescent psychiatry are required to complete a two-year fellowship program, the first year of which can run concurrently with the fourth year of the general psychiatry residency program. This adds one to two years of training.

The United Kingdom and the Republic of Ireland

In the UK, psychiatrists must hold a medical degree. These degrees are often abbreviated MB BChir, MB BCh, MB ChB, BM BS, or MB BS. Following this, the individual will work as a Foundation House Officer for two additional years in the UK, or one year as Intern in the Republic of Ireland to achieve registration as a basic medical practitioner. Training in psychiatry can then begin and it is taken in two parts: three years of Basic Specialist Training culminating in the MRCPsych exam followed by three years of Higher Specialist Training referred to as “ST4-6” in the UK and “Senior Registrar Training” in the Republic of Ireland. Candidates with MRCPsych degree and complete basic training must re-interview for higher specialist training. At this stage, the development of special interests such as forensic, child/adolescent takes place. At the end of 3 years of higher specialist training, candidates are awarded a CCT (UK) or CCST (Ireland), both meaning Certificate of Completion of (Specialist) Training. At this stage, the psychiatrist can register as a specialist, and the qualification of CC(S)T is recognised in all EU/EEA states (subject to Brexit). As such, training in the UK and Ireland is considerably longer than in the US or Canada and frequently takes around 8-9 years following graduation from medical school. Those with a CC(S)T will be able to apply for Consultant posts. Those with training from outside the EU/EEA should consult local/native medical boards to review their qualifications and eligibility for equivalence recognition (for example, those with a US residency and ABPN qualification).

Netherlands

In the Netherlands, one must complete medical school after which one is certified as a medical doctor. After a strict selection programme, one can specialise in psychiatry: a 4.5-year specialisation. During this specialisation, the resident has to do a 6-month residency in the field of social psychiatry, a 12-month residency in a field of their own choice (which can be child psychiatry, forensic psychiatry, somatic medicine, or medical research). To become an adolescent psychiatrist, one has to do an extra specialisation period of 2 more years. In short, this means that it takes at least 10.5 years of study to become a psychiatrist which can go up to 12.5 years if one becomes a children’s and adolescent psychiatrist.

India

In India, an MBBS degree is the basic qualification needed to do Psychiatry. After completing MBBS (including internship) one can attend various PG Medical Entrance Exams and take MD in psychiatry which is a 3-year course. Diploma Course in Psychiatry or DNB Psychiatry can also be taken to become a Psychiatrist.

Pakistan

In Pakistan, one must complete basic medical education, an MBBS, then get registered with Pakistan Medical and Dental Council as a General Practitioner after a one-year mandatory internship, House Job. After registration with PMDC, one has to go for FCPS-I exam, after that four-year training in Psychiatry under College of Physicians and Surgeons Pakistan. Training includes rotations in General Medicine, Neurology, and Clinical Psychology for 3 months each, during first two years. There is a mid-exam IMM (Intermediate Module) and a final exam after 4 years.

Schizophrenia: Clozapine Treatment & Haematological Changes

Published on 01/04/2021 by Andrew MarshallLeave a comment

Research Paper Title

Clozapine Response in Schizophrenia and Hematological Changes.

Background

Clozapine is the only effective medication for treatment-resistant schizophrenia; however, its mechanism of action remains unclear. The present study explored whether its effectiveness is related to changes in haematological measures after clozapine initiation.

Methods

Patients with treatment-resistant schizophrenia commenced on clozapine between January 2007 and December 2014 by the United Kingdom’s largest mental health trust were identified from electronic patient records. Haematological data from these patients were obtained from a monitoring registry. White blood cell, neutrophil, and platelet count were assessed at baseline and during the early phase of clozapine treatment. Clozapine response at 3 months was defined as “much,” or “very much” improved on the seven-point Clinical Global Impression-Improvement (CGI-I) subscale.

Results

In the total sample (n = 188), clozapine initiation was associated with a significant transient increase (peaking in weeks 3 to 4) in white blood cell, neutrophil, and platelet count (P < 0.001). There were 112 (59.6%) patients that responded to treatment; however, none of the haematological factors assessed at baseline, nor changes in these factors, were directly associated with treatment response.

Conclusions

Clozapine treatment is associated with transient haematological changes during the first month of treatment; however, there was no evidence that these were related to the therapeutic response.

Reference

Blackman, G., Lisshammer, J.E.L., Zafar, R., Pollak, T.A., Prutchard, M., Cullen, A.E., Rogers, J., Carter, B., Griffiths, K., Nour, M., David, A.S., McGuire, P., Stewart, R. & MacCabe, J. (2020) Clozapine Response in Schizophrenia and Hematological Changes. Journal of Clinical Psychopharmacology. 41(1):19-24. doi: 10.1097/JCP.0000000000001329.

What is Psychoanalysis?

Published on 01/03/2021 by Andrew Marshall183 Comments

Introduction

Psychoanalysis (from Greek: ψυχή, psykhḗ, ‘soul’ + ἀνάλυσις, análysis, ‘investigate’) is a set of theories and therapeutic techniques used to study the unconscious mind, which together form a method of treatment for mental disorders. The discipline was established in the early 1890s by Austrian neurologist Sigmund Freud, who retained the term psychoanalysis for his own school of thought. Freud’s work stems partly from the clinical work of Josef Breuer and others. Psychoanalysis was later developed in different directions, mostly by students of Freud, such as Alfred Adler and his collaborator, Carl Gustav Jung, as well as by neo-Freudian thinkers, such as Erich Fromm, Karen Horney, and Harry Stack Sullivan.

Psychoanalysis has been known to be a controversial discipline, and its validity as a science is very contested. Nonetheless, it retains a relatively salient influence within psychiatry, albeit more so in some quarters than others. Psychoanalytic concepts are also widely used outside the therapeutic arena, in areas such as psychoanalytic literary criticism, as well as in the analysis of film, fairy tales, philosophical perspectives as Freudo-Marxism and other cultural phenomena.

Basic Tenets

The basic tenets of psychoanalysis include:

A person’s development is determined by often forgotten events in early childhood, rather than by inherited traits alone.
Human behaviour and cognition are largely determined by instinctual drives that are rooted in the unconscious.
Attempts to bring such drives into awareness triggers resistance in the form of defence mechanisms, particularly repression.
Conflicts between conscious and unconscious material can result in mental disturbances, such as neurosis, neurotic traits, anxiety, and depression.
Unconscious material can be found in dreams and unintentional acts, including mannerisms and slips of the tongue.
Liberation from the effects of the unconscious is achieved by bringing this material into the conscious mind through therapeutic intervention.
The “centrepiece of the psychoanalytic process” is the transference, whereby patients relive their infantile conflicts by projecting onto the analyst feelings of love, dependence and anger.

Practice

During psychoanalytic sessions, typically lasting 50 minutes, ideally 4-5 times a week, the patient (or analysand) may lie on a couch, with the analyst often sitting just behind and out of sight. The patient expresses their thoughts, including free associations, fantasies, and dreams, from which the analyst infers the unconscious conflicts causing the patient’s symptoms and character problems. Through the analysis of these conflicts, which includes interpreting the transference and countertransference (the analyst’s feelings for the patient), the analyst confronts the patient’s pathological defences to help the patient gain insight.

History

Sigmund Freud first used the term ‘psychoanalysis’ (French: psychoanalyse) in 1896, ultimately retaining the term for his own school of thought. In November 1899, he wrote the Interpretation of Dreams (German: Die Traumdeutung), which Freud thought of as his “most significant work.”

Psychoanalysis was later developed in different directions, mostly by students of Freud such as Alfred Adler and Carl Gustav Jung,] and by neo-Freudians such as Erich Fromm, Karen Horney and Harry Stack Sullivan.

1890s

The idea of psychoanalysis (German: psychoanalyse) first began to receive serious attention under Sigmund Freud, who formulated his own theory of psychoanalysis in Vienna in the 1890s. Freud was a neurologist trying to find an effective treatment for patients with neurotic or hysterical symptoms. Freud realised that there were mental processes that were not conscious, whilst he was employed as a neurological consultant at the Children’s Hospital, where he noticed that many aphasic children had no apparent organic cause for their symptoms. He then wrote a monograph about this subject. In 1885, Freud obtained a grant to study with Jean-Martin Charcot, a famed neurologist, at the Salpêtrière in Paris, where Freud followed the clinical presentations of Charcot, particularly in the areas of hysteria, paralyses and the anaesthesia’s. Charcot had introduced hypnotism as an experimental research tool and developed the photographic representation of clinical symptoms.

Freud’s first theory to explain hysterical symptoms was presented in Studies on Hysteria (1895; Studien über Hysterie), co-authored with his mentor the distinguished physician Josef Breuer, which was generally seen as the birth of psychoanalysis. The work was based on Breuer’s treatment of Bertha Pappenheim, referred to in case studies by the pseudonym “Anna O.”, treatment which Pappenheim herself had dubbed the “talking cure”. Breuer wrote that many factors could result in such symptoms, including various types of emotional trauma, and he also credited work by others such as Pierre Janet; while Freud contended that at the root of hysterical symptoms were repressed memories of distressing occurrences, almost always having direct or indirect sexual associations.

Around the same time, Freud attempted to develop a neuro-physiological theory of unconscious mental mechanisms, which he soon gave up. It remained unpublished in his lifetime. The term ‘psychoanalysis’ (psychoanalyse) was first introduced by Freud in his essay titled “Heredity and aetiology of neuroses” (“L’hérédité et l’étiologie des névroses”), written and published in French in 1896.

In 1896, Freud also published his seduction theory, claiming to have uncovered repressed memories of incidents of sexual abuse for all his current patients, from which he proposed that the preconditions for hysterical symptoms are sexual excitations in infancy. However, by 1898 he had privately acknowledged to his friend and colleague Wilhelm Fliess that he no longer believed in his theory, though he did not state this publicly until 1906. Though in 1896 he had reported that his patients “had no feeling of remembering the [infantile sexual] scenes”, and assured him “emphatically of their unbelief,” in later accounts he claimed that they had told him that they had been sexually abused in infancy. This became the received historical account until challenged by several Freud scholars in the latter part of the 20th century who argued that he had imposed his preconceived notions on his patients. However, building on his claims that the patients reported infantile sexual abuse experiences, Freud subsequently contended that his clinical findings in the mid-1890s provided evidence of the occurrence of unconscious fantasies, supposedly to cover up memories of infantile masturbation. Only much later did he claim the same findings as evidence for Oedipal desires.

By 1899, Freud had theorised that dreams had symbolic significance, and generally were specific to the dreamer. Freud formulated his second psychological theory – which hypotheses that the unconscious has or is a “primary process” consisting of symbolic and condensed thoughts, and a “secondary process” of logical, conscious thoughts. This theory was published in his 1899 book, The Interpretation of Dreams. Chapter VII is a re-working of the earlier “Project” and Freud outlined his topographic theory. In this theory, which was mostly later supplanted by the Structural Theory, unacceptable sexual wishes were repressed into the “System Unconscious,” unconscious due to society’s condemnation of premarital sexual activity, and this repression created anxiety. This “topographic theory” is still popular in much of Europe, although it has fallen out of favour in much of North America.

1900 to 1940s

In 1905, Freud published Three Essays on the Theory of Sexuality in which he laid out his discovery of the psychosexual phases:

Oral (ages 0-2);
Anal (2-4);
Phallic-oedipal or First genital (3-6);
Latency (6-puberty); and
Mature genital (puberty-onward).

His early formulation included the idea that because of societal restrictions, sexual wishes were repressed into an unconscious state, and that the energy of these unconscious wishes could be turned into anxiety or physical symptoms. Therefore, the early treatment techniques, including hypnotism and abreaction, were designed to make the unconscious conscious in order to relieve the pressure and the apparently resulting symptoms. This method would later on be left aside by Freud, giving free association a bigger role.

In On Narcissism (1915), Freud turned his attention to the titular subject of narcissism. Still using an energic system, Freud characterised the difference between energy directed at the self versus energy directed at others, called cathexis. By 1917, in “Mourning and Melancholia,” he suggested that certain depressions were caused by turning guilt-ridden anger on the self. In 1919, through “A Child is Being Beaten,” he began to address the problems of self-destructive behaviour (moral masochism) and frank sexual masochism. Based on his experience with depressed and self-destructive patients, and pondering the carnage of World War I, Freud became dissatisfied with considering only oral and sexual motivations for behaviour. By 1920, Freud addressed the power of identification (with the leader and with other members) in groups as a motivation for behaviour (in “Group Psychology and the Analysis of the Ego”). In that same year, Freud suggested his ‘dual drive’ theory of sexuality and aggression in “Beyond the Pleasure Principle,” to try to begin to explain human destructiveness. Also, it was the first appearance of his “structural theory” consisting of three new concepts id, ego, and superego.

Three years later, in 1923, he summarised the ideas of id, ego, and superego in “The Ego and the Id.” In the book, he revised the whole theory of mental functioning, now considering that repression was only one of many defence mechanisms, and that it occurred to reduce anxiety. Hence, Freud characterised repression as both a cause and a result of anxiety. In 1926, in “Inhibitions, Symptoms and Anxiety,” Freud characterised how intrapsychic conflict among drive and superego (wishes and guilt) caused anxiety, and how that anxiety could lead to an inhibition of mental functions, such as intellect and speech. “Inhibitions, Symptoms and Anxiety” was written in response to Otto Rank, who, in 1924, published Das Trauma der Geburt (The Trauma of Birth), analysing how art, myth, religion, philosophy and therapy were illuminated by separation anxiety in the “phase before the development of the Oedipus complex.” Freud’s theories, however, characterised no such phase. According to Freud, the Oedipus complex, was at the centre of neurosis, and was the foundational source of all art, myth, religion, philosophy, therapy – indeed of all human culture and civilisation. It was the first time that anyone in the inner circle had characterised something other than the Oedipus complex as contributing to intrapsychic development, a notion that was rejected by Freud and his followers at the time.

By 1936 the “Principle of Multiple Function” was clarified by Robert Waelder. He widened the formulation that psychological symptoms were caused by and relieved conflict simultaneously. Moreover, symptoms (such as phobias and compulsions) each represented elements of some drive wish (sexual and/or aggressive), superego, anxiety, reality, and defences. Also in 1936, Anna Freud, Sigmund’s daughter, published her seminal book, The Ego and the Mechanisms of Defence, outlining numerous ways the mind could shut upsetting things out of consciousness.

1940s to Present

When Hitler’s power grew, the Freud family and many of their colleagues fled to London. Within a year, Sigmund Freud died. In the United States, also following the death of Freud, a new group of psychoanalysts began to explore the function of the ego. Led by Heinz Hartmann, the group built upon understandings of the synthetic function of the ego as a mediator in psychic functioning, distinguishing such from autonomous ego functions (e.g. memory and intellect, which could be secondarily affected by conflict). These “Ego Psychologists” of the 1950s paved a way to focus analytic work by attending to the defences (mediated by the ego) before exploring the deeper roots to the unconscious conflicts.

In addition, there was burgeoning interest in child psychoanalysis. Although criticised since its inception, psychoanalysis has been used as a research tool into childhood development, and is still used to treat certain mental disturbances. In the 1960s, Freud’s early thoughts on the childhood development of female sexuality were challenged; this challenge led to the development of a variety of understandings of female sexual development, many of which modified the timing and normality of several of Freud’s theories (which had been gleaned from the treatment of women with mental disturbances). Several researchers followed Karen Horney’s studies of societal pressures that influence the development of women.

In the first decade of the 21st century, there were approximately 35 training institutes for psychoanalysis in the United States accredited by the American Psychoanalytic Association (APsaA), which is a component organisation of the International Psychoanalytical Association (IPA), and there are over 3000 graduated psychoanalysts practicing in the United States. The IPA accredits psychoanalytic training centres through such “component organisations” throughout the rest of the world, including countries such as Serbia, France, Germany, Austria, Italy, Switzerland, and many others, as well as about six institutes directly in the United States.

The Development of Alternatives to Psychotherapy

In the 1950s, psychoanalysis was the main modality of psychotherapy. Behavioural models of psychotherapy started to assume a more central role in psychotherapy in the 1960s. Aaron T. Beck a psychiatrist trained in a psychoanalytic tradition set out to test the psychoanalytic models of depression and found that conscious ruminations of loss and personal failing were correlated with depression. He suggested that distorted and biased beliefs were a causal factor of depression, publishing an influential paper in 1967 after a decade of research using the construct of schemas to explain the process. Beck developed this into a talking therapy in the early 1970s called cognitive behavioural therapy.

Theories

The predominant psychoanalytic theories can be organised into several theoretical schools. Although these perspectives differ, most of them emphasize the influence of unconscious elements on the conscious. There has also been considerable work done on consolidating elements of conflicting theories.

As in the field of medicine, there are some persistent conflicts regarding specific causes of certain syndromes, and disputes regarding the ideal treatment techniques. In the 21st century, psychoanalytic ideas are embedded in Western culture, especially in fields such as childcare, education, literary criticism, cultural studies, mental health, and particularly psychotherapy. Though there is a mainstream of evolved analytic ideas, there are groups who follow the precepts of one or more of the later theoreticians. Psychoanalytic ideas also play roles in some types of literary analysis such as Archetypal literary criticism.

Topographic Theory

Topographic theory was named and first described by Sigmund Freud in The Interpretation of Dreams (1899). The theory hypothesizes that the mental apparatus can be divided into the systems Conscious, Preconscious, and Unconscious. These systems are not anatomical structures of the brain but, rather, mental processes. Although Freud retained this theory throughout his life he largely replaced it with the structural theory. The Topographic theory remains as one of the meta-psychological points of view for describing how the mind functions in classical psychoanalytic theory.

Structural Theory

Structural theory divides the psyche into the id, the ego, and the super-ego. The id is present at birth as the repository of basic instincts, which Freud called “Triebe” (“drives”): unorganised and unconscious, it operates merely on the ‘pleasure principle’, without realism or foresight. The ego develops slowly and gradually, being concerned with mediating between the urging of the id and the realities of the external world; it thus operates on the ‘reality principle’. The super-ego is held to be the part of the ego in which self-observation, self-criticism and other reflective and judgmental faculties develop. The ego and the super-ego are both partly conscious and partly unconscious.

Theoretical and Clinical Approaches

During the twentieth century, many different clinical and theoretical models of psychoanalysis emerged.

Ego Psychology

Ego psychology was initially suggested by Freud in “Inhibitions, Symptoms and Anxiety” (1926), while major steps forward would be made through Anna Freud’s work on defence mechanisms, first published in her book The Ego and the Mechanisms of Defence (1936).

The theory was refined by Hartmann, Loewenstein, and Kris in a series of papers and books from 1939 through the late 1960s. Leo Bellak was a later contributor. This series of constructs, paralleling some of the later developments of cognitive theory, includes the notions of autonomous ego functions: mental functions not dependent, at least in origin, on intrapsychic conflict. Such functions include: sensory perception, motor control, symbolic thought, logical thought, speech, abstraction, integration (synthesis), orientation, concentration, judgment about danger, reality testing, adaptive ability, executive decision-making, hygiene, and self-preservation. Freud noted that inhibition is one method that the mind may utilise to interfere with any of these functions in order to avoid painful emotions. Hartmann (1950s) pointed out that there may be delays or deficits in such functions.

Frosch (1964) described differences in those people who demonstrated damage to their relationship to reality, but who seemed able to test it.

According to ego psychology, ego strengths, later described by Otto F. Kernberg (1975), include the capacities to control oral, sexual, and destructive impulses; to tolerate painful affects without falling apart; and to prevent the eruption into consciousness of bizarre symbolic fantasy. Synthetic functions, in contrast to autonomous functions, arise from the development of the ego and serve the purpose of managing conflict processes. Defences are synthetic functions that protect the conscious mind from awareness of forbidden impulses and thoughts. One purpose of ego psychology has been to emphasize that some mental functions can be considered to be basic, rather than derivatives of wishes, affects, or defences. However, autonomous ego functions can be secondarily affected because of unconscious conflict. For example, a patient may have an hysterical amnesia (memory being an autonomous function) because of intrapsychic conflict (wishing not to remember because it is too painful).

Taken together, the above theories present a group of metapsychological assumptions. Therefore, the inclusive group of the different classical theories provides a cross-sectional view of human mentation. There are six “points of view”, five described by Freud and a sixth added by Hartmann. Unconscious processes can therefore be evaluated from each of these six points of view:

Topographic.
Dynamic (the theory of conflict).
Economic (the theory of energy flow).
Structural.
Genetic (i.e. propositions concerning origin and development of psychological functions).
Adaptational (i.e. psychological phenomena as it relates to the external world).

Modern Conflict Theory

Modern conflict theory, a variation of ego psychology, is a revised version of structural theory, most notably different by altering concepts related to where repressed thoughts were stored. Modern conflict theory addresses emotional symptoms and character traits as complex solutions to mental conflict. It dispenses with the concepts of a fixed id, ego and superego, and instead posits conscious and unconscious conflict among wishes (dependent, controlling, sexual, and aggressive), guilt and shame, emotions (especially anxiety and depressive affect), and defensive operations that shut off from consciousness some aspect of the others. Moreover, healthy functioning (adaptive) is also determined, to a great extent, by resolutions of conflict.

A major objective of modern conflict-theory psychoanalysis is to change the balance of conflict in a patient by making aspects of the less adaptive solutions (also called “compromise formations”) conscious so that they can be rethought, and more adaptive solutions found. Current theoreticians who follow the work of Charles Brenner, especially The Mind in Conflict (1982), include Sandor Abend, Jacob Arlow, and Jerome Blackman.

Object Relations Theory

Object relations theory attempts to explain the ups and downs of human relationships through a study of how internal representations of the self and others are organised. The clinical symptoms that suggest object relations problems (typically developmental delays throughout life) include disturbances in an individual’s capacity to feel: warmth, empathy, trust, sense of security, identity stability, consistent emotional closeness, and stability in relationships with significant others

Concepts regarding internal representation (aka ‘introspect,’ ‘self and object representation,’ or ‘internalization of self and other’), although often attributed to Melanie Klein, were actually first mentioned by Sigmund Freud in his early concepts of drive theory (Three Essays on the Theory of Sexuality, 1905). Freud’s 1917 paper “Mourning and Melancholia,” for example, hypothesized that unresolved grief was caused by the survivor’s internalised image of the deceased becoming fused with that of the survivor, and then the survivor shifting unacceptable anger toward the deceased onto the now complex self-image.

Vamik Volkan, in “Linking Objects and Linking Phenomena,” expanded on Freud’s thoughts on this, describing the syndromes of “established pathological mourning” vs. “reactive depression” based on similar dynamics. Melanie Klein’s hypotheses regarding internalisation during the first year of life, leading to paranoid and depressive positions, were later challenged by René Spitz (e.g., The First Year of Life, 1965), who divided the first year of life into a coenesthetic phase of the first six months, and then a diacritic phase for the second six months. Mahler, Fine, and Bergman (1975) describe distinct phases and sub-phases of child development leading to “separation-individuation” during the first three years of life, stressing the importance of constancy of parental figures in the face of the child’s destructive aggression, internalisations, stability of affect management, and ability to develop healthy autonomy.

John Frosch, Otto Kernberg, Salman Akhtar, and Sheldon Bach have developed the theory of self and object constancy as it affects adult psychiatric problems such as psychosis and borderline states. Blos (1960) described how similar separation-individuation struggles occur during adolescence, of course with a different outcome from the first three years of life: the teen usually, eventually, leaves the parents’ house (varying with culture).

During adolescence, Erik Erikson (1950-1960s) described the ‘identity crisis,’ that involves identity-diffusion anxiety. In order for an adult to be able to experience “Warm-ETHICS: (warmth, Empathy, Trust, Holding environment, Identity, Closeness, and Stability) in relationships, the teenager must resolve the problems with identity and redevelop self and object constancy.

Self Psychology

Self psychology emphasizes the development of a stable and integrated sense of self through empathic contacts with other humans, primary significant others conceived of as ‘selfobjects.’ Selfobjects meet the developing self’s needs for mirroring, idealisation, and twinship, and thereby strengthen the developing self. The process of treatment proceeds through “transmuting internalisations” in which the patient gradually internalizes the selfobject functions provided by the therapist. Self psychology was proposed originally by Heinz Kohut, and has been further developed by Arnold Goldberg, Frank Lachmann, Paul and Anna Ornstein, Marian Tolpin, and others.

Lacanian Psychoanalysis

Lacanian psychoanalysis, which integrates psychoanalysis with structural linguistics and Hegelian philosophy, is especially popular in France and parts of Latin America. Lacanian psychoanalysis is a departure from the traditional British and American psychoanalysis. Jacques Lacan frequently used the phrase “retourner à Freud” (“return to Freud”) in his seminars and writings, as he claimed that his theories were an extension of Freud’s own, contrary to those of Anna Freud, the Ego Psychology, object relations and “self” theories and also claims the necessity of reading Freud’s complete works, not only a part of them. Lacan’s concepts concern the “mirror stage”, the “Real”, the “Imaginary”, and the “Symbolic”, and the claim that “the unconscious is structured as a language.”

Though a major influence on psychoanalysis in France and parts of Latin America, Lacan and his ideas have taken longer to be translated into English and he has thus had a lesser impact on psychoanalysis and psychotherapy in the English-speaking world. In the United Kingdom and the United States, his ideas are most widely used to analyse texts in literary theory. Due to his increasingly critical stance towards the deviation from Freud’s thought, often singling out particular texts and readings from his colleagues, Lacan was excluded from acting as a training analyst in the IPA, thus leading him to create his own school in order to maintain an institutional structure for the many candidates who desired to continue their analysis with him.

Adaptive Paradigm

The adaptive paradigm of psychotherapy develops out of the work of Robert Langs. The adaptive paradigm interprets psychic conflict primarily in terms of conscious and unconscious adaptation to reality. Langs’ recent work in some measure returns to the earlier Freud, in that Langs prefers a modified version of the topographic model of the mind (conscious, preconscious, and unconscious) over the structural model (id, ego, and super-ego), including the former’s emphasis on trauma (though Langs looks to death-related traumas rather than sexual traumas). At the same time, Langs’ model of the mind differs from Freud’s in that it understands the mind in terms of evolutionary biological principles.

Relational Psychoanalysis

Relational psychoanalysis combines interpersonal psychoanalysis with object-relations theory and with inter-subjective theory as critical for mental health. It was introduced by Stephen Mitchell. Relational psychoanalysis stresses how the individual’s personality is shaped by both real and imagined relationships with others, and how these relationship patterns are re-enacted in the interactions between analyst and patient. In New York, key proponents of relational psychoanalysis include Lew Aron, Jessica Benjamin, and Adrienne Harris. Fonagy and Target, in London, have propounded their view of the necessity of helping certain detached, isolated patients, develop the capacity for “mentalization” associated with thinking about relationships and themselves. Arietta Slade, Susan Coates, and Daniel Schechter in New York have additionally contributed to the application of relational psychoanalysis to treatment of the adult patient-as-parent, the clinical study of mentalisation in parent-infant relationships, and the intergenerational transmission of attachment and trauma.

Interpersonal-Relational Psychoanalysis

The term interpersonal-relational psychoanalysis is often used as a professional identification. Psychoanalysts under this broader umbrella debate about what precisely are the differences between the two schools, without any current clear consensus.

Psychopathology (Mental Disturbances)

Adults

The various psychoses involve deficits in the autonomous ego functions (see above) of integration (organization) of thought, in abstraction ability, in relationship to reality and in reality testing. In depressions with psychotic features, the self-preservation function may also be damaged (sometimes by overwhelming depressive affect). Because of the integrative deficits (often causing what general psychiatrists call “loose associations,” “blocking,” “flight of ideas,” “verbigeration,” and “thought withdrawal”), the development of self and object representations is also impaired. Clinically, therefore, psychotic individuals manifest limitations in warmth, empathy, trust, identity, closeness and/or stability in relationships (due to problems with self-object fusion anxiety) as well.

In patients whose autonomous ego functions are more intact, but who still show problems with object relations, the diagnosis often falls into the category known as “borderline”. Borderline patients also show deficits, often in controlling impulses, affects, or fantasies – but their ability to test reality remains more or less intact. Adults who do not experience guilt and shame, and who indulge in criminal behaviour, are usually diagnosed as psychopaths, or, using DSM-IV-TR, antisocial personality disorder.

Neurotic symptoms – including panic, phobias, conversions, obsessions, compulsions and depressions – are not usually caused by deficits in functions. Instead, they are caused by intrapsychic conflicts. The conflicts are generally among sexual and hostile-aggressive wishes, guilt and shame, and reality factors. The conflicts may be conscious or unconscious, but create anxiety, depressive affect, and anger. Finally, the various elements are managed by defensive operations – essentially shut-off brain mechanisms that make people unaware of that element of conflict.

Repression is the term given to the mechanism that shuts thoughts out of consciousness. Isolation of affect is the term used for the mechanism that shuts sensations out of consciousness. Neurotic symptoms may occur with or without deficits in ego functions, object relations, and ego strengths. Therefore, it is not uncommon to encounter obsessive-compulsive schizophrenics, panic patients who also suffer with borderline personality disorder, etc.

This section above is partial to ego psychoanalytic theory autonomous ego functions.

Childhood Origins

Freudian theories hold that adult problems can be traced to unresolved conflicts from certain phases of childhood and adolescence, caused by fantasy, stemming from their own drives. Freud, based on the data gathered from his patients early in his career, suspected that neurotic disturbances occurred when children were sexually abused in childhood (i.e. seduction theory). Later, Freud came to believe that, although child abuse occurs, neurotic symptoms were not associated with this. He believed that neurotic people often had unconscious conflicts that involved incestuous fantasies deriving from different stages of development. He found the stage from about three to six years of age (preschool years, today called the “first genital stage”) to be filled with fantasies of having romantic relationships with both parents. Arguments were quickly generated in early 20th-century Vienna about whether adult seduction of children, i.e. child sexual abuse, was the basis of neurotic illness. There still is no complete agreement, although nowadays professionals recognize the negative effects of child sexual abuse on mental health.

Oedipal Conflicts

Many psychoanalysts who work with children have studied the actual effects of child abuse, which include ego and object relations deficits and severe neurotic conflicts. Much research has been done on these types of trauma in childhood, and the adult sequelae of those. In studying the childhood factors that start neurotic symptom development, Freud found a constellation of factors that, for literary reasons, he termed the Oedipus complex, based on the play by Sophocles, Oedipus Rex, in which the protagonist unwittingly kills his father and marries his mother. The validity of the Oedipus complex is now widely disputed and rejected.

The shorthand term, oedipal – later explicated by Joseph J. Sandler in “On the Concept Superego” (1960) and modified by Charles Brenner in The Mind in Conflict (1982) – refers to the powerful attachments that children make to their parents in the preschool years. These attachments involve fantasies of sexual relationships with either (or both) parent, and, therefore, competitive fantasies toward either (or both) parents. Humberto Nagera (1975) has been particularly helpful in clarifying many of the complexities of the child through these years.

“Positive” and “negative” oedipal conflicts have been attached to the heterosexual and homosexual aspects, respectively. Both seem to occur in development of most children. Eventually, the developing child’s concessions to reality (that they will neither marry one parent nor eliminate the other) lead to identifications with parental values. These identifications generally create a new set of mental operations regarding values and guilt, subsumed under the term superego. Besides superego development, children “resolve” their preschool oedipal conflicts through channelling wishes into something their parents approve of (“sublimation”) and the development, during the school-age years (“latency”) of age-appropriate obsessive-compulsive defensive manoeuvres (rules, repetitive games).

Treatment

Using the various analytic and psychological techniques to assess mental problems, some believe that there are particular constellations of problems that are especially suited for analytic treatment (see below) whereas other problems might respond better to medicines and other interpersonal interventions. To be treated with psychoanalysis, whatever the presenting problem, the person requesting help must demonstrate a desire to start an analysis. The person wishing to start an analysis must have some capacity for speech and communication. As well, they need to be able to have or develop trust and insight within the psychoanalytic session. Potential patients must undergo a preliminary stage of treatment to assess their amenability to psychoanalysis at that time, and also to enable the analyst to form a working psychological model, which the analyst will use to direct the treatment. Psychoanalysts mainly work with neurosis and hysteria in particular; however, adapted forms of psychoanalysis are used in working with schizophrenia and other forms of psychosis or mental disorder. Finally, if a prospective patient is severely suicidal a longer preliminary stage may be employed, sometimes with sessions which have a twenty-minute break in the middle. There are numerous modifications in technique under the heading of psychoanalysis due to the individualistic nature of personality in both analyst and patient.

The most common problems treatable with psychoanalysis include: phobias, conversions, compulsions, obsessions, anxiety attacks, depressions, sexual dysfunctions, a wide variety of relationship problems (such as dating and marital strife), and a wide variety of character problems (for example, painful shyness, meanness, obnoxiousness, workaholism, hyperseductiveness, hyperemotionality, hyperfastidiousness). The fact that many of such patients also demonstrate deficits above makes diagnosis and treatment selection difficult.

Analytical organizations such as the IPA, APsaA and the European Federation for Psychoanalytic Psychotherapy have established procedures and models for the indication and practice of psychoanalytical therapy for trainees in analysis. The match between the analyst and the patient can be viewed as another contributing factor for the indication and contraindication for psychoanalytic treatment. The analyst decides whether the patient is suitable for psychoanalysis. This decision made by the analyst, besides made on the usual indications and pathology, is also based to a certain degree by the “fit” between analyst and patient. A person’s suitability for analysis at any particular time is based on their desire to know something about where their illness has come from. Someone who is not suitable for analysis expresses no desire to know more about the root causes of their illness.

An evaluation may include one or more other analysts’ independent opinions and will include discussion of the patient’s financial situation and insurances.

Techniques

The basic method of psychoanalysis is interpretation of the patient’s unconscious conflicts that are interfering with current-day functioning – conflicts that are causing painful symptoms such as phobias, anxiety, depression, and compulsions. Strachey (1936) stressed that figuring out ways the patient distorted perceptions about the analyst led to understanding what may have been forgotten. In particular, unconscious hostile feelings toward the analyst could be found in symbolic, negative reactions to what Robert Langs later called the “frame” of the therapy – the setup that included times of the sessions, payment of fees, and necessity of talking. In patients who made mistakes, forgot, or showed other peculiarities regarding time, fees, and talking, the analyst can usually find various unconscious “resistances” to the flow of thoughts (aka free association).

When the patient reclines on a couch with the analyst out of view, the patient tends to remember more experiences, more resistance and transference, and is able to reorganise thoughts after the development of insight – through the interpretive work of the analyst. Although fantasy life can be understood through the examination of dreams, masturbation fantasies are also important. The analyst is interested in how the patient reacts to and avoids such fantasies. Various memories of early life are generally distorted – what Freud called screen memories – and in any case, very early experiences (before age two) – cannot be remembered.

Variations in Technique

There is what is known among psychoanalysts as classical technique, although Freud throughout his writings deviated from this considerably, depending on the problems of any given patient.

Classical technique was summarized by Allan Compton as comprising:

Instructions: telling the patient to try to say what is on their mind, including interferences;
Exploration: asking questions; and
Clarification: rephrasing and summarizing what the patient has been describing.

As well, the analyst can also use confrontation to bringing an aspect of functioning, usually a defence, to the patient’s attention. The analyst then uses a variety of interpretation methods, such as:

Dynamic interpretation: explaining how being too nice guards against guilt (e.g. defence vs. affect);
Genetic interpretation: explaining how a past event is influencing the present;
Resistance interpretation: showing the patient how they are avoiding their problems;
Transference interpretation: showing the patient ways old conflicts arise in current relationships, including that with the analyst; or
Dream interpretation: obtaining the patient’s thoughts about their dreams and connecting this with their current problems.

Analysts can also use reconstruction to estimate what may have happened in the past that created some current issue. These techniques are primarily based on conflict theory (see above). As object relations theory evolved, supplemented by the work of John Bowlby and Mary Ainsworth, techniques with patients who had more severe problems with basic trust (Erikson, 1950) and a history of maternal deprivation (see the works of Augusta Alpert) led to new techniques with adults. These have sometimes been called interpersonal, intersubjective (cf. Stolorow), relational, or corrective object relations techniques. These techniques include expressing an empathic attunement to the patient or warmth; exposing a bit of the analyst’s personal life or attitudes to the patient; allowing the patient autonomy in the form of disagreement with the analyst (cf. I. H. Paul, Letters to Simon); and explaining the motivations of others which the patient misperceives.

Ego psychological concepts of deficit in functioning led to refinements in supportive therapy. These techniques are particularly applicable to psychotic and near-psychotic (cf., Eric Marcus, “Psychosis and Near-psychosis”) patients. These supportive therapy techniques include discussions of reality; encouragement to stay alive (including hospitalisation); psychotropic medicines to relieve overwhelming depressive affect or overwhelming fantasies (hallucinations and delusions); and advice about the meanings of things (to counter abstraction failures).

The notion of the “silent analyst” has been criticized. Actually, the analyst listens using Arlow’s approach as set out in “The Genesis of Interpretation”, using active intervention to interpret resistances, defences creating pathology, and fantasies. Silence is not a technique of psychoanalysis (see also the studies and opinion papers of Owen Renik). “Analytic neutrality” is a concept that does not mean the analyst is silent. It refers to the analyst’s position of not taking sides in the internal struggles of the patient. For example, if a patient feels guilty, the analyst might explore what the patient has been doing or thinking that causes the guilt, but not reassure the patient not to feel guilty. The analyst might also explore the identifications with parents and others that led to the guilt.

Interpersonal–relational psychoanalysts emphasize the notion that it is impossible to be neutral. Sullivan introduced the term participant-observer to indicate the analyst inevitably interacts with the analysand, and suggested the detailed inquiry as an alternative to interpretation. The detailed inquiry involves noting where the analysand is leaving out important elements of an account and noting when the story is obfuscated, and asking careful questions to open up the dialogue.

Group Therapy and Play Therapy

Although single-client sessions remain the norm, psychoanalytic theory has been used to develop other types of psychological treatment. Psychoanalytic group therapy was pioneered by Trigant Burrow, Joseph Pratt, Paul F. Schilder, Samuel R. Slavson, Harry Stack Sullivan, and Wolfe. Child-centred counselling for parents was instituted early in analytic history by Freud, and was later further developed by Irwin Marcus, Edith Schulhofer, and Gilbert Kliman. Psychoanalytically based couples therapy has been promulgated and explicated by Fred Sander. Techniques and tools developed in the first decade of the 21st century have made psychoanalysis available to patients who were not treatable by earlier techniques. This meant that the analytic situation was modified so that it would be more suitable and more likely to be helpful for these patients. Eagle (2007) believes that psychoanalysis cannot be a self-contained discipline but instead must be open to influence from and integration with findings and theory from other disciplines.

Psychoanalytic constructs have been adapted for use with children with treatments such as play therapy, art therapy, and storytelling. Throughout her career, from the 1920s through the 1970s, Anna Freud adapted psychoanalysis for children through play. This is still used today for children, especially those who are preadolescent. Using toys and games, children are able to symbolically demonstrate their fears, fantasies, and defences; although not identical, this technique, in children, is analogous to the aim of free association in adults. Psychoanalytic play therapy allows the child and analyst to understand children’s conflicts, particularly defences such as disobedience and withdrawal, that have been guarding against various unpleasant feelings and hostile wishes. In art therapy, the counsellor may have a child draw a portrait and then tell a story about the portrait. The counsellor watches for recurring themes – regardless of whether it is with art or toys.

Cultural Variations

Psychoanalysis can be adapted to different cultures, as long as the therapist or counsellor understands the client’s culture. For example, Tori and Blimes found that defence mechanisms were valid in a normative sample of 2,624 Thais. The use of certain defence mechanisms was related to cultural values. For example, Thais value calmness and collectiveness (because of Buddhist beliefs), so they were low on regressive emotionality. Psychoanalysis also applies because Freud used techniques that allowed him to get the subjective perceptions of his patients. He takes an objective approach by not facing his clients during his talk therapy sessions. He met with his patients wherever they were, such as when he used free association – where clients would say whatever came to mind without self-censorship. His treatments had little to no structure for most cultures, especially Asian cultures. Therefore, it is more likely that Freudian constructs will be used in structured therapy. In addition, Corey postulates that it will be necessary for a therapist to help clients develop a cultural identity as well as an ego identity.

Cost and Length of Treatment

The cost to the patient of psychoanalytic treatment ranges widely from place to place and between practitioners. Low-fee analysis is often available in a psychoanalytic training clinic and graduate schools. Otherwise, the fee set by each analyst varies with the analyst’s training and experience. Since, in most locations in the United States, unlike in Ontario and Germany, classical analysis (which usually requires sessions three to five times per week) is not covered by health insurance, many analysts may negotiate their fees with patients whom they feel they can help, but who have financial difficulties. The modifications of analysis, which include psychodynamic therapy, brief therapies, and certain types of group therapy, are carried out on a less frequent basis – usually once, twice, or three times a week – and usually the patient sits facing the therapist. As a result of the defence mechanisms and the lack of access to the unfathomable elements of the unconscious, psychoanalysis can be an expansive process that involves 2 to 5 sessions per week for several years. This type of therapy relies on the belief that reducing the symptoms will not actually help with the root causes or irrational drives. The analyst typically is a ‘blank screen’, disclosing very little about themselves in order that the client can use the space in the relationship to work on their unconscious without interference from outside.

The psychoanalyst uses various methods to help the patient to become more self-aware and to develop insights into their behaviour and into the meanings of symptoms. First and foremost, the psychoanalyst attempts to develop a confidential atmosphere in which the patient can feel safe reporting his feelings, thoughts and fantasies. Analysands (as people in analysis are called) are asked to report whatever comes to mind without fear of reprisal. Freud called this the “fundamental rule”. Analysands are asked to talk about their lives, including their early life, current life and hopes and aspirations for the future. They are encouraged to report their fantasies, “flash thoughts” and dreams. In fact, Freud believed that dreams were, “the royal road to the unconscious”; he devoted an entire volume to the interpretation of dreams. Freud had his patients lay on a couch in a dimly lit room and would sit out of sight, usually directly behind them, as to not influence the patients thoughts by his gestures or expressions.

The psychoanalyst’s task, in collaboration with the analysand, is to help deepen the analysand’s understanding of those factors, outside of his awareness, that drive his behaviours. In the safe environment of the psychoanalytic setting, the analysand becomes attached to the analyst and pretty soon he begins to experience the same conflicts with his analyst that he experiences with key figures in his life such as his parents, his boss, his significant other, etc. It is the psychoanalyst’s role to point out these conflicts and to interpret them. The transferring of these internal conflicts onto the analyst is called “transference”.

Many studies have also been done on briefer “dynamic” treatments; these are more expedient to measure, and shed light on the therapeutic process to some extent. Brief Relational Therapy (BRT), Brief Psychodynamic Therapy (BPT), and Time-Limited Dynamic Therapy (TLDP) limit treatment to 20–30 sessions. On average, classical analysis may last 5.7 years, but for phobias and depressions uncomplicated by ego deficits or object relations deficits, analysis may run for a shorter period of time. Longer analyses are indicated for those with more serious disturbances in object relations, more symptoms, and more ingrained character pathology.

Training and Research

Psychoanalysis continues to be practiced by psychiatrists, social workers, and other mental health professionals; however, its practice has declined.

In 2015, psychoanalyst Bradley Peterson, who is also a child psychiatrist and director of the Institute for the Developing Mind at Children’s Hospital Los Angeles, said: “I think most people would agree that psychoanalysis as a form of treatment is on its last legs.” However psychoanalytic approaches continue to be listed by the UK NHS as possibly helpful for depression.

United States

Psychoanalytic training in the United States involves a personal psychoanalysis for the trainee, approximately 600 hours of class instruction, with a standard curriculum, over a four or five-year period.

Typically, this psychoanalysis must be conducted by a Supervising and Training Analyst. Most institutes (but not all) within the American Psychoanalytic Association, require that Supervising and Training Analysts become certified by the American Board of Psychoanalysts. Certification entails a blind review in which the psychoanalyst’s work is vetted by psychoanalysts outside of their local community. After earning certification, these psychoanalysts undergo another hurdle in which they are specially vetted by senior members of their own institute. Supervising and Training analysts are held to the highest clinical and ethical standards. Moreover, they are required to have extensive experience conducting psychoanalyses.

Similarly, class instruction for psychoanalytic candidates is rigorous. Typically classes meet several hours a week, or for a full day or two every other weekend during the academic year; this varies with the institute.

Candidates generally have an hour of supervision each week, with a Supervising and Training Analyst, on each psychoanalytic case. The minimum number of cases varies between institutes, often two to four cases. Male and female cases are required. Supervision must go on for at least a few years on one or more cases. Supervision is done in the supervisor’s office, where the trainee presents material from the psychoanalytic work that week. In supervision, the patient’s unconscious conflicts are explored, also, transference-countertransference constellations are examined. Also, clinical technique is taught.

Many psychoanalytic training centres in the United States have been accredited by special committees of the APsaA or the IPA. Because of theoretical differences, there are independent institutes, usually founded by psychologists, who until 1987 were not permitted access to psychoanalytic training institutes of the APsaA. Currently there are between 75 and 100 independent institutes in the United States. As well, other institutes are affiliated to other organisations such as the American Academy of Psychoanalysis and Dynamic Psychiatry, and the National Association for the Advancement of Psychoanalysis. At most psychoanalytic institutes in the United States, qualifications for entry include a terminal degree in a mental health field, such as Ph.D., Psy.D., M.S.W., or M.D. A few institutes restrict applicants to those already holding an M.D. or Ph.D., and most institutes in Southern California confer a Ph.D. or Psy.D. in psychoanalysis upon graduation, which involves completion of the necessary requirements for the state boards that confer that doctoral degree. The first training institute in America to educate non-medical psychoanalysts was The National Psychological Association for Psychoanalysis (1978) in New York City. It was founded by the analyst Theodor Reik. The Contemporary Freudian (originally the New York Freudian Society) an offshoot of the National Psychological Association has a branch in Washington, DC. It is a component society/institute or the IPA.

Some psychoanalytic training has been set up as a post-doctoral fellowship in university settings, such as at Duke University, Yale University, New York University, Adelphi University and Columbia University. Other psychoanalytic institutes may not be directly associated with universities, but the faculty at those institutes usually hold contemporaneous faculty positions with psychology Ph.D. programs and/or with medical school psychiatry residency programs.

The IPA is the world’s primary accrediting and regulatory body for psychoanalysis. Their mission is to assure the continued vigour and development of psychoanalysis for the benefit of psychoanalytic patients. It works in partnership with its 70 constituent organisations in 33 countries to support 11,500 members. In the US, there are 77 psychoanalytical organisations, institutes associations in the United States, which are spread across the states of America. APSaA has 38 affiliated societies which have 10 or more active members who practice in a given geographical area. The aims of APSaA and other psychoanalytical organisations are: provide ongoing educational opportunities for its members, stimulate the development and research of psychoanalysis, provide training and organise conferences. There are eight affiliated study groups in the United States. A study group is the first level of integration of a psychoanalytical body within the IPA, followed by a provisional society and finally a member society.

The Division of Psychoanalysis of the American Psychological Association (APA) was established in the early 1980s by several psychologists. Until the establishment of the Division of Psychoanalysis, psychologists who had trained in independent institutes had no national organisation. The Division of Psychoanalysis now has approximately 4,000 members and approximately 30 local chapters in the United States. The Division of Psychoanalysis holds two annual meetings or conferences and offers continuing education in theory, research and clinical technique, as do their affiliated local chapters. The European Psychoanalytical Federation (EPF) is the organisation which consolidates all European psychoanalytic societies. This organization is affiliated with the IPA. In 2002 there were approximately 3,900 individual members in 22 countries, speaking 18 different languages. There are also 25 psychoanalytic societies.

The American Association of Psychoanalysis in Clinical Social Work (AAPCSW) was established by Crayton Rowe in 1980 as a division of the Federation of Clinical Societies of Social Work and became an independent entity in 1990. Until 2007 it was known as the National Membership Committee on Psychoanalysis. The organisation was founded because although social workers represented the larger number of people who were training to be psychoanalysts, they were underrepresented as supervisors and teachers at the institutes they attended. AAPCSW now has over 1000 members and has over 20 chapters. It holds a bi-annual national conference and numerous annual local conferences.

Experiences of psychoanalysts and psychoanalytic psychotherapists and research into infant and child development have led to new insights. Theories have been further developed and the results of empirical research are now more integrated in the psychoanalytic theory.

United Kingdom

The London Psychoanalytical Society was founded by Ernest Jones on 30 October 1913. After World War I with the expansion of psychoanalysis in the United Kingdom, the Society was reconstituted and named the British Psychoanalytical Society in 1919. Soon after, the Institute of Psychoanalysis was established to administer the Society’s activities. These include: the training of psychoanalysts, the development of the theory and practice of psychoanalysis, the provision of treatment through The London Clinic of Psychoanalysis, the publication of books in The New Library of Psychoanalysis and Psychoanalytic Ideas. The Institute of Psychoanalysis also publishes The International Journal of Psychoanalysis, maintains a library, furthers research, and holds public lectures. The society has a Code of Ethics and an Ethical Committee. The society, the institute and the clinic are all located at Byron House in West London.

The Society is a constituent society of the International Psychoanalytical Association, IPA, a body with members on all five continents which safeguards professional and ethical practice. The Society is a member of the British Psychoanalytic Council (BPC); the BPC publishes a register of British psychoanalysts and psychoanalytical psychotherapists. All members of the British Psychoanalytic Council are required to undertake continuing professional development, CPD. Members of the Society teach and hold posts on other approved psychoanalytic courses, e.g.: British Psychotherapy Foundation and in academic departments, e.g. University College London.

Members of the Society have included: Michael Balint, Wilfred Bion, John Bowlby, Ronald Fairbairn, Anna Freud, Harry Guntrip, Melanie Klein, Donald Meltzer, Joseph J. Sandler, Hanna Segal, J.D. Sutherland and Donald Winnicott.

The Institute of Psychoanalysis is the foremost publisher of psychoanalytic literature. The 24-volume Standard Edition of the Complete Psychological Works of Sigmund Freud was conceived, translated, and produced under the direction of the British Psychoanalytical Society. The Society, in conjunction with Random House, will soon publish a new, revised and expanded Standard Edition. With the New Library of Psychoanalysis the Institute continues to publish the books of leading theorists and practitioners. The International Journal of Psychoanalysis is published by the Institute of Psychoanalysis. Now in its 84th year, it has one of the largest circulations of any psychoanalytic journal.

India

Psychoanalytical practice is emerging slowly in India, but is not yet recognised by the government. In 2016, India decriminalised suicide in its mental health bill.

Psychoanalytic Psychotherapy

There are different forms of psychoanalysis and psychotherapies in which psychoanalytic thinking is practiced. Besides classical psychoanalysis there is for example psychoanalytic psychotherapy, a therapeutic approach which widens “the accessibility of psychoanalytic theory and clinical practices that had evolved over 100 plus years to a larger number of individuals.” Other examples of well known therapies which also use insights of psychoanalysis are mentalisation-based treatment (MBT), and transference focused psychotherapy (TFP). There is also a continuing influence of psychoanalytic thinking in mental health care.

Research

Over a hundred years of case reports and studies in the journal Modern Psychoanalysis, the Psychoanalytic Quarterly, the International Journal of Psychoanalysis and the Journal of the American Psychoanalytic Association have analysed the efficacy of analysis in cases of neurosis and character or personality problems. Psychoanalysis modified by object relations techniques has been shown to be effective in many cases of ingrained problems of intimacy and relationship (cf. the many books of Otto Kernberg). Psychoanalytic treatment, in other situations, may run from about a year to many years, depending on the severity and complexity of the pathology.

Psychoanalytic theory has, from its inception, been the subject of criticism and controversy. Freud remarked on this early in his career, when other physicians in Vienna ostracised him for his findings that hysterical conversion symptoms were not limited to women. Challenges to analytic theory began with Otto Rank and Alfred Adler (turn of the 20th century), continued with behaviorists (e.g. Wolpe) into the 1940s and ’50s, and have persisted (e.g. Miller). Criticisms come from those who object to the notion that there are mechanisms, thoughts or feelings in the mind that could be unconscious. Criticisms also have been levelled against the idea of “infantile sexuality” (the recognition that children between ages two and six imagine things about procreation). Criticisms of theory have led to variations in analytic theories, such as the work of Ronald Fairbairn, Michael Balint, and John Bowlby. In the past 30 years or so, the criticisms have centred on the issue of empirical verification.

Psychoanalysis has been used as a research tool into childhood development (cf. the journal The Psychoanalytic Study of the Child), and has developed into a flexible, effective treatment for certain mental disturbances. In the 1960s, Freud’s early (1905) thoughts on the childhood development of female sexuality were challenged; this challenge led to major research in the 1970s and 80s, and then to a reformulation of female sexual development that corrected some of Freud’s concepts. Also see the various works of Eleanor Galenson, Nancy Chodorow, Karen Horney, Françoise Dolto, Melanie Klein, Selma Fraiberg, and others. Most recently, psychoanalytic researchers who have integrated attachment theory into their work, including Alicia Lieberman, Susan Coates, and Daniel Schechter have explored the role of parental traumatisation in the development of young children’s mental representations of self and others.

Effectiveness

The psychoanalytic profession has been resistant to researching efficacy. Evaluations of effectiveness based on the interpretation of the therapist alone cannot be proven.

Research Results

Meta-analyses in 2012 and 2013 found support or evidence for the efficacy of psychoanalytic therapy, thus further research is needed. Other meta-analyses published in the recent years showed psychoanalysis and psychodynamic therapy to be effective, with outcomes comparable or greater than other kinds of psychotherapy or antidepressant drugs, but these arguments have also been subjected to various criticisms. In particular, the inclusion of pre/post studies rather than randomized controlled trials, and the absence of adequate comparisons with control treatments is a serious limitation in interpreting the results.

In 2011, the American Psychological Association made 103 comparisons between psychodynamic treatment and a non-dynamic competitor and found that 6 were superior, 5 were inferior, 28 had no difference and 63 were adequate. The study found that this could be used as a basis “to make psychodynamic psychotherapy an ’empirically validated’ treatment.”

Meta-analyses of Short Term Psychodynamic Psychotherapy (STPP) have found effect sizes (Cohen’s d) ranging from .34 to .71 compared to no treatment and was found to be slightly better than other therapies in follow up. Other reviews have found an effect size of .78 to .91 for somatic disorders compared to no treatment and .69 for treating depression. A 2012 Harvard Review of Psychiatry meta-analysis of Intensive Short-Term Dynamic Psychotherapy (ISTDP) found effect sizes ranging from .84 for interpersonal problems to 1.51 for depression. Overall ISTDP had an effect size of 1.18 compared to no treatment.

A meta-analysis of Long Term Psychodynamic Psychotherapy in 2012 found an overall effect size of .33, which is modest. This study concluded the recovery rate following LTPP was equal to control treatments, including treatment as usual, and found the evidence for the effectiveness of LTPP to be limited and at best conflicting. Others have found effect sizes of .44 to .68.

According to a 2004 French review conducted by INSERM, psychoanalysis was presumed or proven effective at treating panic disorder, post-traumatic stress, and personality disorders, but did not find evidence of its effectiveness in treating schizophrenia, panic disorder, obsessive compulsive disorder, specific phobia, bulimia and anorexia.

A 2001 systematic review of the medical literature by the Cochrane Collaboration concluded that no data exist demonstrating that psychodynamic psychotherapy is effective in treating schizophrenia and severe mental illness, and cautioned that medication should always be used alongside any type of talk therapy in schizophrenia cases. A French review from 2004 found the same. The Schizophrenia Patient Outcomes Research Team advises against the use of psychodynamic therapy in cases of schizophrenia, arguing that more trials are necessary to verify its effectiveness.

Criticism

As a Field of Science

Both Freud and psychoanalysis have been criticised in extreme terms. Exchanges between critics and defenders of psychoanalysis have often been so heated that they have come to be characterised as the Freud Wars.

Early critics of psychoanalysis believed that its theories were based too little on quantitative and experimental research, and too much on the clinical case study method. Some have accused Freud of fabrication, most famously in the case of Anna O. Philosopher Frank Cioffi cites false claims of a sound scientific verification of the theory and its elements as the strongest basis for classifying the work of Freud and his school as pseudoscience.

Others have speculated that patients suffered from now easily identifiable conditions unrelated to psychoanalysis; for instance, Anna O. is thought to have suffered from an organic impairment such as tuberculous meningitis or temporal lobe epilepsy and not hysteria (see modern interpretations).

Karl Popper argued that psychoanalysis is a pseudoscience because its claims are not testable and cannot be refuted; that is, they are not falsifiable:

….those “clinical observations” which analysts naively believe confirm their theory cannot do this any more than the daily confirmations which astrologers find in their practice. And as for Freud’s epic of the Ego, the Super-ego, and the Id, no substantially stronger claim to scientific status can be made for it than for Homer’s collected stories from the Olympus.

In addition, Imre Lakatos wrote that “Freudians have been nonplussed by Popper’s basic challenge concerning scientific honesty. Indeed, they have refused to specify experimental conditions under which they would give up their basic assumptions.” In Sexual Desire (1986), philosopher Roger Scruton rejects Popper’s arguments pointing to the theory of repression as an example of a Freudian theory that does have testable consequences. Scruton nevertheless concluded that psychoanalysis is not genuinely scientific, on the grounds that it involves an unacceptable dependence on metaphor. The philosopher and physicist Mario Bunge argued that psychoanalysis is a pseudoscience because it violates the ontology and methodology inherent to science. According to Bunge, most psychoanalytic theories are either untestable or unsupported by evidence. Cognitive scientists, in particular, have also weighed in. Martin Seligman, a prominent academic in positive psychology wrote that:

Thirty years ago, the cognitive revolution in psychology overthrew both Freud and the behaviorists, at least in academia.… [T]hinking…is not just a [result] of emotion or behavior.… [E]motion is always generated by cognition, not the other way around.

Linguist Noam Chomsky has criticized psychoanalysis for lacking a scientific basis. Steven Pinker considers Freudian theory unscientific for understanding the mind. Evolutionary biologist Stephen Jay Gould considered psychoanalysis influenced by pseudoscientific theories such as recapitulation theory. Psychologists Hans Eysenck (1985) and John F. Kihlstrom (2012/2000) have also criticised the field as pseudoscience.

Adolf Grünbaum argues in Validation in the Clinical Theory of Psychoanalysis (1993) that psychoanalytic based theories are falsifiable, but that the causal claims of psychoanalysis are unsupported by the available clinical evidence.

Richard Feynman wrote off psychoanalysts as mere “witch doctors:”

If you look at all of the complicated ideas that they have developed in an infinitesimal amount of time, if you compare to any other of the sciences how long it takes to get one idea after the other, if you consider all the structures and inventions and complicated things, the ids and the egos, the tensions and the forces, and the pushes and the pulls, I tell you they can’t all be there. It’s too much for one brain or a few brains to have cooked up in such a short time.

Likewise, psychiatrist E. Fuller Torrey, in Witchdoctors and Psychiatrists (1986), agreed that psychoanalytic theories have no more scientific basis than the theories of traditional native healers, “witchdoctors” or modern “cult” alternatives such as EST. Psychologist Alice Miller charged psychoanalysis with being similar to the poisonous pedagogies, which she described in her book For Your Own Good. She scrutinized and rejected the validity of Freud’s drive theory, including the Oedipus complex, which, according to her and Jeffrey Masson, blames the child for the abusive sexual behaviour of adults. Psychologist Joel Kupfersmid investigated the validity of the Oedipus complex, examining its nature and origins. He concluded that there is little evidence to support the existence of the Oedipus complex.

Michel Foucault and Gilles Deleuze claimed that the institution of psychoanalysis has become a centre of power and that its confessional techniques resemble the Christian tradition. Jacques Lacan criticised the emphasis of some American and British psychoanalytical traditions on what he has viewed as the suggestion of imaginary “causes” for symptoms, and recommended the return to Freud. Together with Deleuze, Félix Guattari criticised the Oedipal structure. Luce Irigaray criticised psychoanalysis, employing Jacques Derrida’s concept of phallogocentrism to describe the exclusion of the woman from Freudian and Lacanian psychoanalytical theories. Deleuze and Guattari (1972), in Anti-Œdipus, take the cases of Gérard Mendel, Bela Grunberger and Janine Chasseguet-Smirgel, prominent members of the most respected associations (IPA), to suggest that, traditionally, psychoanalysis enthusiastically embraces a police state.

The theoretical foundations of psychoanalysis lie in the same philosophical currents that lead to interpretive phenomenology rather than in those that lead to scientific positivism, making the theory largely incompatible with positivist approaches to the study of the mind.

Although numerous studies have shown that the efficacy of therapy is primarily related to the quality of the therapist, rather than the school or technique or training, a French 2004 report from INSERM concluded that psychoanalytic therapy is less effective than other psychotherapies (including cognitive behavioural therapy) for certain diseases. This report used a meta-analysis of numerous other studies to find whether the treatment was “proven” or “presumed” to be effective on different diseases.

Freudian Theory

A survey of scientific research suggested that while personality traits corresponding to Freud’s oral, anal, Oedipal, and genital phases can be observed, they do not necessarily manifest as stages in the development of children. These studies also have not confirmed that such traits in adults result from childhood experiences. However, these stages should not be viewed as crucial to modern psychoanalysis. What is crucial to modern psychoanalytic theory and practice is the power of the unconscious and the transference phenomenon.

The idea of “unconscious” is contested because human behavior can be observed while human mental activity has to be inferred. However, the unconscious is now a popular topic of study in the fields of experimental and social psychology (e.g., implicit attitude measures, fMRI, and PET scans, and other indirect tests). The idea of unconscious, and the transference phenomenon, have been widely researched and, it is claimed, validated in the fields of cognitive psychology and social psychology, though a Freudian interpretation of unconscious mental activity is not held by the majority of cognitive psychologists. Recent developments in neuroscience have resulted in one side arguing that it has provided a biological basis for unconscious emotional processing in line with psychoanalytic theory i.e., neuropsychoanalysis, while the other side argues that such findings make psychoanalytic theory obsolete and irrelevant.

Many aspects of Freudian theory are indeed out of date, and they should be: Freud died in 1939, and he has been slow to undertake further revisions. His critics, however, are equally behind the times, attacking Freudian views of the 1920s as if they continue to have some currency in their original form. Psychodynamic theory and therapy have evolved considerably since 1939 when Freud’s bearded countenance was last sighted in earnest. Contemporary psychoanalysts and psychodynamic therapists no longer write much about ids and egos, nor do they conceive of treatment for psychological disorders as an archaeological expedition in search of lost memories. (Drew Westen, 1998).

Shlomo Kalo explains that the scientific materialism that flourished in the 19th century severely harmed religion and rejected whatever called spiritual. The institution of the confession priest in particular was badly damaged. The empty void that this institution left behind was swiftly occupied by the newborn psychoanalysis. In his writings, Kalo claims that psychoanalysis basic approach is erroneous. It represents the mainline wrong assumptions that happiness is unreachable and that the natural desire of a human being is to exploit his fellow men for his own pleasure and benefit.

Jacques Derrida incorporated aspects of psychoanalytic theory into his theory of deconstruction in order to question what he called the ‘metaphysics of presence’. Derrida also turns some of these ideas against Freud, to reveal tensions and contradictions in his work. For example, although Freud defines religion and metaphysics as displacements of the identification with the father in the resolution of the Oedipal complex, Derrida (1987) insists that the prominence of the father in Freud’s own analysis is itself indebted to the prominence given to the father in Western metaphysics and theology since Plato.

What is a Psychologist?

Published on 01/03/2021 by Andrew Marshall465 Comments

Introduction

A psychologist is a person who studies normal and abnormal mental states, perceptual, cognitive, emotional, and social processes and behaviour by experimenting with, and observing, interpreting, and recording how individuals relate to one another and to their environments.

Applied Psychology in the United States

Applied psychology applies theory to solve problems in human and animal behaviour. Clinical psychology is a field of applied psychology that focus on therapeutic methods. Other applied fields include counselling psychology and school psychology. Licensing and regulations can vary by country, state, and profession.

Clinical Psychology

Education and Training

In the United States and Canada, full membership in the American Psychological Association requires doctoral training (except in some Canadian provinces, such as Alberta, where a master’s degree is sufficient). The minimal requirement for full membership can be waived in circumstances where there is evidence that significant contribution or performance in the field of psychology has been made. Associate membership requires at least two years of postgraduate studies in psychology or an approved related discipline.

Some US schools offer accredited programmes in clinical psychology resulting in a master’s degree. Such programmes can range from forty-eight to eighty-four units, most often taking two to three years to complete after the undergraduate degree. Training usually emphasizes theory and treatment over research, quite often with a focus on school, or couples and family counselling. Similar to doctoral programs, master’s level students usually must fulfil time in a clinical practicum under supervision; some programmes also require a minimum amount of personal psychotherapy. While many graduates from master’s level training go on to doctoral psychology programmes, a large number also go directly into practice – often as a licensed professional counsellor (LPC), marriage and family therapist (MFT), or other similar licensed practice (see below).

There is stiff competition to gain acceptance into clinical psychology doctoral programs (acceptance rates of 2-5% are not uncommon). Clinical psychologists in the US undergo many years of graduate training – usually five to seven years after the bachelor’s degree – to gain demonstrable competence and experience. Licensure as a psychologist takes an additional one to two years post Ph.D./Psy.D. (licensure requires 3,000 hours of supervised training), depending on the state. Today in America, about half of all clinical psychology graduate students are being trained in Ph.D. programmes that emphasize research and are conducted by universities – with the other half in Psy.D. programmes, which have more focus on practice (similar to professional degrees for medicine and law). Both types of doctoral programmes (Ph.D. and Psy.D.) envision practicing clinical psychology in a research-based, scientifically valid manner, and most are accredited by the American Psychological Association (APA).

APA accreditation is very important for US clinical, counselling, and school psychology programmes because graduating from a non-accredited doctoral programme may adversely affect employment prospects and present a hurdle for becoming licensed in some jurisdictions.

It should be noted that APA membership is not a requirement for licensure in any of the 50 states. This fact should not be confused with APA accreditation of graduate psychology programmes and clinical internships.

Doctorate (Ph.D. and Psy.D.) programmes usually involve some variation on the following 5 to 7 year, 90-120 unit curriculum:

Bases of behaviour: biological, cognitive-affective and cultural-social.
Individual differences: personality, lifespan development, psychopathology.
History and systems: development of psychological theories, practices and scientific knowledge.
Clinical practice: diagnostics, psychological assessment, psychotherapeutic interventions, psychopharmacology, ethical and legal issues.
Coursework in statistics and research design.
Clinical experience:
- Practicum: usually three or four years of working with clients under supervision in a clinical setting. Most practicum placements begin in either the first or second year of doctoral training.
- Doctoral internship: usually an intensive one or two-year placement in a clinical setting.
Dissertation: Ph.D. programmes usually require original quantitative empirical research, while Psy.D. dissertations involve original quantitative or qualitative research, theoretical scholarship, program evaluation or development, critical literature analysis or clinical application and analysis. The dissertation typically takes 2-3 years to complete.
Specialized electives: many programmes offer sets of elective courses for specialisations, such as health, child, family, community or neuropsychology.
Personal psychotherapy: many programmes require students to undertake a certain number of hours of personal psychotherapy (with a non-faculty therapist) although in recent years this requirement has become less frequent.
Comprehensive exams or master’s thesis: A thesis can involve original data collection and is distinct from a dissertation.

Psychologists can be seen as practicing within two general categories of psychology: applied psychology which includes “practitioners” or “professionals”, and research-orientated psychology which includes “scientists”, or “scholars”. The training models endorsed by the American Psychological Association (APA) require that applied psychologists be trained as both researchers and practitioners, and that they possess advanced degrees.

Psychologists typically have one of two degrees: PsyD or PhD. The PsyD programme prepares the student only for clinical practice (e.g., testing, psychotherapy). Depending on the specialty (industrial/organisational, social, clinical, school, etc.), a PhD may be trained in clinical practice as well as in scientific methodology, to prepare for a career in academia or research. Both the PsyD and PhD programmes prepare students to take state licensing exams.

Within the two main categories are many further types of psychologists as reflected by the 56 professional classifications recognised by the APA, including clinical, counselling, and school psychologists. Such professionals work with persons in a variety of therapeutic contexts. People often think of the discipline as involving only such clinical or counselling psychologists. While counselling and psychotherapy are common activities for psychologists, these applied fields are just two branches in the larger domain of psychology. There are other classifications such as industrial, organisational and community psychologists, whose professionals mainly apply psychological research, theories, and techniques to “real-world” problems of business, industry, social benefit organisations, government, and academia.

Specialisations

Specific disorders (e.g. trauma, addiction, eating and sleep disorders, sexual dysfunction, depression, anxiety, or phobias).
Neuropsychological disorders.
Child and adolescent psychology.
Family and relationship counselling.
Health psychology.
Medical Psychology.
Sport psychology.
Forensic psychology.
Industrial and organisational psychology.
Educational psychology.

Clinical psychologists receive training in a number of psychological therapies, including behavioural, cognitive, humanistic, existential, psychodynamic, and systemic approaches, as well as in-depth training in psychological testing, and to some extent, neuropsychological testing.

Services

Clinical psychologists can offer a range of professional services, including:

Psychological treatment (therapy).
Administering and interpreting psychological assessment and testing.
Conducting psychological research.
Teaching.
Developing prevention programmes.
Consulting.
Programme administration.
Expert testimony.

In practice, clinical psychologists might work with individuals, couples, families, or groups in a variety of settings, including private practices, hospitals, mental health organisations, schools, businesses, and non-profit agencies.

Most clinical who engage in research and teaching do so within a college or university setting. Clinical psychologists may also choose to specialise in a particular field.

Prescription Privileges

Psychologists in the United States campaigned for legislative changes to enable specially trained psychologists to prescribe psychotropic medications. Legislation in Idaho, Iowa, Louisiana, New Mexico, and Illinois has granted those who complete an additional master’s degree program in psychopharmacology permission to prescribe medications for mental and emotional disorders. As of 2019, Louisiana is the only state where the licensing and regulation of the practice of psychology by medical psychologists (MPs) is regulated by a medical board (the Louisiana State Board of Medical Examiners) rather than a board of psychologists. While other states have pursued prescriptive privileges, they have not succeeded. Similar legislation in the states of Hawaii and Oregon passed through their respective legislative bodies, but in each case the legislation was vetoed by the state’s governor.

In 1989, the US Department of Defence was directed to create the Psychopharmacology Demonstration Project (PDP). By 1997, ten psychologists were trained in psychopharmacology and granted the ability to prescribe psychiatric medications.

Licensure

The practice of clinical psychology requires a license in the United States and Canada. Although each of the US states is different in terms of requirements and licenses, there are three common requirements:

Graduation from an accredited school with the appropriate degree.
Completion of supervised clinical experience.
Passing a written and/or oral examination.

All US state, and Canada provincial, licensing boards are members of the Association of State and Provincial Psychology Boards (ASPPB) which created and maintains the Examination for Professional Practice in Psychology (EPPP). Many states require other examinations in addition to the EPPP, such as a jurisprudence (i.e. mental health law) examination or an oral examination. Most states also require a certain number of continuing education credits per year in order to renew a license. Licensees can obtain this through various means, such as taking audited classes and attending approved workshops.

There are professions whose scope of practice overlaps with the practice of psychology (particularly with respect to providing psychotherapy) and for which a license is required.

Ambiguity of Title

To practice with the title of “psychologist”, in almost all cases a doctorate degree is required (a PhD or PsyD in the US). Normally, after the degree, the practitioner must fulfil a certain number of supervised postdoctoral hours ranging from 1,500-3,000 (usually taking one to two years), and passing the EPPP and any other state or provincial exams. A professional in the US must hold a graduate degree in psychology (MA, Psy.D., Ed.D., or Ph.D.), or have a state license to use the title psychologist. Additional regulations vary from state to state.

Differences with Psychiatrists

Although clinical psychologists and psychiatrists share the same fundamental aim – the alleviation of mental distress – their training, outlook, and methodologies are often different. Perhaps the most significant difference is that psychiatrists are licensed physicians, and, as such, psychiatrists are apt to use the medical model to assess mental health problems and to also employ psychotropic medications as a method of addressing mental health problems.

Psychologists generally do not prescribe medication, although in some jurisdictions they do have prescription privileges. In five US states (New Mexico, Louisiana, Illinois, Iowa, and Idaho), psychologists with post-doctoral clinical psychopharmacology training have been granted prescriptive authority for mental health disorders.

Clinical psychologists receive extensive training in psychological test administration, scoring, interpretation, and reporting, while psychiatrists are not trained in psychological testing. In addition, psychologists (particularly those from Ph.D. programmes) spend several years in graduate school being trained to conduct behavioural research; their training includes research design and advanced statistical analysis. While this training is available for physicians via dual MD/Ph.D. programmes, it is not typically included in standard medical education, although psychiatrists may develop research skills during their residency or a psychiatry fellowship (post-residency). Psychologists from Psy.D. programs tend to have more training and experience in clinical practice (e.g. psychotherapy, testing) than those from Ph.D. programmes.

Psychiatrists, as licensed physicians, have been trained more intensively in other areas, such as internal medicine and neurology, and may bring this knowledge to bear in identifying and treating medical or neurological conditions that present with primarily psychological symptoms such as depression, anxiety, or paranoia, e.g., hypothyroidism presenting with depressive symptoms, or pulmonary embolism with significant apprehension and anxiety.

Mental Health Professions (US)

Occupation	Degree	Common Licenses	Prescription Privilege
Clinical Psychologist	PhD/PsyD	Psychologist	Mostly No
Counselling Psychologist (Doctorate)	PhD/PsyD	Psychologist	No
Counselling Psychologist (Master’s)	Ma/MS/MC	MFT/LPC/LPA	No
School Psychologist	PhD/EdD	Psychologist	No
Psychiatrist	MD/DO	Psychiatrist	Yes
Clinical Social Worker	Phd/MSW	LCSW	No
Psychiatric Nurse	PhD/MSN/BSN	APRN/PMHN	No
Psychiatric and Mental Health Nurse Practitioner	DNP/MSN	MHNP	Yes (Varies by State)
Expressive/Art Therapist	MA	ATR	No

Marriage and Family Therapist (MFT):
- An MFT license requires a doctorate or master’s degree.
- In addition, it usually involves two years of post-degree clinical experience under supervision, and licensure requires passing a written exam, commonly the National Examination for Marriage and Family Therapists, which is maintained by the American Association for Marriage and Family Therapy.
- Further, most states require an oral exam. MFTs, as the title implies, work mostly with families and couples, addressing a wide range of common psychological problems.
- Some jurisdictions have exemptions that let someone practice marriage and family therapy without meeting the requirements for a license.
- That is, they offer a license but do not require that marriage and family therapists obtain one.
Licensed Professional Counse;lor (LPC):
- Similar to the MFT, the LPC license requires a master’s or doctorate degree, a minimum number of hours of supervised clinical experience in a pre-doc practicum, and the passing of the National Counsellor Exam.
- Similar licenses are the Licensed Mental Health Counsellor (LMHC), Licensed Clinical Professional Counsellor (LCPC), and Clinical Counsellor in Mental Health (CCMH).
- In some states, after passing the exam, a temporary LPC license is awarded and the clinician may begin the normal 3000-hour supervised internship leading to the full license allowing to practice as a counsellor or psychotherapist, usually under the supervision of a licensed psychologist.
- Some jurisdictions have exemptions that allow counselling to practice without meeting the requirements for a license – That is, they offer a license but do not require that counsellors obtain one.
Licensed Psychological Associate (LPA):
- Twenty-six states offer a master’s-only license, a common one being the LPA, which allows for the therapist to either practice independently, or, more commonly, under the supervision of a licensed psychologist, depending on the state.
- Common requirements are two to four years of post-master’s supervised clinical experience and passing a Psychological Associates Examination.
- Other titles for this level of licensing include psychological technician (Alabama), psychological assistant (California), licensed clinical psychotherapist (Kansas), licensed psychological practitioner (Minnesota), licensed behavioural practitioner (Oklahoma), licensed psychological associate (North Carolina) or psychological examiner (Tennessee).
Licensed Behaviour Analysts:
- Licensed behaviour analysts are licensed in five states to provide services for clients with substance abuse, developmental disabilities, and mental illness.
- This profession draws on the evidence base of applied behaviour analysis and the philosophy of behaviourism.
- Behaviour analysts have at least a master’s degree in behaviour analysis or in a mental health related discipline, as well as having taken at least five core courses in applied behaviour analysis.
- Many behaviour analysts have a doctorate.
- Most programmes have a formalised internship programme, and several programmes are offered online.
- Most practitioners have passed the examination offered by the Behaviour Analysis Certification Board.
- The model licensing act for behaviour analysts can be found at the Association for Behaviour Analysis International’s website.

Employment

In the United States, of 170,200 jobs for psychologists, 152,000 are employed in clinical, counselling, and school positions; 2,300 are employed in industrial-organisational positions, and 15,900 are in “all other” positions.

The median salary in the US, in 2012, for clinical, counseling, and school psychologists was US$69,280 and the median salary for organisational psychologists was US$83,580.

Psychologists can work in applied or academic settings. Academic psychologists educate higher education students as well as conduct research, with graduate-level research being an important part of academic psychology. Academic positions can be tenured or non-tenured, with tenured positions being highly desirable.

International

To become a psychologist, a person often completes a degree in psychology, but in other jurisdictions the course of study may be different and the activities performed may be similar to those of other professionals.

Australia

In Australia, the psychology profession, and the use of the title “psychologist”, is regulated by an Act of Parliament, the Health Practitioner Regulation (Administrative Arrangements) National Law Act 2008, following an agreement between state and territorial governments. Under this national law, registration of psychologists is administered by the Psychology Board of Australia (PsyBA). Before July 2010, the professional registration of psychologists was governed by various state and territorial Psychology Registration Boards. The Australian Psychology Accreditation Council (APAC) oversees education standards for the profession.

The minimum requirements for general registration in psychology, including the right to use the title “psychologist”, are an APAC approved four-year degree in psychology followed by either a two-year master’s program or two years of practice supervised by a registered psychologist. However, AHPRA (Australian Health Practitioner Regulation Agency) is currently in the process of phasing out the 4 + 2 internship pathway. Once the 4 + 2 pathway is phased out, a master’s degree or PhD will be required to become a psychologist in Australia. This is because of concerns about public safety, and to reduce the burden of training on employers. There is also a ‘5 + 1’ registration pathway, including a four-year APAC approved degree followed by one year of postgraduate study and one year of supervised practice. Endorsement within a specific area of practice (e.g. clinical neuropsychology, clinical, community, counselling, educational and developmental, forensic, health, organisational or sport and exercise) requires additional qualifications. These notations are not “specialist” titles (Western Australian psychologists could use “specialist” in their titles during a three-year transitional period from 17 October 2010 to 17 October 2013).

Membership with Australian Psychological Society (APS) differs from registration as a psychologist. The standard route to full membership (MAPS) of the APS usually requires four years of APAC-accredited undergraduate study, plus a master’s or doctorate in psychology from an accredited institution. An alternate route is available for academics and practitioners who have gained appropriate experience and made a substantial contribution to the field of psychology.

Restrictions apply to all individuals using the title “psychologist” in all states and territories of Australia. However, the terms “psychotherapist”, “social worker”, and “counsellor” are currently self-regulated, with several organisations campaigning for government regulation.

Belgium

Since 1933, the title “psychologist” has been protected by law in Belgium. It can only be used by people who are on the National Government Commission list. The minimum requirement is the completion of five years of university training in psychology (master’s degree or equivalent). The title of “psychotherapist” is not legally protected. As of 2016, Belgian law recognises the clinical psychologist as an autonomous health profession. It reserves the practice of psychotherapy to medical doctors, clinical psychologists and clinical orthopedagogists.

Canada

A professional in the US or Canada must hold a graduate degree in psychology (MA, Psy.D., Ed.D., or Ph.D.), or have a state license to use the title psychologist.

Finland

In Finland, the title “psychologist” is protected by law. The restriction for psychologists (licensed professionals) is governed by National Supervisory Authority for Welfare and Health (Finland) (Valvira). It takes 330 ECTS-credits (about six years) to complete the university studies (master’s degree). There are about 6,200 licensed psychologists in Finland.

Germany

In Germany, the use of the title Diplom-Psychologe (Dipl.-Psych.) is restricted by law, and a practitioner is legally required to hold the corresponding academic title, which is comparable to a M.Sc. degree and requires at least five years of training at a university. Originally, a diploma degree in psychology awarded in Germany included the subject of clinical psychology. With the Bologna-reform, this degree was replaced by a master’s degree. The academic degree of Diplom-Psychologe or M.Sc. (Psychologie) does not include a psychotherapeutic qualification, which requires three to five years of additional training. The psychotherapeutic training combines in-depth theoretical knowledge with supervised patient care and self-reflection units. After having completed the training requirements, psychologists take a state-run exam, which, upon successful completion (Approbation), confers the official title of “psychological psychotherapist” (Psychologischer Psychotherapeut). After many years of inter-professional political controversy, non-physician psychotherapy was given an adequate legal foundation through the creation of two new academic healthcare professions.

Greece

Since 1979, the title “psychologist” has been protected by law in Greece. It can only be used by people who hold a relevant license or certificate, which is issued by the Greek authorities, to practice as a psychologist. The minimum requirement is the completion of university training in psychology at a Greek university, or at a university recognised by the Greek authorities. Psychologists in Greece are legally required to abide by the Code of Conduct of Psychologists (2019). Psychologists in Greece are not required to register with any psychology body in the country in order to legally practice the profession.

India

In India, “clinical psychologist” is specifically defined in the Mental Health Act, 2017. An MPhil degree of two years duration recognized by the Rehabilitation Council of India is required to apply for registration as a clinical psychologist. This procedure has been criticised by some stakeholders since clinical psychology is not limited to the area of rehabilitation. Titles such as “counsellor” or “psychotherapist” are not protected at present. In other words, an individual may call themselves a “psychotherapist” or “counsellor” without having earned a graduate degree in clinical psychology or another mental health field, and without having to register with the Rehabilitation Council of India.

New Zealand

In New Zealand, the use of the title “psychologist” is restricted by law. Prior to 2004, only the title “registered psychologist” was restricted to people qualified and registered as such. However, with the proclamation of the Health Practitioners Competence Assurance Act, in 2003, the use of the title “psychologist” was limited to practitioners registered with the New Zealand Psychologists Board. The titles “clinical psychologist”, “counselling psychologist”, “educational psychologist”, “intern psychologist”, and “trainee psychologist” are similarly protected. This is to protect the public by providing assurance that the title-holder is registered and therefore qualified and competent to practice, and can be held accountable. The legislation does not include an exemption clause for any class of practitioner (e.g., academics, or government employees).

Norway

In Norway, the title “psychologist” is restricted by law and can only be obtained by completing a 6 year integrated programme, leading to the Candidate of Psychology degree. Psychologists are considered health personnel, and their work is regulated through the “health personnel act”.

South Africa

In South Africa, psychologists are qualified in either clinical, counselling, educational, organisational, or research psychology. To become qualified, one must complete a recognised master’s degree in Psychology, an appropriate practicum at a recognised training institution, and take an examination set by the Professional Board for Psychology. Registration with the Health Professions Council of South Africa (HPCSA) is required and includes a Continuing Professional Development component. The practicum usually involves a full year internship, and in some specialisations, the HPCSA requires completion of an additional year of community service. The master’s programme consists of a seminar, coursework-based theoretical and practical training, a dissertation of limited scope, and is (in most cases) two years in duration. Prior to enrolling in the master’s programme, the student studies psychology for three years as an undergraduate (B.A. or B.Sc., and, for organisational psychology, also B.Com.), followed by an additional postgraduate honours degree in psychology. Qualification thus requires at least five years of study and at least one internship. The undergraduate B.Psyc. is a four-year programme integrating theory and practical training, and – with the required examination set by the Professional Board for Psychology – is sufficient for practice as a psychometrist or counsellor.

United Kingdom

In the UK, “registered psychologist” and “practitioner psychologist” are protected titles. The title of “neuropsychologist” is not protected. In addition, the following specialist titles are also protected by law: “clinical psychologist”, “counselling psychologist”, “educational psychologist”, “forensic psychologist”, “health psychologist”, “occupational psychologist” and “sport and exercise psychologist”. The Health and Care Professions Council (HCPC) is the statutory regulator for practitioner psychologists in the UK. In the UK, the use of the title “chartered psychologist” is also protected by statutory regulation, but that title simply means that the psychologist is a chartered member of the British Psychological Society, but is not necessarily registered with the HCPC. However, it is an offense for someone who is not in the appropriate section of the HCPC register to provide psychological services. The requirement to register as a clinical, counselling, or educational psychologist is a professional doctorate (and in the case of the latter two the British Psychological Society’s Professional Qualification, which meets the standards of a professional doctorate). The title of “psychologist”, by itself, is not protected. The British Psychological Society is working with the HCPC to ensure that the title of “neuropsychologist” is regulated as a specialist title for practitioner psychologists.

Employment (UK)

As of December 2012, in the United Kingdom, there are 19,000 practitioner psychologists registered across seven categories: clinical psychologist, counselling psychologist, educational psychologist, forensic psychologist, health psychologist, occupational psychologist, sport and exercise psychologist. At least 9,500 of these are clinical psychologists, which is the largest group of psychologists in clinical settings such as the NHS. Around 2,000 are educational psychologists.

On This Day … 02 January

Published on 01/02/2021 by Andrew MarshallLeave a comment

People (Deaths)

2016 – Frances Cress Welsing, American psychiatrist and author (b. 1935).

Frances Welsing

Frances Luella Welsing (née Cress; 18 March 1935 to 02 January 2016) was an American Afrocentrist psychiatrist and black supremacist.

Her 1970 essay, The Cress Theory of Colour-Confrontation and Racism (White Supremacy), offered her interpretation on the origins of what she described as white supremacy culture.

She was the author of The Isis Papers: The Keys to the Colours (1991). Welsing caused controversy after she said that homosexuality among African-Americans was a ploy by white males to decrease the black population.

Early Life

Welsing was born Frances Luella Cress in Chicago on 18 March 1935. Her father, Dr. Henry N. Cress, was a physician, and her mother, Ida Mae Griffen, was a teacher. In 1957, she earned a B.S. degree at Antioch College and in 1962 received an M.D. at Howard University. In the 1960s, Welsing moved to Washington, D.C. and worked at many hospitals, especially children’s hospitals. While Welsing was an assistant professor at Howard University she formulated her first body of work in 1969, The Cress Theory of Colour-Confrontation and self published it in 1970. The paper subsequently appeared in the May 1974 edition of the Black Scholar. This was an introduction to her thoughts that would be developed in The Isis Papers. Twenty-two years later she released The Isis Papers, a compilation of essays she had written about global and local race relations.

Career

In 1992, Welsing published The Isis Papers: The Keys to the Colours. The book is a compilation of essays that she had written over 18 years.

The name “The Isis Papers” was inspired by an ancient Egyptian goddess. Isis was the sister/wife of the most significant god Osiris. According to Welsing, all the names of the gods were significant; however, also according to Welsing, Osiris means “lord of the perfect Black”. Welsing specifically chose the name Isis for her admiration of “truth and justice” that allowed for justice to be stronger than gold and silver.

In this book she talks about the genocide of people of colour globally, along with issues black people in the United States face. According to Welsing, the genocide of people of colour is caused by white people’s inability to produce melanin. The minority status of whites has caused what she calls a preoccupation with white genetic survival.

She believed that injustice caused by racism will end when “non-white people worldwide recognize, analyze, understand and discuss openly the genocidal dynamic.” She also tackled issues such as drug use, murder, teen pregnancy, infant mortality, incarceration, and unemployment, in the black community. According to Welsing, the cause of these issues is her definition of racism (white supremacy). Black men are at the center of Welsing’s discussion because, according to her, they “have the greatest potential to cause white genetic annihilation.”

Views

In The Isis Papers, she described white people as the genetically defective descendants of albino mutants. She wrote that due to this “defective” mutation, they may have been forcibly expelled from Africa, among other possibilities. Racism, in the views of Welsing, is a conspiracy “to ensure white genetic survival”. She attributed AIDS and addiction to crack cocaine and other substances to “chemical and biological warfare” by white people.

Welsing created a definition of racism, which is her theory of non-white genocide globally. She refers to racism and white supremacy synonymously. Her definition is “Racism (white supremacy) is the local and global power system dynamic, structured and maintained by those who classify themselves as white; whether consciously or subconsciously determined; this system consists of patterns of perception, logic, symbol formation, thought, speech, action and emotional response, as conducted simultaneously in all areas of people activity: economics, education, entertainment, labour, law, politics, religion, sex, and war. The ultimate purpose of the system is to ensure white genetic survival and to prevent white genetic annihilation on Earth – a planet in which the overwhelming majority of people are classified as non-white, (black, brown, red, and yellow) by white skinned people. All of the non-white people are genetically dominant (in terms of skin colouration) compared to the genetic recessive white skinned people”. Welsing was against white supremacy and the emasculation of black men.

Criticisms

Welsing stated that the emasculation of the black man prevents procreation of black people. According to Welsing, this is one of the goals of racism (white supremacy). She calls this effeminisation as a form of oppression. An extension of feminising black men is also described by Welsing as bisexuality and homosexuality.

Death

By 30 December, 2015, Welsing suffered two strokes and was placed in critical care at a Washington, D.C.-area hospital. She died on 02 January 2016, at the age of 80.

On This Day … 01 January

Published on 01/01/2021 by Andrew MarshallLeave a comment

People (Births)

1946 – Claude Steele, American social psychologist and academic.

Claude Steele

Claude Mason Steele (born January 1, 1946) is a social psychologist and emeritus professor at Stanford University, where he is the I. James Quillen Endowed Dean, Emeritus at the Stanford Graduate School of Education, and Lucie Stern Professor in the Social Sciences, Emeritus.

Formerly he was the executive vice chancellor and provost at the University of California, Berkeley. He also served as the 21st provost of Columbia University for two years. Before that, he had been a professor of psychology at various institutions for almost 40 years.

He is best known for his work on stereotype threat and its application to minority student academic performance. His earlier work dealt with research on the self (like self-image and self-affirmation) as well as the role of self-regulation in addictive behaviours.

In 2010, he released his book, Whistling Vivaldi and Other Clues to How Stereotypes Affect Us, summarising years of research on stereotype threat and the underperformance of minority students in higher education.

Education

He enrolled at Hiram College in Hiram, Ohio, where he earned a B.A. in psychology in 1967.

At Hiram College, Steele’s passion for reading novels led to an interest in how the individual faces the social world. After being fully immersed in the Civil Rights Movement and the issues of racial equality, rights, and the nature of prejudice as a child, Steele formed a desire to study the topics in a scientific manner. He was especially keen to discover their effects on social relationships and quality of life. Steele was inspired by African-American social psychologist Kenneth Clark’s TV appearance discussing the psychological implications of the 1964 race riots in Harlem, New York City, which led to doing behavioural research. Steele conducted early experimental research at Hiram College in physiological psychology (looking at behavioural motives in Siamese fighting fish) and social psychology (studying how African-American dialect among kids maintains ethnic/racial identity), where he worked under the mentorship of social psychologist, Ralph Cebulla.

In graduate school, he studied social psychology, earning an M.A. in 1969 and a Ph.D. in 1971 at Ohio State University, with a minor in statistical psychology. His dissertation work, with faculty adviser Tom Ostrom at Ohio State, focused on attitude measurement and attitude change.

Research

Throughout his academic career, his work fell into three main domains of research under the broad subject area of social psychology: stereotype threat, self-affirmation, and addictive behaviours. Although separate and distinct, the three lines of research are linked by their shared focus on self-evaluation and how people cope with threats to their self-image and self-identities.

Addictive Behaviours:
- Although many people primarily associate Steele with his significant contributions in the development of stereotype threat research, the 14 years of his post-doctoral academic career that he spent at the University of Washington were focused on addictive behaviours and the social psychology behind alcohol use and addiction.
- He was interested in the role of alcohol and drug use in self-regulation processes and social behaviour.
- Among his major findings were that alcohol myopia, the cognitive impairment by alcohol use, reduces cognitive dissonance, leads to more extreme social responses, increases helping behaviour, reduces anxiety when it is combined with a distracting activity, and enhances important self-evaluations.
Self-Affirmation:
- While studying the effects of alcohol use on social behaviour, Steele was formulating a theory about the effects of self-affirmation.
- Developed in the 1980s, self-affirmational processes referred to the ability to reduce threats to self-image by stepping back and affirming a value that is important to self-concept.
- Steele often uses the example of smokers who are told that smoking will lead to significant negative health outcomes.
- The perception that they may be evaluated negatively by their willingness to engage in negative behaviours threatens their self-image.
- However, affirming a value in a domain completely unrelated to smoking but important to one’s self-concept: joining a valued cause, or accomplishing more at work, will counter the negative effects of the self-image threat and re-establish self-integrity.
- Self-affirmation theory was originally formulated as an alternative motivational explanation for cognitive dissonance theory that threats to the self led to a change in attitudes rather than psychologically inconsistent ideas, and self-affirmational strategies can reduce dissonance as effectively as attitude change.
- His research on self-affirmation and its effects demonstrated the power of self-affirmation to reduce biased attitudes, lead to positive health behaviours, and even improve the academic performance of minority students.
Stereotype Threat:
- Steele is best known for his work on stereotype threat and its application to explain real-world problems such as the underperformance of female students in mathematics and science classes as well as Black students in academic contexts.
- Steele first began to explore the issues surrounding stereotype threat at the University of Michigan, when his membership on a university committee called for him to tackle the problem of academic underachievement of minority students at the university.
- He discovered that the dropout rate for Black students was much higher than for their white peers even though they were good students and had received excellent SAT scores.
- That led him to form a hypothesis involving stereotype threat.
- Stereotype threat refers to the threat felt in particular situations in which stereotypes relevant to one’s collective identity exist, and the mere knowledge of the stereotypes can be distracting enough to negatively affect performance in a domain related to the stereotype.
- Steele has demonstrated the far-reaching implications of stereotype threat by showing that it is more likely to undermine the performance of individuals highly invested in the domain being threatened and that stereotype threat can even lead to Black people having significant negative health outcomes.
- The theories of stereotype threat can be applied for better understanding group differences in performance not only in intellectual situations but also in athletics.
- Steele has spearheaded many successful interventions aimed at reducing the negative effects of stereotype threat, including how to provide critical feedback effectively to a student under the effects of stereotype threat, inspired by the motivating style of feedback of his graduate school adviser, Ostrom, and how teacher practices can foster a feeling of identity safety.
- That would improve performance outcomes by elementary school minority students.

Book: Managing Depression with Mindfulness for Dummies

Published on 12/31/2020 by Andrew MarshallLeave a comment

Book Title:

Managing Depression with Mindfulness for Dummies.

Author(s): Robert Gebka.

Year: 2016.

Edition: First (1st).

Publisher: Tyndale Momentum.

Type(s): Paperback and Kindle.

Synopsis:

If you suffer from depression, you know that it is not something you can simply snap yourself out of. Depression is a potentially debilitating condition that must be treated and managed with care, but not knowing where to turn for help can make an already difficult time feel even more harrowing. Thankfully, Managing Depression with Mindfulness For Dummies offers authoritative and sensitive guidance on using evidence based and NHS approved Mindfulness Based Interventions similar to Cognitive Behavioural Therapy (CBT) to help empower you to rise above depression and discover a renewed sense of emotional wellbeing and happiness. The book offers cutting edge self-management mindfulness techniques which will help you make sense of your condition and teach you how to relate differently to negative thought patterns which so often contribute to low mood and depression.

The World Health Organisation predicts that more people will be affected by depression than any other health problem by the year 2030. While the statistics are staggering, they offer a small glimmer of hope: you are not alone. As we continue to learn more about how depression works and how it can be treated, the practice of mindfulness proves to be an effective tool for alleviating stress, anxiety, depression, low self-esteem, and insomnia. With the tips and guidance offered inside, you′ll learn how to apply the practice of mindfulness to ease your symptoms of depression and get your life back.

Heal and recover from depression mindfully.
Understand the relationship between thinking, feeling, mood, and depression.
Reduce your depression with effective mindfulness practices.
Implement positive changes and prevent relapse.

Whether you are struggling with low mood or simply wish to learn mindfulness as a way of enriching your life, Managing Depression with Mindfulness For Dummies serves as a beacon of light and hope on your journey to rediscovering your sense of wellbeing, joy and happiness.

Book: Conquer Worry And Anxiety

Published on 12/31/2020 by Andrew Marshall1 Comment

Book Title:

Conquer Worry And Anxiety – The Secret To Mastering Your Mind.

Author(s): Daniel G. Amen (MD).

Year: 2020.

Edition: First (1st).

Publisher: Tyndale Momentum.

Type(s): Paperback and Kindle.

Synopsis:

You can overcome worry and anxiety today. It is possible to feel better fast – and to make it last.

Many people, mental health professionals included, think therapy needs to be long, hard, and painful – a lifelong commitment. And while some people will need help longer than others, it is often possible for people to start feeling better right now. If you engage in the right behaviours and strategies, you will optimise your brain health – and see the benefits in your everyday life.

In Conquer Worry and Anxiety , renowned psychiatrist Dr. Daniel G. Amen will guide you to lasting change, teaching you how to make decisions that serve your brain’s health and set you on a path to a happier, healthier life. Each of us can make small changes that, over time, create amazing results.